The Political Ecology of Malaria: Emerging Dynamics of Wetland Agriculture at the Urban Fringe in Central Uganda 9783839450536

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Matian van Soest The Political Ecology of Malaria

Medical Humanities  | Volume 4

In memory of Aart van Soest

Matian van Soest, born in 1984, is a social and cultural anthropologist with a regional focus on Eastern Africa and a thematic interest in infectious diseases. He works as scientific coordinator of the collaborative research center “Future Rural Africa” at the Universities of Bonn and Cologne and is a member of the AG Medical Anthropology of the German Anthropological Association.

Matian van Soest

The Political Ecology of Malaria Emerging Dynamics of Wetland Agriculture at the Urban Fringe in Central Uganda

This book was accepted as dissertation thesis by the Faculty of Arts and Humanities of the University of Cologne. The dissertation was developed in the research project “GlobE - Wetlands in EastAfrica: Reconciling future food production with environmental protection” funded by the German Federal Ministry of Education and Research and the German Federal Ministry for Economic Cooperation and Development (Funding Code: 031A250 A-H).

Bibliographic information published by the Deutsche Nationalbibliothek The Deutsche Nationalbibliothek lists this publication in the Deutsche Nationalbibliografie; detailed bibliographic data are available in the Internet at http:// dnb.d-nb.de

© 2020 transcript Verlag, Bielefeld All rights reserved. No part of this book may be reprinted or reproduced or utilized in any form or by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying and recording, or in any information storage or retrieval system, without permission in writing from the publisher. Cover layout: Maria Arndt, Bielefeld Cover illustration: Development area with newly constructed houses between Namulonge and Kiwenda, picture by author. Typeset by Justine Buri, Bielefeld Printed by Majuskel Medienproduktion GmbH, Wetzlar Print-ISBN 978-3-8376-5053-2 PDF-ISBN 978-3-8394-5053-6 https://doi.org/10.14361/9783839450536 Printed on permanent acid-free text paper.

Contents Acknowledgments.................................................................................................... 9 Abbreviations............................................................................................................11 Figures and Tables.................................................................................................. 13 1. Introduction....................................................................................................... 15 Relevance of the study and literature............................................................................ 16 The need for an ecological context................................................................................ 18 Research questions....................................................................................................... 20 Outline of the book........................................................................................................ 22 2. Malaria: A brief overview............................................................................... 25 Global Perspective........................................................................................................ 27 The parasite’s life cycle................................................................................................ 30 The interplay of humans, mosquitoes, and parasites................................................... 32 Malaria in numbers........................................................................................................ 34 Progression of the disease........................................................................................... 40 Malaria testing and treatment of clinical malaria......................................................... 43 Malaria treatment.......................................................................................................... 44 Local understandings of malaria.................................................................................. 45 Plurality of meanings, syncretic models....................................................................... 46 Perceptions of malaria: a “killer disease”?................................................................... 48 3. Ethnographic research in Uganda: Language and ethics in the field................................................................... 51 Initial considerations.................................................................................................... 52 Interdisciplinary research projects and their methodological implications......................................................................... 54 Qualitative research in a foreign research setting: the issue of language.................................................................................................... 55 Working with an interpreter.......................................................................................... 57

Hiring an assistant........................................................................................................ 63 Doing research, constructing the field......................................................................... 65 Positionality: A German researcher in Uganda............................................................. 69 Doing research in a health facility.................................................................................74

4. Kampala’s urban fringe: Socio-economic dynamics and transformations...................................... 79 Central Uganda.............................................................................................................. 79 Infrastructure............................................................................................................... 84 The Namulonge Research Farm.................................................................................... 86 Wetlands........................................................................................................................ 88 Land ownership and land use........................................................................................ 90 Structural adjustment: the 1998 Uganda Land Act........................................................ 91 Colonial legacies: the introduction of mailo land......................................................... 92 Mailo land in Namulonge................................................................................................ 96 Health in local context.................................................................................................. 97 Health care in Uganda................................................................................................... 97

5. Providing malaria treatment: Different forms of healthcare in Uganda...................................................101 Self-medication and individualized conceptions of health......................................... 109 Mapping healthcare.......................................................................................................112 Healthcare in Uganda: Historical Perspective..............................................................114 Formalized healthcare..................................................................................................117 Informal healthcare......................................................................................................119

6. Coping with malaria: Facets of health seeking........................................ 129 Costs of biomedical malaria treatment.......................................................................134 Malaria treatment outside the biomedical arena.........................................................138 Peter..............................................................................................................................141 Gerald........................................................................................................................... 146 Mukyala Nakakande...................................................................................................... 149 7. Agriculture in the urban fringe: The ambivalent role of wetlands................................................................. 155 Wetland agriculture and mosquitoes........................................................................... 155 Malaria and Agriculture................................................................................................ 157 Wetlands as economic resource.................................................................................. 160 Wetland mining.............................................................................................................163 Fisheries....................................................................................................................... 165 Malaria and agriculture: local perceptions.................................................................. 167

Malaria campaigns and wetland agriculture................................................................ 169 Wetlands as a last resort............................................................................................. 170 The ambivalent character of wetlands........................................................................ 178

8. Conclusion...........................................................................................................181 Outlook......................................................................................................................... 186

References...............................................................................................................191

Acknowledgments

Writing a book is a lengthy undertaking. Over the years I have enjoyed the supervision, help, and support of a number of people, without whom it would have not been possible to complete the doctoral thesis out of which this book developed, and whom I would like to thank at this point. First and foremost, I am indebted to the many persons of Namulonge and the surrounding villages and trading centers, who welcomed me into their homes, shared their stories with me, and endured my countless questions. For reasons of confidentiality I refrain from naming them individually; however, I want to emphasize how much I have appreciated the many enriching interactions I had with them in Uganda. Completing this book would not have been possible without the supervision and advice of Michael Bollig. I am grateful for his trust in my work as well as his continuing professional support. I also benefited greatly from the feedback of Clemens Greiner, and wish to thank him for his encouragement. Moreover, I’d like to acknowledge the input and critical feedback of Hansjörg Dilger and the entire AK Medical Anthropology at the FU Berlin. I am grateful for having been welcomed into the workgroup in Berlin, and enjoyed the opportunity to discuss my work with scholars in the field of Medical Anthropology. Devoting myself to this book and the underlying research project was only possible with the financial support of the German Federal Ministry for Education and Research (BMBF) and the German Federal Ministry for Economic Cooperation and Development (BMZ). I had the opportunity to develop and carry out my research, enjoying a doctoral stipend. My research endeavors would have remained fruitless without the immense help and assistance of Khadija Mubarrak and Christopher Musaazi. The value of their work goes far beyond the task of mere translation, and, as I argue in the book itself, this has epistemological implications: the findings presented in this text are as much theirs as they are mine. Furthermore, I greatly profited from their critical and open minds. Also I like to acknowledge Daniel Kyallo for adding my set of questions to the questionnaire used in his household survey, which he facilitated in Wakiso district.

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I also want to thank Patrick Kinyera for his help with the translation and transcription of interview recordings, James Ssemuju for his help with the documentation of statistical records, Habtamu Tegegne for his assistance in the analysis of the quantitative data, Veronika Steffens for her assistance in Cologne – especially the design of the maps used in this book, and Betty Najjemba for her assistance during group interviews. For his sketch of the plasmodial cycle used in this book I would like to thank Marlin van Soest. My work has been accompanied by my friends and colleagues at the University of Cologne and in the GlobE research project. For their feedback, stimulating discussions, company and moral support I would like to thank in particular: Innocent Mwaka, Johanna Treidl, Souleymane Diallo, Diego Menestrey, Elsemi Olwage, Gerda Kuiper, Hauke Vehrs, Manon Diederich, Qian Zhu, Holger Jenss, Andrés Wahl, Susanne Ziegler, Sonja Burghoff, Kai Behn, and Carmen Anthonj as well all other doctoral and post-doctoral researchers at the department of Anthropology, who are too numerous to be named. Last but certainly not least, I want to mention Ana Castillo, who patiently accompanied me through the good as well as hard times of my work on the book. I’m thankful for her ongoing loyalty as a friend and wife, despite my prolonged travels to Uganda.

Abbreviations

ACT AIDS BMBF BMZ DDT DGSKA HC HIV IMR IRB JICA MAAIF MMR MoH MoNR NaCRRI NARO NRM OPD RBM RDT TCMP UBOS UGX UN VHT WHO WW II

Artemisinin-based Combination Treatment Acquired Immunodeficiency Syndrome Bundesministerium für Bildung und Forschung (German Federal Ministry of Education and Research) Bundesministerium für wirtschaftliche Zusammenarbeit und Entwicklung (German Federal Ministry for Economic Cooperation and Development) Dichloro diphenyl trichloroethane Deutsche Gesellschaft für Sozial- und Kulturanthropologie (German Anthropological Association) Health Center Human Immunodeficiency Virus Infant Mortality Rate Institutional Review Board Japan International Cooperation Agency Ministry of Agriculture, Animal Industry and Fisheries Maternal Mortality Rate (Ugandan) Ministry of Health (Ugandan) Ministry of Natural Resources National Crops Resources Research Institute National Agricultural Research Organisation National Resistance Movement Outpatient Department Roll Back Malaria Partnership Rapid Diagnostic Test Traditional and Complementary Medicine Practitioner Uganda Bureau of Statistics Ugandan Shillings United Nations Village Health Team World Health Organization World War II

Figures and Tables

Figure 1: Worldwide malaria distribution from the mid-19th century until 2007. Adapted from Mendis et al. (2009: 804)................................................................. 28 Figure 2: Life cycle of the Plasmodium parasite.......................................................... 32 Figure 3: Malaria test results at the Namulonge HC III between November 2014 and October 2015................................................................................................... 36 Figure 4: Monthly distribution of positive malaria test results at the Namulonge HC III between November 2014 and October 2015........................................................... 38 Figure 5: Gender and age distribution of patients tested for malaria at the Namulonge HC III between Novem-ber 2014 and October 2015................................................ 39 Figure 6: View on downtown Kampala from Mengo hill. Picture by Clemens Greiner................................................................................... 80 Figure 7: The urban center of Kampala and the trading centers Namulonge and Kiwenda at its northern fringes......................................................................81 Figure 8: Map of the research area, showing the wetlands and relevant places......... 82 Figure 9: Advertisement poster by Zion Estates, along Kampala-Gayaza Road (top left), and an online adver-tisement by Zion Estates, promoting their plots between Namulonge and Kiwenda (top right). A satellite image clearly reveals the planned development area, and the first houses can be seen (bottom). Towards the bottom of the picture parts of the NaCCRI farm, located in the wetland are visible; the settlements on the upper right side of the image are part of Balita. Sources: photo by author, advertisement from www.zion.co.ug/, satellite image from Google Maps, screenshot taken on March 23, 2015.............. 83 Figure 10: Example of an “entobazi”; picture by author................................................ 90 Figure 11: Example of an arable “ekisenyi”; picture by author...................................... 90 Figure 12: Signpost of the Namulonge Health Center III, picture by author.................. 99 Figure 13: Filling the jerrycans..................................................................................... 126 Figure 14: Jerrycan prepared to be filled..................................................................... 126 Figure 15: Waiting for consultation.............................................................................. 127 Figure 16: Preparation of medicinal herbs and barks.................................................. 127 Figure 17: Musawo during consultation........................................................................ 127 Figure 18: Jerrycans lined up to be filled..................................................................... 127 Figure 19: Cabbage field in wetland.............................................................................. 128

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Figure 20: Wetland-field prepared for planting........................................................... 128 Figure 21: Gerald’s brick-workshop in the wetland...................................................... 128 Figure 22: Clay-mining pits filled with rain water........................................................ 128 Figure 23: Using the wetland as a washing-bay.......................................................... 128 Figure 24: James’ fishpond.......................................................................................... 128 Figure 25: Parts of the Mairye Estates and Xclusive Cuttings flower farms................161 Table 1: Distribution of test results across age groups at the Namulonge HC III between November 2014 and October 2015........................................................... 37

“The human malaria connection is an ever– changing dance, which includes moving forward and back, spinning with partners in tandem or sometimes in opposite directions. Movements of both human beliefs and biological actions. Overlapping meanings. Those belief systems include bioscience and local, preventive behaviors.” James C. McCann (2014: 3) “In the same way that ecologists talk about ecological cascades that facilitate disease emergence, social scientists speak of the scalar and multifaceted dimensions of influence in social systems – from an individual in a community to the wider political economy – that guide, constrain, or otherwise affect disease risk.” Craig R. Janes, Kitty K. Corbett, James H. Jones and James Trostle (2012: 1885)

1. Introduction

The second decade of the new century is coming to an end; the public as well as academic discourse on the future of sub-Saharan Africa is dominated by topics such as climate change, population growth, and global neoliberalism. Not surprisingly then, this book is also related, in the larger sense at least, to these debates: in the coming chapters I will look at the wetland-malaria nexus in central Uganda and its significance in the context of the future prospects of the continent, especially with regard to pressing issues of global warming, population pressure, and foreign investments. Climate change is likely to change the use of wetlands as well as the distribution of malaria. So is the rapid population growth in East Africa, as well as the global interest in the continent’s arable land.

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Malaria and wetlands are linked by water: the characteristic element of wetlands provides the biotope in which mosquito larvae thrive. In the wake of global climatic change, temperatures in the tropics are expected to rise, while the seasonal rainfall patterns are becoming increasingly unpredictable. The rising temperatures allow for malaria parasites to survive in higher altitudes, while the irregular rainfall makes farmers dependent on the water resources of Africa’s wetlands. Moreover, the rapidly growing population of East Africa needs to be fed and the farmers’ demand for arable land is growing. Wetlands prove to be a promising resource in that regard as they are largely idle, full of water, and in extensive areas still unclaimed. Lastly, these aspects make them attractive to agricultural investors from Europe, America and China, all rushing for the world’s last agricultural frontier: only in Africa do we still find large chunks of watered, fertile land, seemingly unused and waiting to be exploited. The dynamics that this rush unleashes have far-reaching consequences, social as well as political, environmental, and of course economical.

Relevance of the study and literature The empirical study that forms the foundation of this book developed in the context of a larger, multidisciplinary research project, funded by the German ministry for education and research (BMBF), that was designed with the above-outlined debates in mind. The research project titled “GlobE – Wetlands in East Africa: Reconciling future food production with environmental protection”, was based on the question how the current dynamics in sub-Saharan Africa will impact the future food security in East Africa. The project should scrutinize the agricultural production potential of wetlands in East Africa, research the environmental and health-related risks of wetland agriculture, and eventually formulate advice for the development of policies for the regulation of wetland use in the respective research countries. Within the context of this project I had the chance to design my own research on the links between wetland agriculture and malaria at the urban fringe in Uganda. Malaria is a rather obvious health risk of wetland agriculture. As mentioned before, wetlands and malaria are linked by water. And while there are doubtlessly other important water-related and water-borne diseases that are an issue in the realm of wetland agriculture, malaria is arguably the most important one (cp. Malan et al. 2009: 754-760). No other water-related disease kills more people worldwide, and no other water-related disease is pandemic in much of the tropical world. Malaria is an old disease and much has been said about it. Long before the first written accounts of the sickness, people would have talked about the disease,

1. Introduction

and over the course of the centuries medical experts all over the world have experimented with methods to heal sufferers of the intermitted bouts of fevers and chills. With that in mind, one might ask why in 2018 it is still relevant to write yet another book about malaria. The easy answer would be that in this time of rocket science and self-driving cars it is baff ling that malaria is still is one of the main causes of morbidity and mortality across Africa. As long as there are people suffering from malaria there will be a need to find solutions to the malaria problem – and thus to further the scientific understanding of the disease by investigating and writing about it. But there is more. Malaria is an ambiguous disease, ancient and well researched yet at the same time remaining mysterious and unknown. Our understanding of what we know today as “malaria” is subject to both space and time, continuously changing, evolving, adapting, and becoming more refined. Whereas in postwar Europe and America people have largely forgotten about malaria and today remain with but a vague idea of what malaria is, the disease is part of everyday life in the tropics. In that regard it makes sense that malaria keeps inspiring scholars, authors and researchers to contribute to the documentation of the ever-changing image of malaria, and to document the contemporary articulations of malaria in an increasingly globalized world. While in the west the notion of malaria as an exotic “killer-disease”, fed by the devastating numbers of children dying each year of malaria in rural Africa, persists and fuels the fears of exotic parasites from the far-away tropics, malaria wears a different mask in the so-called “global South”, where it is often an everyday nuisance to the local populations. Before beginning this research my own image of malaria was also rather one-sided, dominated by the biomedical understanding of the disease and biased by the alarming figures represented in the popular media, by my ideas of tropical medicine, and by the deceptive, superficial knowledge of my friends and acquaintances who had travelled to the tropics before me. Ironically, learning how malaria shapes the lives of people who are exposed to the disease on a daily basis and how the disease is dealt with as an everyday threat, many of my informants learned how malaria is non-existent in the lives of most Europeans. Many must have wondered why a German, never having been exposed to malaria himself, travels all the way to Uganda to find out about a disease that does not exist in his home country. In a way then, studying and writing about malaria is part of understanding the “global South” and deconstructing the category from a medical perspective. After all, malaria is not only part of what we categorize today as the “global South”, but it shares a common history in that it was constructed as a tropical disease by use of the same mechanisms by which the “West” was distinguished from the so-called “developing world”. Apart from the humanitarian and health-related angles, there then is a political relevance to the malaria topic. In an increasingly interconnected yet unequal

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world it is almost imperative to address the different lifeworlds, realties and also inequalities that coexist in this shared world. Writing about malaria – moreover from an anthropological perspective, with a qualitative methodological approach and room for detailed, individual accounts of localized viewpoints – has therefore also to be understood as an attempt to make sense of an increasingly irrational and seemingly contradictory world. This book, although clearly written from the perspective of a biomedically informed view on malaria and with the hope in mind to contribute to the struggle against the disease and its deadly toll, is first and foremost an attempt to understand global inequalities and their manifestations in the form of malaria, by virtue of the example of central Uganda.

