Primary Health Care initiatives in colonial Kenya

World Development Vol. 26, No. Y, pp. 1701-1717, 1998 0 1998 Elsevier Science Ltd All rights reserved. Printed in Great Britain 0305-750&‘98/$19.00+0.00

Pergamon

PII: SO305750X(98)00067-9

Primary Health Care Initiatives in Colonial Kenya MIRIAM S. CHAIKEN* Indiana University of Penmylvania, Indiana, PA 15705, U.S.A. Summary. - Most contemporary development practitioners have only passing familiarity with development strategies employed by their predecessors, especially for programs that occurred during colonial periods. An examination of the colonial medical system of Kenya reveals that many of the strategies now employed in Primary Health Care programs were preceded by comparable programs administered by the colonial medical authorities. The colonial system did not include universal or egalitarian access to health care, nor were the programs ever adequate to remedy many of the major threats to health, but the lessons derived from a careful review of this period validate the appropriateness of many Primary Health Care approaches now promoted. In particular, the emphasis on decentralized, preventive medical services, the use of comprehensive immunization programs, concerted efforts at improvements in sanitation, and promotion of health education were important components of the colonial medical services, that effected positive changes in the health of indigenous populations. Examination of specific colonial programs should inform contemporary Primary Health Care policies. 0 199X Elsevier Science Ltd. All rights reserved Kev words - Kenva. Primarv Health history, colonial iedicine ’ 1.

Care. health

INTRODUCTION

In the mid-1970s multinational donor agencies and international groups reached a consensus that the existing programs of health care delivery in developing countries were seriously inadequate. They acknowledged that many of the efforts that had been made in the previous decades to address health standards had made little impact. Especially in the new countries of Africa, most of which had by then been independent for over a decade, the conditions of health, nutrition, and population growth appeared to be worsening, rather than improving, in spite of considerable effort and funding to address these problems. Because this disenchantment was widespread, the World Health Organization (WHO) and UNICEF jointly convened a meeting at Alma Ata in 1978 to develop a new paradigm for health care strategies, termed Primary Health Care. The outcome of the Alma Ata Conference was a re-formulation of health care systems, and a goal of establishing ‘health for all by the year 2000.’ Primary health care advocates a series of specific practices aimed at disease prevention and management, and is predicated on a philosophy of egalitarian access to health care. The specific elements of Primary Health Care programs vary from one place or agency to another, but generally these plans are based on

policy, community

based

health

care, colonial

the assumption that decentralization of services and decision-making will permit a more responsive and appropriate health service, and emphasize prevention and public health education, rather than curative care. Primary Health Care programs appropriately recognize that many of the persistent problems facing the developing world are ultimately a product of poverty, gender-based and class inequality, marginal infrastructure, and isolation. Traditional government health services were founded on centralized, highly technical approaches, controlled by ‘experts’, while primary health care programs seek to prevent disease, address the conditions in impoverished communities that foster much of *Funding for the research, both in Syracuse and England, was provided by Indiana University of Pennsylvania’s Senate Research Fellowship. I am grateful to Drs Ginger Brown and Phillip Neusius for their assistance in securing research support. While conducting the archival research David Brokensha, and A. H. Peter Castro were instrumental in helping gain access to important sources, and the staffs of the Royal Commonwealth Society (especially Terry Barringer) and Rhodes House were very helpful. The Department of Anthropology at University of California, Santa Barbara kindly provided research support during a sabbatical period which permitted me to draft this paper. Ben Chaiken, Tom Conelly, and Peter Castro provided useful comments on an earlier version of this paper. To all I remain indebted.

1701

1702

WORLD DEVELOPMENT

the health problems, and instill community-based responsibility and management for health maintenance (den Besten et al., 1995; Kasonde and Martin, 1994; Walker, 1995; Woelk, 1994). Recent examinations of the implementation of Primary Health Care (PHC) have noted problems and failures. For example, Woelk (1994) and Walker (1995) have both noted how the ideal of cooperative, interdisciplinary staff participating on health teams and delivering empathetic, effective care has not been realized. Staff with advanced training are reluctant to relinquish status and authority, assignments in rural areas are perceived as hardship postings, and there has been only lip-service paid to the integration of village-based health workers into the medical cadres. Similarly, Haddad and Fournier (1995) note that the commitment to equal access to care is financially problematic for most developing countries, yet introducing fees for cost recovery as advocated by the Bamako Initiative results in a marked decline in the use of services, clearly antithetical to the goals of egalitarian health care delivery. Mburu notes that ‘people do not like buying preventive care’ (Mburu, 1992, p. 421) and yet the success of PHC is synonymous with widely accessible, effective preventive programs. This creates an obvious dilemma; how can we implement effective PHC programs and improve health for millions of deserving people, while acknowledging the forces that threaten to erode the central tenets of PHC? How do we counteract these negative tendencies? Historical research on colonial medical services may provide some insight. I argue that while the Kenyan colonial medical serves were fundamentally hierarchical, and often paternalistic and coercive, they also managed to implement effective programs that were nearly identical to Primary Health Care programs today. The strategies they employed, their priorities for service delivery, and their unwavering commitment to preventive medicine provide instructive lessons for contemporary development planners.

2. CONTEMPORARY CONDITIONS HEALTH IN KENYA

OF

Examining historical cases of health policy is often neglected by contemporary development practitioners; I count myself among those guilty of this charge. In focusing our energies toward addressing the daunting problems that confront us, we tend to look forward rather than to the past, especially in countries where the past is

associated with a colonial legacy we now view as exploitative. A thorough review of colonial health policies in Kenya would, in retrospect, have provided important insights for my work as a development anthropologist. In the mid-1980s I worked as a consultant to UNICEF’s Kenya Programme Office, helping establish a baseline of data on conditions of malnutrition and health and sanitation infrastructure in an area of western Kenya, and engaging and training a core of local staff who would then be affiliated with rural health centers. I also consulted on a farming systems research project in other areas of western Kenya. During this period I had ample opportunities to formally research and informally observe health conditions. It was clear that western Kenya was seriously underserved; the health centers and clinics were located at great distances for many people, and services available were minimal, especially in the government-run centers that were poorly supplied and inadequately staffed. On a number of occasions I was told of patients turned away because no staff was on duty, I met women who were sent home in labor because there were no bed sheets for the delivery room or razor blades to cut the umbilical cord, and on one memorable occasion in one of the more ‘affluent’ health centers, I saw over 60 children immunized with two needles for lack of supplies. Local people routinely commented that there was little point in seeking treatment at the Health Center because they knew there were no stocks of drugs for treatment, and seriously ill patients often remained at home because it was common knowledge that there was no fuel for the Health Center jeep to transport the patient to the district hospital. My formal interviews in the rural villages indicated that the great majority of the children had received no immunizations or they were seriously behind in the recommended regimen. Most mothers had few resources to provide appropriate foods for their small children so weaning babies subsisted largely on a thin maize meal and water gruel. Nutritional testing indicated that the rate of clinical stunting (indicating long-term nutritional inadequacy) hovered around 30% among preschool children in most of the villages I surveyed, and the infant mortality rate for babies O-24 months was 221 per 1000, more than double the Kenyan national average at the time. Not a single household had access to safe water supplies, and 60-80% of rural households had no latrine (see Chaiken, 1988; Chaiken, 1990; Conelly and Chaiken, 1987; Conelly and Chaiken, 1993).

PRIMARY

HEALTH

CARE

This is the context in which primary health care programs are most desparately needed, and where the potential for positive impact is great. It was my assumption that the problems I witnessed in western Kenya were largely a product of the region having been ignored and neglected in economic development plans beginning with the colonial period, and from centralized medical services that failed to serve the most remote communities, such as those where I was working. My assumption about the colonial roots of these problems were also a product of the new directions advocated in the post-Alma Ata years, and from an initiative underway in Kenya in the mid-1980s to decentralize development programs to overcome some of the pronounced urban bias in service availability. It seemed logical to conclude that PHC and the ‘district focus’ were reactions to earlier failures. My assumptions were logical, but I was wrong. While pursuing field research I frequently heard (and often dismissed) anecdotal information from local people about how some aspects of health and sanitation services had been better in the colonial days. Subsequent review of archival literature in Rhodes House (Oxford University), the Royal Commonwealth Society (Cambridge), and the Kenya National Archives on microfilm at Syracuse University library suggest that there is foundation for the positive memories expressed by local people. The records in these archival sources by definition solely represent the voices of the colonial staff, and thus reflect their views which might well not be shared by the African populate. Turshen (1984, p. 5) argues that apologists for colonial regimes often look myopically at the medical services, proclaim their humanity, or even argue that their philosophy ran counter to that of imperialism: had their activities not been hampered by budgetary limitations, they would

ultimately have created an African medical service. While acknowledging that the entire colonial enterprise was fundamentally exploitative, and that its’ staff routinely sought to rationalize their actions and make their efforts appear successful to their superiors, there is little doubt that many of the specific strategies they employed were not only justified, but effective. Indeed it is clear that the colonial Department of Medical Services addressed many of the identical issues that are common today, and were often more effective than services available in the mid-1980s. In many respects they experimented with principles of Primary Health care long before the approach was fashionable or mandated.

