tag:theconversation.com,2011:/uk/topics/zimbabwean-health-23161/articlesZimbabwean health – The Conversation2020-04-30T15:56:49Ztag:theconversation.com,2011:article/1374242020-04-30T15:56:49Z2020-04-30T15:56:49ZPentecostals and the spiritual war against coronavirus in Africa<figure><img src="https://images.theconversation.com/files/331361/original/file-20200429-51485-1rqyap8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Stefan Heunis/AFP/Getty Images</span></span></figcaption></figure><p>Since the emergence of <a href="https://theconversation.com/africa/search?utf8=%E2%9C%93&q=COVID-19&sort=relevancy&language=en&date=week&date_from=&date_to=">COVID-19</a>, a number of <a href="https://www.ft.com/content/7c3a17c6-f130-4659-972f-0fe9ebc7102b">media commentators</a> and <a href="https://www.theelephant.info/features/2020/03/23/religion-in-the-age-of-coronavirus/">academics</a> have reflected on the “<a href="https://religiousmatters.nl/dealing-with-a-spiritual-virus-whither-the-prophetic/">spiritualisation</a>” of the pandemic among responses in different African settings. </p>
<p>There’s been particular interest in the influence of prominent <a href="https://www.britannica.com/topic/Pentecostalism">Pentecostal</a> pastors on public health messaging. Some have expressed concern about the possible consequences of their invocations of spiritual warfare. </p>
<p>We’ve examined how <a href="https://www.grammar-monster.com/glossary/idiom.htm">idioms</a> of (spiritual) warfare have been deployed in response to the coronavirus pandemic and wish to bring a broader perspective to recent debates about these dynamics. We consider examples from Tanzania and Zimbabwe, drawing on our ongoing research in these settings.</p>
<p>Many Pentecostal Christians, in Africa as well as <a href="https://www.theguardian.com/us-news/2020/apr/04/america-rightwing-christian-preachers-virus-hoax">other continents</a>, portray the coronavirus as a “<a href="https://www.biblegateway.com/passage/?search=Ephesians+6%3A12&version=NRSV">spiritual force of evil</a>” rather than as a biomedical disease. </p>
<p>Through this lens, the world is presented as a <a href="https://www.academia.edu/31074897/Occupying_the_Global_City_Spatial_Politics_and_Spiritual_Warfare_among_African_Pentecostals_in_Hong_Kong">battleground</a> between God and the agents of Satan. For those who enlist to “fight for Jesus”, the most effective weapon is prayer. </p>
<p>Spiritual warfare provides a <a href="https://www.biblestudytools.com/bible-study/topical-studies/spiritual-warfare-lesson-1-understanding-the-battle-11554631.html">framework</a> for explaining and responding to both mundane and extraordinary events – from a cancelled flight to a global pandemic. But despite their close association with Pentecostals, these militarised idioms may also <a href="https://brill.com/view/book/edcoll/9789004281875/B9789004281875-s008.xml">resonate</a> with other groups.</p>
<h2>The prophet</h2>
<p>In Zimbabwe, <a href="https://emmanuelmakandiwa.com/">Prophet Emmanuel Makandiwa</a> has been <a href="https://www.thezimbabwemail.com/zimbabwe/outrage-as-emmanuel-makandiwa-goes-blasphematory/">criticised</a> for reassuring his congregants that they will be “spared” from the virus. This will happen through prayer and the divine protection he mediates. “You will not die, because the Son is involved in what we are doing,” he says, calling it </p>
<blockquote>
<p>the freedom that no medication can offer. </p>
</blockquote>
<p>This <a href="https://www.zimeye.net/2020/04/06/watch-video-makandiwa-vows-he-will-never-take-coronavirus-vaccine/">declaration</a> epitomises a sense of Pentecostal “exceptionalism”, embodied in the claim to be “<a href="https://www.biblegateway.com/passage/?search=John+17%3A16&version=NRSV">in this world but not of this world</a>”. It clearly risks instilling a level of complacency among his followers about the threat of the virus. It amplifies the possibility of <a href="https://religioninpublic.com/2020/04/03/pentecostalism-public-health-and-covid-19-in-nigeria/">noncompliance</a> with government <a href="https://www.reuters.com/article/us-health-coronavirus-zimbabwe/zimbabwe-locks-down-to-fight-coronavirus-amid-economic-crisis-idUSKBN21H2DF">safety measures</a>.</p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/331030/original/file-20200428-110779-17g9fw5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/331030/original/file-20200428-110779-17g9fw5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/331030/original/file-20200428-110779-17g9fw5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=600&fit=crop&dpr=1 600w, https://images.theconversation.com/files/331030/original/file-20200428-110779-17g9fw5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=600&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/331030/original/file-20200428-110779-17g9fw5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=600&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/331030/original/file-20200428-110779-17g9fw5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=754&fit=crop&dpr=1 754w, https://images.theconversation.com/files/331030/original/file-20200428-110779-17g9fw5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=754&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/331030/original/file-20200428-110779-17g9fw5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=754&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Advert for online service led by Prophet Makandiwa.</span>
<span class="attribution"><span class="source">Christ TV Channel/Twitter</span></span>
</figcaption>
</figure>