The need for an ecological context Being a mosquito-borne disease, malaria evokes questions about the relations between humans and mosquitoes, which inevitably touches upon ecologies as well. In the natural sciences the importance of the ecology of a place has long been recognized and noted. Devastating malaria epidemics were linked to large-scale environmental projects, like the building of dams or canals, agricultural production schemes, deforestation, or draining programs (cp. for example Harrison 1978; Lewis 1937). Eventually, the appreciation of the connection between humans, mosquitoes, and parasites and their respective habitats led to attempts to eradicate the disease by controlling the mosquito vector and its breeding grounds. In the social sciences, however, malaria only became a topic of research towards the end of the last century, when mainly (medical) anthropologists pointed out the social dimension of health and disease in general and malaria in particular (cp. Packard/ Brown: 1997: 187). Disease ecology, or what Alex Nading prefers to call the “entanglement […] of microbes, vectors, human hosts and landscapes” (Nading 2013: 64), particularly with regard to malaria, is only recently becoming a topic of anthropological enquiry (ibid: 63-68; cp. Chandler/Beisel 2017: 416; King 2010: 42-46; Townsend 2011: 182183). However, with the rise of global health as a distinct degree program taught at universities across the globe, and in the wake of internationally agreed-upon health goals, such as the health-related Millennium Development Goals, medical anthropologists increasingly criticize the lack of regard for the highly localized factors of disease exposure and health risks. In their critique of the global health approach to related problems, Neely and Nading point out the need to integrate the concept of place into the analysis and understanding of disease, suffering, and healing, and ultimately also health interventions (Neely/Nading 2017: 61-62). In their view it is essential to appreciate the place-based determinants of health such as location, gender, ethnicity, and class (ibid: 57), and to carve out “how people

1. Introduction

in places address health problems, produce knowledge about them, and regulate them in ongoing, interactive engagement with their environments […]” (ibid: 58). The call for a political ecology approach to health is then partly also rooted in the disregard for the local contexts of disease distribution in an internationalized, donor-dependent health landscape. While the global malaria pandemic is doubtlessly shaped by a range of factors that apply to the whole of Africa, there is a lack of regard for the localized, placebased factors that shape the pandemic in different locations. So far it has mainly been historians who have written about the ecological and political factors of malaria (cp. for example Chakrabarti 2014; McCann 2014; Packard 2007; Webb 2009). Comparable approaches from within the social sciences are rather few. However, whereas I argue that anthropology has so far only dealt marginally with malaria’s disease ecology, there are of course a number of excellent, recent publications within the field of medical anthropology that are revealing the social, and political dimensions of the disease. For example, Caroline Meier zu Biesen shows how the use of the medicinal plant Artemisia annua in Tanzania must be understood against the backdrop of global market dynamics and power structures (Meier zu Biesen 2013). Vinay Kamat reveals how social dynamics articulate themselves in the responses of single mothers to malaria in their children in Dar es Salaam (Kamat 2013). René Umlauf has pointed out how the introduction of rapid diagnostic tests and the associated regulations with regard to treatment have changed the way in which patients in Uganda deal with the disease (Umlauf 2017a). Furthermore, Susanna Hausmann Muela has extensively published on malaria in Tanzania’s Kilombero f loodplain, and looked at local conceptualizations of malaria and the associated symptoms, the search for treatment, as well as the gender-related articulations of the management of the illness (Hausmann Muela/Muela Ribera/Tanner 1998; Hausmann Muela 2000; Hausmann Muela et al. 2012; Muela Ribera/Hausmann Muela 2011). Also working in Tanzania, Stacey Langwick has discussed the medical pluralism with regard to malaria and the different conceptualizations of the disease (Langwick 2007). Annika Launiala and Marja-Liisa Honkasalo have worked on risk perceptions of malaria in rural Malawi (Launiala/Honkasalo 2010), and Uli Beisel shows how the production and distribution of mosquito nets as a technical response to growing insecticide resistance of mosquitoes disregards the importance of ecological contexts and undermines local economies (Beisel 2015).

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Research questions With my own research on malaria, I intend to understand the malaria pandemic in Uganda from the perspective of the changing wetland ecology and the underlying dynamics, both social and political. Apart from showing how malaria is made sense of locally, how people in central Uganda deal with the disease, and how they perceive the associated risks, I will point out that it is crucial to also consider the local social and political, as well as ecological context of the disease. In central Uganda the rapid urban expansion and the local tenure system provide the backdrop to my analysis of the malaria epidemic. It should be mentioned at this point that my own perspective on malaria is very much informed by the biomedical conceptualization of the disease. I certainly learned much about malaria over the course of the research endeavor, including its implications on everyday life, and my engagement with the topic helped to deconstruct my previously simplified and in parts problematic perception of the disease – clearly the perspective of an outsider who has not had many encounters with the disease himself. While my image of malaria has thus changed somewhat, from that of a tropical killer-disease to a more nuanced picture of a curable disease that is subject to a multitude of political, social, economic, ecological and other factors, I nonetheless regard the biomedical conceptualization of the disease, including the medical science that it is based on, as essential to the analysis of the malaria problem. In order to be successful, the struggle against the malaria epidemic will doubtlessly have to address the findings from social scientists, geographers, historians, and political scientists as well as the insights of local experts and stakeholders. However, at the core there must be a biomedical concept of the disease, its treatment, and its prevention. Medical anthropology, as one of the most important sub-disciplines within anthropology, has since the 1980s increasingly emancipated itself from biomedicine and started to critically assess biomedical practices, the related body-politics and the medicalization of numerous domains of public life (cp. Baer/Singer 2009; Singer 2004).1 Moreover, an important strand within the sub-discipline has looked at health as the outcome of global political processes, critically reviewing international incentives to target health-related problems and their associated campaigns (cp. Lock/Nichter 2002). Furthermore, medical anthropologists have since long demonstrated that health and healing are embedded in pluralistic and syncretic models of medicine (cp. Baer 2011). In that regard, this text certainly is to be located within the stream of the critical medical anthropology of this time, as I review the malaria pandemic in Uganda and its larger social, political and 1 The most prominent examples would be the medicalization of pregnancy and childbirth, as well as ageing and mental wellbeing.

1. Introduction

ecological context, and show how the local response to malaria is embedded in a pluralistic and syncretic model of health, healing and medicine. The questions that guided this research were aimed at investigating the local perception of malaria and the ways in which the disease is dealt with among smallholder farmers who make use of wetlands in central Uganda. Furthermore, in order to understand the problem of malaria in the local ecological, political and social context, I included questions about the drivers and constraints of wetland agriculture, treatment-seeking, and the healthcare system. In order to complement the picture of malaria, and because the disease was relatively new to me, I included the perspectives of the local medical practitioners, from both biomedical and other backgrounds. The core questions of the research were as follows: 1. How is malaria perceived and dealt with among wetland users in Uganda? 2. What different kinds of healthcare are available in central Uganda to treat malaria? 3. How is the use of wetlands for economic production linked to the occurrence of malaria in Kampala’s urban fringe? 4. What are the drivers of and constraints on the utilization of wetlands for economic production? The first question serves to generally document the views and understandings of malaria among wetland users in Kampala’s urban fringe and contrast them to the biomedical conceptualization of the disease. This includes the connected ideas for preventive measures and treatment, as well as the ways in which they are accessed and used. The second research question aims at outlining the different forms of healthcare available in Uganda, as well as the according institutions, infrastructures, and expertise. This includes biomedical as well as other, alternative forms of medical knowledge. With the third research question I intend to shed light on the links between wetland agriculture, mining, and other activities in wetland areas, and malaria. Here, I am interested in the views of wetland users, and the perspectives of other natural scientists, as well as the observable traits. Moreover, I intend to understand wetlands not solely as mosquito habitats but also as sources of economic capital that enable people to access malaria treatment and prevent an infection. The third of the four main research questions also asks about the significance of wetlands as sites of economic production and, more specifically, about the push and pull factors that underlie the increasing use of wetlands in Kampala’s urban fringe. The related sub-questions serve to identify social and political forces that characterize the utilization of wetlands. Lastly I am interested in identifying the hindrances and limitations facing wetland production, especially

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with regard to malaria, but also in more general terms, looking at implications of wetland transformations in the longer term.

Outline of the book This book is structured into eight chapters, including the introduction and conclusion. While I present the general topic of malaria in Africa and its relevance in the introduction, the first chapter also serves to point out the need for a social science and political ecology perspective on the disease that is sensitive to place and its articulations. Furthermore, I outline the general interest of my study and the central research questions that guided the research. In the second chapter I will go deeper into the malaria topic, brief ly discussing the biomedical history of malaria research as well as the scientific findings with regard to etiology, treatment, and disease prevention. Furthermore, I illustrate how malaria has, through large-scale interventions and ecological changes, been shaped into a tropical disease, with its epidemiological epicenter in sub-Saharan Africa. Moreover, I will contrast the biomedical understanding of malaria with the local, syncretic model of the disease and its treatment. In the third chapter I present my methodological approach and discuss the ethical implications of doing research on malaria in central Uganda. Most importantly, I address the issue of working with an assistant and interpreter, and critically assess its epistemological repercussions and consequences for the research process. Moreover, I claim that the issue of the language proficiency of anthropologists in their respective research settings needs to receive more attention within the discipline and at the academy, especially with regard to its methodological implications and the ethical issues that come along with cooperating with an assistant. With the fourth chapter I turn to the empirical material of my research. Here I will introduce the setting of my research, specifically looking at it as a peri-urban space that has to be understood in the context of the nearby city. The chapter also presents the anthropological field as a place that is constituted of social interactions and shifting positionalities. Moreover, I look at the highly specific tenure regime in the area and connect the locale to its colonial past. This perspective provides the background for the ecological transformations of wetland-systems that are currently ongoing, as I argue that the current dynamics with regard to shifts in land ownership drive smallholders into wetlands, seeking agricultural land. In chapter five I discuss the available treatment for malaria and the ways it can be accessed. The availability of malaria treatment is subject to a range of social structures, most importantly class, gender, and political regulations. Moreover, I argue that the search for malaria treatment is by no means a straightforward

1. Introduction

endeavor, but is shaped by a multitude of factors, individual decisions and evaluations. Some of the devastating consequences of malaria in central Uganda are rooted in the common strategies people there employ to cope with health constraints: delay of treatment-seeking, self-diagnosis, and a trial-and-error approach to healthcare. Chapter six builds on the observation that the access to healthcare is constrained by a range of factors. Here I take a closer look at individual case studies to highlight the way in which malaria is dealt with and how it is perceived. Moreover, I look at specific factors that determine the possible options to access healthcare and the evaluation thereof, particularly looking at class and gender. As I will show, access to malaria treatment is also closely linked to ideas about the disease, its etiology, and medicine in general. The last ethnographic chapter, chapter seven, presents the links between malaria and the various uses of wetlands, especially agriculture, in central Uganda. By means of selected case studies I evaluate the motivations of smallholders to move into wetlands in order to make them economically productive. Moreover, I critically assess the ecological impacts of wetland utilization, especially with regard to the creation of mosquito habitats, and complement that view with the risk perceptions of local wetland users. In the conclusion I finally tie the findings together and relate them to the broader debate on malaria, locally as well as on a global scale. After returning to the research questions raised in this introduction, I will look at the value of the findings for the current efforts to fight the disease. Furthermore, I highlight the importance of the regard for context and the need for qualitative, place-based research.

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“Everything about malaria is so moulded [sic] and altered by local conditions that it becomes a thousand different diseases and epidemiological puzzles. Like chess, it is played with a few pieces, but it is capable of an infinite variety of situations.” Lewis Hackett (1937: 266) “What was once a global affliction – the primary public health disaster in the United States during the nineteenth century, the principal disease of British India, the core challenge of the modernizing Italian state in the twentieth century, and the elusive target of the first global eradication campaign of the World Health Organization (WHO) – is now broadly regarded as a ‘tropical disease’.” James L.A. Webb Jr. (2009: 2-3)

2. Malaria: A brief overview It is hardly possible to write about local understandings of malaria without taking into account the biomedical narrative about malaria and the associated construction of the disease – even more so when one has little to no experience with the disease of one’s own. Understanding the risks of a malaria infection from a biological viewpoint and looking at the magnitude of malaria in epidemiological terms helps one to appreciate the incentive that drives the current campaigns to tackle the disease. Furthermore, following the biomedical take on malarial symptoms and their cause puts the response to malaria into perspective. In the first part of this chapter I therefore intend to sketch a brief yet comprehensive overview of malaria as viewed and constructed in the biomedical realm. In so doing I will touch upon the topic from a global, regional (focusing on East Africa), and local (looking specifically at my research area) perspective, incorporating epidemiolog-

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ical and historical information I deem relevant to the comprehension of the data I present later on in the text. On the other hand, in order to contextualize the response to malaria of people on the ground, it is also essential to include the local conceptualization of the disease and its cause. How is malaria understood locally, and what are the associated implications of a malaria infection? What does the term “malaria” entail in the local discourse, and how is it used? Looking into these questions will facilitate a better understanding of the local ways to deal with malaria, and provide the conceptual background to the ethnographic material of the later chapters. This chapter’s paragraphs on the biomedical and scientific approach to malaria do not contain novel data that has not been discussed elsewhere already; nor do they contain information that has not been written up in other academic literature – more precisely and eloquently than I ever could, at that.1 People familiar with the scientific perspective on malaria can therefore easily skip this section, and proceed with the accounts of malaria in the local context of central Uganda. For the readers to whom malaria is but a term for a vaguely known mosquito-borne disease, the chapter provides some contextual information relating to the material I discuss later on. Having an idea about the magnitude of malaria, on a global scale as much as on the regional level, as well as the processes and campaigns that have shaped malaria as we know it today, is important in order to understand the implications of malaria in a confined setting, and for the analysis of the qualitative data I collected in central Uganda. After discussing the epidemiology of malaria and taking a look back at the history of malaria treatment and prevention, I present a statistical overview of malaria – the facts, if one will – beginning on a global scale and zooming in to the local level of central Uganda. At the end of the chapter I brief ly contrast the biomedical understanding of malaria with the local use of the term, and discuss possible sources of bias that can be rooted in this mismatch.

1 For the reader interested in a more thorough account of the structural and political backgrounds to malaria I recommend Randall Packard’s 2007 book “The Making of a Tropical Disease”, as well as Frank Snowden and Richard Bucala’s edited volume titled “The Global Challenge of Malaria” (2014b). For a comprehensive overview of the biomedical and scientific facts on malaria see the 4th edition of Warrell and Gille’s “Essential Malariology” (2002). A well-written and highly readable book on the history of malaria is Desowitz’s “Malaria Capers” (1993).

2. Malaria: A brief overview

Global Perspective Malaria is – or rather, has become – the infamous tropical disease par excellence. Many of the Western travelers seeking advice regarding prophylactic anti-malaria medication prior to their trip to the tropics are most likely unaware that just half a century ago malaria was still endemic in many of the temperate zones of the globe, including for example central Europe and North America (Müller 2011: 22). The story of how malaria has become a disease mainly associated with the tropical world is a fascinating one, telling us much about global health politics, biomedically informed intervention campaigns, environmental change, and the complex interrelation of humans, mosquitoes, and parasites. Randall Packard argues that… “[…] it is critical to view the disease as part of a wider historical narrative in which human actions have encouraged the breeding of malaria vectors, exposed populations to infection, and facilitated the movement of malaria parasites. At the center of this narrative have been efforts to exploit the land through the development and expansion of agricultural production. Other human activities have shaped the epidemiology of malaria; warfare, mining, and the building of roads and railways have all been associated with its appearance or expansion. Population movements, whether voluntary or spawned by the forced recruitment of labor, warfare, or famine, have also contributed in a number of ways to the emergence of malaria in various parts of the globe. Urbanization, particularly in the tropics, has produced conditions that generated malaria transmission. Anopheline mosquitoes have readily exploited the various man-made conditions […].” (Packard 2007: 11) While in the early 21st century malaria is confined mainly to the tropical climatic zones, and most prominently in sub-Saharan Africa, it still is a major disease, accounting for millions of deaths every year. Despite the repeated efforts to eradicate it, malaria remains one of the leading causes of death, especially among young children in many countries on the African continent. Advances in medical research and the development of the promising chemical pesticide DDT,2 as well as the founding of international bodies like the United Nations (UN) and the World Health Organization (WHO) after the end of WWII have sparked hopes among scientists, politicians and health workers, as well as the populations of malaria ridden nations, to win the fight against malaria and wipe out malaria from the surface of the earth – a campaign motivated more by anticipated economic and political gains than by humanitarian ideals (Farley 2008: 158-59). Today we know that the war against malaria has been lost, as billions of people, especially across 2 Dichloro diphenyl trichloroethane.

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Africa, continue to live in malaria-endemic zones. In the light of the above-cited passage of Packard’s book, one has to ask how it is that malaria continues to be a problem in sub-Sahara Africa, more than elsewhere on the planet. Figure 1: Worldwide malaria distribution from the mid-19th century until 2007. Adapted from Mendis et al. (2009: 804)

If the global transmission of malaria, as Packard argues, is the outcome of a wide range of human interactions with our environment, why is the African continent still burdened by the disease, while it is under control elsewhere? One of the many answers to that question is rooted in the poverty that hamstrings many African countries. Malaria is by no means a new disease, and has plagued humans across the globe for millennia. Historical documents from ancient China and India, as well as Assyrian and Greek texts, document the typical intermittent bouts of fever that are likely to describe what we today know as symptoms of malaria (Gilles 2002a: 1). And genetic analysis of the Plasmodium organism shows that the malaria parasite is in fact much older than the emergence of mammals themselves, dating back as far as 30 million years (Cormier 2011: 31). There are about 200 different forms of malaria parasites, which, over the course of time, have become adapted to certain reptiles, birds, and mammals (Rich/Ayala 2006: 125). Of all malaria species, there are five that cause illness in humans: (1) Plasmodium falciparum (2) P. vivax (3) P. ovale (4) P. malariae and (5) P. knowlesi.3 There are various theories as to when 3 P. knowlesi has only recently been recognized as human pathogen. Originally identified as simian Plasmodium parasite specialized to live in macaque hosts, it can also induce malaria sym-

2. Malaria: A brief overview

the Plasmodium parasite became adapted to human hosts, and it is likely that the different species have developed independently of each other (ibid: 137-38). In the case of P. falciparum, it is probable that it evolved around four to ten million years ago, out of a parasite form common to apes (Webb 2009: 27). However, it was probably not until the Neolithic revolution and the dawn of agriculture that P. falciparum infected a large number of the African population. After all, to survive, Plasmodium parasites need a pool of human hosts who are repeatedly bitten by the same mosquito (at least twice) to transmit the parasite from one human to the next (Rich/Ayala 2006: 141).4 Whereas nowadays malaria is confined mainly to the tropics, it was once spread across most parts of the world. Until well into the 19th century the lion’s share of the world’s population lived at risk of malaria infections, reaching as far north as the arctic circle (Mendis et al. 2009: 803, cp. figure one). The term “malaria” in fact stems from Italian expression mal’aria, meaning “bad air”, falsely attributing the feverish illness to the foul smells of the Pontine Marshes south of Rome, where malaria was endemic until the second half of the 20th century.5 Orchestrated efforts to tackle the disease have had tremendous success in some parts of the world, most notably in southern Europe and North America, but also in some parts of Latin America and Asia. Contracting malaria in Italy – or elsewhere in Europe for that matter – has become unthinkable today, and neither do the inhabitants of the Mississippi-Delta or Rio de Janeiro suspect a malaria infection when they are struck by fever. In contrast, travelling from Europe to destinations in much of the so-called global South typically involves prior medical consultation and advice on the vaccinations and prophylactic measures recommended for the country one travels to – more often than not including suggestions for malaria prophylaxis.6 ptoms in humans. However, this rarely occurs and is regionally confined to south-east Asia (Rich/Ayala 2006: 125). Conway and Baum (2002: 351) point out, however, that there are plenty of theories and deba4  tes about the origins of P. falciparum. James Webb, for instance, argues against the spread of P. falciparum simultaneously with the Neolithic revolution (Webb 2017: 486). Currently it is not possible to bring certainty to the subject. This pre-germ-theory European, biomedical terminology, as James McCann points out, links 5  malaria to its wetland ecology. In contrast, most vernacular terms for malaria in Africa refer to the disease’s main symptom – the fever (cp. McCann 2014: 6). This is also the case in Buganda, where malaria is of ten referred to as “musujja”, meaning fever. Personally I am of the opinion that, at least in Germany, these consultations, however reaso6  nable they may be, need to be critically assessed. One is asked questions about one’s intended contact with the “local population”, advised to take precautionary measures, and to avoid food and drinks from untrusted sources. By means of such medical counseling in the country of origin (in the so-called “developed world”), travel destinations in the “underdeveloped world” and, most importantly, their populations, are constructed as medical threats in themselves. I would argue that much of what we know today as tropical medicine is rooted in such a problematic

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The fact alone that malaria has become a disease of the warmer hemispheres does not make it a tropical disease. It is rather the constraints that malaria has posed to colonial powers and their administrations and armies that have made it the number-one topic of tropical medicine, in itself a discipline that developed out of the colonial encounter and late 19th-century imperialism (Chakrabarti 2014: 141-163; Neill 2012: 205; Packard 1997: 281). Mark Nichter reminds us that “[…] the very representation of “tropical diseases” is problematic. It is a carryover from colonial medicine, when diseases common to the tropics were responded to by military-style campaigns enabling economic and military expansion” (2008: 153). During the colonial conquest of Africa by European forces, malaria has repeatedly posed a major challenge to the invading troops, who at times were swept away in their hundreds by the tertian fevers (cp. Chakrabarti 2014: 126-140). In other cases, like the construction of the Panama Canal, it was the workers, brought in from Jamaica, Martinique, and Barbados, who fell victim to malaria in thousands (Harrison 1978: 157-160). No wonder then, that colonial powers were desperately looking for a solution to the problem. Towards the end of the 19th century epidemiologists, physicians, and biologists were eagerly looking to decipher the transmission route of the disease. Malaria is ranked among the vector-borne diseases, as the infection occurs with the bite of a mosquito. What can almost be considered common knowledge today was suspected for a long time and finally proven in 1897 by Ronald Ross, when he succeeded in isolating the malaria pathogens discovered earlier, in 1880, by the French military doctor Alphonse Laveran, from the guts of an Anopheles mosquito. It took another ten years until the complex life-cycle of the Plasmodium parasite had finally been unraveled, revealing the fatal relation between humans, parasites, and mosquitoes (Müller 2011: 24-27).7 The Plasmodium parasite needs both – humans as well as mosquitoes – as hosts in order to procreate. In turn, the mosquito depends on human blood for its multiplication, making the human the victim in this intricate relation.