IN COLONIAL

KENYA

3. THE COLONIAL

1703

MEDICAL

SERVICES

By the 192Os, the medical staff began advocating strategies for improving service delivery while maximizing the cost effectiveness of the Medical Department budget, using language that echoes that of contemporary PHC programs.’ The emphasis in colonial medical services in Kenya throughout the 20th century was preventive rather than curative care, which included consistent efforts to improve sanitation, enhance public health education, to control the spread of infectious disease through vector management and immunization where possible, and to expand training of indigenous staff. Common elements in a Primary Health Care approach typically include such programs as:

-

-

-

-

-

community-based paraprofessional health workers who are responsible for delivery of basic services and conducting public health education in their community, village-based delivery of basic health services, especially for management of chronic illness (TB, leprosy), family-planning supplies, and management of nutritional surveillance activities, vector control for management of insect borne disease (especially malaria, onchocerciasis, human trypanosomiasis or sleeping sickness, and filariasis), community-based sanitation programs, to improve access to potable water, expand usage of latrines, and consequently reduce parasitic infections, and comprehensive immunization programs.

The emphasis on preventive care in the Kenyan colonial medical service seems to stem from several principles. First, the British medical system, when compared with the American, had an especially strong inclination toward preventive care, rather than palliative or curative care. There was a well-established hierarchy of health paraprofessionals who provided ‘domicilary’ services and health extension. The colonial medical system shared the goal of creating a cadre of skilled indigenous staff to bolster the European contingent (Beck, 1981; Lyons, 1994). Second, from the outset, the colonial medical service physicians frankly acknowledged the limitation of curative approaches to effect any systemic improvement in community well-being. This was especially true in the pre-WWII era, as modern antibiotics were not generally available and anti-malarials had limited effectiveness. These professionals were quite aware of the link between poor environmental conditions and the common diseases and sought to address the

1704

WORLD DEVELOPMENT

conditions that fostered disease. Third, colonial medical officials understood that the increasing demand for health services by the indigenous population that resulted as the effectiveness of Western medicine became well-established would never equal the limited resources (both staff and funding). These resources could be easily exhausted by the unlimited demand for curative care, while still not addressing the root causes of the problems (see also Beck, 1981).* Fourth, the presence of the white settler population presented the medical service with a special challenge. Medical officers were well aware that the risk of contagion for vulnerable Europeans was substantial if they ignored the reservoir of disease among the Africans (Mburu, 1992). Officials used this threat to the European population as a source of leverage to secure funding from the colonial office for medical services (Beck, 1981): Finally, some of the colonial approach that seems in retrospect rather visionary may ultimately stem from colonial paternalism. While many colonial medical officers expressed sincere dedication to improving the welfare of the African masses, colonial policies sought to eradicate ‘backwardness’ and to ‘elevate’ the African masses, making such approaches as improving the sanitation and public education (propaganda campaigns in parlance of the period) an appealing blend of preventive medicine and paternalistic haughtiness. (a) Decentralization of health services The management of the colonial enterprise took place through a system known as Indirect Rule. Under this system, there was a distinct hierarchy of decision-making responsibilities into the domains of central or local government. The central government, minimally supervised by the Colonial Office, was responsible for defense, transportation and roads, police, post-primary educational services and specialized medical services, while local government was charged with local medical services, preventive and sanitary care, local water supplies, feeder roads, and primary education (Hannigan, 1958, p. 6). The administration of local government was carried out by European staff assigned to provincial headquarters, and led by a Provincial Commissioner. The provincial staff, in turn, supervised other European and African staff at the District and Divisional levels, with each of these offices managed by a District Commissioner (DC) and District Officer (DO) respectively. After 1924, the colonial government

established Local Native Councils (LNC, renamed African District Councils in 1950) that were staffed by appointed and elected members of the local indigenous population. The LNCs were charged with levying local taxes but had only limited autonomy for setting priorities for disbursement of the funds they collected. At the locational level, indigenous ‘chiefs’ were appointed by the District Commissioner to serve as representatives of their area and to impose the directives of the colonial administration. This allocation of authority was perceived by the policy makers in the Colonial Office as an efficient approach to utilizing resources effectively, and was justified on three grounds; first, it provided training in democratic function as ‘a democratic way of life also imposes responsibilities on the people, who must be prepared to pay taxes and help in the running of affairs in the community to which they belong’ (Hannigan, 1958, p. 2; also Hailey, 1970, p. 96). Second, decentralization tapped local leadership, and provided an opportunity for expression of local opinions and grievances. Finally, it reduced the danger of apathy in people as they are more inclined to take an interest in their affairs if they have control over them. For example, the LNCs mandated and funded services that the central government did not adequately provide, such as education and some health services (Hannigan, 1958). Critics of British Indirect Rule note that these justifications are rather hollow, as the real key to the effectiveness of the system was the way in which indigenous people could be utilized (perhaps even coopted) to be the front line of administration, effectively maintaining their own colonization. This cost less to manage and made Africans responsible for collecting taxes to fuel the colonial enterprise. Whichever view one accepts, it appears that for health service development, the colonial medical services formed a reasonably effective partnertship with the Local Native Councils. The LNCs were often stacked with representatives who were perceived as cooperative by the British administrators, and while the District Commissioner was always the ex-ofjkio head of each LNC and thus exerted considerable influence, these councils do appear to have routinely mandated health care services, particularly maternity and child welfare clinics, as a local priority for funding and support. Throughout the early 20th century the health infrastructure expanded through the funding assistance of the LNCs which raised money by levying council taxes, which permitted the local dispensaries and health centers to operate without charging fees

PRIMARY HEALTH CARE IN COLONIAL KENYA to the Africans (although Asian and Europeans were expected to pay fees at private medical centers, mostly in Nairobi).J The colonial medical services, while headquartered in Nairobi, established early on a decentralized pattern for service delivery. This is not unlike the Community Based Health Care (CBHC) advocated as part of contemporary development policy. There were health centers and dispensaries, and eventually regional hospitals funded by the colonial development office, as well as rural clinics established and supported by the LNCs. In the annual reports prepared by the Directors of Medical Services, and in reports of regional Medical Officers of Health, acknowledgement of the importance of support from Local Native Councils is routine: Without exception these local authorities are taking a real interest in the promotion of health, and marked improvements in sanitation are now to be seen in the areas under their control (KCP, 1930, p. 22). The Director of Medical Services in 1933, A. R. Paterson noted in his annual report that the effects of the Depression necessitated economizing measures and he reiterated the commitment to organize medical services in the Reserves on a district level. He indicated that his priorities were to advise the local public health authority, i.e. the District Commissioner with regard to the promotion and safeguarding of the public health. To advise individuals with regard to hygiene and sanitation, that is to engage in health propaganda and to endeavour to educate the community with regard to personal and domestic hygiene and sanitation. To provide medical relief (KCP, 1933, p. 4). Paterson

poignantly

describes

the

goals

and

role of the colonial medical service: of even greater importance than the relief of sickness is its prevention, and with the latter object in view both doctors and nurses, and midwives, as well as health visitors and sanitary inspectors, must come into the most intimate contact with the people in their own homes from day to day; and if the behests of these workers are to carry weight . ..so medical workers must live among the people in all quarters of the area to be served; and they must be sufficient in number, and so posted that there is intimate and easy contact between the whole of the personnel of the medical service and the folk of the countryside.. Facilities for treatments must, therefore, be brought almost to their doors, while teaching must be taken actually over their doorsteps. For these purposes the primary health centers have been established (KCP, 1933, p. 5).

1705

In the previous years’ annual report, Paterson documented the history of the development of the decentralized services: Previous to 1920 there were no Government Institutions in the native reserves which could properly be termed hospitals, while only one European medical officer was posted to these areas and there was no African staff which had been systematically trained in any fashion.. .By 1932 (through the leadership of his predecessor, John Gilks), there were fourteen medical units in the reserves comprising well equipped hospitals under the charge of Medical Officers, and over one hundred subsidiary dispensaries, the European personnel in these reserves had risen from one medical officer to seventeen medical officers, nine European nursing sisters, and six European sanitary inspectors where before there had been none, and in addition a fairly highly trained, literate, and efficient African staff of about one thousand strong had been brought into being. The large amount of medical relief now rendered, and the equally large amount of educational work directed toward the improvement of domestic environment now undertaken, is the result of administrative measures to be introduced in 1920-22 (KCP. 1932, p. 2).’