<p>Prophet Makandiwa has also been accused of perpetuating <a href="https://theconversation.com/uk/topics/the-anthill-podcast-27460">conspiracy theories</a>. Drawing Biblical allusions to the “<a href="https://www.biblegateway.com/passage/?search=Revelation+13%3A16-18&version=NRSV">mark of the beast</a>”, he has warned followers about “microchip” implants. These, he predicts, will accompany future vaccination campaigns. This claim has also been made by pastors <a href="https://religioninpublic.com/2020/04/03/pentecostalism-public-health-and-covid-19-in-nigeria/">elsewhere</a> in the <a href="http://www.daily-mail.co.zm/covid-19-fuels-5g-conspiracy-theories/">African</a> continent. </p>
<p>In Uganda, steps have already been taken to <a href="https://www.newvision.co.ug/new_vision/news/1517283/pastor-yiga-spend-seven-prison">prosecute</a> pastors spreading misinformation.</p>
<h2>The president</h2>
<p>Efforts to “spiritualise” the virus have also been pursued by some African leaders. For example, Tanzanian President <a href="https://www.thecitizen.co.tz/news/PROFILE--John-Pombe-Joseph-Magufuli-/1840340-2927326-k4xewcz/index.html">John Pombe Magufuli</a> described COVID-19 as a demon (<em>shetani</em>). Through it Satan seeks to “<a href="https://www.youtube.com/watch?v=7r8T0Wx4sQI">destroy</a>” Tanzanian citizens. </p>
<p>Despite the government promoting physical distancing, he declared that churches or mosques would not be closed because this is where God and “true healing” (<em>uponyaji wa kweli</em>) are found.</p>
<p>Invoking the idiom of spiritual warfare, Magufuli explained that COVID-19</p>
<blockquote>
<p>cannot survive in the Body of Jesus (and) will be burned away.</p>
</blockquote>
<p><a href="https://mg.co.za/africa/2020-04-27-crisis-what-crisis-how-not-to-handle-a-pandemic/?utm_medium=Social&utm_source=Facebook#Echobox=1588004073">Commentators</a> have observed that Magufuli is himself a Roman Catholic (albeit with Pentecostal <a href="https://www.youtube.com/watch?v=SqP_XHggKO4&feature=emb_title">ties</a>). Yet few have acknowledged his implication that God can also be “found” in mosques, nor his <a href="https://kenyanbreaking.co.ke/others/chemsheni-mwarubaini-magufuli-tells-tanzanians/">recommendation</a> that Tanzanians also embrace indigenous medicinal practices for protection. </p>
<p>In a country where Christians don’t constitute a clear religious majority, Magufuli invokes the rhetoric of spiritual warfare to articulate a sense of national religious identity.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/331367/original/file-20200429-51495-5pp5lk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/331367/original/file-20200429-51495-5pp5lk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/331367/original/file-20200429-51495-5pp5lk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/331367/original/file-20200429-51495-5pp5lk.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/331367/original/file-20200429-51495-5pp5lk.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/331367/original/file-20200429-51495-5pp5lk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/331367/original/file-20200429-51495-5pp5lk.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/331367/original/file-20200429-51495-5pp5lk.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">A woman walks past an election billboard featuring now president of Tanzania, John Magufuli in Dar es Salaam.</span>
<span class="attribution"><span class="source">Daniel Hayduk/AFP/Getty Images</span></span>
</figcaption>
</figure>
<p>These invocations mostly adopt a rhetorical style reminiscent of Pentecostal pastors but maintain a broad, inclusive focus on God (<em>Mungu</em>). </p>
<p>Tanzanians responded enthusiastically to Magufuli’s <a href="https://www.voanews.com/covid-19-pandemic/tanzanian-president-declares-3-days-national-prayer-help-defeat-coronavirus">call for</a> citizens “of every faith” to participate in three days of national prayer. Many took to social media to circulate photos and <a href="https://twitter.com/MsigwaGerson/status/1251444039376920577?s=20">videos</a> featuring the Tanzanian flag and words of prayer. </p>
<h2>Some perspective</h2>
<p>Yet a growing number of <a href="https://africanarguments.org/2020/04/27/president-magufuli-covid-19-we-need-leadership-not-prayers/">commentators</a> have criticised Magufuli. As with Makandiwa, they argue that his use of spiritual warfare rhetoric generates a dangerous expectation of viral immunity. </p>
<p>Some <a href="https://africasacountry.com/2020/04/the-devil-coronavirus">commentators</a> have taken Magufuli’s emphasis on prayer to be <a href="https://twitter.com/MsigwaPeter/status/1252894425124126720">emblematic</a> of the government’s perceived <a href="https://twitter.com/fatma_karume/status/1253583821116715009?s=20">failure</a> to <a href="https://www.newframe.com/tanzanias-state-response-to-covid-19-under-fire/">adequately address</a> the <a href="https://www.bloomberg.com/news/articles/2020-04-23/tanzanian-president-says-country-can-ill-afford-a-virus-lockdown">pandemic</a>. </p>
<p>The government, say critics, has fallen prey to “<a href="https://twitter.com/ThatBoyKhalifax/status/1241789034231484425">superstitious</a>” thinking. <a href="https://twitter.com/IanBabi/status/1252312358535471105?s=20">Some</a> draw allusions to the use of water-based medicine in the <a href="https://pdfs.semanticscholar.org/6df4/70fd66fbb5cd32e13802f54e4b91324504ad.pdf">Maji Maji</a> rebellion against German colonial rule. </p>
<p>As <a href="https://africasacountry.com/2020/04/praying-through-the-pandemic">others</a> have <a href="https://africasacountry.com/2020/04/the-devil-coronavirus">observed</a>, the act of giving spiritual agency to the virus as a “personal demon” can also serve to downplay structural failures which have contributed to its spread. It <a href="https://www.academia.edu/39252346/Pentecostalism_economics_capitalism_putting_the_Protestant_Ethic_to_work">divests responsibility</a> to both COVID-19 as a sentient “enemy” and citizens.</p>