The parasite’s life cycle The Plasmodium parasites causing malaria among humans are just a few out of the many Plasmodium parasites that cause similar illnesses in other animals. Each genus has, over time, become specialized to certain hosts. Plasmodium falmedical evaluation of the world, and contributes a great deal to the slanted image of the “global South” that dominates in the public discourse. Because of the high number of fatalities due to malaria transmitted by Anopheles mosquitoes, 7  these vectors are sometimes dubbed the “deadliest animal on earth”.

2. Malaria: A brief overview

ciparum, the deadliest of the human malaria parasites, only infects humans, and can only thrive in the salivary glands of around 40 mosquito species of the Anopheles genus (Service/Townson 2002: 59). Plasmodium berghei, on the other hand, causing malaria among mice, poses no harm to humans, is only transmitted by Anopheles stephensi mosquitoes, and only affects rodents (Sinden/Gilles 2002: 31). What they have in common is the complex life-cycle of the parasites, which go through different stages in both the mammal host and the mosquito, changing in shape and reproductive function over time. Understanding the development process and the different life stages of the Plasmodium parasite has racked the brains of many scientists for years. For non-biologists I don’t deem it necessary to understand the process depicted in figure two in detail. However, in order to comprehend how malaria is transmitted, what causes its symptoms and why it can be life-threatening, it is necessary to take a closer look at the processes on the cellular level. The cycle can roughly be divided into five stages and begins with the infectious bite of a mosquito (cp. figure two). While mosquitoes usually thrive on the sugar provided by f loral nectar, female Anopheles mosquitoes need a blood meal, providing them with the necessary proteins in order to produce eggs. Penetrating the human skin, the mosquito injects saliva into the wound, while sucking out blood. Apart from substances that prevent the blood from clotting, the saliva of an infectious bite also contains Plasmodial Sporozoites (1). Typically, an infectious bite contains not more than fifteen Sporozoites, however, this is enough to cause malaria in a person. Once entered into the human blood circulation, these Sporozoites travel to the liver, where they infect cells. Here they divide into multinucleated Schizonts, until the liver cell bursts open, releasing Merozoites into the blood stream (2).8 In the blood these Merozoites enter the Erythrocytes, the red blood cells, within which they mature into their ring forms, the so-called Trophozites, which divide again into multinucleated Schizonts that eventually cause the affected blood cells to burst open, spilling out Merozoites – the cycle continues (3). However, some of the Merozoites that have entered a red blood cell develop into male and female Gametocytes, which are ingested by a mosquito taking a blood meal (4). Inside the guts of the mosquito, the Gametocytes then reproduce by developing Sporozoites, which are released into the salivary gland of the mosquito (5). The next time the mosquito bites a human, the life cycle of the plasmodium is completed by transmitting the disease to a new person or reinfecting the original host.

8 In the case of Plasmodium vivax and Plasmodium ovale infections, dormant Schizonts can develop, which sometimes lead to outbursts of malaria symptoms months or even years after the initial infection.

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Figure 2: Life cycle of the Plasmodium parasite, design by Marlin van Soest

The duration of the plasmodial cycle in the mosquito is highly dependent on the climatic conditions. Depending on the outside temperature it can be between twenty-two and nine days. In the human host the reproduction takes between ten and fourteen days. P. falciparum needs temperatures above 20°C to reproduce, which explains why falciparum malaria is mainly confined to the tropics and sub-tropics (Müller 2011: 48-49, 55-56; Gilles 2002b: 25-27).

The interplay of humans, mosquitoes, and parasites Looking at the Plasmodium cycle helps to explain some of the peculiarities of a malaria infection. For instance, the bursting of the red blood cells is what causes the symptomatic fever attacks typically associated with a malaria. Because it takes some days for the Merozoites to mature into Trophozoites and eventually break up into Schizonts, the fever attacks come intermittently, in intervals of 48 hours, or in the case of a P. malariae infection, after 72 hours. These repeated bouts of temperature increase have earned malaria the monicker “tertian” or “quartan” fever. The potentially fatal nature of the P. falciparum strain is caused by its rapid reproduction and because the Merozoites affect all stages of the Erythrocytes, leading to severe anemia. The other strains of human malaria are less aggressive in that regard and usually do not end in fatality (Müller 2011: 49). Ad-

2. Malaria: A brief overview

ditionally, the remains of the burst blood cells clot, causing stress on the spleen, which often swells. Convulsions, symptomatic of so-called “cerebral malaria”, are caused by affected Erythrocytes that stick to the walls of the smaller blood vessels and block the blood supply in the brain capillaries – another peculiarity of the falciparum strain. The life cycle of the Plasmodium parasites makes it also apparent that it is necessary for the same mosquito to bite twice to transmit malaria from one person to another. A mosquito that only takes a single blood meal cannot transmit malaria.9 On the other hand, it also illustrates that people suffering from a malaria infection form a reservoir of Gametocytes that can be transmitted to other people. Often entire households are struck by malaria at the same time, as the infection is passed on from one person to the other by the same mosquito. This stresses the importance of taking preventive measures against mosquito bites in the case of a malaria infection – especially when sharing a house with other people. But aside from the danger of infecting other people, one risks the possibility of reinfection. Often malaria patients do not show the typical intermittent fevers because they have received several infectious bites, causing Merozites to be released into the bloodstream in shorter intervals. Finally, the various stages the Plasmodium parasite passes through are one of the reasons why there still is no effective vaccine against malaria infections. For example, while a vaccine might be effective against Sporozoites it won’t help once Merozites have developed. So far it hasn’t been possible to develop a vaccine that shows 100 per cent efficacy against one of the parasite’s stages. Modern antimalarial medication is therefore a combination of different active substances that attack different stages of the parasite. Another factor that hampers the development of effective vaccines is the fact that malaria is a parasitic infection and not a bacterial one. Classic immunization by means of exposure to innocuous pathogens is not possible, and the natural variation between parasites within the same strain is making it difficult to develop an inoculant that is universally effective (Müller 2011: 101-02; Webb 2009: 179). However, arguably the most important reason for the slow development of a vaccine is the lack of demand. Malaria is mostly endemic in poor countries, lacking solvent buyers. The market rules to which pharmaceutical companies adhere prevent them from investing in the costly research and accreditation procedures that the production of a vaccine entails (Desowitz 2000: 180). In places in which malaria has been endemic, populations have developed partial immunity against the disease. Probably the best known example is the 9 As Andrew Spielman and Michael D’Antonio remind us: “an old mosquito is your worst enemy” (Spielman/D’Antonio 2001: 97), pointing out the fact that it is not so much the number of mosquitoes and mosquito bites, as the mosquitoes’ longevity that determines at what rate malaria is transmitted from one person to the next.

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sickle-cell mutation, a transformation of the red blood cells, which renders them insusceptible to invasion by Merozoites (Arese et al. 2006: 25-26).10 But even aside from genetic immunity against malaria, continued exposure to malaria pathogens usually leads to a partial immunity, as the body’s immune system is sensitized against the Plasmodium parasites. This explains why children are the most vulnerable to malaria infections, as their immune systems have not yet been sufficiently exposed to malaria. Adults living in malaria-endemic regions usually experience milder symptoms after a malaria infection, and the disease does typically not result in fatality. However, reinfection and heavy exposure to malaria Sporozoites can still cause serious illness among individuals that have developed partial immunity, and lead to cases of complicated malaria. Furthermore, interrupted exposure to malaria leads to a decay of the immunity – people returning to a malaria endemic region after a longer stay in a non-endemic area often experience serious periods of illness after having been bitten by an infectious mosquito (Marsh 2002: 256-57).

Malaria in numbers As outlined above, malaria has long been one of the major health concerns across large parts of the globe, and has been recognized as a serious constraint to economic and colonial undertakings. Efforts to push back the disease started in the 19th century, and as soon as the mosquito as disease vector was discovered, focused on the control and even eradication of those insects. The emphasis on mosquitoes was further pronounced with the development of DDT as a highly effective and cheap insecticide in the 1930s. After the end of WW II, with the founding of international health bodies such as the WHO, the eradication of malaria through widespread, concentrated vector control seemed realistic (Packard 2009: 57-62). While the Global Malaria Eradication Campaign has doubtlessly been effective in many places of the world where malaria has since vanished, it is far from having succeeded in eradicating the disease from the globe’s surface. If anything, the widespread mosquitoes’ resistance against DDT, and the subsequent neglect of malaria after the failure of the campaign, exacerbated malaria prevalence in many places in the “global South” and made malaria one of the most important health threats worldwide. 10 The sickle-cell mutation is genetically handed down. When a person who inherited the sickle cell from one of his or her parents is infected with malaria, the disease symptoms will remain mild, as only parts of the Erythrocytes will be affected. However, in cases where both parents pass the sickle-cell mutation on to their child, it will lead to sickle-cell anemia, a potentially fatal condition (cp. Arese et al.: 2006).

2. Malaria: A brief overview

Packard (2007: 154), among others (cp. for example Webb 2014; Müller 2011), has shown how the “worldwide malaria eradication campaign” has in fact never really been a global effort, as the African continent, in large parts, has been left out. The political situation in many of the African states striving for independence was considered risky, the infrastructure too weak, and the hinterland too inaccessible to facilitate a successful spraying operation. Africa would be targeted at a later stage, when the eradication had been completed elsewhere. Unfortunately, it never came to that, as DDT-resistance had become a widespread problem and the interest and faith in the success of the campaign had become diluted. Malaria in Africa has remained a major health threat, and, until the disastrous epidemic of HIV/AIDS, has been the number-one cause of death in most sub-Saharan African countries (Snowden/Bucala 2014a: vii). However, the problem of malaria has improved somewhat over the past two decades, and with a renewed, joint international effort to roll back malaria, cases have until recently been declining. Regardless, the progress of the last ten years has stalled and malaria continues to affect the lives of millions of people, mainly in sub-Saharan Africa. According to the last data published by the WHO, there have been 219 million malaria cases worldwide in 2017, 92 per cent of which in Africa (WHO 2018: 36). Furthermore, the WHO estimates that in 2017 about 435,000 people worldwide died of malaria, 403,000 of them in Africa (ibid: 42). These numbers show quite dramatically how the problem of malaria today is mainly limited to the African continent. Zooming in on East Africa, the problem of malaria has to be regarded against the backdrop of high levels of poverty and high population growth-rates. Some of the world’s fastest growing countries in terms of population numbers are located in East Africa, and most people still depend directly on agriculture as a source of income. The population pressure has effects on the distribution of malaria. Far-reaching, man-made alterations of the environment – mainly deforestation, cutting of bushland, and the conversion of papyrus swamps into arable farming land – have led to an increase of surface-water temperatures and improved the breeding conditions for Anopheles mosquitoes. Himeidan and Kweka (2012), for example, show how the profound changes in land cover of the last 30 years can be linked to the increased transmission of malaria in the East African highlands. With regard to the expected increases in temperature in the wake of global climatic change, populations in the elevated and so-far malaria-free zones in East Africa are potentially at risk of epidemic outbreaks of malaria in the future (Ermert/ Fink/Paeth 2013: 752). With regard to Uganda, the burden of malaria is high. Malaria is endemic in about 95 per cent of the country, and the entire population, now more than 41 million people, live in high-transmission areas. In 2016 there were around 10 million cases of malaria, of which approximately 12,000 ended fatally, making Uganda a

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country with one of the world’s highest malaria incidence and parasite transmission rates (WHO 2017; Wielgosz et al 2012: 1-2; Yeka et al. 2012: 185). Zooming in further, to the northern edges of Wakiso district, the area where I did research, malaria is indeed one of the major health problems, accounting for roughly a third of outpatient cases.11 Here, at the urban fringe of Kampala, the malaria epidemic has to be regarded against the backdrop of wetland transformations and land redistributions. Between November 2014 and October 2015 a total of 5,241 patients were tested to verify a suspected case of malaria. A little more than a quarter of the suspected cases were confirmed, while 27 tests showed an invalid test result, and in five cases the result was missing (cp. figure three). Figure 3: Malaria test results at the Namulonge HC III between November 2014 and October 2015

Divided into age cohorts, the data show that a suspected malaria case is more likely to be confirmed among younger patients. About 35 per cent of the patients between six and fifteen years of age who came to the Namulonge HC III between 11 This number is based on the patient registers of the Namulonge HC III, the public health ward in my research area. Between November 2014 and October 2015, 16,744 patients consulted the health-ward’s medical staff, out of which 5,241 were tested on the suspicion of a malaria infection. These numbers do not include patients with chronic conditions, who usually visit the HC III on specific clinic days.

2. Malaria: A brief overview

November 2014 and October 2015 with malarial symptoms tested positive for malaria (cp. table 1). According to this trend the youngest age bracket – infants and children up to five years of age – should show the highest percentage of positive malaria tests, however, this is not the case. I separated the infants and children under five years, as they face the highest risk of a malaria infection and are considered a separate target group in national as well as international malaria campaigns. Moreover, seeking healthcare for young children is different from that for adults. Self-medication, alternative medicine, or services from the private-for-profit sector might be preferred sources for treatment of a malaria infection for children. Furthermore, the Ugandan Ministry of Health established so-called village health teams (VHTs), which offer help in the management of malaria cases of infants and children younger than five. Malaria cases which are handled by the VHTs are consequently not ref lected in the data from the public HC III. In his book on malaria among children in Tanzania, Vinay Kamat gives a detailed description of the ways in which (mostly) mothers handle their children’s malaria infection. Table 1: Distribution of test results across age groups at the Namulonge HC III between November 2014 and October 2015 Age/Test result

Negative

Positive

Invalid

Total

‹6

878 (74.9%)

287 (24.49%)

7 (0.6%)

1172 (100%)

Jun-15

1104 (65.06%)

585 (34.57%)

8 (0.56%)

1697 (100%)

16-25

748 (70.23%)

311 (29.2%)

6 (0.56%)

1065 (100%)

26-35

477 (75.96%)

141 (22.67%)

4 (0.64%)

622 (100%)

36-45

285 (80,06%)

71 (19.94%)

0

356 (100%)

He points out that health-seeking behavior must be understood against the backdrop of a range of cultural, economic, political, and social factors (2013: 21). With regard to parents’ decisions to access treatment of their children it is often the interpretation of the symptoms, and what Kamat calls “cultural models of fever” (Kamat 2006: 2948) – local understandings of malarial symptoms; I will return to this in more detail later in this chapter – that guides their choices (ibid: 2957; Kamat 2013: 80-83).

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Figure 4: Monthly distribution of positive malaria test results at the Namulonge HC III between November 2014 and October 2015

When looking at the distribution of suspected malaria cases over the year, it becomes clear that malaria occurs throughout the year, but with significant seasonal f luctuations: it occurs more often during the rainy months of the year, and concurs with the rainfall in the region (cp. figure four). The graph shows a visible peak in verified malaria cases in the months of May and June 2015, just after the heavy rains of the long wet season in April and May have set in. The delay of about six weeks can be explained by the time it takes for mosquitoes to breed and for the Plasmodium parasites to reproduce in the bodies of both mosquitoes and humans. Furthermore, the graph shows that slightly more than half of the malaria cases occur in women (54.4 per cent). However, when looking at the gender distribution of all malaria tests carried out at the HC III, it becomes apparent that 57.9 per cent of the total malaria tests were done on females (cp. figure five). This gender imbalance is further emphasized when disregarding patients of fifteen years or younger – the lion’s share of the patients, and the age groups that typically access healthcare through their parents: of the 2,369 remaining patients, about 65 per cent were female, compared to only 35 per cent male patients (1,540 female cases, 828 male cases, and 1 invalid case). Children are often taken care of by their mothers, who, lacking the financial means, rely on the public healthcare sector for medical treatment. Looking at the younger age cohorts, the gender distribution is in fact more equal, almost 50/50 for the youngest age bracket.

2. Malaria: A brief overview

Figure 5: Gender and age distribution of patients tested for malaria at the Namulonge HC III between November 2014 and October 2015

In contrast, adult women are consulting the health center seeking malaria treatment much more frequently than men, an imbalance which is most pronounced for ages between 26 and 35 years (almost 70 per cent female). It is important to take note that the presented data is derived from a public health facility, and thus does not represent the much larger private-for-profit sector. Nonetheless, there are a number of ways to understand this gender imbalance, some of which I will discuss in more detail in chapter six, where I present vignettes to illustrate the gender dynamics that shape health-seeking and the access to treatment. There are some points, however, that are worth discussing in this chapter. The first impression might be that women are simply more susceptible to malaria than men. That holds true only to a certain extent. While the probability of contracting malaria through an infectious bite is the same for both sexes,12 pregnant women are more prone to developing severe anemia, and thus also more likely to be in need of professional help (Reuben 1993: 474-75). Furthermore, the unequal gender distribution might also be rooted in the fact that in general women visit the health center more often than men. During antenatal care women are screened for all kinds of infections, and doctors as well as nurses are alert to detect 12 Due to their occupations and nightlife, men even tend to be more exposed to infectious mosquito bites than women.

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malaria rather sooner than later, and thus also quicker to test women at the slightest sign of symptoms. What is more, because women often have more experiences with public healthcare, they might also have a more positive stance towards the health center and maybe even know some of the staff. Time constraints are a further reason that might explain why men are less likely to go to the public health center for treatment. Buying treatment from the private healthcare sector is simply much quicker than waiting long hours at the public health ward. However, when I asked for explanations, doctors as well as patients, both from the private as well as from the public sector, mentioned money constraints as one of the first reasons for this phenomenon. Women often simply do not have access to the money needed to go to private health facilities, buy treatment on their own, or use treatment outside of the public sector. Furthermore, it is noteworthy that the age-distribution of the patients with malaria symptoms at the HC III represents the Ugandan population structure quite well. The age pyramid for Uganda has the classic shape that is attributed to a rapidly growing population, with the youngest age group accounting for the largest part of the population, while the numbers decrease the older the agegroups become. In the above graph (figure five), the youngest age group seems to be underrepresented among the malaria patients at the public health ward of Namulonge. This irregularity is rooted in the fact that the youngest age cohort only includes children of up to five years of age, while each of the rest of the groups collect together patients within a given ten-year age-span. Before discussing the local conceptualization of malarial symptoms I will first look into the biomedical analysis of the symptomatic aspects of malaria. Understanding the biomedical view of the bodily processes that occur with a malaria infection explains the complications and lethality of the disease, and is ultimately linked to the local conceptualizations of malaria. In the following paragraphs I will therefore brief ly outline the onset of an infection with P. falciparum and the associated symptoms as understood in the biomedical realm. In the remainder of the chapter I will then return to the aforementioned local conceptualizations of malaria and discuss the disease in a cultural context.

