Introduction: Sustaining the Life of the Polis

How are publics of protection and care defined in African cities today? The effects of globalization and neo-liberal policies on urban space are well documented. From London to São Paulo, denationalization, privatization, offshoring and cuts in state expenditure are creating enclaves and exclusions, resulting in fragmented, stratified social geographies (see Caldeira 2000; Ong 2006; Harvey 2006; Murray 2011). ‘Networked archipelagoes’, islands connected by transnational circulations of capital, displace other spatial relations and imaginaries. Spaces of encompassment, especially, such as ‘the nation’ or simply ‘society’ as defined by inclusion within a whole, lose practical value and intellectual purchase as referents of citizenship (Gupta and Ferguson 2002; Ferguson 2005). In African cities, where humanitarian, experimental or market logics dominate the distribution of sanitation and healthcare, this fragmentation is particularly stark (see, for example, Redfield 2006, 2012; Fassin 2007; Bredeloup et al. 2008; Nguyen 2012). Privilege and crisis interrupt older contiguities, delineating spaces and times of exception. The ‘public’ of health is defined by survival or consumption, obscuring the human as bearer of civic rights and responsibilities, as inhabitants of ‘objective’ material worlds ‘common to all of us’ (Arendt 1958: 52). Is it possible, under these conditions, to enact and imagine public health as a project of citizens, animated in civic space?

Public Health, at Street Level

The essays below bring into view workers at the lower levels of urban medical research, sanitation, healthcare and public health; a group of African citizens who, historically, have had a well-defined set of rights and responsibilities for their civic space. Moving across the city to collect rubbish, data, samples and patient follow-up forms, they engage directly with the urban population or segments of it. We followed this movement: its fluidity and abruptness, its locations and delineations, its crossings and stoppages, the materials it touches upon, and the boundaries it traces and transgresses. Guided by professional tasks and personal aspirations, interrupted by obstacles and gaps – in employment, infrastructure or supplies – they deploy their skills and labour to serve and thereby recognize a public of fellow citizens.

We call them ‘street-level health workers’, invoking Michael Lipsky’s (1980) ‘street-level bureaucrats’; those who inhabit and manipulate the interface between official structures and citizens’ lives, between the planners’ offices and the public spaces of governance. But can they still be called bureaucrats? As volunteers, thesis students, uniformed cadets, community participants or employees on short-term contracts, they mediate between institutions and citizens, but not in a smooth and sustained way over the course of their work lives. Their positions in NGOs, research partnerships, municipal politics and public health regulation are uncertain, usually temporary and often informal. They no longer embody the figure of the street-level worker as a routine labourer maintaining the city as part of a stable career. This older figure, at least potentially, could acquire expertise, a sense of vocation and of cumulative transformative action on health, over the course of her/his life, linking the material urbs to the civic polis. But what happens to these ties – between individual and collective, daily repetition and better future, urbs and polis – when the duration, institutional attachments and material conditions of street-level work are eroded or destabilized?

Rapid population growth and the privatization of ‘public’ services, including water provision, sanitation and healthcare, are major challenges to urban public health in Africa. Secure jobs and especially public employment are increasingly rare for public health workers in Ibadan, Dakar and Kisumu. They live in and care for expanding cities dominated by informal economies and planning, positioning themselves as observers but also inhabitants of unregulated spaces: from slums and unplanned urban developments to illicit drug markets. Yet recent changes in the healthcare landscape have also afforded new opportunities that are particularly marked in, if not unique to, each of these cities. Kisumu’s growth in the past fifteen years is clearly associated with transnational investments in HIV research and care. This ‘HIV economy’ generates clinical trials and NGO activity, but also new spaces and relations...