The decentralized system continued from the inception of the colonial health services, and while there were systematic upgrades of the central hospital facilties in cities such as Nairobi and Mombasa, the primary emphasis remained on the expansion of small-scale, rural units, alternatively termed dressing stations, health centers, dispensaries, or clinics, depending on the era and the current vocabulary. As illustrated in Table 1, the professional (i.e. European) staff did not grow significantly during the first half of the century, but the number of centers and patients served grew dramatically. Each dispensary or out-station functioned as a satellite of the closest regional hospital, and each of these hospitals was directed by a European Medical Officer of Health (MOH) who reported directly to the Director of Medical Services in Nairobi.” Most hospitals had only a handful of European staff, and increasingly follwing WWII the mid-level positions were occupied by Africans, even including some African Assistant Medical Officers who had completed medical school training. In 1949 T. Farnsworth Anderson was appointed the Director of Medical Services, after a long career of service in the rural clinics and hospitals. He believed that the medical services should parallel the colonial administration in organization and saw it as odd that the Provincial Commissioner had no counterpart in the Medical Department. As a result, he created the posts of Senior Medical Officer, and assigned one to each province to oversee comprehensive

1706

WORLD

DEVELOPMENT

Table 1. Kenya colony health infrastructureand service delivery” Year

Budget in f

Number out dispensaries

1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1943 1944 1945 1946 1947

177436 126243 126593 134031 178964 198 265 204801 233 506 2.50 834 252061 219357 280 829 319689 362 693 425 287 478019

20 46 62 61 64 68 82 82 82 106 107

Medical staff (European) 39 34 32 40 48 50 61 70 72 66 54 43 51 47 53 58

African & Asian in-patients

African & Asian out-patients

29 676 25718 29051 26039 26915 29 088 35691 35551 31382 92485 112822 124619 145 898 156888

151222 163 278 185448 173 949 189 420 194 686 220 973 252610 261795 604 374 589 963 674 832 796 008 801395

# Out-dispensary visits

Estimated population in millions

110509 185718 153618

534709 646 033 1121292 1033 447 1029 860 1218073 1286 879

3.9

5.3

to have been recorded differently in different years, and/or were reported in different formats depending on who was the Director of Medical Services that prepared the annual report. Some years are missing from the records, and during some of the years during WWI annual reports were either not prepared or were not sent to the repository in London that I consulted. The number of staff reported appears to include only European

“The data appears

Medical Officers, and excludes African and Asian staff, nurses, sanitary inspectors, and other paraprofessionals. Although not included in the table, the funding for and services for the European population was always disproportionately generous. Sources: Kenya Colony and Protectorate Medical Department Annual Reports 1932, 1945, 1947 (Royal Commonwealth Society Collections, Cambridge; Beck, 1981).

health services for their regions (Farnsworth Anderson, 1973, p. 59). The MOH and later Senior Medical Officers participated in meetings of the District Team, an interagency advisory board that determined local development and administrative priorities. This team was headed by the District Commissioner, and might include representatives from the departments of Medicine, Agriculture, Public Works and Education. The District Commissioner held a parallel leadership role in the Local Native Councils and thus was well aware of the concerns and priorities of both European professionals working in this region, and the indigenous leaders. In contrast to the historical pattern of dispersal of health services, Mburu notes that today over half the doctors in public service in Kenya serve in a single large hospital, the Kenyatta National Hospital in Nairobi, where the care is typically perceived by the populace as poor, congested, and inadequate, though highly technical services such as open heart surgery are available (Bijleveld and Varkevisser, 1982, p. 225; Mburu, 1992, p. 422). The population of rural areas are disproportionately undeserved. Beck (1981) notes that following independence in 1963, an administrative philosophy of ‘region-

alism’ gave rise to the continuing dispersal of decision-making authority, but also mandated complete financial support from regional sources, rather than from the central authority of the Ministry of Health. This produced a ‘corresponding decline in quality service in many areas where the expense of rural health centers . . .could not be met by local county councils’ (Beck, 1981, p. 53).

(b) Staff training and interethnic relations From the outset, one of the greatest challenges to the effectiveness of the decentralized medical services was the availability and training of African staff to provide a cadre of capable civil servants able to spearhead educational programs and provide the basics of health care throughout the colony. These decentralized rural clinics had staff of very diverse quality and qualifications, and reports of unreliable staff and those doing yeoman service for little pay appear in roughly equal numbers. The most frequent concern expressed by senior medical staff was the uneven training and supervision of staff in remote centers, which closely mirrors contem-

PRIMARY

HEALTH

CARE

porary concerns (Haddad and Fournier, 1995; McCusker, 1982; Walker, 1995; Woelk, 1994). The decentralized system and classification of positions held by Africans was largely designed by John Gilks, who was Director of Medical Services for much of the 1920s. Posts were created for ‘African Laboratory Assistants,’ Dressers, Native Sanitary Assistants and others, each of which had specific job responsibilities and at least in theory were suitably trained. For example, training of sanitary assistants included information on proper house and latrine construction. techniques for building rat-proof granaries, and furniture building, and were held in the workshops of the Kenya and Uganda Railway, while female dressers were trained in the Native Hospital in Mombasa (KCP, 1928). By 1931 the Jeanes School in Nairobi was established and initiated a two-year curriculum on public health and basic curative medicine that would qualify graduates to be the primary staff members of the dispensaries (KCP. 1931). As years progressed and access to primary and secondary education became more widespread, the qualifications for entry to training and the training regimen itself became more rigorous and demanding. In 1932, the Senior Medical Officer in North Kavirondo, Dr James Neill, described how rural dispensaries should ideally be models of hygienic living, staffed by African dressers who live at the center, and who could provide a screening or triage service for the hospital while treating localized medical problems such as yaws, syphilis, leprosy, and malaria control (KMSR/NH, 1932). Neill’s superior, A. R. Paterson,’ then serving as Director of Medical Services commended the increasingly important role that African staff played in the colonial medical service: Of these factors (that account for improvements in health) by far the most outstanding is the part which the African himself has in the last ten years become able to play and is now playing in the public health service. Today, as hospital assistants, dressers, health workers, dispensers, laboratory assistants, storekeepers and clerks, Africans are rendering increasingly efficient service which ten years ago could not have been rendered at all except by Europeans, or in some cases Asiatics. In 1922 with but few exceptions the African staff was untrained and exceedingly inefficient. Africans were then employed only as dressers and menials, and the standard of nursing service was poor to a degree. Today the standard of nursing by Africans in almost every hospital is, taking everything in consideration, a high one, and as a result the amount of medical and surgical assistance which the medical officer can render is correspondingly greater. Furthermore, as dressers at out dispensaries. as health workers and propagandists, as

IN COLONIAL

KENYA

1707

laboratory workers and as clerks, Africans have provided the medical officer everywhere with hundreds of hands where before he had only two, while in some fields, and particularly in the field of propaganda, the new hands are the more effective

because they are African (KCP, 1932, p. 2). Because the competition for the prestigious posts in the medical services was quite intense, the medical officers were often able to select the best candidates for training, unlike the first generation of African dressers who learned their limited knowledge during WWI after being drafted into the British Army. Training expectations were consistently upgraded from the 1930s through the 195Os, in spite of competition for resources and tight budgets that resulted from the Depression and WWII (MRNKD, 1931; MR/NHK, 1937). In 19.50, the Senior Medical Officer for Nyanza Province advocated the expanded use of village-based women staff: The modern expression of social preventive measures lies in the Health Centre concept, but this edifice is likely to degenerate into enlarged out-patient departments of hospitals unless the domestic investigtaions press their usefulness. With the African mind always returning to repetitive curative work, and despite the practice in the United Kingdom whereby the Health Visitor is firstly a trained nurse, a cadre of ‘health visitors’ must be established with no curative knowledge, but a knowledge of healthy living only.. Women are best adapted to the duties of Health Visiting, and if they are trained by a qualified Nurse,. the proper touch will be given.. .(upon certification, they) are posted to their homes and work within easy distance of the home and Health Centre.. such peaceful penetration will touch the womenfolk intimately (SMOIN, 1950).