Progression of the disease The symptoms and complications, as well as the onset of the disease, differ somewhat depending on the individual malaria strains. As the P. falciparum genus causes the gravest symptoms and is the most common form of malaria in East Africa, I will limit my (brief) description to this particular strain. Also, it should be noted that my account does not do justice to the depth of the analysis and observations that have been documented in medical literature. However, as I intend

2. Malaria: A brief overview

to understand the disease from an anthropological perspective, I don’t deem it necessary to go deeply into the matter, and will keep my description simple.13 Malaria causes a rather unspecific set of symptoms. However, experiencing a full-blown falciparum malaria must be torture. René Umlauf writes that “[h]aving experienced several times how it actually feels to have malaria […] affords individuals with specific bodily knowledge of the presence or absence of the disease” (2017b: 453, original emphasis). Most prominently people suffer from fever, chills, and breakouts into sweat, usually accompanied by extreme head- and body aches – or, as one of my interlocutors has put it: “malaria can make you feel warm but [at the same time] you really need to sit under the sun, [so] that the sun can shine on you. You can even start shivering, yet its neither at night nor has it rained on you”.14 However, in the case of P. falciparum malaria the fever attacks are often not as pronounced as with the milder forms of malaria, and often do not appear in the intermittent intervals of the tertian or quartan fevers associated with other Plasmodium strains (Müller 2011: 48). Nausea is not uncommon, and patients are reported to throw up. Diarrhea can occur, as does increased blood pressure and dizziness (Warrell 2002: 193-94). The breakdown of red blood cells releases hemoglobin into the bloodstream, which causes visibly darker urine, and leads to an enlarged spleen, which in severe cases is prone to ruptures. Also, malaria patients with an advanced infection usually show signs of anemia, most notably an increased heartbeat, paleness, and shortness of breath. Severe hypoglycemia – extremely low blood-sugar levels – is also classified as a sign of a complicated malaria infection (ibid.). As mentioned earlier, in advanced cases, when the disease affects the central nervous system, P. falciparum can lead to so-called “cerebral malaria”, typically manifested in uncontrolled convulsions and coma. Molecular changes in the infected Erythrocytes cause them to stick to the inner walls of the blood vessels, leading to blockages in the capillaries (Warrell/Turner/Francis 2002: 240).15

13 To the reader who is interested in a more profound description of the progression of the disease I recommend the medical literature on the topic, for instance Warrell and Gille’s (2002) edited volume “Essential Malariology”, which I already cited earlier. 14 During my research I conducted interviews in both Luganda and English, often using both languages in the same conversation. Whenever Luganda was used I relied on the help of an interpreter. Throughout the thesis, when citing from interview transcripts and field notes, I will remain as close as possible to the original wording and grammar used in the transcripts, only correcting or changing sentences when the original would otherwise be unintelligible or unclear. This also reflects my own understanding of the interviews and conversations. 15 There are, in fact, several more reasons causing cerebral symptoms in a complicated case of P. falciparum malaria. For the reader interested in a detailed description I recommend the chapter on “pathology and pathophysiology of human malaria” by Warrell, Turner and Francis (2002).

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The WHO distinguishes between “uncomplicated” and “severe” cases of malaria. An uncomplicated case is usually associated with mild symptoms, and is fairly easy to treat. Patients with uncomplicated malaria are not in a life-threatening condition. Severe malaria on the other hand is potentially fatal, and requires quick and specific treatment. Especially with non-immune patients an untreated infection with P. falciparum progresses quickly into a life-threatening condition. There are reported cases of patients having died within 24 hours after showing the first symptoms (Warrell 2002: 194). Apart from the infection with Plasmodium parasites, curing malaria usually also entails treatment of the associated complications, such as extreme fever, anemia, neurological complications, and low blood-sugar levels. Regardless of the severity of malaria symptoms, partial immunity, multiple infections, and cross-infection with other diseases sometimes make it hard to judge whether one indeed suffers from malaria, or if the experienced maladies are rather symptomatic of another disease. Adding to that comes the fact that in endemic areas malaria rarely causes life-threatening conditions in adults (Marsh 2002: 252).16 In contrast to the image portrayed by international health bodies, in endemic areas malaria is often not perceived as a “killer disease” and therefore often not taken seriously (cp. Kamat 2013: 81). Especially in the early stages of a malaria infection the disease symptoms often remain mild, and can be easily misinterpreted. This holds even more true for toddlers and young children who cannot articulate their complaints. It is left to the caretakers to judge whether the symptoms indeed point to a malaria infection or are merely caused by a bacterial infection. Writing about malaria among children in Tanzania, Vinay Kamat observes that “[m]others commonly believe that they are dealing with an ordinary fever and not malaria or any other serious illness complicated by fever. Hence they extend their wait-and-watch period” (ibid. 2013: 102). Citing one of the mothers he interviewed, Kamat illustrates how a child’s behavior can easily be misjudged: while being feverish now, the child is playing around just a moment later (ibid: 120). I made similar observations in Uganda myself. Unless the malaria symptoms become more severe, it can be hard to tell malaria from a less harmful infection. From a biomedical perspective, the only way to rule out a malaria infection is by testing the blood of an ill person in order to find out whether the Erythrocytes are showing signs of the blood-stage of the Plasmodium parasite (Umlauf 2017a: 226).17 16 It is important to note that while adults who have acquired specific immunity might not fall seriously ill with malaria, they still play an important role in the transmission of the disease, as they remain carriers of the parasite. 17 Alternatively, one can deduce the presence of malaria parasites in the patient’s blood by detecting the presence of antigens in the blood sample – usually by means of the now-common rapid diagnostic tests, so-called RDTs.

2. Malaria: A brief overview

Malaria testing and treatment of clinical malaria Classically, a malaria test is done by means of a microscopic blood analysis. For that, a drop of blood from the suspected malaria patient is smeared on a microscopic object slide, dried, and then stained for better color contrast. Afterwards the slide is examined through a microscope. In case of a malaria infection one expects to see red blood cells infected by Merozoites. The number of the affected blood cells is then estimated and classified on a three-level scale, indicated by “+” symbols, in order to judge the severity of the infection (and make decisions about the following treatment). All in all, microscopic malaria diagnosis can be performed within half an hour. In addition to the necessity of a microscope and electricity, it also takes a fairly well-trained and skilled lab technician to carry out a microscopic blood-smear analysis– conditions that are unfortunately not easily met in East Africa.18 This is one of the reasons that malaria treatment is often prescribed on clinical diagnosis alone: based on the reported symptoms and examination results, rather than on diagnostic laboratory tests. One of the major advances in the field of malaria control over the last two decades has been the large-scale introduction of rapid diagnostic tests (RDTs), which allow for a fairly quick and easy malaria diagnosis by relatively unskilled medical personnel. Furthermore, the portability of the tests makes the laboratory redundant and opens up the possibility of testing people virtually anywhere – socalled point-of-care testing (cp. Chandler et al. 2011: 937-38). Testing is done by applying a drop of blood to a test strip, which is prepared with dye-labeled antibodies which react with parasite antigens. With the help of a buffer f luid the blood-antibody mix is drawn across the test strip, where a chemical reaction will result in the appearance of one or two test lines – one indicating that the antibodies have traveled correctly across the test-strip, the other indicating the presence of antigens. Carrying out the test takes fifteen to twenty minutes and the results are easily interpreted (Umlauf 2017a: 60-63). However, RDTs come with a number of drawbacks. First of all, RDTs provide only an indirect diagnosis of malaria. Rather than proving the presence of Plasmodium parasites in the patient’s blood, they merely indicate the presence of antibodies, from which the presence of parasites can be inferred. What is more, the blood of people who are frequently exposed to infectious malaria bites often contains traces of antigens, whereas there is no detectable parasitic load. Consequently, in some cases RDTs wrongly show a positive test result. Furthermore, they are generally more expensive than microscopic blood smear analysis. RDTs come in the form of pre-produced plastic cassettes, and have to be discarded after 18 See Hommel (2002) for a detailed manual explaining how to carry out microscopic blood-smear analysis and identify a malaria infection.

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use. In contrast, microscopic slides are cheap to produce and can be reused countless times. Regardless of these drawbacks RDTs are generally recommended by the WHO and other international health bodies as a diagnostic tool for malaria infections in areas where microscopic blood analysis is not available. In the context of increasing parasite resistance against the most common and cheap antimalarial medication, the issuing of medicines based on clinical diagnosis alone has been proscribed in many countries, including Uganda. This regulation of the prescription of antimalarial drugs only after prior diagnosis by means of blood analysis bears far-reaching consequences for patients on the ground. In his book “Mobile Labore” René Umlauf (2017a) argues that RDTs are yet another step in the medicalization of treatment, and an additional technological component in the management of malaria. Depending on the perspective, the introduction of RDTs does not have only positive consequences for the different actors involved in the diagnosis and treatment of malaria. For patients the diagnosis of malaria and access to treatment has been further complicated, as antimalarial medication is only prescribed after positive diagnosis. Moreover, a negative test result reveals the limits of public healthcare, as medical staff are forced to refer patients to larger/private healthcare facilities in order to diagnose the cause of the fever symptoms and find the proper treatment for the disease. As I will show in the coming chapters, the public healthcare sector in Uganda suffers from a bad reputation, partially also because of the regulations linked to the introduction of RDTs.

Malaria treatment Once diagnosed, clinically or by means of blood testing, malaria is usually treated with biomedical pharmaceuticals. There are a number of treatment options, depending on a number of factors, most importantly the severity of the symptoms and the age of the patient. In chapters five and six I will investigate the available treatments in central Uganda and the related costs more thoroughly and more critically. For the current chapter it will suffice to keep the description limited to the historical and epidemiological background of the common treatments. Long before the cause of malaria was identified, effective treatments were known. In the aftermath of the colonial conquest of South America, the Spaniards discovered what the indigenous peoples had known before: the bark of the cinchona tree had antipyretic properties and provided a cure to the cyclical, tertian fevers that raged in Europe as well as in the Americas (Webb 2009: 94; cp.

2. Malaria: A brief overview

Gänger 2016).19 In China the plant Artemisina annua has long been appreciated for its medical qualities, among which is the treatment of feverish diseases. And across Africa there are many known plants that have been used for generations to treat malaria (cp. Hsu 2009, and Andrade-Neto et al. 2004). Modern, biomedical antimalarial medication is often based on derivatives of these medicinal plants. Most prominently, quinine, isolated from the cinchona bark, has for much of the 20th century been the go-to antimalarial drug that biomedical doctors resorted to in order to treat malaria. In fact, during the period of British and Dutch colonial conquest in Africa and Asia, the limited resources of cinchona bark significantly shaped the possibility of colonial endeavors and spurred the search for alternative antimalarial medication (Chakrabarti 2014: 126-127). Once quinine, the active component of the cinchona bark, had been isolated, it quickly became the active ingredient of many common treatments against malaria. Later it was replaced by the related chloroquine, which could be synthesized and showed fewer side-effects. Since the parasites developed resistance to chloroquine and its derivatives, artemisinin-based combination therapies have become the recommended treatment for P. falciparum infections in Uganda and elsewhere, while artesunate or quinine injections are the drug to fall back on in case the first-line treatment fails (Ministry of Health [MoH] 2016: 196).

Local understandings of malaria The biomedical understanding of malaria leaves little room for interpretation and is constructed as a factual matter, which can only be discussed on the grounds of new insights and findings from scientific experiments. Over 150 years’ worth of malaria research has produced a clear-cut image of the disease: Malaria is caused by the injection of Plasmodium parasites into the blood cycle through the bite of an infectious Anopheles mosquito; blood analysis is needed in order to verify a malaria infection, and only a limited number of medicines with very specific chemical ingredients can be used to treat a malaria infection. Malaria, if left untreated, can cause life-threatening conditions, and in order to prevent malaria, one has to control the mosquito vector. As I will show in the following paragraph, this biomedical perspective on malaria contrasts, at least in parts, with the common view of my respondents. The discrepancy between the biomedical and the popular notion of malaria is important when it comes to the analysis of treatment-seeking and the management of 19 The name “Cinchona” is presumed to be in honor of the countess of Chinchon in Peru, who suffered from tertian fevers. A local physician treated and cured her illness with the barks of the “fever-tree” (Chakrabarti 2014: 25).

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malaria. As we will see, the way in which people deal with malaria is partly rooted in their particular understanding of the disease, its implications, and ultimately the threat it poses. This, of course, goes for all diseases, and holds true for people across the globe, not only for the case of central Uganda. However, as I will argue, the potentially fatal consequences of a malaria infection make it particularly relevant to look at the popular perspectives on and conceptualizations of malaria.

Plurality of meanings, syncretic models On a hot day in 2014, still during the exploratory phase of my research, I joined Peter, a friend and my “key informant”,20 and his colleagues at their work in a swamp where they maintained rice plots and carried out assisting tasks that arose in the context of a field-experiment that was part of a study under the umbrella of the GlobE research project. During a break Peter pulled out a plastic bottle with water from his bag and quenched his thirst. Being thirsty myself, I asked for a sip. He laughingly denied my request: “This water is not for you; I took it from the pond down there. It’s not boiled and will only give you malaria”. I argued that I doubted that I would get malaria from drinking unboiled water, but pointed out that I agreed with Peter that I should probably not drink the water from the pond, as I could imagine catching typhoid or another water-borne disease from it. Peter then explained to me that in Luganda, the language spoken in central Uganda, typhoid was referred to as “malaria” as well. The anecdote is interesting for several reasons, starting with Peter’s preoccupation with regard to my health, and his concern that his water might not be suitable for me. My body seems not to be steeled against the perils of unsafe drinking water – it does not need to be. Unlike Peter and his colleagues, I can afford the luxury of bottled water. In the next chapter I will elaborate more on my positionality; here I want to focus on the implications of Peter’s statement with regard to his understanding of the term malaria. The conversation struck me, as it made me aware that what I understood as malaria was different from the meaning of the term as it was used in Luganda. In Uganda, and I assume elsewhere in East Africa, the English term “malaria” is commonly used generally to describe feverish maladies that have little to do with the biomedical definition of the term, other than the unspecific set of symptoms. Head and body aches, fever and diarrhea can signal a “malaria” infection. In fact, as I have outlined earlier, in the healthcare ward, a 20 For the sake of the anonymity of my interlocutors I use pseudonyms throughout the text. While Peter was indeed to me what in anthropology is commonly referred to as a “key informant”, I am critical of the term. In the third chapter I will critically assess the implications of crediting people as “informants” or “assistants” (cp. Sanjek 1993: 13).

2. Malaria: A brief overview

clinical malaria diagnosis would be based on much the same symptoms. In contrast to the clear-cut pathology that underlies the biomedical definition of malaria, the disease remains surprisingly ambivalent when it comes to the description of its symptoms. As I have described earlier in this chapter, the range of clinical symptoms associated with a malaria infection is wide, and overlaps with the symptoms of other diseases. It is for this reason that in the biomedical sector blood analysis is usually done to rule out malaria as the cause for the symptoms, rather than to confirm a suspicion. Hence, the local use of malaria as an umbrella term for a range of ailments should not be too surprising. Following the biomedical understanding of malaria, the symptoms associated with a malaria infection could potentially be caused by a range of pathogens. When it comes to the local understanding of the disease, this ambiguity is translated in the broad use of the term malaria: from the standpoint of many of my interlocutors, it is the term malaria that can describe a variety of symptoms, rather than the disease which manifests itself in a combination of signs. Like with many diseases there is more than one way to express malarial symptoms in Luganda. For example, musujja, meaning “fever” in English, describes merely raised body temperatures; okulumwa omutwe refers exclusively to headaches; and kuddukana describes diarrhea, which many people suffering from malaria experience. Musujja gw’en sili, roughly translating to “mosquito fever”, is probably the most congruent with the biomedical definition of malaria, as it connects the feverish symptoms to an infectious mosquito bite. However, in this case too the term refers only to the fever associated with malaria. The symptoms associated with what, in the biomedical realm, is classified as “severe” malaria – convulsions, anemia, low blood sugar – all have their dedicated Luganda translation.21 However, not everyone merges the combined symptoms under an overarching term. This, as I will show in chapter six, has implications for treatment-seeking and the management of the disease. Furthermore, with infants and young children, it becomes difficult to diagnose symptoms such as head or body aches, as children are often too young to articulate their complaints. In these cases, parents or guardians diagnose the disease based on their observations, rather than the personal illness experiences of their children. The unspecific terminology and the discrepancy between my own view of malaria and that of my interlocutors posed an obstacle in the course of my research. What were people referring to when they talked about “malaria”, especially in a sentence that was otherwise worded in Luganda? What did they mean when they 21 Convulsions are translated as yabwe; anemia in Luganda is okugwamu omusayi; hypoglycemia can be loosely translated to sukaali. Furthermore, obutagala kulya refers to a loss of appetite, nakanyamma to body aches; all are symptoms that are typically associated with a malaria infection.

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used the word “musujja”? Were they talking merely about fever, or did they specifically mean symptoms that matched my biomedical understanding of the disease? Although I myself did not master Luganda sufficiently to be able to understand what was said around me, and relied on the help of a translator in order to carry out interviews, I soon took notice that people frequently made use of English terms in their everyday conversations. But what did that mean when it came to malaria? Did the English term include the biomedical understanding of the word, or was it bestowed with the local meaning of the term? How would my interviewees understand the term when I asked them about “malaria”? In chapter three I will discuss in more detail the techniques I used in order to make sure that my interlocutors and my assistant, as well as myself, spoke about the same concept, and how I dealt with the confusion that could arise. At this point it might suffice to take note that the difference in meaning, and the diverging vocabulary used to to express an illness, determine a disease, and articulate an illness experience pose a potential source of bias and misunderstanding. It is worth considering this misunderstanding when it comes to the evaluation of international campaigns to drive back malaria.

Perceptions of malaria: a “killer disease”? Already well into my research, when debriefing after an interview, my assistant and translator suggested we should ask our interlocutors about their thoughts on malaria as a “killer disease”. The advice seemed odd to me at first: every year hundreds of thousands of people die because of malaria; I couldn’t imagine anyone not thinking of malaria as a serious and potentially lethal disease. My assistant explained to me that his own notion of malaria was not that of a deadly disease, and while he knew that children died of malaria, he did not regard malaria as one of the major health problems in Uganda. There was HIV, Tuberculosis, Ebola, or the related Marburg Virus, which were all “killer diseases” in his view, but certainly not malaria. In his cautious and polite way he hinted to me that the people we interviewed might have similar views. After our conversation I added “malaria: a killer disease?” as a point on my interview guidelines, and, as it turned out, my assistant’s hint proved invaluable to my research, and changed the way I would look at malaria in the local context. Despite the high death rates from malaria in central Uganda, the disease is typically not regarded as a life-threatening condition. On the contrary, the everyday character of the disease downplays its potential severity, and what’s more, the fact that among adults malaria rarely develops into life-threatening conditions undermines the claim that malaria is one of the leading causes of premature death in Uganda. It is mainly young children and people with a compromised im-

2. Malaria: A brief overview

mune system, or people already suffering from another health condition, among whom a malaria infection can develop into a severe illness. Furthermore, malaria is a very common illness in Uganda, as across much of sub-Saharan Africa; most people have experienced the disease at least a couple of times during their lives, and a good number of my informants mentioned falling ill with malaria around once a year, on average. Put in that way, malaria has much in common with the typical cold that I know from Germany – a sickness I would not exactly classify as “killer disease” either. The commonplace nature of the disease, combined with its unspecific symptoms (or rather, the unspecific meaning of the term “malaria” as it is used in the local context) take away much of the sense of threat that might otherwise be associated with it. The fact that malaria is often not perceived as a deadly disease is partly also due to the interpretation of the symptoms associated with severe malaria. Especially the convulsions and cramps typical of cerebral malaria tend to be regarded as signs of spirit possession, which needs to be treated outside the biomedical healthcare sector. In fatal cases the death is then not attributed to malaria but rather to so-called “witchcraft” or localized disease etiologies. Contrary to the local perception of malaria as an everyday disease, the Western perception, including my own, is one of a dangerous, exotic, and complicated disease that is the cause of countless deaths every year. I do not think that either of the two perspectives bears more truth than the other, and would argue that one always has to contextualize a disease and its perception in order to understand people’s view of it. Disease is always shaped by local circumstances and thus viewed differently according to those local contexts. As I have outlined in the first half of this chapter, Western medical sciences have constructed malaria as a lethal, tropical disease. The fact that the Western pharmaceutical industry earns a lot of money from the prescription of prophylactic medication provides a simple economic interest in the upholding of that image. And what’s more, malariologists would probably agree: malaria is indeed a dangerous disease for Western travelers, because of their lack of immunity against P. falciparum. On the other hand, however, the local perception of malaria equally makes sense if viewed in context. Malaria is an everyday phenomenon, which probably most of the people have survived at least once or twice during their lives. People experience malaria in their daily lives, and see how it can be overcome. And as I have explained earlier, the people who, from a biomedical point of view, have died of malaria, might, in the eyes of Ugandans, have rather died from other ailments: spirit possession, degedege, or other diseases. And what would it mean if in one’s everyday life, one would be constantly exposed to a “killer disease”? The day-to-day experience with malaria has led people to develop strategies to deal with the disease – both culturally as well as genetically – and to learn to live with it, rather than in spite of it. From that perspective, malaria is indeed not a “killer disease”, but instead simply an ordinary health risk.