<p>There is a risk, however, that exaggerating the “idiosyncrasy” of the Tanzanian government’s response to COVID-19 – and indeed that of Prophet Makandiwa – may perpetuate another myth of “exceptionalism”. One which echoes colonial depictions of African populations as singularly “superstitious” and “<a href="https://brill.com/view/journals/exch/32/2/article-p123_4.xml">incurably religious</a>”. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/331415/original/file-20200429-51474-1l1zfhi.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/331415/original/file-20200429-51474-1l1zfhi.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/331415/original/file-20200429-51474-1l1zfhi.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/331415/original/file-20200429-51474-1l1zfhi.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/331415/original/file-20200429-51474-1l1zfhi.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/331415/original/file-20200429-51474-1l1zfhi.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/331415/original/file-20200429-51474-1l1zfhi.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/331415/original/file-20200429-51474-1l1zfhi.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">A billboard in Lagos, Nigeria.</span>
<span class="attribution"><span class="source">Markus Matzel/ullstein bild/Getty Images</span></span>
</figcaption>
</figure>
<p>In truth, spiritual warfare idioms have been diversely invoked – and unevenly received – across the continent. They have <a href="https://www.theelephant.info/features/2020/03/23/religion-in-the-age-of-coronavirus/">prompted</a> lively “<a href="https://blogs.lse.ac.uk/africaatlse/2020/04/20/covid19-religious-institutions-public-health-science-africa/">religion and science</a>” debates. </p>
<p>Moreover, the plausibility of spiritual warfare idioms should not be exclusively attributed to people’s religious sensibilities. After all, “warfare” is the <a href="https://www.thetimes.co.uk/article/in-defence-of-war-metaphors-in-the-covid-19-conflict-k8l08nngv">signature trope</a> with which global political figures, health experts, and media commentators have framed COVID-19. </p>
<p>Like Magufuli, world leaders like the UK’s <a href="https://www.mirror.co.uk/news/politics/boris-johnson-declares-coronavirus-war-21707803">Boris Johnson</a>, France’s <a href="https://www.cnbc.com/2020/03/17/coronavirus-france-president-macron-warns-we-are-at-war.html">Emmanuel Macron</a> and the US’s <a href="https://time.com/5806657/donald-trump-coronavirus-war-china/">Donald Trump</a> have all invoked warfare motifs against the single, identifiable “enemy”. </p>
<p>European governments have also been <a href="https://economicsociology.org/2020/04/24/herd-immunity-is-epidemiological-neoliberalism/">accused</a> of using this framing to shift responsibility onto citizens as “combatants”, whether for failing to adhere to physical distancing or for their biomedical frailty. Narratives of individuals heroically “<a href="https://www.theguardian.com/commentisfree/2020/apr/07/horror-coronavirus-real-imaginary-war-britain">winning their war</a>” against a decidedly personal demon are no less persuasive to some in Europe than to some in Africa.</p>
<p>None of this is intended to take away from the ambivalent and sometimes plainly harmful effects of attempts to spiritualise the pandemic. Nor is it to imply that religiously informed strategies of communication and implementation are incompatible with more “temporal” methods. </p>
<p>Religious groups like Pentecostal congregations may indeed constitute an important “<a href="https://religionanddiplomacy.org.uk/2020/03/30/covid-19-and-pentecostals-in-africa/">public health resource</a>” when it comes to delivering <a href="https://www.rug.nl/research/centre-for-religious-studies/religion-conflict-globalization/blog/wash-your-hands-and-be-washed-in-the-blood-of-the-lambpentecostalism-and-the-coronavirus-30-03-2020">services</a> and <a href="https://www.rug.nl/research/centre-for-religious-studies/religion-conflict-globalization/blog/wash-your-hands-and-be-washed-in-the-blood-of-the-lambpentecostalism-and-the-coronavirus-30-03-2020">messaging</a>. And they can cultivate a sense of hope and <a href="https://www.newframe.com/thoughts-on-the-planetary-an-interview-with-achille-mbembe/">mutual care</a> in the face of uncertainty. </p>
<p>Rather, we suggest as anthropologists and scholars of religion, this warfaring rhetoric might stem from a shared discomfort among Africans and Europeans alike at the prospect of an adversary without discernible self-will or conscience. An impersonal demon. </p>
<p>As literary critic <a href="http://www.boundary2.org/2020/04/anders-engberg-pedersen-covid-19-and-war-as-metaphor/?fbclid=IwAR2HThyE2hfKiLUVNj9IaQPwL89uVyoJL1KG0FNFCWR8LeZBdb-a9EoBKMw">Anders Engberg-Pederson</a>
articulates it:</p>
<blockquote>
<p>We declare war on the virus, because we want it to be something that it is not.</p>
</blockquote><img src="https://counter.theconversation.com/content/137424/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Dr Benjamin Kirby receives funding from the British Academy.</span></em></p><p class="fine-print"><em><span>Josiah Taru has previously received funding from a Human Economy Programme (University of Pretoria) to conduct fieldwork between 2015-17. </span></em></p><p class="fine-print"><em><span>Tinashe Chimbidzikai receives funding from Max Planck Institute for the Study of Religious and Ethnic Diversity, Germany. </span></em></p>Framing the fight against coronavirus as a spiritual war may stem from a shared sense of discomfort about an adversary without discernible conscience; an impersonal demon.Benjamin Kirby, British Academy Postdoctoral Research Fellow, University of LeedsJosiah Taru, Lecturer, Great Zimbabwe UniversityTinashe Chimbidzikai, Doctoral Research Fellow, Max Planck Institute for the Study of Religious and Ethnic DiversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/919252018-02-15T08:59:46Z2018-02-15T08:59:46ZMorgan Tsvangirai: the man who dared Zimbabweans to dream again<figure><img src="https://images.theconversation.com/files/206532/original/file-20180215-131010-9l2lt6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Morgan Tsvangirai was a thorn in the side of Robert Mugabe's government.</span> <span class="attribution"><span class="source">Reuters/Peter Andrews</span></span></figcaption></figure><p>One never forgets their first job. For me it was not the work experience that left an indelible impression, though it was appreciated. It was that one day at work when all seems to be ordinary and then mundane, routine tasks are disrupted for just a few minutes and everything changes.</p>