The employment of African women in midwifery at hospitals was well established by this time, as a midwifery training program had opened in 1935 at the Lady Grigg Maternity Centre in Nairobi, but there was always a more acute shortage of skilled women staff than of males. This shortage of trained women was lamented routinely by European officers at all levels of the health services, and was attributed to the deeply ingrained traditional role of women in Kenyan cultures. The bias against female education resulted in few females attaining the minimal literacy and educational prerequisites compared with males. Those who received sufficient education were often daughters of chiefs or civil servants, and their relatively prominent families were often loath to relinquish supervision of their daughters for a two- or three-year period while they enrolled in residential training programs, hence the numbers of qualified appli-

1708

WORLD

DEVELOPMENT

cants was always short of the goal (Holden, 1984; KCP, 1947; Robertson, 1993; Turshen, 1984, p. 165). After the late 1940s greater efforts were made to incorporate women into the staff. Some of the most menial positions that women had occupied (sweepers who assisted with bedpans) were abolished and these tasks incorporated into the job descriptions of more skilled staff such as trained nurses. The women trainees were house in a proper compound with pleasant accommodations at the Mary Griffiin Nurses Home and a European supervisor was resident who served as a chaperone to allay fears of the women’s parents at home. The trainees were dressed in pink uniforms, and upon completion of their training were graduated as Assistant Nurses Grade I, many of whom later qualified as registered nurses and were permitted to pursue advanced training in midwifery (Farnsworth Anderson, 1973, p. 68). A European nurse and supervisor who worked closely with many trained African midwives gave strong praise for their abilities. Robertson notes that these midwives had a deep sense of mission and were highly valued by the women they assisted (especially in the Muslim coastal areas where sexual segregation prevented women from seeking help from male professionals). The midwives frequently dealt with the most complicated cases as the majority of women delivered their babies at home and only came to the health center or hospital when the labor was accompanied by serious complications (Robertson, 1993; see also Holden, 1984). The efficiency and important contributions of the African staff are noted routinely in monthly reports by Medical Officers in Charge, as they worked directly with the African staff and so were able to observe their abilities daily (MR/NHK, 1937; MR/‘NKD, 1931; MR/NHSN, 1949). The Medical Officers frequently lamented the fact that they were unable with their limited budget to provide more advanced training to their most competent staff, or upgrades of their housing and other support.* They lived in close proximity to their African staff, so while informal interactions in friendship would have been unlikely given the rigid class system, they perceived themselves as knowledgeable about the lives of their staff: Though they are all good fellows, the presence of the staff is something of a blister. They live - in some cases together with their families - in and near the European compounds. Their poultry make gardening virtually impossible,. . and their gramophone records lack variety (IHC/MR, 1953).

While they seem quick to praise staff whose contributions merit notice, those European officers who directly supervised African staff were also quick to complain about a staff member who they perceived as lazy, untrustworthy, corrupt, poor at record-keeping, or whose personal accommodations did not meet the standard of hygiene expected of Medical Department staff (MRHUNN, 1953; KMSR/NH, 1932; SMOICK, 1940; SMO/N, 1932). Contemporary research on efficacy of Primary Health Care staff would surely avoid such personal and paternalistic judgments, however, similar statements about professional performance are often expressed. Recent studies have noted problems when health workers demonstrate attitudes of superiority (Bijleveld and 1982; McCusker, 1982) lack Varkevisser, empathy (Haddad and Fournier, 1995, p. 748; Walker, 1995, p. 819) or when there are conflicts exhibited between staff (Walker, 1995; Woelk, 1994, p. 1030). While the vocabulary used is more professional and appropriate, the concerns about staff training, supervision, adherence to policy, and performance persist. (c) Preventive medicine (i) Medical safaris One of the keys to the effective administration of preventive medicine care was the routine medical safaris that would visit remote communities to perform diagnostic and curative services, for immunization campaigns, screening of tropical illnesses, and public health education. Members of the medical department at all levels were obligated to conduct these safaris, revisiting locations on a monthly rotation which gave them an intimate knowledge of the problems and conditions in their constituencies, and dramatically increased the number of indigenous people who were able to capitalize on health services (Gann and Duignan, 1978, pp. 223, 205; Robertson, 1993). In early years and in very remote districts these safaris were conducted on foot with porters carrying supplies, including enough tents and camping equipment that the health team created a small village in each location where they encamped. Although spending about 25-30% of working time on safaris was the norm (Gann and Duignan, 1978, p. 223; Holden, 1984) Farnsworth Anderson reports that about half his time was spent on safari, and each medical officer was allowed twenty porter-loads of personal belongings which included the tent, which was four loads, as well as four boxes of medical supplies. The loads

PRIMARY

HEALTH

CARE

were carried on the heads of the porters who were provided, as required, by the local chief and paid by the Government.. The morning after getting into camp I used to hold a clinic and sometimes as many as a hundred patients would turn up. After clinic I generally had a haraza (open meeting) and talked to the people in Swahili, interpreted into KiTeita, about prevalent disease, general intestinal worms and how to prevent them. The method of prevention was to dig pit latrines and the reason for this was explained and illustrated by a demonstration of roundworm eggs under the microscope. This was always a popular entertainment and the people queued up to take their turn to have a look. In the Teita Hills there was a very high incidence of ascaris or roundworm, higher than I have met with anywhere. I well remember examining the labourers on Wundanyi, the one and only coffee farm in the place. There were 96 of them and 94 were positive. The active prosecution of latrine campaigns in districts heavily infested with intestinal worms was the idea of Dr Paterson. who was Deputy Director of Sanitary Services, and as much was responsible for the public health and preventive medical services. It was due to his teaching and influence that we in the Medical

Service came to realise the importance of preventive medicine amongst primitive people (Farnsworth Anderson, 1973, p. 24). In later years the duration of these safaris was decreased by the use of motorized vehicles to aid transportation, and these continued through WWII even at times of severe fuel shortage. The commitment to maintaining the schedule of safaris appears to have remained a high priority, as even the constraints presented by the Depression and WWII did not eliminate this practice, in the earlier years of the decade, keeness for the real work of the reserves became ever more notable as the opportunity to ascertain the needs of the people in rural areas, and to perform work efficiently, increased and the habit of travelling was then well established. It is to the lasting credit of the staff of medical officers and sanitary inspectors that in the period of depression when the financial provision for travelling became entirely inadequate to meet the needs of the districts, and incomes as well as allowances had been reduced, no officers reduced the amount of their travelling opportunity, but all without exception continued to the utmost extent that they could afford to carry on their work at their own expense (KCP, 1932, p. 7).

In 193 I, the Medical Officer in Charge for North Kavirondo (now Kakamega District) reported that sufa~is were completed for all but 2 months of the year, though there were many difficulties in obtaining vehicles. Of the 11 dispensaries in the district, all were visited at least every other month, most monthly, and they saw 116069 cases in the year. Dr Farnsworth Anderson noted that they did impromptu visits to additional locations without dispensaries,

IN COLONIAL

KENYA

1709

increasing the patient load by 7836 and he noted that by combining hospital services with remote clinics, they had served over 75000 people that year, representing about 20% of the total district population (MR/NKD, 1931). These mobile visits continued throughout the colonial period, both for routine service delivery, and in response to outbreaks (or reported outbreaks)’ of plague, human trypanosomiasis, malaria, schistosomiasis, etc. Farnsworth Anderson became the Director of Medical Services in 1950 and reports on new initiatives to increase the efficacy of the medical sufauis. He had been long persuaded of the importance of this strategy as the safaris and health centers had originally been envisioned as a means to take pressure off the hospitals, but they also consequently brought ‘the benefits of modern medicine closer to the patients and their homes.‘. Full mobile dispensaries were set up in well-equipped Land Rovers to reach densely populated, but undeserved areas and for use in situations of emergency (KCP, 1955). Many of the safari logs that were obligatory for the medical staff and District Officers took on a rather formulaic style, but it is clear that these trips provided meaningful opportunities for public inspections of health and sanitation facilities (ubuttoirs, public latrines, marketplaces), conditions affecting school children, and an opportunity for discussion and health education (DOISN, 1949-50). Efforts at adult education, largely through the ‘Ladies Homecraft’ clubs and buruzns (town meetings) were commonplace. In the buruzus, held while on medical safaris or when any administrative staff visited rural locales, presentations were made in Kiswahili and often translated into local languages, and provided an opportunity for health education and questions and answers to be discussed. These buruzas might deal with topics as diverse as the proper design of pit latrines to the issuance of identity cards, but were from the point of view of the Europeans in attendance, an opportunity for dialog and debate.“’ The equivalent practice in contemporary Primary Health Care are mobile clinics. These are promoted as a means to serve people who live at a distance from formal health care centers, without the expense of building and staffing permanent facilities. Maintaining routine schedules for mobile clinic visits is often a problem today, as access to vehicles, fuel, willing staff, and necessary supplies are often absent (Woelk, 1994, p. 1032). Inconsistent visits can have serious consequences, such as promoting

1710

WORLD DEVELOPMENT

drug resistance (Bijleveld and Varkevisser, 1982, p. 22.5) contributing to incomplete immunization coverage and hence child mortality (Brockerhoff and Derose, 1996) and undermining public confidence in the reliability of health services.

