Beyond realism: Africa’s medical dreams: Introduction

The most tragic form of loss isn’t the loss of security; it’s the loss of the capacity to imagine that things could be different.

( Bloch 1986 )

The world has long since dreamt of something of which it needs only to become conscious for it to possess it in reality.

(Karl Marx, 1843, letter to Arnold Ruge, cited in Jameson 2005 : 281)

Africa has long provided fertile ground for the medical imagination. From the colonial ‘civilizing mission’ to the ingenuity of post-Ebola ‘pandemic bonds’, African pathologies and potentials have kindled some of biomedicine’s wildest fantasies (while testing the limits of its efficacy, rationality and universality; see, for example, Fanon 1959 ; Vaughan 1991 ; Lyons 2002 ; Hoppe 2003 ; Lachenal 2017 ; 2018 ). Dystopian images of Africa – of tropical miasma, preventable deaths, barren women and orphaned children, wildfire epidemics depopulating the continent and spreading beyond it – have intersected with visions of discovery, salvation, progress, productivity and mastery, but also with aspirations to equality, welfare, self-determination, authenticity, prosperity and rights.

Biomedical fantasy and scripted futures

From the outset, the dream of imperial conquest in Africa was entangled with that of medical conquest, an entanglement that fostered discovery and innovation (e.g. Headrick 2012 ; Neill 2012 ). Although primarily directed towards securing and sanitizing enclaves of colonial military, administrative and economic activity, this newly scientific medicine was deployed, at the same time, to perform the potentially further-reaching ideological work of Christian and European order and benevolence (e.g. Comaroff 1993 ; Conklin 1997 ; Comaroff and Comaroff 2009 ). From the 1940s, biomedicine, fuelled by accelerating traffic between bodies, experimentation and technology, was hitched to the bigger ambitions of late-colonial, and then (inter)national, welfare and development ( Cooper 2002 ; Tilley 2011 ; Lachenal 2017 ). New modes of investment, not only in Africans’ bodies but also in their professional mobility, modernity and prosperity, were materialized by expanding the reach of biomedicine – by building clinics and hospitals ( Prince , this issue); training and promoting African personnel ( Geissler et al ., this issue); dispensing new medicines, vaccines and insecticides through mass, mobile action (e.g. Vaughan 1991 ); or nurturing healthy dispositions as a civic virtue (e.g. Hunt 1999 ).

In Africa, the transformative promises of development were invoked initially to define a reformed colonialism, one willing to invest in the continent’s economic and political future at a time of broader post-war moral and political reconstruction ( Cooper 2002 ). At the same time, the focus on a narrow techno-politics of development often served to deflect revolutionary forms of anti-colonial liberation. Development programmes were also pursued to bring about decolonized international linkages (on either side of, as well as across, the East–West Cold War divide; see, for example, Prince , this issue) and national governance, thereby reordering the postcolonial world and Africa’s place in it. In the post-independence decades, medicine and health were targets of international programmes of cooperation based on technical assistance and technology transfer ( Lachenal 2011 ). Some of these retraced old metropole–colony routes while seeking to infuse interactions with new ethical, material, professional and political possibility. Others opened onto different pathways of exchange and solidarity connecting Africa to new poles of the Cold War world in a context of humanitarian competition. Liberal visions of technological liberation from obstacles to trade and security (and the need for social reform; see, e.g., Reinhardt 2015 ; Packard 2016 ) were complemented and reshaped against the different propositions of ‘socialist internationalism’– operating in part through international organizations such as the WHO ( Antic et al . 2016 ; Vargha 2018 ). Medical training and the development of health services were also cornerstones of African state expansion and nation building (e.g. Kusiak 2010 ).

As the post-war economic boom faltered in the late 1970s, the appropriateness of basing healthcare and development on expensive, imported, technology-based strategies and of aiming for universal public provision was called into question, notably by the newly emerging academic discipline of ‘health economics’ (e.g. Forget 2004 ). In some circles, the rethinking of development inspired new kinds of public health dreams, initially directed at the universal provision of at...