<p>It was a hot summer’s day, the typical Harare heat burning us up. Hope was on the horizon; the type that brings storm clouds on a clear day to usher in rain. I worked until 4pm in a popular grocery store located in the affluent suburb of Chisipite. Unannounced, a burly stout imposing figure approached the till with a broad smile and distinctive round cheeks. </p>
<p>It was <a href="https://theconversation.com/zimbabwes-morgan-tsvangirai-heroic-herald-of-an-epoch-foretold-91845">Morgan Tsvangirai</a> himself. </p>
<h2>A man of the people</h2>
<p>We all knew who he was. A seasoned <a href="https://www.theguardian.com/world/2018/feb/14/morgan-tsvangirai-obituary">trade unionist</a>, that face most often featured on newspapers’ front pages. <a href="https://www.youtube.com/watch?v=kKP_X-blQu4">A thorn in the side</a> of Robert Mugabe and his regime, Tsvangirai was the man with whom Zimbabwe’s working class most identified. Many times when a stay-away was called and we didn’t go to school, this smiling customer had been the chief architect. To some, he was seen as a messiah.</p>
<p>Others saw him as little more than a rabble rouser and accused him of being the root cause of Zimbabwe’s economic decline and political hostility.</p>
<p>On that day, he was clad in his party t-shirt and holding a basket full of groceries. All the attention in the shop was centred on him. But Tsvangirai was a man of the people, and shifted that focus back to those around him. He engaged in small talk, bemoaned the lack of rain – the earth was dusty and thirsty for a drink, he said.</p>
<p>Approached by two mothers with suckling infants, he expressed his desire that the Zimbabwean health system would improve so that no child would ever have to die of malnutrition or another preventable ailment again.</p>
<p>He teased a young man in a Zimbabwe football t-shirt. Zimbabwe, Tsvangirai said, would qualify for the next soccer world cup. </p>
<p>As a young man doing his first job during that long hot summer, I gained more than work experience that day. I got life experience from a man who was not only simple but humane. There was a dissonance, too. This couldn’t be the same man the state told us brought sanctions and troubles to a country once viewed as Africa’s breadbasket. He’d even been blamed for keeping the rain from falling. </p>
<p>His parting shot to us that afternoon was sobering, and arresting. It challenged all the stereotypes and falsehoods that had been circulated as facts. Walking out, unaccompanied by bodyguards and fresh from chats with the many ordinary Zimbabweans in the store, he said:</p>
<blockquote>
<p>Don’t be afraid of the idea of change. A new Zimbabwe is upon us and we need you.</p>
</blockquote>
<h2>A unique power</h2>
<p>That was Morgan Tsvangirai’s unique power. He made Zimbabweans excited about the idea of change. Our ability to dream had been quashed. But he wasn’t afraid of this idea of change – he even had the bruises to show for it.</p>
<p>It is a hope and a dream he never let go of. Frail in his last days and consumed by cancer, Tsvangirai saw some of that change begin to unfold. It’s <a href="https://www.africanindy.com/news/morgan-tsvangirai-seriously-ill-11533915">sad that he will</a> not be around to experience the next steps on Zimbabwe’s journey. But his ability to make us dream will live on,<a href="https://theconversation.com/a-military-coup-is-afoot-in-zimbabwe-whats-next-for-the-embattled-nation-87528">even beyond his</a> own life. </p>
<p>His legacy, ideologies, and simplicity carry the nation of Zimbabwe forward.</p><img src="https://counter.theconversation.com/content/91925/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Willie Chinyamurindi receives funding from National Research Foundation. </span></em></p>Morgan Tsvangirai’s unique power was that he made Zimbabweans excited about the idea of change.Willie Tafadzwa Chinyamurindi, Associate Professor, University of Fort HareLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/758792017-04-19T15:18:49Z2017-04-19T15:18:49ZIncreasing caesarean sections in Africa could save more mothers’ lives<figure><img src="https://images.theconversation.com/files/165836/original/image-20170419-6349-gduz3q.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>Caesarean sections have been lifesaving procedures for hundreds of thousands of women across the world who experience complications during labour.</p>
<p>Globally, it’s estimated that <a href="http://dx.doi.org/10.1371/journal.pone.0148343">just under 20% of births</a> take place via caesarean section – a percentage that’s gone up over the last three decades. This has raised concerns, particularly in high-income countries where generally <a href="https://www.ncbi.nlm.nih.gov/pubmed/27642019">too many caesarean sections</a> are performed.</p>
<p>But in many African countries women who are medically required to have caesarean sections are not able to access them. This is due to several reasons, the most prominent being weak health systems and a lack of resources.</p>