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The assessment of the risk of malaria has also to be regarded against the backdrop of the immediate presence of death in people’s everyday lives. Measured against my own experience with death, I was struck how often I was confronted with obituaries and notices of someone’s death. During my fieldwork luckily none of my acquaintances has passed away, nonetheless I was repeatedly told about a death case in someone’s wider family, among them, unfortunately more than once, also children. More often than not it was not clear nor important what the cause of death. Malaria, so it seemed, had not been the case of death in any of the cases. In light of this, the evaluation of malaria as a relatively harmless disease makes sense. Considering the large number of death cases due to unknown causes, or causes unrelated to health issues, the fatality of malaria might indeed seem negligible. It is an easy guess that the perception of malaria as an everyday disease, rather than the image of a “killer disease” that dominates the Western narrative about malaria, has an impact on the way people manage a malaria infection and deal with the disease. In the remainder of this thesis I will look more closely into treatment-seeking and the management of malaria among smallholders in Uganda. As I will show, a great part of the local conceptualization of malaria is linked to the perception of the disease as a minor health threat. In a wider sense, the discrepancy between the Western image of malaria and the localized notion might add to the persistence of malaria as one of the important diseases in sub-Saharan Africa. In the conclusion I will discuss whether the local perception of malaria is adequately incorporated in the international efforts to roll back the disease, and how it could help to make the campaign against malaria more effective. Furthermore, as I will argue, in order to make sense of the malaria epidemic in the 21st century, one needs to contextualize the disease by understanding it against the backdrop of the local conditions. Apart from local policies, ecologies, and socialities, this must also include the local conceptualization and understanding of the disease. Moreover, in order to critically assess the role of biomedicine and its hegemonic position with regard to the control, prevention, and treatment of malaria, one has to contrast it against other perceptions of the disease, its threat, and its implications. The diverging images of malaria that are prevalent in central Uganda illustrate the statement raised in the introduction of this book quite well: malaria has many faces, and while it is a thoroughly researched disease, it remains mysterious and surprisingly unknown.

“He said that if culture was a house, then language was the key to the front door, to all the rooms inside. Without it, he said, you ended up wayward, without a proper home or a legitimate identity.” Khaled Hosseini (2013: 362) “One dirty little secret of the discipline is that most anthropologists do not attain ‘near-native’ competence in the languages of the people they study […].” Akhil Gupta (2014: 398)

3. Ethnographic research in Uganda: Language and ethics in the field The discussion of the applied methods and its ethical implications is crucial to the understanding of every research and its results – certainly with regard to anthropological work, which, due to its specific, often qualitative methodology, gives a central place to its research techniques. At least since Malinowski, the ethnographer personifies the scientific measuring device: the anthropologist observes and participates in social interactions in order to understand an alien viewpoint, often termed “foreign culture”. The anthropologist is not only an observer, but also an interpreter of “culture”, who, by engaging with people during a period of long-term research, analyzes their way of dealing with the world. Anthropology’s qualitative approach, first and foremost through participant observation of, and long-term engagement with, “the field” (for lack of a better term), comprises a set of extremely suitable tools when it comes to the understanding of social lifeworlds. However, rarely can we rely on qualitative accounts alone. Much as in most anthropological research, I too, experimented with different methods and research techniques, both qualitative and quantitative, with participant observation at the core. I tried my best to keep diaries, field notes, and jottings, as advised in most handbooks on the methodology of Anthropology. In my thesis I draw from infor-

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mal conversations as well as extensive semi-structured interviews and group interviews. I used participatory methods, such as free-listing, mapping, and transect walks, and struggled with focus-group discussions.1 A colleague from the GlobE project kindly allowed me to add a section on malaria to the household survey he facilitated, and I was able to acquire statistical data on malaria treatment at the health center in Namulonge. I consulted experts on land tenure, health care, and health professionals. I read through reports and historical accounts. Most of all, however, I tried to spend as much time as possible with people from my research area, in order to understand their view of the world they were living in.

Initial considerations The epistemological implications that arise out of such qualitative fieldwork and long-term engagement of the researcher with people of a foreign culture make it imperative to discuss the applied research techniques and methods, certainly in Anthropology, whose scholars have, over the course of the last three decades, raised concerns about the subjectivity of the ethnographer in the process of knowledge production (cp. for example Clifford 1986; Spiro 1996). As the discipline’s name implies, anthropological work deals with humans. Next to the discussion of the research methods, an anthropological text should therefore also include a ref lection on the ethical implications of the research – more so in my case, as a scholar at a German university. Anthropological research in Germany is still, for good reasons, not subject to institutionalized, ethical reviews. Outside of Anthropology, the ethics of research with and on humans has been debated extensively, most prominently in psychology and medical sciences, and has led to the establishment of institutional review boards (IRB) that issue ethical clearances for research proposals. Anthropologists have, however, expressed skepticism over the practicability and feasibility of ethical reviews of research proposals for anthropological research, and, especially in Germany, have been reluctant to institutionalize ethical review processes. Ethnographic research cannot be adequately planned in advance, or so it is argued, and researchers need to adapt their research questions, techniques, and methods to unforeseen research contexts and situations. Having subsequent changes of the research proposal approved by a review committee is hardly possible, and would seriously limit the re-

1 It proved very difficult to hold a focus-group discussion while relying on a translator. In my attempts I was repeatedly reminded of Russel Bernard’s book on research methods in Anthropology: “Leading a focus group requires the combined skills of an ethnographer, a survey researcher, and a therapist.” (Bernard 2011: 175).

3. Ethnographic research in Uganda: Language and ethics in the field

searcher’s f lexibility to adapt to specific research contexts (Dilger 2011; von Unger/ Dilger/Schönhuth 2016). As Dilger, Mattes, and Huschke write: “Knowledge production in, and the epistemological foundations of, anthropology and ethnographic research are fundamentally different from research in the natural or other social sciences and humanities, as they rely exactly on that level of unpredictability (and potential deviance) of the research process that is not covered (or even desired) by narrow definitions of ethical protocols, discrete sampling, or the goal of obtaining quantifiable and reproducible knowledge.” (Dilger/Mattes/ Huschke 2015: 3) Nonetheless, and despite the criticism, for ethnographers in the Anglophone world it has become mandatory to pass their research proposals through IRBs before research can start. In Germany this is still not the case. Ethical clearances for anthropological research are not mandatory,2 and neither are there institutionalized review boards installed by the German Anthropological Association (DGSKA – Deutsche Gesellschaft für Sozial- und Kulturanthropologie). At German universities level, ethical committees are usually only found at the medical faculties (von Unger/Dilger/Schönhuth 2016: 2, Dilger 2015: 1). However, the debate about ethical implications of anthropological research and the ethnographer’s responsibilities is taking place in Germany as well. For example, the DGSKA released ethical guidelines for anthropological research in 2009 (cp. Hahn/Hornbacher/ Schönhuth 2008).3 While this declaration is hardly comparable to an IRB, and does not constitute an obligatory “pre-fieldwork checklist” for anthropologists, it does, however, encourage a conscious evaluation of the ethical implications of ethnographic research, and provide ground for a much-needed discussion about the ethics of fieldwork, without hampering the f lexibility and ref lexivity necessary for ethnographic research. Since ethnographic studies in Germany are not subject to prior ethical approval, a critical ref lection on research methods becomes all the more important. Precisely because the questions that guide the research, and the techniques used to answer them, are likely to develop during the research process, an open discussion is needed. What are the implications of doing research in a foreign setting,

2 Unlike empirical medical research, or psychological experiments with human subjects, which have to pass ethical reviews, including in Germany. 3 The document titled ‘The “Frankfurt Declaration” of ethics in social and cultural anthropology’ was published in 2009, and can be downloaded from: https://www.dgska.de/dgska/ethik/. Individual workgroups within the DGSKA have published ethical statements earlier than that: the AG Entwicklungsethnologie released their declaration in 2001, followed by the AG Medical Anthropology in 2005.

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and what are the – perhaps unintended – side-effects of one’s research? How does a researcher perceive her field, and how might the anthropologist be perceived by his so-called informants? And, most importantly, what impact does research with humans have on the studied communities? In this chapter I will address these questions. After outlining my approach to anthropological research and the way in which I carried out my research, I critically ref lect on my work and look at broader questions that arise out of this ethical evaluation. I will discuss the techniques I used to collect the data that provide the main body of this book, including a review of the – sometimes unexpected – circumstances that informed and constrained my research. My positionality as researcher, as perceived by myself as well as through the eyes of the people I interacted with, will be included in this discussion, as well as the implications of working with a research assistant, and the role of the assistant in the processes of fieldwork, data collection, and knowledge production. Methodology and research techniques also offer insights to the ways in which my research assistants and I constructed “the field”. Finally, the ref lection will include ethical and moral considerations that came up during the research process.

Interdisciplinary research projects and their methodological implications This book developed out doctoral thesis which I wrote in the context of a larger, multidisciplinary research project on wetlands in East Africa funded by the German Ministry for Education and Research (BMBF – Bundesministerium für Bildung und Forschung). The project’s goal was to investigate possible agricultural uses of wetlands, with special attention to several criteria, among which was the health implications of wetland uses. Within the project there were a number of positions for doctoral as well as master students, who had the chance to develop a thesis within the framework of the larger project. Research would be carried out in close cooperation with a number of East African partner organizations in four countries – Rwanda, Tanzania, Kenya, and Uganda – as well as representatives of the respective governments. The decision to participate in a project financed by third-party funds in Germany had far-reaching methodological implications, which, at the time, I dismissed as minor setbacks. With the ongoing bureaucratization of academic research projects, certainly those integrating scientists from different disciplinary as well as institutional backgrounds, research agendas become increasingly oriented towards the production of results to meet the donor’s expectation. Financing is granted for a limited amount of time, provided that the pre-decided milestones have been met, and the evaluation has otherwise been positive. On itself

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this procedure is reasonable, and should promote good academic practice as well as productive research. However, there are certain drawbacks to the evaluation process that hinder the facilitation of thorough research, especially with regard to the limited time frame within which research has to be completed. What might make sense for other academic disciplines does not necessarily apply to Anthropology, with its long-term research work and in-depth engagement with the field site. An abundant time frame is essential for the preparation and implementation of sound ethnographic research and the production of good research results. Limiting the period for which funding is granted conf licts with the demands to produce scientifically thorough research findings. Gerd Spittler (2001: 22) argues that, due to changing funding and employment regulations, time is increasingly becoming a scarce resource for anthropologists in Germany, especially at the beginning of their careers. While the fact that Anthropology in Germany is increasingly integrated into multidisciplinary, government-funded research programs is generally a welcome development, there is at the same time less money for extensive PhD projects. Unlike in, for example, the United States where a PhD study in Anthropology typically can take up to nine years (ibid: 22), the funding budget for qualitative research projects simply does not allow for this kind of extensive research venture. There are some methodological implications that come with it, some of which I want to discuss here. I’m mainly concerned with the lack of time and funding for language training. While sufficient language capacity should be a fundamental prerequisite for anthropological research, especially with regard to its core methodology, participant observation – how is one to participate in people’s daily life, if one is not even able to communicate with them? – it is simply not feasible to master a foreign language, a grammatically very distinct one at that, within the time limits of a modern PhD study. This is probably one of the drawbacks of “mainstreaming” Anthropology, by incorporating it into larger, multidisciplinary research agendas.

Qualitative research in a foreign research setting: the issue of language The researcher’s language proficiency is rarely discussed in anthropological literature – and certainly not the lack thereof. While it is at times possible to draw conclusions about the language skills of anthropologists from their ethnographic texts, the language capacity of the researcher, and, even more importantly, the use of an interpreter, is typically not explicitly mentioned in the methods or ref lection chapters of anthropological monographs. Anthropologists have made long-term fieldwork and the fieldworker’s close engagement with her field site,

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the central and distinguishing element of their discipline. Hinting at problems regarding the communication with one’s subject matter undermines the credibility of the researcher: how is one to decipher peoples’ social and cultural structures, when one cannot even master their language? To anthropologists working in the Malinowskian tradition, language competence is a must. Pointing out the lack thereof is undercutting one’s authority as ethnographer and cultural expert (Bank 2008: 572; Borchgrevink 2003: 113-15; Tanu/Dales 2016: 353). Regarding the ref lexive turn the discipline went through during the 1980s and 90s, the scant discussion of language capacity within anthropology is surprising to say the least (Middleton and Cons 2014: 280). It would be naïve to assume that all ethnographers are in fact f luent in the languages spoken in their research area – the above mentioned time constraints of the common research project make it hard, even for linguistically-gifted people, to master a foreign language to the required level – which stresses the need to elaborate more on the topic and its methodological implications (Gupta 2014: 398). In an attempt to break the silence on the epistemological implications of language proficiency and the role of interpreters in anthropological fieldwork, Axel Borchgrevink calls for a re-evaluation of the central assumptions about anthropological fieldwork and an open discussion of the use of language in the field (2003: 115). Relying on research assistants and interpreters is a common strategy to cope with lacking language skills. This does not necessarily have to be a bad option; neither does it automatically diminish the quality of the research. It does, however, call for careful (re)consideration of the applied methods and research strategies. In my own case, I was given funding for a relatively generous period of 40 months, within which I should plan and carry out research, and complete a thesis. Of these 40 months, twelve were reserved for fieldwork, leaving little time to master Luganda, the predominant language spoken in my research area. Although I took some Luganda classes and tried my best to improve my vocabulary while in the field, my level of proficiency in Luganda remained relatively superficial. Whereas my rudimentary language knowledge did help me to “break the ice” when meeting new acquaintances and stand out from the mass of average bazungu 4 – more often than not people seemed positively surprised, even thrilled to hear me struggle putting together a phrase in their language – I was by no means able to sustain a meaningful conversation in Luganda, let alone to carry out an interview. Whereas English is not my first language either, I am considerably more f luent in it than most of my informants. English might be Uganda’s official language, but it is not the most spoken language in the country. If people speak it at all, it is mostly only their second or third language, and not used much in typical everyday 4 The Kiswahili term muzungu (plural bazungu), describing a white person, is widely used across Uganda.

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life situations in my research area. Few of the people I spoke with had completed more than primary education (if at all), and spoke only broken English at best. It makes a world of difference whether one approaches people in a language they are f luent in or a language they struggle with, and which they might feel they ought to know better. I knew that conducting research in English would only be possible in a few settings and with a select group of informants. Not being able to rely on English as a research language had far-reaching consequences in my case. From the outset on it was clear that it would not be possible for me to completely submerge myself in the society around me, and that I had little choice other than relying on an interpreter in order to conduct research. My language limitations therefore forced me to think more about my role as researcher, my positionality in the field, and the ways in which I interacted with my informants. I will get back to this point and my ascribed role as muzungu later on in this chapter.

Working with an interpreter Although often frowned upon in anthropology, relying on an interpreter during ethnographic fieldwork is not necessarily bad anthropological practice (Palriwala 2005: 164). It does, however, call for careful consideration of the methodological and epistemological implications for one’s research. Borchgrevink identifies four domains in which the inf luence of the interpreter is of particular significance. He lists (1) access to information; (2) the communication process; (3) translation itself; and (4) the assistant’s inf luence on the anthropologist and her fieldwork (Borchgrevink 2003: 109). In the following paragraphs, I want to elaborate more on these points and connect them to my own research experiences. To start with, working with an interpreter raises issues concerning the ways in which information is accessible, and which methodological tools can be used. For example, it calls into question to what extent participant observation is a feasible method. At this point, one might want to take a closer look at participant observation as a methodological tool in Anthropology (and other academic disciplines). The method has over the last 100 years or so become the central method of anthropological research by means of which anthropologists seek to access culturally distinct groups and understand their social practices. Participation in social interactions is the essential element that differentiates the method from other forms of observation. As Spittler points out, mere observation is often confined to measurements and counting, most prominently practiced in the natural sciences (2001: 15). Observation as a methodological tool can also be used in ethnographic research. For example, I observed the prices of malaria treatments, and I measured the sizes of land plots. I counted the number of

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malaria tests carried out at the local health center and made note of their results. Equipped with a GPS device, I measured the distances from people’s homes to the closest dispensary, and with a camera I took photographs of medicinal plants. This kind of observation doesn’t differ much from the methods applied in natural sciences (except of course in terms of quality and scope), and is usually perfectly feasible with or without the help of an assistant. It becomes more difficult if one does not want only to count or measure things, but instead to observe social behavior. Without the necessary language skills the help of an assistant is inevitable for such observations. For example, recalling her research experience in the Netherlands, the Indian anthropologist Rajni Palriwala argues that relying on an interpreter, she could (almost) only observe interactions that took place between herself, her translator and her informants, while missing out on the interactions that did not include her interpreter – simply because she could not understand what was being said (Palriwala 2005: 157-159). When one depends on the interpretations of an assistant, it becomes difficult to observe everyday interactions between third-party people (at least if one wants to understand the information that has been exchanged), and one has to discuss observations with an assistant or key informant in order not to misinterpret them. To further complicate matters, in the social sciences observations are often combined with questions, and, most prominently in Anthropology, with participation (Spittler 2001: 16-17). Depending on the specific research context, as well as the particular situation in which one wants to participate, this can become a difficult task when one does not speak the language of the people observed. Relying on an interpreter it is quite unlikely to allow one to practice “full participation”, sometimes referred to as “going native”. But at the same time it is also wrong to assume that is entirely impossible to participate in the daily lives of one’s informants. After all, by doing research one is engaged in interactions with people (Wind 2008: 86). I will get back to the limitation and chances to apply different levels of participant observations during my own research later in the text. For now, it may suffice to note that, because of the language barrier, I had to think more closely about the ways in which I would be able to use this classical method in order to answer my research questions. What interactions could I participate in, and with whom? In which situations, if at all, would I be able to overcome my status as outsider? A further complication of working with an assistant has to do with the communication process, and lies in the fact that one is not alone when doing research. During interviews there are two people listening, two people asking questions, two people watching, and, as it might appear to many, two people researching. While this is not necessarily a problem in all cases, there are situations in which this can become an issue, for example when an interview deals with sensitive topics that people do not easily talk about. Some things are said in confidence or are