(ii) Health sutveys Two important components of preventive health care that were common from the 1930s both through safaris and out-dispensary visits, health-screening were and immunization campaigns. The lack of reliable national census figures and the complexity of conducting systematic health screening on a national level made the administration of local-level surveys an important tool for medical officers. The results of their surveys provided them with both a greater understanding of the degree to which various health problems affected their constituto their pleas for ency, and gave weight additional support from the central medical authorities. Although it was not a primary goal, some of these health surveys also effectively represent the first important research in tropical medicine in Africa, and the results were reported in professional medical proceedings. For example, early accounts of drug-resistant malaria and descriptions of techniques for treating anemia through reducing parasite loads resulted from the routine medical surveys conducted by medical officers serving in rural areas (SNAR, 1954). Clearly many of the European medical officers were deeply moved by the extent of which tropical illnesses plagued the rural populace, and they remained committed to alleviating suffering to the extent they were able. While some of the musings I have read lament the backwardness and resistance to change that they perceived in the Africans, others were remarkably sympathetic and seemed committed to improving standards of living and addressing the endemic diseases that were so problematic. These empathetic statements were most commonly expressed by Medical Officers, whose training in alleviating human suffering perhaps better prepared them for an open attitude toward Africans than staff in other colonial offices. For example, in 19.59, Dr J. Reidy, the Provincial Medical Officer wrote a sarcastic and in many ways brilliant criticism of a senior official in the Ministry of Agriculture in response to complaints that the doctors were overly concerned about the potential fluorescence of mosquitos posed by plans for fish pond construction. The agricultural official argued this energy was misplaced as the ‘medicos’ should be focusing on the real problem

of bed bugs that put Europeans who have resident African domestic staff at risk. Dr Reidy developed a coherent description of the likely epidemiology of the spread of mosquitoes (and hence malaria) in the proposed fish pond, and noted that: As the disease becomes established the development of immunity would result in a declining mortality rate, and even though the people would rarely react severely to the presence of the parasites in their bodies, they would be grossly anaemic like the Luos now living in the Kano Plain (an area of expansive Asian owned sugar plantations), who never know what it is like to feel well from the day they are born, to the day the die.. Dr Ouko, the Medical Officer of Health, Central Nyanza, recently examined two groups of people...(and he) found that over 60% were suffering from Bilharzia (schistosomiasis). It is therefore obvious that in those localities where both Biharzia and malaria are endemic, they are causing far more misery, suffering, and wretchedness than was ever caused by the waves of Plague, Cholera, and Smallpox which swept England before, during and after the Industrial Revolution. They are considered to be largely responsible for an infantile mortality rate of 400 in the affected regions. This means that out of every thousand children who are born, four hundred die before reaching one year of age. I doubt very much if bed bugs could cause a single death (PMO/N, 1959). Their surveys validated their observations about the extent of ill-health among Africans by providing an empirical understanding of the frequency and severity of many ailments. In surveys of fecal samples to test for parasites, Dr Neil1 found that more than half of the 3000 samples screened in 1931 were positive (KMSR/ NH, 1932) and in western Kenya Dr J. J. HarleyMason reported in 1932 that 17.4% of 1316 tested were positive for malaria, 9.3% (n = 150) for human trypanosomiasis, 100% of the 53 sampled for schistosomiasis, 16 of 94 sputum samples were positive for TB (17.0%), and of 1199 fecal exams 943 or 78.6% were positive for one or more parasites (K&SKMR/NH, 1932). Another study undertaken in 1948 sought to compare rates of TB endemicity with nutritional status and rates of mortality, so they could better understand the negative synergism of disease and malnutrition (KCP, 1949; see also MRMO/K, 1940). Then as now, many indigenous people lived with overwhelming daily challenges to their health and well-being and this was a sincere concern for the medical department staff. As with contemporary programs, maintaining a research component is essential to monitor the efficacy of program interventions, as well as to develop and test new treatment regimens

PRIMARY HEALTH CARE IN COLONIAL KENYA

(Brockerhoff

and Derose,

1996; den Besten et 1995).

al., 199.5; Haddad and Foumier,

(iii) Immunization campaigns From the 1930s the widespread use of immunization to prevent the spread of disease was an important strategy. In the early years plague and smallpox were targeted, and later on they also other vaccines were developed, addressed tuberculosis and polio. In early years immunization campaigns met with resistance (Castro, 1997; Vaughan, 1994) and people sometimes hid their children to prevent inoculation. The efficacy of the smallpox vaccine to prevent this dramatic and often fatal disease became well-established, and the curative power of the sinduno (needle) to treat yaws and other pernicious problems quelled much of the opposition (see Lyons, 1994). Reports of medical officers in the 1930s include statistics on numbers of smallpox immunizations, and the difficulties of conducting immunization campaigns due to the need to keep the vaccines cold, problems mobilizing the necessary staff, or dealing with uncooperative local chiefs. It appears that rather than conducting routine, scheduled immunization drives, inoculation campaigns were carried out in response to reported cases of a disease. For example, in 1930 a smallpox outbreak in Mombasa resulted in the compulsory vaccination or revaccination of the entire population of the city, and ‘in less than a fortnight, over seventy thousand persons were vaccinated, and after the end of February, no further cases were reported’ (KCP, 1930, p. 20). In 1946, the report of the District Medical Officer of Kericho District reported that in response to the 104 documented cases of smallpox (that produced nearly 30% mortality), they initiated an immunization campaign and gave 70000 inoculations (DMO/K, 1946). Another outbreak of smallpox in 1949 warranted an even greater response; the Senior Medical Officer for Nyanza Province, reported that they had immunized 45000 people in Kisumu town, 426445 in Central Nyanza (from a population estimated at 461772) and in South Nyanza 633460 (a number larger than what the then current census projected as the population). No mass immunizations were warranted in the northern part of the province as it has previously been covered, and selective immunization focused only on those who lacked an immunization scar (SMON, 1949). Whether we have a complete trust in census or medical statistics from this era or not, it appears that there was a concerted and effective mass immunization

1711

program, even in this relatively remote province that is only unevenly served by the health infrastructure today. As time progressed, the medical service increasingly tried to conduct systematic immunizwith and ation campaigns, vaccination re-vaccination on a schedule rather than in response to outbreaks. Toward this end over 1.4 million people were immunized against smallpox between 1940-45 (despite WWII), but this goal of universal immunization coverage appears never to have been fully accomplished (KCP, 1945, p. 20). In the late 1950s in response to the outbreak of polio in the lush agricultural areas north of Nairobi, an emergency immunization of 60000 children with Sabin oral vaccine was conducted, while they laid the foundation for a national oral polio campaign for the nation (KCP, 1959, p. 17). In 1960 another polio outbreak in South Nyanza District (39 documented cases) resulted in the administration of 152101 Sabin oral immunizations (DC/SN, 1960). By the 1950s BCG immunization against tuberculosis was common, as well as typhoid in areas where it was a significant risk (MRHA/H, 1954). Vaccines were manufactured in laboratories in Nairobi, in cooperation with the Insect Borne Diseases Division (Farnsworth Anderson, 1973) and were shipped all over Africa as the need arose. In addition, they collaborated with a similar laboratory in Dar es Salaam where a vacuum flask packed with ice, salt, and sawdust was developed for transporting fragile vaccines while maintaining the cold chain (Clearkin, n.d.). Since the Alma Ata Convention, major interhealth organizations, especially national UNICEF, have made expanded immunization coverage the linchpin of service improvement strategies, because of the essential function of childhood immunization in reducing child mortality. UNICEF has provided portable propane fueled freezers and vaccine carriers to maintain the cold chain, and subsidized serum for thousands of localized programs in Africa. (iv) Sanitation, vector control, and public health education Improved sanitation was aggressively pursued as one of the keys to an effective preventive care system, especially in the population and market centers. The centrality of sanitation improvements as a means to address pernicious health problems is well established, but actions taken under the guise of sanitation campaigns often met with resistance. Obligatory brush clearing, burning of thatch houses that were badly infested