<p>This needs to be fixed as women in sub-Saharan African suffer from the highest maternal mortality ratio in the world. <a href="http://apps.who.int/iris/bitstream/10665/194254/1/9789241565141_eng.pdf?ua=1">Close to 550 women die</a> for every 100 000 children that are born. This amounts to 200 000 maternal deaths a year – or <a href="http://apps.who.int/iris/bitstream/10665/194254/1/9789241565141_eng.pdf?ua=1">two thirds of all maternal deaths</a> per year worldwide.</p>
<p>Some of these deaths could be prevented if skilled health personnel were able to perform caesarean sections safely. But this would require proper equipment and supplies including drugs and blood transfusions. </p>
<p><a href="http://onlinelibrary.wiley.com/doi/10.1111/1471-0528.13592/pdf">Research</a> shows that low-income countries with the lowest caesarean section rates also have the highest maternal mortality rates.</p>
<p>Improving the access and availability of caesarean sections on the continent is therefore pivotal to reducing the number of maternal deaths and to achieve the sustainable development goal on maternal health of reducing maternal deaths to less than 70 per 100 000 live births by 2030.</p>
<h2>Africa’s challenge</h2>
<p>Between 1990 and 2015 maternal mortality dropped by about <a href="https://data.unicef.org/topic/maternal-health/maternal-mortality/#">44% across the world</a>. And several countries in Africa have halved their levels of maternal mortality between 1990 and 2015. In Mali, for example, 1010 women died for every 100 000 children born in 1990. By 2015, this figure dropped to 587.</p>
<p>Despite this massive reduction, more than 800 women continue to die from preventable causes around childbirth every day, most in sub-Saharan Africa and South Asia. And millions more will suffer serious injuries, infections, complications or disabilities due to insufficient treatment.</p>
<p>The World Health Organisation <a href="http://apps.who.int/iris/bitstream/10665/161442/1/WHO_RHR_15.02_eng.pdf">has found</a> that in countries where at least 10% of women have caesarean sections the number of maternal and newborn deaths decrease.</p>
<p>The organisation has not identified an ideal caesarean section rate, however there’s evidence that rates <a href="https://www.ncbi.nlm.nih.gov/pubmed/26624825">above 20% at country level</a> might be to too high. But it encourages governments to make every effort to provide the procedure to women in need of it. </p>
<p>Africa has the lowest caesarean section rate in the world. In Europe about a quarter of births are conducted via caesarean section while Latin America and the Caribbean have caesarean section rates of about 40.5%.</p>
<p>In Africa only 7.3% of babies are born via this method. But it’s a very mixed picture across the continent. Some countries have very high rates such as Egypt (51.8%) and Mauritius (47%), the highest in Africa. And despite a 4.5% overall increase across the continent from 1990, there’s been a decline in some countries like Nigeria and Guinea which now stands at about 2%. Zimbabwe has maintained its caesarean section rates at 6%.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/164652/original/image-20170410-8858-yivomi.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/164652/original/image-20170410-8858-yivomi.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=382&fit=crop&dpr=1 600w, https://images.theconversation.com/files/164652/original/image-20170410-8858-yivomi.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=382&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/164652/original/image-20170410-8858-yivomi.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=382&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/164652/original/image-20170410-8858-yivomi.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=480&fit=crop&dpr=1 754w, https://images.theconversation.com/files/164652/original/image-20170410-8858-yivomi.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=480&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/164652/original/image-20170410-8858-yivomi.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=480&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Caesarean section rate in selected African countries.</span>
<span class="attribution"><span class="source">Provided</span></span>
</figcaption>
</figure>
<h2>When caesars matter</h2>
<p>Caesarean sections often happen at the end of a series of complex events. There can be both pre-existing and pregnancy related complications. The need for caesarean sections can be aggravated by a range of issues such as delays in accessing the appropriate level of care, transportation delays as well as a shortage of necessary technologies. </p>
<p>Complications require prompt access to quality obstetric services equipped with life-saving drugs, including antibiotics, and the ability to provide blood transfusions or other surgical interventions.</p>
<p>But there are several barriers to improving the caesarean section rates in a country. These include:</p>
<ul>
<li><p>a shortage of midwives, obstetricians, anaesthetists, laboratory and other allied personnel,</p></li>
<li><p>limited access to health care, information and </p></li>
<li><p>a lack of equipment. </p></li>
</ul>
<p>Cost is another significant barrier. <a href="http://www.who.int/healthsystems/topics/financing/healthreport/30C-sectioncosts.pdf">It was estimated</a>, almost a decade ago, that it would cost US$430 million to perform the almost 3 million additional caesarean sections needed. </p>
<h2>Different playing fields</h2>
<p>While reducing unnecessary caesarean sections may be a priority in high-income countries, access to it will save more lives, particularly in countries where deliveries in a health care facility are considered a luxury.</p>
<p>Many African countries are trying to increase the number of women delivering in a health care facility by a skilled birth attendant. In Africa, <a href="http://www.who.int/gho/maternal_health/skilled_care/skilled_birth_attendance_text/en/">more than 40%</a> of births are not attended by a skilled health provider.</p>