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not said because of the presence of the interpreter. I, as a European foreigner, who lacks knowledge about Baganda customs and is not yet significantly entangled in social relations within Uganda, might appear as a harmless outsider. My research assistants on the other hand, are perceived differently: as Ugandans they supposedly share certain cultural values, and are situated within a shared social context in which some things might be better left unsaid. The significance of the individual qualities of the interpreter for the communication process become clear when taking a closer look. Writing about interpreters in medical contexts, Elaine Hsieh points out that translators have an active part in the process of communication and frequently shift between different roles in the communication process (Hsieh 2008: 1367-1368). Hsieh’s findings do not only apply to medical interpreters, but, in my opinion, concern interpreters in general. The common assumption is that good interpreters should act as conduits, passing on information between interviewer and interviewee and remaining otherwise invisible in the communication process. It is, however, very difficult to maintain that role, and neither would it always be the best practice to do so. Sticking strictly to what has been said, regardless of nonverbal messages, is hardly possible, and would make the communication process cumbersome as the interpreter refrains from clarifying answers or questions. Furthermore, interpreters can play an active part in translating by choosing formulations that are appropriate for the cultural and situational context. There are other important qualities of an interpreter that can inf luence the communication process, and that one might want to seek. Prior experience with interpreting might be useful as good translation is a complex task that, to be done well, requires a lot of skill. Also, it can be a great advantage if the interpreter is familiar with qualitative social research methods, as well as the research topic. Understanding the research questions as well as the theoretical concepts can greatly improve the translation process, as it enables the assistant to translate the researcher’s at times broad and abstract inquiries into useful questions that can be understood by the interviewees (De Neve: 2006: 83). Professional, skilled interpreters are, however, difficult to find, and often demand high salaries that exceed one’s research budget. In my case I hired a young woman who had previous experience as a research assistant (although not as an interpreter) in a project on wildlife conservation, and a young man who had just finished a bachelor study in public health. I invested time explaining to them what I was looking for in an interpreter and made them familiar with qualitative research techniques. In the course of the research we built up a common modus operandi and learned to work as a team. Throughout the research both my assistants constantly worked on their translation skills and improved considerably over the time we worked together. This brings me to the third domain outlined by Borchgrevink: the issue of translation. Choosing an interpreter is by no means a straightforward task, and

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should be carefully evaluated. There are a number of things to be considered, dealing with the translator’s qualifications and the ethical implications of becoming an employer. The interpreter’s language skills are an obvious concern. Being f luent in both the researcher’s language of choice (in my case, English) as well as the language spoken in the research setting is a basic requirement. Depending on the setting, there might be few eligible people who are f luent in the local vernacular as well as a second language, most commonly English. In my case however this was not really a problem. English is widely used across Uganda, especially in and around Kampala. Whoever has completed primary school education is usually able to understand and speak basic English. But as a researcher one might want to ask for more than just basic language proficiency: only an interpreter who is sensitive to fine language nuances and different vernacular expressions of the core-concepts can include them in the translation. For example, in my own research my assistant made me aware of at least two different classifications of wetlands in Luganda: entobazi and ekisenyi, the former meaning a f looded wetland, unsuitable for agricultural use; the latter describing a drier, often drained wetland, that is arable. In English these differences cannot be captured with dedicated terms, it therefore requires the alertness of the interpreter to draw the researchers’ attention to such peculiarities. Another implication of the interpreter’s inf luence on the translation process, emphasizes the need for triangulation and constant, careful checks. Triangulation in qualitative research is in all cases important. Not being able to converse in the language spoken in one’s field site, however, further emphasizes the imperative to be critical about the information one receives and, more importantly, to be careful not to jump to conclusions too fast (Borchgrevink 2003: 107). A common pitfall is the translation process itself, through which information can be falsely interpreted. To counter this, I made sure to prepare interviews together with my assistants, and debriefed them afterwards. Of course, semi-structured interviews can only be planned to a certain extent; their methodological value lies precisely in the unpredictable momentum that is inherent to their open design. Mostly the preparation consisted of discussing what information and insights I hoped to get out of the interview, and going through the catalogue of questions that should lead through the interview. The subsequent debriefing of the interview mostly helped me to clarify things and evaluate the technical aspects of the interview. Furthermore, I had most of the interviews transcribed by my assistants and asked them to retranslate the recorded answers of my informants (rather than just transcribing the English episodes of the recording). Sometimes the situation during an interview would not allow for a thorough translation of answers. For example, it could happen that an interview partner would describe a situation or answer a question in a lengthy monologue, which my assistant summarized in two sentences. Clearly, some information was left out in favor of allowing a more

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natural conversation that wouldn’t bore the interviewee. Debriefing as well as the retranslation in the transcripts would make sure that that information was not lost. In some cases, when an interview was particularly interesting or touched upon crucial topics, I had them transcribed and back-translated by a third party. This helped me to better understand the ways in which my interpreters translated concepts into Luganda (and back), if they translated things correctly, and whether there were ambiguous terms. In some I went over the retranslated transcript together with my assistants in order to point out issues to them. These techniques (hopefully) helped my assistants to better understand what I was looking for, and improve their interpreting skills, while I learned a lot about how terms were being used and expressed in Luganda. There are more things to consider, apart from language proficiency, that are of importance when working with an interpreter, and which Axel Borgrevink summarizes as the assistant’s inf luence on the research. For example, interpreters often provide access to the study area and facilitate the initial contact with informants. “The research assistant”, Gupta writes, “is often key to which networks are created and how they come into being. He is the person who makes certain kinds of possibilities for fieldwork ‘emerge’ by actively forging connections and networks between the ethnographer and local actors” (2014: 399). In that regard, it is a great advantage if the assistant comes from the research area and has good social skills. Similarly, ethnicity, gender, religion, social status, and health are also important aspects of how research assistants are perceived in the field and the ways conversations and interviews will unfold. On top of that, personal characteristics without doubt also play an important role. During the course of my research I hired two assistants/interpreters who helped me tremendously with my research endeavors. One of them, Khadija Mubarrak, was a Muslim woman, ethnically a Musoga, while the second, Christopher Musaazi, was a Christian Muganda.5 While I don’t want to value one over the other and I don’t think there is an ideal set of characteristics that a research assistant should bring to the field, I did notice differences in the ways my two interpreters were perceived in the field and were acted upon. Depending on the specific context, Khadija, being a woman and a mother, proved very sensitive to the struggles of other mothers with children suffering from malaria; in other circumstances I was happy to have worked with Christopher, who had an academic background in social sciences and public health. It is important to be aware of these differences when gathering and analyzing data, as interpreters inevitably shape the information that one collects. 5 While I use pseudonyms throughout the text, I make an exception in the case of my assistants – though not without their approval. Inspired by Banks’ article “The ‘intimate politics’ of fieldwork” (2008: 571-72) I consider it important to acknowledge the role of my assistants for my research, without whom this study would simply not have been possible.

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Assistants can, because of their individual qualities, either open or close doors for the researcher and in doing so, determine the course of the fieldwork. As a researcher working with an assistant, one has thus to be aware that the communication process is facilitated by the interpreter. Assistants provide access to informants and allow for verbal interaction between informant and ethnographer, and frequently act as mediators, moderators, and sometimes even as “cultural brokers” (Hsieh 2008 :1375; cp. Schumaker 2001: 193). Drawing from her own research experience Palriwala describes how her assistant bridged the cultural gap between herself and her Dutch informants. Through her assistant’s active role in the research process “the interview became a conversation and moved into a richer interaction of laughter and discussion beyond the immediate narrative” (Palriwala 2005: 165). I, too, recall similar moments, in which the data that informed my findings were derived out of such three-way discussions between my informants, my interpreter, and me. Debriefings after interviews are clearly very important in that context and as a researcher one can learn a good deal from that. As Geert De Neve writes, “there is little doubt that however important assistants’ practical help in terms of access may be, their most valuable contributions relate to the ways in which they facilitate the ethnographer’s reflection, enhance their understanding and ultimately enable their construction of what is known as ‘anthropological knowledge’.” (De Neve 2006:87) I constantly discussed the progress of my research with my assistants, and appreciated their opinions and suggestions for further steps. Their input was invaluable to my research and finally also to the production of this text. My research assistants (as well as my key informants – more on that below), had to endure my endless questions and helped me to make sense of the world I set out to study. It is because of the contribution of research assistants to anthropological research that the role of research assistants needs to be stressed more in the discussion of and ref lection on one’s research techniques. In his short article on the relationship between “assistants and their ethnographers”, Roger Sanjek problematizes his colleagues’ silence on that matter. “For more than a hundred years, members of the communities and cultures studied by anthropologists have been major providers of information, translation, fieldnotes, and fieldwork. While professional ethnographers – usually white, mostly male – have normally assumed full authorship for their ethnographic products, the remarkable contribution of these assistants – mainly persons of colour [sic] – is not widely enough appreciated or understood”. (Sanjek 1993: 13)

3. Ethnographic research in Uganda: Language and ethics in the field

When we look at fieldwork as an “intersubjective process” (De Neve 2006: 73) that happens mainly by means of social interactions with people in the field, the assistants’ central role in the fieldwork process becomes apparent. Because of the language barrier, most of the communication on the field has to go through an interpreter, who inevitably plays a role in the ways in which interviews are carried out and in which ethnographic material is produced. Assistants play an active part in the construction of the ethnographer’s field site, and shape it by guiding the researcher through it. During my own research, I spent a considerable amount of time accompanied with my research assistants who facilitated my social interactions and legitimized my presence at my research locations. More often than not, they made me feel more comfortable in a location where I, because of my alien appearance, attracted attention, comments, and curiosity. Again, I fully agree with Borchgrevink, who writes that “[w]orking with an interpreter may help [when we have difficulties in communicating, experience ourselves as clumsy in interactions, and feel isolated and lonely] by providing a partner in the venture, someone with whom to communicate, who may evolve into a friend and may come to take a personal interest in the research. Not only can this make the fieldwork more pleasurable, it can also translate into a lot of extra enthusiasm and energy for the research.” (Borchgrevink 2003: 111-112) As I have outlined above, working with an assistant has important implications for the research process. Anthropologists, who are in a way their own instrument of measurement, rely on their perception of social lifeworlds. Including an interpreter in the research process adds a serious source of possible distortion to the collection of ethnographic data. It is important to be aware of this bias, and to develop techniques to cope with it. However, apart from the interpreter’s inf luence on the research and the findings, there are other important issues to consider.

Hiring an assistant Hiring an assistant brings with it the important ethical and moral responsibilities of an employer. This should not be taken for granted or left unmentioned. Middleton and Cons remind us that… “[i]f there is anything that clearly distinguishes research assistants from other informants and helpers it is this condition of employment. While these fieldworkers may become key informants, cultural brokers, co-authors, and even friends, they

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remain employees. As such, the commodification of ethnographic labor proves integral to the researcher–assistant partnership.” (Middleton/Cons 2014: 284) All too easy employees may be exploited, or pushed to do work that goes beyond their personal limits. Especially in countries with a high level of unemployment, few labor unions, and bad labor relations, employees are quick to agree to disadvantageous working conditions and willing to sacrifice parts of their personal rights and dignities in order to gain an income. In Uganda I sometimes witnessed working conditions that were shocking to me as an outsider coming from Germany: ridiculously low salaries and delayed payments, little free time or private space, lack of social securities, just to mention a few aspects. Hiring “[…] a native assistant” as Gupta puts it, “[…] may put the ethnographer in a difficult ethical and moral position, as he may find himself replaying the dynamics of a racial, colonial order that he finds repugnant” (2014: 398). This poses pressing questions when one becomes an employer oneself. How is one to deal with such issues? What salary is fair? What rights should one grant the employee, and what are the expectations attached to one’s role as employer? Finally, one also has to think about how to protect oneself as an employer from being exploited by the employee. In my case I employed two assistants who worked directly under my supervision, and I had another four people carrying out individual assignments for me.6 In all cases I made sure to define the work relation with my assistants in a contract that stated the rights and responsibilities for both sides and which was signed by both parties beforehand. In the cases of the hired assistants who accompanied me during my research, I set a salary that could be considered generous according to local standards (not, however, when measured against German working conditions), which I topped up with an optional bonus if deadlines had been met and the quality of the work was satisfying. This, so I hoped, would encourage my assistants to stick to appointments and arrive on time, and motivate them to work ambitiously. In the contract I defined 48 working hours per week, with one day off per week (although a typical working week for my assistant usually consisted of less than that). In the case of the people I hired for individual assignments the payment of course depended on the respective task, and was generally set through mutual agreement, and not specified in a contract. I had several interviews transcribed and re-translated by Patrick Kinyera, a freelancer specialized in that field, whose charge was based on the length of the recorded material. In another case, I asked James Ssemuju to record statistical data on malaria tests in the health center of my research area, and to enter them into a spreadsheet which I could then 6 In addition to that, Veronika Steffens and Habtamu Tegegne helped me with various tasks during later phases of my work in Germany. As they were employed by the University of Cologne and didn’t work exclusively under my supervision I have left them out of the discussion at this point.

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later analyze statistically. In an attempt to carry out focus-group discussions I paid an additional assistant, Betty Najjemba, on six occasions to help facilitate these events. Finally, when needed, I asked Robert Kissa, a local motorcyclist, to transport me, and at times my interpreter, to certain places or pick me up.

Doing research, constructing the field The anthropological field is an abstract construct that is rather difficult to grasp, and which evolves and changes over the course of fieldwork. In stark contrast to the research setting I describe in chapter four – a physical entity with clear, mappable boundaries (cp. for example chapter four, figure eight) – the conceptual field is rather constituted of interactions, and greatly dependent on what one is looking for and whom one asks (Palriwala 2005: 159; Gupta 2014: 399; Schumaker 2001: 255). Also, if the field is constructed through interactions rather than being constituted in material characteristics the field might vary depending on the perspective of the observer and his or her positionality. What’s more, since the field is made up of social actors it is not possible to bind it to a limited physical area. People move in and out of a place and are entangled in a web of relations and inf luencing factors that go beyond the locale of a research setting. My research was guided by a set of questions regarding health in general and malaria in particular. Furthermore, I was interested in the links between malaria and the use of wetlands. Whom I hoped to talk to was therefore initially determined by these questions. I set out to look for people who had knowledge of and dealt with health and malaria, as well as people who worked in wetlands. But over the course of the research, the way in which I constructed my field was increasingly inf luenced by information I collected, by hints from informants, and to a large extent by chance. Being open-minded while doing fieldwork, and being open to unexpected encounters, can be considered a methodological technique, by means of which one will learn what aspects are important in regard to one’s research questions. Geert de Neve calls this technique “serendipity”, an “openness, which allows for insights to be gained by following unplanned lines of enquiry”, which “is not so much about ‘making sudden discoveries’ as about a particular willingness on the part of the fieldworker to learn from and build on informants’ self-conscious and ref lexive engagements with their own social environment” (2006: 78). While the serendipity concept stresses the unpredictability and unplannable character of ethnographic fieldwork, it also makes clear that through one’s learning from the interactions with informants, those informants also play an active part in constituting one’s ethnographic field. After all, Gupta reminds us, that “[…] the field is not a given space that the fieldworker walks into. Rather, it is constituted by the network of connections and linkages forged in doing fieldwork” (2014: 399).

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The field is constructed in what is called “fieldwork”, the ethnographic research process (Gupta/Ferguson 1997: 5-13). Over a period of two years between 2014 and 2016, I repeatedly came to Uganda in order to do fieldwork and collect data. In total I spent twelve months in my research site, which was located at the northern fringe of Kampala (cp. chapter four). The choice to divide my fieldwork into different phases drew some attention from fellow PhD students and colleagues. While it might not be the classical approach to carry out anthropological fieldwork, which is by spending a prolonged time within a certain community, typically around a year,7 I have much to say in favor of separated field visits. First of all, it is of course demanding to spend such a significant amount of time away from home. One might have responsibilities and obligations at home or leave behind dear ones. For me this was probably the most important reason to cut fieldwork into – metaphorically speaking – more digestible chunks. Apart from that it proved to be very helpful to have periods to step back from the field and look at things from a distance. After collecting data for a longer time period, the sheer amount of ethnographic material can become overwhelming and it gets difficult to maintain an overview of what one’s records show. I found it very helpful to have the opportunity to leave the field after a certain time and look at my fieldwork and the collected data from within a different context and reread my fieldnotes in a different light. At times I felt I could not see the wood for the trees; having the opportunity to take a break from fieldwork countered that. It goes without saying that the exchange with colleagues and supervisors, as well as the possibility to look into scholarly literature, was also beneficial. Furthermore, breaking up a prolonged stay in the field into multiple visits to Uganda allowed me to perceive changes that would have otherwise gone unnoticed. I was able to include events and data from a period of 28 months in total (while working in Uganda for “only” twelve), and therefore to gain a better perception of longer-term dynamics, or to become aware of certain dynamics in the first place. Another positive aspect of returning to the research site several time is the act of returning to the field. I had the impression that my relations with my informants in Uganda intensified each time I met them again. Certainly one could argue that a prolonged stay always leads to a better understanding of and incorporation into the field site. However, to me it seems outdated to assume that a finite field stay, however long, will enable one to overcome some of the differences between researcher and the population in the research area (cp. Howell/Talle 2011: 1-2). In terms of wealth and the corresponding power relations there always will be a disparity between the researcher 7 This is different in the US: Howell and Talle write that “[t]he most common form of sustained ethnographic fieldwork is undertaken as one period of eighteen to twenty-four months in connection with one’s doctoral degree” (2011: 6). This links well to my earlier remarks in this chapter about the implications of thriftily budgeted research funds in Germany.