1712

WORLD

DEVELOPMENT

with plague carrying fleas, and penalties imposed by sanitary inspectors for violations of regulations were all opposed by locals (Vaughan, 1994). Yet despite the unpopularity of these in sanitation actions, seeking improvements remained a central mission (MRMO/Ksi, 1940; SI/CK, 1932).” As part of their efforts, subsidized concrete latrine slabs were available for purchase, sanitary inspectors supervised the abattoirs and public latrines, inspected shops and marketplaces for cleanliness and issued citations for violations. Model granaries, storehouses, livestock sheds, and houses were constructed to provide ‘examples’ of healthful living quarters, and demonstrations were included at the agricultural fairs. The colonial medical services trained a variety of sanitation assitants, including water jimdis (technicians) who were trained to line water sources with concrete and deter livestock from water points, and ‘rat boys’ who were paid to trap rats and periodically screen for plague outbreaks. The pursuit of vermin appears to have been a relentless goal from the 1920s and records the number of rats exterminated by staff were included in the monthly and quarterly reports of each dispensary and health center. These figures were sometimes summarized in annual reports such as in the case when the DMS noted that 1.8 million rats had been exterminated in the previous year (KMSRNH, 1932; 1953; Bolton, 1975; see also MRHI/NN, Vaughan, 1994, p. 187). It appears that two outcomes were considered evidence of the effectiveness of the vermin control staff, either the absence of any cases of bubonic plague, or an increase in the number of rats killed over previous months. Effective rat catchers were commended, those who did not produce adequate evidence of their diligence were criticized: Until better methods of inspection can be devised, I see no benefit in the records. The records of rats caught by our ratcatcher, I frankly do not believe are true.. .From his method of approach to the work I believe the only rats he can ever catch are those who voluntarily sacrifice themselves (IHCIMR, 19.53). One one occasion one of the senior medical officers used the carcasses of rats captured by the rat catcher to play a joke on his superior. A. R. Paterson, who was then Director of Medical and Sanitary Services, was described by the rank and file as being quite formal and humorless, Dr Paddy Clearkin took the rat carcasses captured by his staff and draped them over a huge termite hill such as are commonly found in semi-arid regions of Kenya, and had his photograph taken

to it, giving the illusion that they had caught a veritable mountain of rats. Apparently Paterson did not recognize this photo as bogus and carried it around the colony for months exhorting Clearkin’s peers to emulate his success (Clearkin, n.d., p. 146). Indigenous staff and community mobilization efforts were both directed at routine insect vector control, both through spraying of pesticides such as ‘Paris Green’ and DDT, and through drainage and oiling of standing water pools (Bolton, 1975; Clearkin, n.d.; KCP, 1928; KCP, 1931; KCP, 1935; KCP, 1945; KCP, 1947; KCP, 1959). In addition, periodic screenings for malaria were conducted by screening blood samples or palpating spleens for malaria were conducted to learn about the frequency and endemicity of the disease. It was through this research that many health professionals came to understand that in areas of high endemicity, over 90% of the adult population may harbor the malaria parasite, though the outbreaks are periodic. Increases of cases of clinical illness among adults often correlated with seasons of extreme work, malnutrition, secondary infections, and poor living conditions, thus providing clues as to how to reduce the severity of outbreaks (Farnsworth Anderson, 1973; Beck, 1981). Malaria was and continues to be an intractable public health problem in Kenya, but in the cases of two other localized insect-borne diseases, the vector control strategies that the colonial medical service pursued were effective. In reflecting on his career as Director of Medical Services in the early 195Os, Farnsworth Anderson notes two of the significant accomplishments he saw in his career were the eradication of the simulium fly in western Kenya, and hence the elimination of onchocerciasis (River Blindness) and the elimination of the Aedes mosquito on the Kenya coast, which eradicated the source of yellow fever (Farnsworth Anderson, 1973). By the time Kenya gained independence, the colonial medical services had eradicated or nearly eliminated cholera, plague, typhus, onchocerciasis, and relapsing fever (Beck, 1981, p. 51) all of which represent significant accomplishments. Malaria was never effectively controlled during the colonial period (nor after), nor were efforts to control human trypanosomiasis through tsetse fly spraying and bush clearing. next

4. DISCUSSION

AND CONCLUSION

There are many examples in the archival literature that support my contention that aspects of the colonial medical system were

PRIMARY

HEALTH

CARE

precursors of the policies now current in Primary Health Care. In his memoirs, a former District Medical Officer and Director of Medical Services wrote, Six and half years after I retired, Kenya gained its independence. We were always led to believe that it was government policy that the local people, white and black, would get self-government of some sort of multi-racial basis eventually, but nobody thought it would happen in our generation. However at the time I left, and presumably at independence, we handed over a first class medical service. Morale was high, discipline was good, and there was a spirit of disinterested service. There is unfortunately a feeling amongst many British people, especially those who have never been abroad, that there is something to be ashamed of in our Colonial past. This comes of our well known habit of belittling our achievements. But I have seen the Colonial Service from the inside for thirty years, and I can assure the doubters that if ever the British people had reason to be proud, it is of their Colonial record. I hope that one day this will be generally recognized (Farnsworth Anderson, 1973).

While it is important not to overstate the accomplishments of the Colonial medical service, nor to ignore the fundamentally exploitative nature of the colonial enterprise, there is truth in Farnsworth Anderson’s expression of pride in the achievements of the Medical Service. There remain intractable problems that were not solved or even diminished by their efforts (notably malaria and childhood mortality), but there were also significant advances and lessons that should be retained by this generation of policy makers and practitioners. The administrators at the provincial and district level had a fair degree of autonomy to establish policies that they believed would be most appropriate for their area, and they made compelling cases based on ground truth in their reports to their superiors. They were very familiar with the rural conditions of endemic disease, poor sanitation, and marginal nutrition that fostered the sicknesses that they witnessed. They understood the ultimate solution, and perhaps the only cost-effective strategy, was to promote public health education, community based health screening and treatment, immunization, and comprehensive sanitation improvements to mitigate the problems they faced. As noted by one Senior Medical Officer in 1949, after describing a long litany of health problems treated in the previous year, ‘This incredible bill of ill health illustrates the need of preventative services adequately. Almost every second person in the district (South Nyanza) attended once for ill health’ (SMO/N, 1949). The model of

IN COLONIAL

KENYA

1713

decentralized health care focused on the prevention of disease, staffing by paraprofessionals, and a strong emphasis on the etiology of illnesses all of which proved to be reasonably effective means to address the needs of the masses with limited professional staff and resources. The communitybased systems were responsive to change and local conditions, and by training and equipping local people for work in the health services they promoted dedication and service, as the staff served their own communities. Through experimentation and research, they pioneered many treatments and methods of prevention that were revolutionary for their time. They were the first to discover the efficacy of sulpha drugs for the treatment of pneumonia, they documented the antagonistic reaction between malnutrition, intestinal parasites, and anemia, they demonstrated that ‘bonification’ or draining and control of standing water would significantly reduce the mosquito population, and hence aid in the control of malaria (Curtin, 1992). They promoted hygienic birthing conditions and reduced the incidence of deaths from neonatal tetanus. They immunized millions of Africans to prevent the scourges of smallpox, bubonic plague, polio, and other preventable diseases (in many cases the statistics they record suggest that they achieved considerably higher rates of immunization coverage than what we find today). They initiated the village-based management of both tuberculosis and leprosy, diseases that require long courses of treatment and that had formerly depended on sanitariums or colonies that separated patients from their families for years (Bijleveld and Varkevisser, 1982). They educated local people and committed staff resources to the goal of protecting drinking water supplies, and improving access to sanitation in villages. While their successes were often short of their overall goals, they still provide a model of cost-effective health care delivery, and appear as successful, if not more so, at improving Kenyan’s health than the contemporary medical systems. The most serious problems that they encountered persist today. They repeatedly called for more staff, and African staff with advanced training, so that they could deal with routine medical problems in the rural dispensaries and Health Centers. They advocated midwifery and ‘homecraft’ training for women staff, improved understanding of the etiology of disease as well as curative regimens for all staff. Although they were not at all hesitant to label African staff as incompetent when they believed the charge warranted, they were quick to praise dedicated,

1714

WORLD DEVELOPMENT

conscientious, independent African staff who managed to provide important services with little logistical support or training. They routinely decried the problems of inadequate financial support to address the crushing health problems they witnessed. Some health problems are little improved since the colonial period, such as water-borne parasites; others are new problems or exacerbated from earlier years, as in the case of the emergence of AIDS and the spread of drugresistant malaria. The failure of the Colonial Medical Service to make progress on these pernicious problems is not surprising as the billions spent and thousands of hours expended in the succeeding 30 years have similarly failed to make dramatic inroads. The oft-quoted homily about those who forget the past being condemned to repeat it bears consideration in this case. In this instance, the failure to adequately review and analyze the strategies employed in the colonial period has meant that we failed to learn the often positive consequences of actions taken by our predecessors. Our failure is a result of the natural inclina-

tion to reinvent

society in the euphoria that accompanies liberation and independence, but we appear to have thrown the good out with the bad in our wholesale rejection of the colonial legacy. Perhaps the two most important lessons to draw from this case study concern the specific strategies associated with Primary Health Care, and the egalitarian ideology that promotes this approach. First, the legacy of the colonial medical service demonstrates that the emphasis on decentralized preventive health services is the most viable and cost-effective means to promote improvements in health in developing countries. Second, while the promotion of universal access to health care and a system based on social equality are appropriate and worthy goals, the absence of true egalitarianism should not be an

excuse for failing to promote Primary Health Care. The colonial system by definition was inequitable and exploitative, yet within this rigid hierarchical system it was still possible to implement many programs that were consistent with PHC strategies, and to achieve many of the goals of the ‘modern’ system of Primary Health Care.