<p>Inequities in access to caesarean sections across different parts of sub-Saharan Africa and other low-income countries need to be addressed. And soon if the continent wants to reduce its unacceptably high maternal mortality rates.</p><img src="https://counter.theconversation.com/content/75879/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Salome Maswime received funding from the South African Medical Research Council, Carnegie Corporation of New York for a PhD on Measures to reduce morbidity and mortality from caesarean section related haemorrhage. </span></em></p><p class="fine-print"><em><span>Gwinyai Masukume does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Many women in African countries who are medically required to have caesarean sections aren’t able to access them due to weak health systems and a lack of resources.Salome Maswime, Lecturer in Obstetrics and Gynaecology, University of the WitwatersrandGwinyai Masukume, Medical Doctor, Epidemiologist and Biostatistician: University College Cork, University of the WitwatersrandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/518792016-02-26T04:02:47Z2016-02-26T04:02:47ZMyths and misconceptions stop African men from going for a vasectomy<figure><img src="https://images.theconversation.com/files/112713/original/image-20160224-16429-1w8smkf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Vasectomies allow fathers to have a more active role in family planning. </span> <span class="attribution"><span class="source">shutterstock</span></span></figcaption></figure><p>In many parts of the world, family planning is still considered a woman’s responsibility. This has prevented men from being more involved in family decisions about fertility. But it has also limited their access to family planning services targeted at them.</p>
<p>A vasectomy, or male sterilisation, is considered one of the few fertility control methods that allows men to take personal responsibility for <a href="http://www.ncbi.nlm.nih.gov/pubmed/23144022">contraception</a>. </p>
<p>Global <a href="http://www.un.org/en/development/desa/population/publications/pdf/family/worldContraceptivePatternsWallChart2013.pdf">contraceptive patterns</a> for 2013 show that only 2.2% of the world’s men have had vasectomies. This is compared to female sterilisation which sits at 18.9%.</p>
<p>Countries with the highest vasectomy rates include Canada where 22% of men of reproductive age have had a vasectomy. This compares to the UK with 21%, New Zealand with 19.5% and the US with 11%. In Africa <a href="http://www.fhi360.org/sites/default/files/media/documents/no-scalpel-vasectomy-rwanda.pdf">0.1%</a> of men have undergone vasectomies. </p>
<p>But on the continent, vasectomies could be one of the most effective male birth control methods. They are inexpensive and could therefore have a major impact on sustainable development and population growth. But the procedure is misunderstood and as a result poorly used.</p>
<p>There is a knowledge gap about the vasectomy procedure as a family planning method in several African countries. Only 38% of women and <a href="http://dhsprogram.com/pubs/pdf/FR308/FR308.pdf">48% of men</a> in Kenya knew of a vasectomy for family planning. In Nigeria this figure dropped to only 16% of married women and <a href="http://dhsprogram.com/pubs/pdf/FR293/FR293.pdf">27% of men</a> identified. In Liberia, this figure stood at <a href="http://dhsprogram.com/pubs/pdf/FR291/FR291.pdf">20%</a> for both married women and men. </p>
<p>For family planning to be effective <a href="http://www.ncbi.nlm.nih.gov/pubmed/25922638">emerging evidence</a> increasingly shows that men must both support women’s use of contraceptives and use male fertility control methods if necessary.</p>
<h2>A risk free procedure</h2>
<p>A vasectomy is an effective (and increasingly reversible) method of birth control. It involves clamping, cutting, or sealing the duct that conveys sperm from the testicle to the urethra.</p>
<p>It is a fairly quick, simple and straightforward procedure which lasts barely 30 minutes. It can be done in a doctor’s practice or clinic on an outpatient basis, and under local anaesthesia. There are also very few risks or <a href="http://www.ncbi.nlm.nih.gov/pubmed/6534499">complications</a>.</p>
<p>Very few vasectomies fail or go wrong. In very rare cases, the duct spontaneously reconnects. But only about 1 in every 500 women have an <a href="http://www.who.int/mediacentre/factsheets/fs351/en">unintended pregnancy</a> in the year after their partner has undergone a vasectomy.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/112716/original/image-20160224-32745-t94dqj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/112716/original/image-20160224-32745-t94dqj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/112716/original/image-20160224-32745-t94dqj.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/112716/original/image-20160224-32745-t94dqj.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/112716/original/image-20160224-32745-t94dqj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/112716/original/image-20160224-32745-t94dqj.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/112716/original/image-20160224-32745-t94dqj.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Very few vasectomies fail or go wrong.</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
</figcaption>
</figure>
<h2>A low uptake</h2>
<p>Despite all of this, the uptake of vasectomies in Africa remains consistently low. </p>