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and the local population. In a way it seems far-fetched to me, to assume it could be neglected at a certain point. Choosing a research site or area is arguably the most determining part in the process of developing a field site, as it defines the locale in which the largest part of fieldwork is being done. This does not happen by chance, but is rather the result of a number of systematic and pragmatic decisions (cp. Gupta/Ferguson 1997: 11). As the project proposal and preliminary research of the larger GlobE research project had indicated, and as is ref lected in literature on wetland agriculture in Uganda, the region around Kampala is very dynamic with regard to the agricultural use of swamps. Currently there are momentous processes concerning the (re-)distribution of land going on, and small-scale farmers are increasingly drawn into wetlands to eke out an income for themselves. These processes have potentially far-reaching consequences – ecologically, socio-economically, and also with regard to health. Looking at a research site at the urban fringe was thus a prerequisite in order to observe these dynamics. I selected the area around Namulonge for rather pragmatic reasons: the GlobE project had plans to run a set of experiments at the national agricultural research institute in the trading center, and hired a project house as well as office and laboratory spaces located on the institute’s premises. Locating my research in the same area would come with a number of benefits, or so I hoped. I anticipated to contextualize my data with other research findings of my colleagues, and it would allow me to make use of the infrastructure provided by the NaCCRI institute and the GlobE research project (most importantly the project house and the office space). Moreover, the proximity to the research institute kept me up to date with the progress of my colleagues’ research and project-internal developments, and provided me with an entry point into my “field”. Last, but certainly not least, doing research in Namulonge also had the pleasant advantage that I could distract myself once in a while from the at times arduous and lonely research work by meeting my colleagues for a drink. During my fieldwork I stayed most of the time in the house of a young family in Balita, one of the villages in my research area. I got to know Peter, father of three children and the head of the household I stayed in, through a colleague in my research project. At the time I met him, Peter coordinated the field activities that were part of a rice experiment my colleague had designed. When he heard that I was looking for a place to stay in the area he kindly offered me a room in his house. He and his family helped me tremendously in getting to know the village and some of its inhabitants. It was not without initial (or prolonged?) disbelief, however, that Peter took me in. To him and most other people I met it didn’t make sense that I preferred the simple living conditions of his home to the modest comfort of the NaCCRI guesthouse that my research project rented. Why would a wealthy (measured against local standards) white man from Germany lower himself to the rudimentary living conditions of a poor Ugandan farmer’s family? What

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I assumed to be a necessary move in order to show that I was not put off by the poor standard of living in the village, was instead regarded as yet another ridiculous peculiarity of eccentric foreigners. Nonetheless, it gained me the curiosity of many and made it easier for me to get to know people. Also, by sharing the everyday rhythms and helping out in the household, I gained insight into the lifeworld of Peter and his family. Among other things, this helped me to better understand the sometimes harsh reality of the rudimentary living conditions the area. I don’t want to proclaim that I ever lost my status as outsider nor that I became a “member” of the family as some anthropologists assert they did during their research. However, staying with Peter and his family certainly allowed me to create a bond between him, his family, and me, and gave me a certain sense of belonging to the place, a reason to be in the field that went beyond my work as a researcher: Peter provided me with a home. And while I did much of my paper- and computer-work from the project’s offices on the nearby research farm, I usually set out to meet with my informants from Peter’s home. Apart from a friend, Peter also became my key informant, as we discussed a lot of topics regarding my research (and certainly also beyond the immediate scope of my research) and because he helped me to understand everyday live at the urban fringe in Uganda. He also linked me up with many of his acquaintances, introduced me to local authorities, and helped me patiently with my Luganda. From the start of my research, it was clear that my field would include medical institutions and professionals, biomedical as well as others. I started by introducing me and my research plans to the local councilors of the villages I intended to carry out research in, and asked them if they knew of health professionals or experts on health-related matters in their communities. In that I way I soon had a list of people working in the medical field, whom I then tried to contact. From there I used the snowball technique to widen my network. Concerning the biomedical institutions, I started by mapping the clinics, medical wards, health centers, drugstores, and other openly visible medicine businesses in the area. Over the course of my research I passed by each of these facilities to present my research to the clinicians, health workers, and pharmacists and invited them to an interview or inquired about the possibility to visit them at their workplace. In order to make contacts among wetland users I used mixed techniques. In some cases, I began by taking extensive walks through the wetlands and talking to people I met there; in other cases, I approached people based on suggestions I had been given earlier; sometimes it was a mix of both. After a while I had established a number of contacts, which I would then revisit intermittently. In that way, people gradually came to know me and my research and I had the impression to know the key actors in the field of health in the area of Namulonge. During my stay in the field I moved much between Peter’s home, where I would usually spend the nights, and the agricultural research station, from where I did much

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of my computer- and paperwork. This made sense, especially in the beginning of my research, as Peter’s home was by then not connected to the power grid. But my frequent visits to the Namulonge research farm also introduced me to many people there. As a major employer and administrator of land in the region, this was valuable to my research. Of course, while no longer urban, the fringe of Kampala is still densely populated, and I was far from knowing everyone who lived in the villages I did research in. Still, I could not pass the street unrecognized, and towards the end of my research I sometimes struggled to reach appointments on time as I constantly had to stop for a polite chat and to greet acquaintances. How I was perceived in and around Namulonge, and how I perceived the area and the people, obviously changed over the course of my research, especially after each of my returns to the field. This shifting positionality of course has methodological implications that are worth discussing.

Positionality: A German researcher in Uganda Social interactions are to a large extent shaped by the ways the actors perceive each other and themselves. What we know or assume about our counterparts will likely guide our expectations as well as our behavior in a social situation. Of course, the same is true for the researcher in the field: we don’t enter the field as a tabula rasa, nor are we free of suppositions about our informants (Schramm 2005: 173). As social actors we are positioned in a web of relations, that determines our interaction with others. This position changes the more we get to know about our interaction partners. Regarding my own case, I was constantly made aware of my ascribed position. As I mentioned earlier, being identified as muzungu by most people in Uganda already made clear from the start that people had a list of assumptions about me. Whereas I was assured the term muzungu was a term free of any judgment, I’m somewhat skeptical as to whether that was indeed the case. Being white in Uganda almost certainly implies that one is a foeigner who travelled to Uganda from abroad – usually a costly endeavor. Muzungu then not only signifies “white person”, but also “foreigner” and “rich person”. In plain words, there are only three types of bazungu in Uganda: tourists, development workers, and researchers. As tourists are hardly ever seen in Namulonge, and given the prominent research facility next to the trading center, it was easy for people to guess what I had come to do in the area. Although I doubt that people identified me as an anthropologist, nor that many people knew what anthropologists typically do, I am quite certain

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that I was seen as a researcher.8 From my own perspective, my skin color, as well as the dramatic financial inequality between me and most of my informants, also told a story about colonial history and the economic exploitation of the global South by the Western world. My own research was a classic example of “studying down” (cp. Nader 1972). Compared to most of the people I interviewed, I had more money, was better educated, more mobile, and healthier,9 and the same was true for both of my assistants. An unequal encounter of that kind – between my assistants and me on one side, and my informants in Namulonge and the surrounding villages on the other – requires a good deal of ref lection on one’s methodological approaches to one’s research topic and the larger implications of one’s work. Writing about medical research in East Africa, Melissa Graboyes points out, that “[t]here was, and is, very little understanding of the key components of what medical research is, who does the research and why, and what constitutes the risks and benefits” (2015: 10). While I did not do medical research (although I was at times mistaken for a medical researcher), I think Graboyes’ comment applies to anthropological research as well: generally, people did not fully understand the objectives of my research, and neither did I have the feeling people comprehended the ways in which I did research as an anthropologist. Most importantly, I wonder if people were aware of the implications of them being studied. While I doubt whether the use and implications of my research were understood by everyone I met, it would be a mistake to believe that my informants were not aware of the ways in which I benefited from their cooperation in interviews and questionnaires. A frequent counter-question asked by people I asked to participate in my research, therefore, was: “but how do we benefit from that?”. Against the backdrop of such unequal relations in terms of possibilities, this is certainly a justified question – and an uncomfortable one at that. What do I have to offer in exchange? Although I compensated the time and efforts informants invested in my research with gifts, lunch invitations, or sometimes small payments, and helped out close acquaintances wherever and whenever I could, I was, of course, not able to improve the situation of each of my interlocutors. Neither is it probable that my research will result in imminent changes for the local population. As an – in my case – German 8 Even among academic colleagues I am repeatedly asked what kind of research anthropologists do and how they do it (to be fair, I also don’t understand much of the theoretical and methodological approaches of some of my colleagues in the natural sciences). 9 This, of course, depends on the definition of “healthy”. My physical fitness was definitely in a poorer condition than that of most of my informants, and with regard to malaria, my body is certainly more susceptible than the bodies of people who have been repeatedly exposed to malaria infections. But in terms of, for example, access to healthcare, and exposure to health threats, I am more fortunate than most Ugandans, a fact that is reflected in the diverging life expectancies of people from Germany and Uganda.

3. Ethnographic research in Uganda: Language and ethics in the field

researcher in Uganda doing research among smallholders one has to be aware of the unequal relations one inevitably engages in. The “writing culture debate” has produced critical questions about ethnographic practices and initiated a search for alternatives. Do anthropologists, by comparing cultures in order to identify similarities, not create differences between cultural entities? Do we, by pointing out cultural attributes, not also fix them as markers of differentiation? After all, anthropology as a discipline relies on “the other” in order to carry out meaningful research. Even more importantly, pointing out differences also implies pointing out unequal relations of power, especially since it is typically Western scientists researching non-Western peoples (Abu-Lughod 1991: 146). An anecdote from my research in Uganda is illustrative here: After introducing myself and my work to a group of men who were producing bricks in one of the wetlands in my research area, one of the workers asked me, clearly puzzled, if there were Ugandans in Germany carrying out research on a disease that was non-existent in their home country. Up until that point I had never thought of my research in that way, and frankly, I had no good answer to the man’s remark. Unfortunately, I of course knew of no Ugandan scientist carrying out research in Germany on a disease that was hardly existent in Uganda. I could have tried to weaken his implicit critique and hastily told him about the few accounts of non-Western anthropologists who carried out research in the West that I knew of.10 The question he really asked, however, was of course why I, as a German/Westerner, was interested in that topic, and how it was that only Western researchers f ly to Africa to carry out research on a topic that should not be relevant to them, and why there are no African students coming to Europe to do anthropological work? How come a fairly young German scholar with little experience in Uganda, let alone Africa, wants to carry out research on Malaria, a disease that he has learned of only through books? Where does my interest spark from? Engaging with academia in general, and Anthropology in particular, I increasingly wonder where the Western urge to understand the workings of the world stems from, and how our view of the world, our view of ourselves, is based on this need to understand the unknown. Coming from the global North, researching Africa is not entirely unproblematic, as one’s position as researcher is tied to questions about power, wealth, global dependencies, and claims to truth. Lila Abu-Lughod encourages anthropologists, and 10 In fact, I only know of the Indo Dutch Programme on Alternatives in Development (IDPAD) set up by the Indian Council of Social Science Research and the Netherlands Foundation for the Advancement of Tropical Research. A number of publications by Indian and Nepalese Anthropologists working in the Netherlands have been produced within that program, mainly dealing with the Dutch welfare system. For a description of the project see Das (1985); for an insight into the work of the participating Anthropologists I recommend Pradhan (1989) and Chowdhury (1990), as well as Palriwala (2005), whom I cited earlier.

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scientists in general, to be critical about the backgrounds and roots of scientific research, especially when it is carried out in the so-called “global South”: “We need to ask questions about the historical processes by which it came to pass that people like ourselves could be engaged in anthropological studies of people like those, about the current world situation that enables us to engage in this sort of work in this particular place, and about who has preceded us and is even now there with us (tourists, travelers, missionaries, AID consultants, Peace Corps workers). We need to ask what this ‘will to knowledge’ about the Other is connected to in the world.” (Abu-Lughod 1991: 148) The questions she raises are relevant to my own research. My initial interest in Medical Anthropology lies in its applicability. When I learned about the cultural aspects of medicine, disease, and healing I immediately could think of many ways how to put these insights into practical use. Much of what I know of Western biomedicine completely disregards the cultural aspects that are inscribed into the human body. Dealing with a health-related topic in tropical Africa seemed a good way of putting the privileges I enjoyed as a German student and junior researcher to good use. But of course, that interest also stems from the distorted image I have of Africa as a place or category. A concept, created throughout the colonial encounter (and upheld thereafter), from which the West could differentiate itself by pointing out Africa’s shortcomings (cp. Ferguson 2006: 2-3). In historical perspective, Anthropology contributed much to the construction of Africa as a category or ‘notion’, as Mbembe (2001: 2) calls it. Dealing with the subject, I come to realize that my research, or even more strongly, my initial interest in the topic is rooted in the same, slanted understanding of the category “Africa”. There is no easy way out, other than engaging with Africa and its people and ref lecting critically on one’s own views and understandings of the world. Although, if I was to make the decision today, I might make different choices concerning the topic or the place of my doctoral research, I am still convinced that Anthropology, in its methodology as well as its theory, offers possibly the best available backdrop for an unequal encounter of that kind. The ref lexivity of one’s own methods, theories, and practices that Anthropology as a discipline calls for, is unique in academia. Although it has repeatedly put the discipline in crisis, it is of utmost importance to remain self-ref lexive and critical. Only if one dares to ask the sometimes uncomfortable questions about the implications of one’s work, both theoretically and in practical terms, is it possible to advance out of a given dilemma. In that regard my research has taught me a lot about my own view of the world and my stance towards africanist Anthropology. Doing research on topics that address the inequalities within this world is ultimately also a way of making sense of the contradictory place this world is. As mentioned before in the intro-

3. Ethnographic research in Uganda: Language and ethics in the field

duction of this book, doing research in the “global South” has a relevance in that it addresses issues of global inequality, colonial heritage, and Western privilege. While I was never explicitly confronted with these ideas about my position as a Western researcher in Uganda, these assumptions are articulated implicitly in of some of the interactions I had – as the above vignette of my encounter with the bricklayers illustrates. I find it important to be aware of this position when carrying out research in the “global South” and to critically ref lect upon its implications. As Katharina Schramm points out, “[b]oth ‘researcher’ and ‘researched’ do embody the nexus that slavery, colonialism and more current streams of globalisation [sic] have generated – it determines the space of our encounter(s)” (Schramm 2005: 173). This, she continues, calls for a reconsideration of methodological approaches, and raises questions, especially about one’s position as researchers in the field. My research, and my position as researchers in Africa cannot be completely understood without including the often violent legacy that Western powers left in Africa, and that shape the globalized world as we know it today. In that context I think that as a Western scholar in Africa I have a moral obligation to critically engage myself with my privileged position in these relations across time and space, and actively scrutinize my perceived role as researcher in Uganda. Translated into the daily research praxis this calls for humility towards one’s informants and the emphasis of their importance for one’s research (rather than the importance of one’s research for the informants) and not to take their participation for granted. In some cases, this could mean that I had to withdraw from methodological techniques, when I had the feeling they were inappropriate within a specific context, also due to my position as German researcher. This applied mostly to my research in health facilities, a topic I will elaborate further in the coming paragraphs. Over the course of my research I did my best to challenge my assumptions and views of the people I met and the society I encountered, as well as I hoped to alter people’s assumptions about me. I have already mentioned my efforts to learn Luganda, and my decision to move in with Peter’s family. Showing interest in people as well as explaining the intentions of my research to informants can thus not solely be ascribed to my personal curiosity about life in Uganda, but must also be seen as a way to change my position in the social relations I established with my informants. In some cases, the role of the curious, foreign researcher can be advantageous, for example when I could hide behind the naivety of an unknowing outsider, or when my status as a guest and/or foreigner granted me access to domains that would have otherwise been inaccessible to me. For instance, doctors and healers were generally open to talking to me and readily answered my questions, and I have been willingly invited into the homes of many. In other cases, however, my research was hindered considerably by my role as outsider, foreigner, and muzungu. Especially with regard to the health aspect of my research, I was confronted with situations that made me decide to choose a different method-

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ological approach, as I felt I was running into ethical complications. In the following paragraph I will elaborate more on this particular methodological dilemma. Going deeper into my experiences in a public health facility, I will illustrate how this particular research setting led me to a personal limit of observational research as a method of data collection.

Doing research in a health facility Throughout my research I engaged as much as possible with people who, in one way or another, worked in and around wetlands. I tried to learn about their ways of dealing with health, and more specifically with malaria. In order to broaden my scope and to approach malaria in a more holistic manner, I also wanted to incorporate the views of health professionals and learn about the ways in which malaria is articulated in their daily work. In order to do so I approached a number of health workers from the biomedical as well as alternative healthcare sector. The largest and most prominent health institution in my research area is the Namulonge Health Center III (HC III), a public health ward. Ideally, or so I hoped, it would be possible to participate in the consultation hours and learn about the ways in which malaria was communicated between doctor and patient, and follow the doctor’s process of making a diagnosis. In order to get access to the health center I presented my research as well as my preliminary research permit to the board of the district’s health department in Wakiso, and was given permission to carry out research in Namulonge’s HC III. Equipped with an introduction letter signed by Wakiso’s district health officer as well as my GlobE affiliation, I was warmly welcomed into the health center, and the doctor indeed invited me to join him and the staff at the HC III during their daily routines at the health center. In some regards a hospital setting is a rather extraordinary space for ethnographic research, which contrasts with everyday social spaces in several ways, and therefore deserves special attention with regard to the methodology and, more importantly, the self-ref lection of the researcher. Long, Hunter and Van der Geest (2008: 73), point out the liminality of hospital spaces: people are removed from society and are transformed into patients through the process of diagnosis and prescription of treatment. Eventually, so the idea goes, patients re-enter society as healthy persons with the new identity of a “survivor” or a “healed” person. It can be argued that the hospital as a social space is highly ambiguous, in that it is a place apart from everyday social spaces, yet and at the same time exists as an extension of society. On the one hand the hospital serves as the battleground against disease, hierarchically ordered and armed with sophisticated knowledge and technology. On the other hand, the hospital exists of course in a larger so-

3. Ethnographic research in Uganda: Language and ethics in the field

cial context and is frequented by social actors who trespass and shape its borders (Street/Coleman 2012: 5-9). The hospital, with its strict hierarchical organization and the delicate situation of its patients, can be a tricky context within which to conduct ethnographic research. As a researcher one has to find the appropriate position within the hospital’s hierarchy, and not to interfere in the patient-doctor encounter. Anticipating ethically sensitive situations at the health ward, I talked as much as possible about my plans, ideas, and fears to the staff at the health center before starting my research there. Since my assistant was not allowed to accompany me during the consultation hours I relied on the doctors and nurses to translate for me (which they were willing to do). One of my main concerns was the introduction of myself to the patients and the patients’ consenting to me doing research during their doctor’s consultation. Whereas I decided not to work with informed consent forms at the HC III, the patients had to be informed about my intentions as a researcher, my research questions, and the confidentiality with which I would treat all information. Most of all, people had to be informed about their right to withdraw from my research at any point, and to ask me to leave the room when they felt uncomfortable with my presence. Before I started my visits at the HC III, I discussed the importance of these points with the practitioner in charge, as well as the head nurse, both of whom I would follow through the health ward. However, once I began taking up work at the health center things proved to be different from what I had hoped for, and while I was granted access to a lot of valuable data and insights I soon found myself caught in situations that I considered ethically problematic. The medical doctor in charge at that time – a man of my own age, in his early 30s, recently graduated from medical school – willingly opened the doors to the HC III for me and introduced me to the staff. In fact, it seemed he was excited about my research and eager to help me. He assured me I could access the information needed and ordered his staff to help me answer my questions. His only request to me was that I would wear a white lab-coat in order to signal to patients that my presence at the medical consultation was approved by the staff of the Health Center and that I was an authorized researcher. In fact, doing participatory research in a hospital or health ward leaves one with only three choices: either one becomes part of the staff, a patient, or a visitor (Van der Geest/Finkler 2004: 1998). By wearing a white coat, I inevitably took over the role of a staff member. In retrospect I probably should have objected at that time already, as I did not want to carry out research disguised as a medical professional and considered it unfeasible to carry out participant observation under these circumstances. As Gitte Wind argues, it is questionable if we can speak at all of “participant observation” in a hospital setting, as anthropologists are neither doctors nor patients and cannot easily slip into these roles, because they either lack the expertise or are not sick. She proposes the term “negotiated interactive observation” to describe

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ethnographic research methods that explore social relations in a context in which it is not possible to take up a participative role (Wind 2008: 87). However, in that moment, anxious about the doctor’s opinion of my research, I was ignoring the implications of wearing a white coat and did not turn down his generous offer to accompany him during his work. Starting a discussion about the necessity of wearing a lab coat would have seemed rude to me at that point. It is an easy guess that wearing a lab-coat at the health center led many to believe I was myself a doctor. The word spread, that I was working in the HC III, and it was not long after I had started to attend the consultation hour that people on the street addressed me as musawo.11 Some of the patients coming to the health center attributed to me the same authority and medical knowledge as to a doctor, and, more importantly, treating me with the same respect as a doctor. Not many would deny a doctor’s request to carry out research during their consultation, even if sensitive medical information was discussed – certainly not in the Ugandan context, where it is often considered rude to deny a hierarchically higher-ranking person a request. During the first consultation sessions I thoroughly introduced myself to the patients as I had planned, asking the doctor to translate for me. Soon, however, the doctor became impatient, since my introduction took considerable time. He asked me to leave the talking to him; after all, he assured me, he knew what I intended to say. I doubt, however, that he introduced me to his patients as faithfully as I had wished for, and wonder if he explained to people their right to withdraw from my research and the option of me leaving the room for the time of the consultation. And even if he did, in hindsight I wonder if patients would have declined the request, as it came from their doctor (and from me, who was also inadvertently “playing the role” of a medical professional). While I was careful to consider possible ethical issues while planning and carrying out research, I could not help but blunder into situations that I did not feel comfortable in for ethical reasons. From my perspective as a German researcher, medical information is highly sensitive and the patient’s approval of the disclosure of his health status to third parties is an absolute prerequisite, regardless of the nature of the medical condition. The lax way of dealing with such matters at the health center shocked me and put me in an awkward position. On the one hand the consultation hours proved to give me a valuable insight into the local ways of dealing with health issues. On the other hand, however, the situation in

11 This happened only a few times and in a playful, joking manner (so I hope). It nonetheless made me think about the ways in which I was perceived by the people in the villages in which I carried out research. Although I made sure to stress that I was working as a social scientist and had no professional medical knowledge, I doubt whether all of the people I met made that distinction. After all, I was of course interested in medical topics and I met some of my informants in a medical context.

