East African Doctors: A History of the Modern Profession (review)

Based on extensive archival research and a meticulous review of the vernacular press, this study explains how Africans became physicians in twentieth century Uganda, Kenya and Tanzania.

At the outset, John Iliffe states that "Not since the origins of mankind has East Africa been so important to the world as it is today. The special importance comes from the AIDS epidemic" (p. 1). Claiming that East African doctors have charted the "epidemiology of heterosexually transmitted AIDS" and devised control strategies, Iliffe ends his book "as it began, with AIDS" (p. 244). This frames the analysis, with assumptions about AIDS that merit careful scrutiny.

Chapters two through nine epitomize the lucid style of historical reconstruction associated with Iliffe. The chapters on post-colonial public health document how deteriorating political economies (not some rainforest virus) produced the classic symptoms of sickness--fever, persistent cough, diarrhea and weight loss--that American researchers redefined as a new and distinct illness (AIDS) in 1984, declaring it was caused by a single virus (HIV) which could be transmitted through sexual contact.

Under colonial education systems, an elite corps of African trainees dissected cadavers, learned precision in dosages and relied on microscopes "to embody rationality and enlightenment" (p. 49). In the 1940s, Uganda physician Sebastiano Kyewalyanga promoted hospitals and doctors for babies so Africans would achieve "better health, stressing regular breastfeeding, hygiene, nutrition, better housing, [and] the advantages of modern medical aid" (p. 84). Bernard Omondi, a Kenyan doctor in the 1950s, diagnosed the causes of death at Kerugoya district hospital--pneumonia, gastroenteritis, tuberculosis and kwashiorkor--as a "syndrome with malnutrition at its root," due primarily to socio-economic changes (p. 107). The writings of these men impressed Iliffe "by how optimistic they were at this time of their ability to improve their societies" (p. 109).

Chapters 7-9 are a compelling treatment of public health debacles that set the stage for AIDS: the violence in Uganda, corruption and financial stringency that attended capitalist development in Kenya, and attempts to transform the medical system in a socialist direction in Tanzania. After independence, public health was weakened by fiscal constraints, population growth, the spread of tuberculosis, and the endemic environmental diseases: "malaria in the lowlands and respiratory infections in the highlands" (p. 133).

During Idi Amin's destructive regime, per capita income declined by 6.2% per year and the Ministry of Health's real expenditure per person fell 85% while the country endured cholera and typhus epidemics, a major expansion of sleeping sickness, and the worst measles epidemic in its history. At Mulago Hospital and Medical School, the water supply broke down for a decade, the mortuary's refrigeration system collapsed, sewerage ceased to function, X-ray units did not work, and the food store was "full of rats and vermin" (p. 147).

Insecurity persisted after Amin's ouster. Immunization rates among infants in 1985 were only 13% for polio, 17% for measles, and 37% for tuberculosis. The illicit sale of pharmaceuticals grew rampant as selfmedication with illegal drugs was the "surrogate for a collapsing medical system" in a country whose GDP per capita in 1985 remained 43 percent lower than in 1970. "The accumulated deterioration made the late 1980s the nadir of health services," writes Iliffe, when "the pain and squalor of dilapidated hospitals" left them with little water, electricity, sewerage, equipment, transport, or drugs (pp. 155-56).

A similar degeneration affected Kenya. The open selling of drugs, "apart from . . . the possibility of poisoning," alarmed doctors because "it bred drug resistance." By 1992, "the dose of penicillin needed to cure gonococcal infection had increased over a hundredfold" (pp. 190-91).

Tanzania shifted expenditures and doctors from urban hospitals to village health centers to cultivate ujamaa egalitarianism. Despite successful mass immunizations against measles, polio, and tetanus, public health worsened by the 1980s. Health facilities "were often dilapidated and the staff demoralized, chiefly for lack...