NOTES 1. Sporadic efforts to address the health of Africans did occur prior to the 192Os, especially in response to waves of human trypanosomiasis at the turn of the century (Lyons, 1994) and the worldwide influenza epidemic of 1918. The majority of systematic health services in Kenya during the first two decades of colonial rule were provided by mission hospitals and clinics that were established at this time. 2. The emphasis on preventive versus curative care did not necessarily reflect the preferences of Africans, especially those who held office in the Local Native Councils. The efficacy of Western medicines (especially the dramatic improvements that followed injections, or sinduno) produced a high demand for curative care, whether or not ran injection or medicine would be effective. Unlike efforts to promote sanitation or inculcate changes in behaviors, curative medicine was quickly and easily accepted by most Africans, and continued to be utilized, as well as the services of traditional healers who were also consulted by indigenous people. 3. This is not to imply that colonial medical services in the Kenya colony were provided for the African population only in areas of the country with substantial European settlement, indeed, the services were quite well distributed, and this situation appears unique in the British colonies of East Africa. Turshen (1984) has written a thorough evaluation of the failure of the colonial medical service in neighboring Tanganyika to effect any improvement in the health of the common

people. Beck (1981) and McCusker (1982) report that there was little emphasis on the expansion of decentralized services, preventive care, or integration of medical and sanitary programs from the earliest colonial medical services in Tanganyika. The greatly dispersed population, the absence of European settler population, an emphasis on large-scale, capital-intensive development projects (such as ports and railroads), and a relatively late entry into the administration of the Tanganyika Territory (after WWI) all contributed to the markedly different policies than those found in Kenya. Turshen notes that in 1949 the Tanganyika Territory Legislative Council ‘decided to continue to concentrate resources on curative services. While acknowledging the more lasting benefits of prevention and social medicine, the council rationalized its decision of the grounds that curative medicine was demanded by the people’ (Turshen, 1984, p. 144). Vaughan (1994) describes a similar situation in Nyasaland (now Malawi) in which medical services administered by the colonial administration ignored ‘preventive medicine and health education for the magic bullets of medical science’ (Vaughan, 1994, p. 183). Mission health services in Nyasaland, she argues, were inextricably linked with induced ideological change and thus ideas about treatment of disease were associated with moral positions. Lyons contrasts the use of medical auxiliaries or African paraprofessionals in British Uganda with the Belgian Congo (now Zaire) (Lyons, 1994). The Belgians are often criticized for failing to provide

PRIMARY

HEALTH

CARE

opportunities for higher education resulting in the total absence of trained African doctors at the time of independence, whereas Uganda was the home of the well-regarded medical school at Makerere University. The Belgians, however, did dramatically expand the use of African auxiliaries to a far greater degree than was typical in the British colonies, and at independence thousands of trained [email protected] sustained the health care system through difficult times and thus ‘unintcntionally bequeathed to the Zaireans the advantages of an extensive primary health care infrastructure’ (Lyons, 1994, p. 223). 4. As the years went by an a class of more prosperous middle-class Africans emerged, they sometimes sought and paid for private medical care. Throughout this period Africans continued to consult indigenous healers and occasionally charlatans who illegally practiced an imitation of Western medicine, such as administering injections of bogus drugs. When these imposters were caught they were prosecuted. In I951 the colonial medical service began discussing the imposition of fees for select services. Shortly thereafter they instituted a fee for in-hospital births (‘confincments’) and in the mid-1950s a few additional services such as X-rays were sometimes charged. Routine preventive care (such as well-baby clinics and immunizations) and most curative services continued to be available free to the user through the end of the colonial period in 1963. This provides an interesting the fee contrast to recovery recommendations promoted in the Bamako Initiative. 5. The earliest African staff were carryovers from among the men drafted for the Army in WWI. They received minimal on the job training while in service as ‘dressers’ (literally deriving from their responsibilities to change dressings), or stretcher bearers, known as the Carrier Corps (a.k.a. Kariokor). Hence their abilities to deal with the ubiquitous problems found in rural villages was very limited. h. In the course of the colonial period the titles of staff changed repeatedly, from the director to the lowest member of staff. For example, the head of the medical service was called the Principle Medical Officer (PMO), Director of Medical and Sanitary Services (DMSS), and the Director of Medical Services (DMS). To add to the confusion, the same acronyms had different meanings at different periods, PM0 was also at one time a Provincial Medical Officer, the highest ranking African staff were known as African Assistant Medical Officers (AAMO) or later Assistant Medical Officers (AMO). See Patterson (1981, p. 1 I) for a discussion of comparable changes in terminology in Ghana. To minimize confusion, I have referred to the head of the health services as the DMS throughout the paper. 7. Many of the same names reappear throughout this as the staff of the Medical Division was paper. relatively small, and those responsible for much of the written records had long careers in the Medical services. In some cases there are veiled disagreements between professionals in their memos and correspondence, in many cases they express admiration for each

IN COLONIAL

KENYA

1715

other’s contributions and wisdom. For example, John Gilks is praised for establishing the structure of the colonial medical system and his successor, Paterson, was responsible for emphasizing sanitation and preventive medicine ov’er curative cam. Yet both of these men are disparaged hy another physician, P. A. Clearkin, who said that Paterson was humorless and plodding and he makes many disparaging remarks about Gilks who he said was weak and too concerned with appcarantes, so that when a botched diagnosis and poor surgical techniques resulted in the death of the Governor, Gilks (who had assisted in the surgery) covered up the fact that the head surgeon was a known drug addict (Clear-kin. nd.). X. They complained that their hudgets were inadcquate for other needs as well. They wanted to replace outdated latrines with water closets, buy X-ray machines and lab equipment, have more reliable petrol and vehicle access in short. like developmental programs today - there was always too little money to meet all programmatic needs. 9. The archives also contain numerous records of panics in local communities that necessitated visits and screening by the medical staff. In some cases it appears that indigenous political leaders, chiefs and members of the Local Native Councils used these events to attract attention to their communities, and often wrote incendiary descr-iptions of the devastation they wcrc facing. The medical hierarchy invariably responded with an investigation, and as often as not. it appears that the scare was unfounded and the clinical tests indicated prohlems other than the one reported by the local lcadcrs (SMO/N. 194.3; PC/N, 1949). IO. While the European staff perceived htrrclztr, as very participatory. this sentiment may welt not have been shared by the Africans attending thcsc events. In my work in the 19XOs I attended many hrrrrrw.t at which important information or directives were shared with those in attendance. The leaders of the harcrza often expressed satisfaction with the receptiveness of the crowd, while as an ohscrver in the audience I often perceived them a\ disinterested and unmoved. this rcsistancc to I I. Perhaps ironically I encountcrcd sanitation improvements in my own work with UNICEF in the mid-l9XOs. My baseline study of Mbita Division, South Nyanza demonstrated that in the rural areas that comprise most of the Division, (,I)-XOQ of the households had no latrine facilities. Periodically the Ministry of Health sent out directives instructing local officials to ensure that the entire populace under their administration had some sanitation facilities, and the Chiefs would duly direct everyone to build a latrine or c/zoo or face punishment. Local people found carthen floored latrines ohjcctionahle (snakes can hide there, they smell. there arc Ilies) and local customs dictated that men and women should not perform hase bodily functions in the same place. Consequently many people satisfied the letter of the law by building a small hut on their compound (though often did not include the pit

1716

WORLD DEVELOPMENT

in the construction) so that when the chief strolled by he would see the hut as evidence of their compliance

with his directives, hence these mock-latrines jokingingly referred to as the ‘chiefs choo.’

were

REFERENCES Beck, A. (1981) Medicine, Tradition and Development in Kenya and Tanzania, 1920-1970. Crossroads Press, Waltham, MA. Bijleveld, I. and Varkevisser, C. M. (1982) Leprosy control in east Africa: medicalization in developing countries. In The Use and Abuse of Medicine, ed. M. deVries, R. L. Berg and M. Lipkin, Jr. Praeger Publishers, New York, pp. 224-234. Bolton, H. L. (1975) A Life in Agrica: Memoirs of H. L. Bolton, unpublished manuscript, Rhodes House MSS Afr. s. 1571. Brockerhoff, M. and Derose, L. F. (1996) Child survival in east Africa: the impact of preventive health care. World Development 24(12), 1841-1857. Castro, A. H. P. (1997) Personal communication. Chaiken, M. S. (1988) Anthropology, nutrition and the design of a health intervention in Western Kenya. In Anthropology of Development and Change in East Africa, ed. D. B. Brokensha and P. Little, pp.