<p>In <a href="http://dhsprogram.com/pubs/pdf/fr229/fr229.pdf">Kenya</a> only one of the 24 125 married women who were surveyed said her husband had undergone a vasectomy. In <a href="http://dhsprogram.com/pubs/pdf/SR192/SR192.pdf">Senegal</a> and <a href="https://dhsprogram.com/pubs/pdf/FR293/FR293.pdf">Nigeria</a> none of the married women surveyed said their husbands had undergone vasectomies. And only 0.01% of the men interviewed in <a href="https://dhsprogram.com/pubs/pdf/FR254/FR254.pdf">Zimbabwe</a> admitted having a vasectomy. </p>
<p>The low uptake derives from a number of factors. Our field research suggests that a major reason for this is the cultural belief that a man’s fertility belongs to the community as a whole. As a result, men who go for vasectomies risk stigma and contempt. There are several myths and misconceptions surrounding the procedure. These include: </p>
<ul>
<li><p>Local beliefs associating vasectomy with de-masculinisation, framing it in terms of castration</p></li>
<li><p>notions that vasectomy causes painful sex, weight gain and obesity among men, and makes men develop female features, such as breasts</p></li>
<li><p>fears that it would reduce their sex drive and sexual satisfaction </p></li>
</ul>
<p>In addition, another challenge is that few health and family planning providers on the continent offer vasectomy services or discuss it in family planning counselling sessions. One study in <a href="http://www.ncbi.nlm.nih.gov/pubmed/22282576">Nigeria</a> reflects that only 5.8% of doctors discussed vasectomies during counselling sessions.</p>
<p>In our project in western Kenya, we wanted to increase the knowledge and uptake of family planning services, including vasectomies.</p>
<p>When the project began there were no recorded cases of vasectomies. By the end of 2014, 118 vasectomies had been done. </p>
<p>Community health workers were meticulously trained to help local communities understand vasectomies, family planning and men’s role in reproductive and family health. The consistent and careful engagement using clear and accurate messages and information helped people accept the practice. </p>
<h2>Changing the mentality</h2>
<p>Our work promoting the uptake of family planning in western Kenya has raised critical lessons about vasectomies and male involvement in family planning in Africa.</p>
<p>The first lesson is that men can become more involved in fertility planning and childbearing decisions. It happens when they are supported to make a strong personal connection to the issue of family and reproductive health and well-being. </p>
<p>The second is that vasectomies will be accepted as a method of family planning when the myths and misconceptions surrounding it are systematically dispelled. </p>
<p>A third lesson is in the value of getting community male champions to popularise vasectomies. The few men who undergo vasectomies often do so secretly and are rarely willing to speak out in support of the practice. Locally respected and authoritative men must be identified and recruited to act as ambassadors of change challenging myths and misunderstandings and highlighting the benefits of the procedure.</p>
<p>It is also important that health care providers who can offer vasectomy counselling and procedures are available. When we started our project, few providers had the necessary skills to perform the procedure. By mid-2015, the project had trained over 100 health providers. </p>
<p>Efforts to improve the uptake of vasectomy in Africa will fail without the accompanying training of health professionals.</p>
<p>What is urgently needed is a bold and innovative plan to address misconceptions and change perceptions around the process, communicate its benefits and ensure there are adequate numbers of well trained providers to offer it.</p><img src="https://counter.theconversation.com/content/51879/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Chimaraoke Izugbara works for the African Population and Health Research Center. He receives funding from the Packard Foundation, Hewlett Foundation, Sida, MacArthur Foundation, and the Wellcome Trust. </span></em></p><p class="fine-print"><em><span>Michael Mutua receives funding from the David and Lucile Packard Foundation for the data collection and staff time at African Population and Health Research Center. </span></em></p>Vasectomies could be an effective male birth control method in Africa but the procedure is misunderstood and therefore poorly used.Chimaraoke Izugbara, Head of Population Dynamics and Reproductive Health and Director of Research Capacity Strengthening, African Population and Health Research CenterMichael Mutua, Data analyst, African Population and Health Research CenterLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/511432015-12-04T04:26:44Z2015-12-04T04:26:44ZWhat drove women to lie in an HIV clinical trial in southern Africa<figure><img src="https://images.theconversation.com/files/104299/original/image-20151203-6775-gcwapn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A woman prepares ribbons ahead of World Aids Day. </span> <span class="attribution"><span class="source">Reuters/Antony Njuguna</span></span></figcaption></figure><p>Two years ago women were found to have lied in a clinical trial in South Africa for a new HIV drug. The VOICE trial was <a href="http://www.nejm.org/doi/full/10.1056/NEJMoa1402269">unsuccessful</a> due to low adherence. When the trial was completed it was revealed many women involved had not been honest about their adherence to the drug regime they had signed up to take.</p>
<p>The fact that the trial did not achieve its aim of proving the drugs were effective led to a <a href="http://mg.co.za/article/2013-03-08-00-women-confound-hiv-researchers/">fierce debate</a> about the <a href="http://news.sciencemag.org/biology/2013/03/human-nature-sinks-hiv-prevention-trial">morality</a> of clinical trials and the role of women in them.</p>
<p>Many directed blame at the women. They were accused of deliberate deception to remain in the trial to access “stipends” of between US$10 and $15. They were also accused of being responsible for prolonging the spread of HIV.</p>