237-250. Westview Press, Boulder, CO. Chaiken, M. S. (1990) Participatory development and African women: a case study from Western Kenya. In Social Change and Applied Anthropology: Essays in Honor of David W Brokensha..ed. M. S. Chaiken and A. K. Fleuret, pp. 84-98. Westview Press, Boulder, co. Clearkin, P. A. (n.d.) Ramblings and Recollections of a Colonial Doctor; 1913-1958, unpublished manuscript in 3 volumes at Rhodes House, MSS Brit. Emp. R.411-3. Conelly, W. T. and Chaiken, M. S. (1987) Land, labor and livestock: impact of intense population pressure on nutrition in western Kenya. Paper presented at Association Anthropological the American Meetings, Chicago, IL. Conelly, W. and Chaiken, M. S. (1993) Inequality and gender in the control of resources in agro-pastoral systems: the Luo and Luhya of western Kenya. Paper presented at the Meetings of the Association of Women in Development, Washington, DC. Curtin, P. D. (1992) Medical knowledge and urban planning in colonial tropical Africa. In Social Basis of Health and Healing in Ajiica, ed. S. Feierman and J. M. Janzen, pp. 235-255. University of California Press, Berkeley, CA. DC/SN (196) District Commissioner/South Nyanza. Annual Report, South Nyanza District 1960, KNA AR 1434 KSIi22 AR 1960. den Besten, L., Bat, M., Glatthaar, I. I. and Walker, A. R. P. (1995) Changes in the anthropometric status of rural African under-fives during a decade of primary health care. Journal of Tropical Medicine and Hygiene 98,361-366.

DMO/K (1946) District Medical OfficerKericho, District Annual Medical and Sanitary Report 1946, KNA 3/622 Pub 4/2/8 Deposit 3 Box 10.

DO/SN (1949-50) District Officer/South Nyanza, Safari Reports, unpublished documents, Rhodes House MSS Afr. S 852. Farnsworth Anderson, T. (1973) Reminiscences Books I & 2. Unpublished manuscript at Rhodes House Mss Afr. S 1653. Gann, L. H. and Duignan, P. (1978) Rulers of British Africa, 1870-1914. Croom Helm, London. Haddad, S. and Fournier, P. (1995) Quality, cost and utilization of health services in developing countries. A longitudinal study in Zaire. Social Science and Medicine 40(6), 743-753.

Hailey, Lord M. (1970) Colonial government through indirect rule: the British model. In The Africa Reader: Colonial Africa, ed. W. Cartey and M. Kilson, pp. 94-101. Vintage Books, New York. Hannigan, A. St. J. J. (1958) What is Local Govemment? A Study of Local Government in Kenya and England. Eagle Press of the East African Literature

Bureau, Kampala and Nairobi, Royal Commonwealth Society Ref. No. -46m. Holden, P. (1984) Nursing Sisters in Nigeria, Uganda, 1929-1978. Oxford Development Tanganyika, Records Project, No. 18, Rhodes House Library, Oxford. IHC/MR (1953) Itesio Health CentreiMonthly Report July 1953, KNA Box 11 31362 (PH. 6/l/2). Kasonde, J. M. and Martin, J. D. (1994) Experiences with Primary Health Care in Zambia. World Health Organization, Geneva. KCP (1928) Kenya Colony and Protectorate, Medical Department Annual Report, at RCS, Cambridge University, Ref. No. L46. KCP (1930) Kenya Colony and Protectorate, Medical Department Annual Repott, at RCS, Cambridge University, Ref. No. L46. KCP (1931) Kenya Colony and Protectorate, Medical Department Annual Report, at RCS, Cambridge University, Ref. No. L46. KCP (1932) Kenya Colony and Protectorate, Medical Department Annual Report, at RCS, Cambridge University, Ref. No. L46. KCP (1933) Kenya Colony and Protectorate, Medical Department Annual Report, at RCS, Cambridge University, Ref. No. L46. KCP (1945) Kenya Colony and Protectorate, Medical Department Annual Report, at RCS, Cambridge University, Ref. No. L46. KCP (1947) Kenya Colony and Protectorate, Medical Department Annual Report, at RCS, Cambridge Universitv, Ref. No. L46. KCP (1949) Kenya Colony and Protectorate, Medical Deuartment Annual Reuort, at RCS, Cambridge University, Ref. No. L46: KCP (1955) Kenya Colony and Protectorate, Medical Department Annual Report, at RCS, Cambridge University, Ref. No. L46.

PRIMARY

HEALTH

CARE

KCP (1959) Kenya Colony and Protectorate, Medical Department Annual Report, at RCS, Cambridge University, Ref. No. L46. KMSR/NH (1932) Kisumu Medical and Sanitary Report/Native Hospital, KNA 211040 (PH. 5/2/l). K&SKMR/NH (1932) Kisii and South Kavirondo Medical Report/Native Hospital, KNA 2/1040 (PH. 51211). Lyons, M. (1994) The power to heat: African medical auxiliaries in colonial Belgin Congo and Uganda. In Contesting Colonial Hegemony: State and Society in Africa and India, ed. D. Engels and S. Marks, pp. 202-223. British Academic Press, London. Mburu, F. M. (1992) The social production of health in Kenya. In The Social Basis of Health and Healing in Africa, ed. S. Feierman and J. M. Janzen, pp. 409-425. University of California Press, Berkeley, CA. McCusker, J. (1982) Attitudes and training of health professional in Tanzania. In The Use and Abuse of Medicine, ed. M. deVries, R. L. Berg and M. Lipkin, Jr. DO. 248-253. Praeeer Publishers. New York. MRH%H (1954) Mocthly Report ‘of the Hospital AssistantiHamisi, Monthly Report for Hamisi Health Centre FebruaryiMarch, KNA Box 11 31362 (PH. 61112). MRHA/NN (1954) Monthly Report of the Health Inspector/North Nyanza, KNA Box 11 3/362 (PH. 61112). MRMO/K (1940) Monthly Report Medical Officer/ Kakamega, Monthly Report of the Native Hospital of Kakamega, North Kavirondo, KNA 211050 (PH. 41212). MRMO/Ksi (1940) Monthly Report Medical Officer/ Ksii, Monthly Report of the Native Hospital of Kisii, South Kavirondo; KNA 211049 (PH. 41213). MRiNHK (19371 Medical Reoort. Native Hosvital of Kisumu, ‘KNA’211040 (PH. $211). MRiNHSN (1949) Medical Report, Native Hospital of South Nyanza, Memo on Medical Department Policy and Development Schemes and Training of Medical Personnel, KNA 211063 (PH. 2/l/l). MIUNKD (1931) Medical Report, North Kavirondo District, KNA 212041 (PH. 521). Patterson, K. D. (1981) Health in Colonial Ghana: Disease, Medicine and Socio-economic Change, 1900-1955. Crossroads Press, Waltham, MA. PC/N (1949) Provincial Commissioner/Nyanza, Correspondence relating to sleeping sickness in South Nyanza. KNA Box 39 211057 (PH. 3111112).

IN COLONIAL

KENYA

1717

PMO/N (1959) Provincial Medical OfficeriNyanza, Correspondence to T. Hughes-Rice, Assistant Director for Agriculture, KNA deposit 3 Box 9 31325 (PH. 113). Robertson, B. (1993) Angels in Afiicu. A Memoir qf Nursing in the Colonial Service. Radcliffe Press, London. SI/CK (1932) Sanitary Inspectors/Central Kavirondo, Annual Report for Central Kavirondo. Masseno. KNA 2110401 PH. 51211. SMO/CK (1940) Senior Medical Officer/Central Kavirondo, Report on the Medical Arrangements at Kisumu in the Central Kavirondo District. KNA 211051 (PH. 11213). SMO/N (1932) Senior Medical OfficeriNyanza, Letter from the Senior Medical Officer to the Medical Officer of Maseno, KNA 211053 (PH. l/l/l/l). SMO/N (1943) Senior Medical OfficeriNyanza, Report on Smallpox Vaccinations, KNA Box 39 211069G (PH. 3/l/13). SMO/N (1949) Senior Medical Officermyanza, Annual Report for Nyanza Province 1949, KNA Box 31622 Pub 4/2/8 Deposit 3 Box 10. SMO/N (1950) Senior Medical OfficeriNydnza, On the Implementation and Interpretation of Social Medicine in the Native Reserves with special reference to Nyanza Province, Report Submitted to the Provincial Team Meeting for Discussion. KNA 31341 PH. 219. SNAR (1954) South Nyanza Annual Report. KNA 1428 KSI/16 AR 1954. Turshen, M. (1984) The Political Ecology of Disease irl Tanzania, Rutgers University Press, New Brunswick. NJ. Vaughan, M. (1994) Health and hegemony: representation of disease and the creation of the colonial subject in Nyasaland. In Contesting Colonial Hegemony: State and Society in Africa and India, ed. D. Engels and S. Marks, pp. 173-201. British Academic Press, London. Walker, L. (1995) The practice of primary health care: a case study. Social Science and Medicine 40(h), 815-824. Woelk, G. B. (1994) Primary health care in Zimbabwe: can it survive? An exploration of the political and historical developments affecting the implementation of PHC. Social Science and Medicine 39(8). 1027-1035.