<p>Our <a href="http://www.tandfonline.com/doi/full/10.1080/01459740.2015.1116528#abstract">research</a> wanted to find out why the women who participated in the research lied. </p>
<p>It found many women in the trial came from the rural areas of South Africa and neighbouring states. They were young and unmarried, and many faced uncertain futures. They struggled to find work and many were caught in abusive relationships. And frequently they had no choice but to engage in exploitative relationships with men, employers, police and landlords. The trial represented hope for a better future.</p>
<p>Although the money was a motivation, it was not the main reason they participated in the trial. Instead, the trial allowed them to access good quality health screening and care and to be viewed as responsible virtuous women. It gave them a chance to forge a new moral identity, challenging the stereotypes of “loose” single women.</p>
<h2>The trial</h2>
<p>When the clinical trial was introduced to test the effectiveness of drugs on healthy women as a means of prevention, it was thought this would tackle the challenge of new HIV infections.</p>
<p>If they were successful, it would have resulted in a single product containing one or a combination of drugs – administered orally or vaginally – that could protect high risk women simply by it being taken daily.</p>
<p>The Vaginal and Oral Interventions to Control the Epidemic trial, more commonly referred to as VOICE, took place in Zimbabwe, South Africa and Uganda. The drugs were given to women considered most at risk of contracting HIV. These are women between the ages of 15 and 49, who have an incidence rate of more than 2% in South Africa alone.</p>
<p>More than 5000 women were part of the study to test novel ways for women to protect themselves from HIV infection using pre-exposure prophylaxis.</p>
<p>Some of the women took a pill containing two anti-HIV drugs while others took pills containing only one. A third set were given a vaginal gel with one of the drugs while a fourth set were given an inert gel or dummy pills.</p>
<p>Adherence calculations based on pill counts, interviews and audio computer aided self-interviews showed that adherence ranged from 86% to 90%. Just under half of the participants rated their own adherence as <a href="http://www.nejm.org/doi/full/10.1056/NEJMoa1402269">“very good”</a>.</p>
<p>But an analysis of the pharmacokinetic (PK) tests to detect the drug in blood samples taken from 647 women, found the drug in less than half of the samples. This directly contradicted participants’ claims and exposed them as “dishonest”.</p>
<h2>A rhetoric of blame</h2>
<p>The criticisms of the women in the trial echo similar allegations that young women deliberately fall <a href="http://journals.cambridge.org/action/displayAbstract?fromPage=online&aid=365428&fileId=S0021932005000957">pregnant</a> or even intentionally expose themselves to HIV to receive state welfare <a href="http://www.tandfonline.com/doi/abs/10.2989/16085900609490386">grants</a>.</p>
<p>These criticisms also potentially threaten public confidence in clinical trials because they place a question mark over the trust established between trial participants, and the scientific community and donors.</p>
<p>In Hillbrow, where we conducted our <a href="http://www.tandfonline.com/doi/full/10.1080/01459740.2015.1116528#abstract">research</a>, we found that many women came from rural areas in South Africa and neighbouring states. Only half were employed and even those who had jobs struggled to sustain work.</p>
<p>Many women were migrants. Because of this they experienced the disruption of social networks and frequently had no choice but to engage in exploitative relationships with men, employers, police and landlords.</p>
<p>They also valued the trial, which was reflected in the <a href="http://www.biomedcentral.com/1472-6874/14/88">high retention</a> rates. It helped them get regular health checkups, HIV testing and quality care at clinics.</p>
<p>While they welcomed the US$15 travel stipends, the trial represented more than immediate monetary gain. Participating in the trial was an investment in “a better life”, as 40-year-old Lily put it. The logic was that if the trials worked, their lives would also improve. Being part of a solution to the AIDS epidemic was also extremely meaningful.</p>
<p>The trial also disrupted the monotony of sitting at home unemployed.</p>
<h2>Performing perfect participation</h2>
<p>Although participants faced considerable difficulties in adhering to taking the study product once a day, many portrayed themselves as “perfect participants”, never missing a dose.</p>
<p>Why did the women feel it necessary to sustain this fiction of perfection? The trial was seen as an opportunity for the women to assert credibility. For them, admitting to being non-adherent threatened their ongoing participation in the trial. This would have affected the benefits as well as their social status.</p>
<p>Trial participants wanted to redefine themselves as virtuous women. They used the trial as a way to do so. Reputations were managed as women crafted an image of themselves as responsible agents looking to a better future. Crucially, this rested on a performance of being the “perfect trial participant”, whether or not this reflected their adherence.</p><img src="https://counter.theconversation.com/content/51143/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jonathan Stadler receives funding from USAID, NIH, UKAID, and the MRC </span></em></p>Women who were found to have lied in a clinical trial testing anti-HIV drugs were heavily criticised. But there are several factors that drove them to lie.Jonathan Stadler, Technical Head, Social Science Research, Wits Reproductive Health and HIV Institute, University of the WitwatersrandLicensed as Creative Commons – attribution, no derivatives.