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the doctor’s office did not comply with my ethical standards for scientific research, which inevitably led to my decision to no longer attend the clinic’s routines. Marcia Inhorn describes similar experiences from her own research, feeling certain that many of her informants only participated in her research because they felt grateful and indebted toward their physicians (Inhorn 2004: 2101-02). While it is often assumed that the Anthropologist, by means of participant observation, is able to mingle and blend in in just about every social situation, I personally believe that in the health center I had encountered the limits of this methodological approach. The data had to be gathered in some other way – one that would have to be ethically unproblematic. Eventually I chose to conduct interviews with both, patients and medical professionals separately. This gave me the opportunity to thoroughly introduce myself and my research to the respondents and to make sure to explain my concern, as well as stressing their options to opt out of the interview. And since I did not have to wear a lab-coat any longer I was able to establish a different role, namely that of a researcher who had no medical expertise whatsoever. Still, even in such a setting one has to be aware of one’s own role as a researcher, and the role that one is ascribed to. While I was careful to explain my research interests and the larger goal of the project, I am doubtful whether I could address all of my informants’ concerns, and I wonder whether every one of my interview partners seriously considered the option of backing out of the interview. Establishing oneself as a researcher already equips one with a certain authority. It implies an academic education, as well as connections to the associated social circles. On top of that, researchers in medical Anthropology naturally often talk about medical topics, and ask questions related to health. This can be problematic. As I described earlier, it can lead people to mistake a (medical) anthropologist for a medical researcher, if not a doctor. How one is perceived in the field does not necessarily match with the image one has of oneself, and neither does one have much control over it. Throughout my own research I was repeatedly reminded of that, and it made me realize how important a mutual trust relation with one’s interlocutor is – a fact that underlines the necessity of long-term fieldwork in Anthropological research.

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“Anthropology, more than perhaps any other discipline, is a body of knowledge constructed on regional specialization, and it is within regionally circumscribed epistemic communities that many of the discipline’s key concepts and debates have been developed.” Akhil Gupta and James Ferguson 1997: 8

4. Kampala’s urban fringe: Socio-economic dynamics and transformations Central Uganda Kampala, the capital of Uganda, is located at the northern shores of Lake Victoria, Africa’s largest lake, at an altitude of about 1,200 meters above sea level. Although the city is located just slightly north of the equator, the climate is pleasant thanks to the elevation of the region. Central Uganda is densely populated and the economic hub of the country, with all the major companies as well as the country’s financial sector being located here. Before Kampala, Uganda’s only city, became an urban center, the area had been used as hunting grounds due to the abundance of game animals. It was the center of the Baganda kingdom, and still today the Kasubi Tombs, the Kabaka’s burial grounds, and the royal palace are located here (Omolo-Okalebo et al. 2010: 153-54). Sometimes referred to as “the city of the seven hills”, the city’s name stems from the adaption of the Luganda term kasozi k’empala, translating to “hill of the Impala”. It was here that the British later founded a fort, around which the city grew (Low 2009: 78, cp. figure six). Throughout the colonial time, Kampala, or Mengo as it was referred to at that time, always served as the capital of the Baganda kingdom, with the Kabaka’s palace and offices located there, while Entebbe, some thirty kilometers south of Kampala, was established as the headquarters of the British colonial administration (Lwasa 2010: 11-12). Historically, central Uganda has been populated by the Baganda, the predominant ethnic group in the region, who formed one of the biggest and most dominant kingdoms of central Africa’s great lakes region (Karlström 1999: 26-27). The British,

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who declared Uganda their protectorate in 1894, made use of the existing power structures to enforce their system of indirect colonial rule. Throughout the colonial period and ever since, Buganda has been the economic, political, and cultural center of the country. Due to the favorable climatic conditions and fertile soils in the region, the British concentrated their investments there, and compared to other parts of the country Buganda enjoyed a better road network as well as a public service infrastructure (including health services and education), which still holds true today. It is not surprising then that the favorable conditions, as well as the encouraged recruitment of people from less fertile regions in the country by the British, attracted migrants from other parts Uganda as well as neighboring countries. A census in 1948 estimated that 34 per cent of the total population in Buganda where ethnically non-Baganda (Fortt 1973a: 95), and still today the region, especially the hub around Kampala, attracts laborers from various parts of the country. Whereas Luganda, the Bantu language spoken by the Baganda, is still the most widely spoken language in the region,1 the population is composed of people with different ethnic and national backgrounds and equally different languages. Many people in the area, especially those with a migratory background, are f luent in more than one language commonly spoken in the area, one of which would commonly be Luganda; only a few people I met claimed not to understand Luganda.2 Figure 6: View on downtown Kampala from Mengo hill. Picture by Clemens Greiner

1 Some Baganda even claim it is the most important language in the whole of Uganda – which says something about the Baganda. 2 Interestingly, these were mostly people who were relatively well educated and could rely on English in their daily lives People who rely on petty trade or other low-paid work are typically quick to master Luganda.

4. Kampala’s urban fringe: Socio-economic dynamics and transformations

Taking one of the northern exit routes out of the busy city, one drives through the densely populated suburbs of Wakiso district, passing over numerous gentle hills until one reaches Gayaza, a town that marks the border of the conurbation. From here the surroundings change considerably. While the landscape of soft hills remains the same, the degree of urbanization decreases notably. Coming from Kampala, the road to Gayaza is continuously adjoined with houses and other structures, and although road signs mark the borders between villages and townships it is hard to tell where the city really ends and a commune starts. Moving further north from Gayaza the villages become trading centers, settlements erected on the tops of hills, while the previously urbanized valleys are now characterized by the lush, green color of cultivated croplands. Figure 7: The urban center of Kampala and the trading centers Namulonge and Kiwenda at its northern fringes

It is there, about 25 kilometers, or a one-hour drive (if traffic allows) north of Kampala that I conducted research and collected most of my ethnographic data. More precisely, we are looking at Namulonge, a trading center in Busukuma Sub-County, at the north-eastern edges of Wakiso district and its surrounding trading centers and villages (cp. figure seven). Although classified as rural by the Ugandan authorities, the growing inf luence of the conurbation can be clearly seen when taking a closer look. Throughout my research I learned that what I first perceived as a rural area, dominated by agriculture as the main economic activity, could be better described as the peri-urban areas of Kampala (Simon 2008:170). The urban uses of the land are emerging quickly and land is an increasingly contested resource, while the proximity of the nearby city, with its markets and jobs, is of growing importance to the area.

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As in many parts of the so-called global South, in Uganda too there is a visible trend of urban growth. Kampala’s population is rapidly increasing and the city has long outgrown its administrative borders (Vermeiren et al. 2012: 200-201). According to the last population census in Uganda a little more than 1.5 million people were living within the borders of Kampala in 2014, compared to roughly 1.2 million in 2002, the year of the previous census. In the same time period the population of Wakiso district, which encloses the Ugandan capital, has more than doubled from around 900,000 inhabitants in 2002 to over 2 million in 2014 (Uganda Bureau of Statistics [UBOS] 2016: 8-9; UBOS 2006: 46). Including Mukono, the densely populated district neighboring Wakiso to the east, the metropolitan area of Kampala is home to over four million people and the number is growing, so far without an end in sight. Figure 8: Map of the research area, showing the wetlands and relevant places

The proximity of the city can be felt in numerous ways in the area around Namulonge. Many of the economic activities in the area are aimed at the markets in town. That applies to agricultural products like cash crops, eggs, and poultry, and also to other products such as building materials like bricks, stones, sand, and clay. Also, the value of land rises steadily and real estate firms buy out large chunks of land to then subdivide them into smaller plots and resell them profitably. The good connection to the city makes the area attractive to the growing middle class in Kampala who are willing to commute in order to afford a home. The major reseller of land in the Namulonge area is Zion Estates, which takes pride in selling “plots on all roads entering Kampala city” (cp. figure nine). Bordering the Namulonge wetland, located in the valley between the Namulonge trading center and Balita,

4. Kampala’s urban fringe: Socio-economic dynamics and transformations

the neighboring village to the north, Zion Estates have opened up a vast development area for housing estates, measuring about 62 hectares or roughly 150 acres (cp. figure nine). So far the number of new inhabitants in the area is reasonably small, but the prospect of many wealthy Kampalians entering the community is causing rumors. I particularly recall a conversation with the local councilor3 of Balita, who was concerned that the adjoining estates would lead to a population increase that called for a new, independent village community, which eventually would have to elect its own councilor. He didn’t feel capable of representing the wishes of so many people nor did he wish to, as he saw the newcomers as distinct from the people in Balita in that they came from Kampala, were wealthy, and didn’t originally belong to this part of Uganda. Figure 9: Advertisement poster by Zion Estates, along Kampala-Gayaza Road (top lef t), and an online advertisement by Zion Estates, promoting their plots between Namulonge and Kiwenda (top right). A satellite image clearly reveals the planned development area, and the first houses can be seen (bottom). Towards the bottom of the picture parts of the NaCCRI farm, located in the wetland are visible; the settlements on the upper right side of the image are part of Balita. Sources: photo by author, advertisement from www.zion. co.ug/, satellite image from Google Maps, screenshot taken on March 23, 2015

3 In Uganda every village elects a councilor, the so-called chairman or LC (Local Councilor). Councilors are ranked from LC1 to LC5, from the administrative entities of village, parish, sub-county, and District (in hierarchical order).

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The increasing demand for land encourages landowners to sell parts of their properties, putting the current occupants under pressure. Land is increasingly becoming a valued commodity, which ultimately has implications for the poorer part of the population, who typically do not possess land. I will come back to this point in a later paragraph dedicated to land tenure in Uganda.

Infrastructure As described earlier, Namulonge and the surrounding area appears at first sight to be of a rural character. The impression stems from the clearly separated villages, the dispersed settlements, and the prominence of agriculture in the area. In the following section I describe the infrastructure in the area, paying special attention to the economic implications for the local population. I will include the present institutions, facilities, and larger companies. This will help to provide a better impression of the research area, and is of particular importance when analyzing the healthcare sector in central Uganda in the following chapter. First however, I want to brief ly outline the conceptual ideas behind the term infrastructure as I intend to use it in this chapter. Infrastructure can have various meanings. Generally, the word is understood as referring to structures and services that support the working of a certain region and its population, mostly in economic terms (Howe et al. 2015: 2). While I want to confine my analysis to manmade structures that have an immediate effect on transportation and communication, as well as the general functioning of the services available in the region (especially with regard to health and health care), it should be noted that the concept can be understood in broader terms, allowing for the inclusion of for example services (such as healthcare) and facilities (such as schools and markets). Taking into account the economic aspects of infrastructures, ecosystems can be thought of as infrastructures as well. What’s more, for the lack of a better source, wetlands are often valued for their water supply – a classic example of an infrastructure. Arguably the most important infrastructure in the region is the tarmacked road connecting Gayaza with Zirobwe, and passing through the trading centers Namulonge and Kiwenda. Tarmacked in 2009, it shortened the journey time to Gayaza and Kampala considerably, and made the region attractive to investors and Kampalans in search for affordable ground. As described earlier, Zion Estates, a large company that invests in land holdings, develops land for construction and has built a network of smaller streets, as well as the basic infrastructure for the future installation of an electrical grid. On their posters, the company advertises their plots as being close to the road and explicitly state their proximity to the city (cp. figure nine).

4. Kampala’s urban fringe: Socio-economic dynamics and transformations

In order to get to town, one is best advised to board one of the frequent minibuses, the infamous matatu taxis, that connect the outer trading centers with the city center. A journey costs around 6,000/= UGX (approximately € 2) and takes about an hour. The road does not only serve to connect the radiating trading centers to the market and business places of the capital, it also serves as the central vein of the electrical grid of the region. Along the roadside electricity poles are set up, supplying the surrounding urbanizations with power. In order to be connected, a household or a business has to compensate Umeme, Uganda’s main electricity distribution company, for the expenses. Needless to say only few of the private households are powered. However, if power is not cut, the electricity allows for important services. For example, it enables the laboratory technician of the local health center to use a microscope in order to examine blood-smear samples, and test them on possible malaria infections. Concerning water management, the area around Namulonge had next to no infrastructure.4 Freshwater is derived from wells or boreholes and distributed at best by hard-working boys trying to sustain a living; certainly not, however, through pipes. Some of the better-off households or enterprises have water pumped into elevated tanks, from where it then can be tapped. For the disposal of wastewater there is no infrastructure other than the road-ditches. Commonly pit-latrines, constructed and maintained under the responsibility of the owner, serve to satisfy the daily needs of people in the area (only the NaCRRI Farm maintained a pipe network and a small sewage treatment plant). Although frequently overstretched, the mobile communication network around Kampala is offering reasonably good coverage, and mobile telephones as well as, to a lesser extent, internet-based smartphone applications are long-established means of communication. Most people, even poorer households, have a mobile phone at their disposal, connecting them to at least two lines, to be able to access the cheapest fares and cope with limited network capacities during peak hours. Mobile phones are by far the most important means of communication in Uganda, which of course has an effect on the activation and provision of healthcare, as we will see in a later chapter. What is arguably even more important than the possibility of making and receiving calls is the banking utilities that many mobile network providers offer. Services like ‘MTN Mobile Money’ allow registered

4 This has changed since I completed my research in 2016. As Peter has told me, the local government has meanwhile installed water pipes along the main roads in the trading centers, branching off into the adjacent villages. Few households, however, can afford an access point. The installation of a water pipe system is related to the demographic dynamics taking place at the urban fringe, which is increasingly attracting affluent buyers working in town – people who can afford and demand access to piped water.

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users to use their mobile phone to transfer and withdraw money, and in some cases even to make payments. This service can be tremendously important when it comes to seeking healthcare and access to treatment. As I will describe later on, Mobile Money is often used to send money to relatives, for example to pay for their health-related expenses.

The Namulonge Research Farm The wetland at the bottom of the valley bordering Namulonge was chosen as super-test site by the GlobE research project. Apart from the high population density and the diverse use of wetlands in the region, one of the main reasons for making Namulonge a research site within the project was the presence of a NARO5 institute. Formerly a research farm for cotton production, founded by the British Cotton Research Corporation in 1942, the premises became state-owned and are now under the administration of the National Crops Resource Research Institute (NaCCRI), one of NARO’s six research centers (Arnold: 1976: 1-2). Nowadays the Namulonge research farm is an important employer in the region. As a research farm it hosts various research projects, both national and overseas-funded. Scientists from various countries in Africa as well as other parts of the world are engaged in ongoing research. Non-academic people are also employed and hosted by the research institute, mainly as field workers, night guards, technicians and in other service oriented positions. The former staff quarters of the research institute are now populated by people affiliated with the research institute, most of whom have roots outside of the Buganda area. In an article about the climatic trends in central Uganda, Nsubuga, Olwoch and Rautenbach describe the role of the research station as follows: “Namulonge is well known for intensive smallholder agricultural practices and is also a research site of the National Crop Resources Research Institute (NaCRI [sic]), which strives to develop varieties and farming technology for the people of Uganda. It is rural in nature and most of the residents are either current or past employees of the research institute. Agricultural practices in and around Namulonge are therefore significantly influenced by NaCRI [sic].” (Nsubuga/Olwoch/Rautenbach 2011: 120) Recently there have been rumors about a land deal affecting the NaCCRI premises. The Ugandan tycoon Aamir Sabharwal intended to buy parts of the land in order to build a private university, and later a tomato-processing plant. After the land was 5 National Agricultural Research Organisation; see also: http://www.naro.go.ug/

4. Kampala’s urban fringe: Socio-economic dynamics and transformations

declared idle by the Ugandan government, a deal was made and Aamir Sabharwal was told he could go ahead with his investment plans. This, however, sparked protest, both from the political opposition as well as NARO, which eventually led to controversy concerning the ownership and intended use of the land in question. The premises of the research institute are vast. In 1945 the British Cotton Growing Coroporation leased 908 hectares of ground from a Muganda landowner for a period of 99 years, with the plan to set up a research facility for cotton plants in order to boost the cotton production in their African colonies (Arnold 1976: 5-7). While the research facility was thriving prior to the political turmoil in Uganda during the regime of Idi Amin, it was no longer feasible to maintain the facilities during the political regime, and the premises were donated to the Ugandan government. Although the heir of the land presented the lease contract over the land, the Museveni government claims that at that time the ownerships rights were transferred to the Ugandan government as well. After all, Amin promoted a tenure reform in the country, affecting in particular central Uganda and the socalled mailo land holdings (more on that in a bit). After a heated debate in both the political and public domain, the land deal with Aamir Sabharwal was proclaimed illicit and reversed. Up until today there have been no attempts to construct either a tomato sauce factory or any other larger investment structure on these grounds. However, many people, especially among the NaCCRI administration, are still suspicious as to whether this really is the end of the story. Some suspect that the deal was turned down only to calm the waves before the 2016 election in the country, and that debates might soon rise again. In fact, the issue of the rightful ownership of the land in the region has not been satisfactory settled. For my own research there are several aspects of the NaCCRI research farm that are relevant. First of all, the above outlined debates about the rightful ownership of the land, its future prospects, and the interests of investors in the grounds illustrates the heated atmosphere surrounding land in the urban fringe. Not only is land ownership a complex, and value-laden topic, it also involves hierarchies, relations of power, and notions of belonging. It also demonstrates the increasing interest in land close to the city – the demand for land on the outskirts of Kampala is rapidly increasing. Furthermore, as has been pointed out before, and as will be shown in more detail later on in this book, the research institute is a major employer in the region and provides agricultural land to many of its employees. Finally, because it was hosting the central field trial of the GlobE-project, it also provided a valuable starting-point for my research.

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Wetlands As mentioned earlier, there are various definitions of wetlands in use. In the context of the GlobE project I see wetlands as areas of land that are characterized by water. In that regard the hilly landscape of central Uganda is strongly characterized by humid areas, mostly found in the valley bottoms in between the hills’ slopes. Especially outside of town the valleys are often wet and swampy. The ubiquitous wetlands therefore inf luence the lives of the people living in the region, either directly as a resource or indirectly as an attribute of the landscape as understood by Ingold – being “constituted as an enduring record of – and testimony to – the lives and works of past generations who have dwelt within it […]” (1993: 152). If left untouched, pristine valley-bottom wetlands in Uganda are usually covered with a thick, impenetrable bush of papyrus plants, meters high. Especially during the wet seasons, the ground is covered with water; in some cases, it becomes humid and muddy during the dry period. Marshlands are delicate ecosystems with a range of qualities, most importantly the filtering of water, functioning so to speak as natural sewage treatment plants (Bosma/Glenk/Novo 2017: 181; Huising 2002: 127). It is estimated that roughly the half of the Ugandan wetlands are used in some way to support household demands and/or generate an income. Especially in the urban areas wetlands are often intensively used, and predictions point to further intensification of wetland utilization in future years (Turyahabwe et al: 2013: 95-96). Accordingly, most of the marshlands in the Namulonge area are intensively used for various income-generating purposes, most notably the production of cash crops, like tomatoes, cabbage or, increasingly, staple crops like rice or maize. Other economic activities taking place in wetlands include the excavation of clay, sand, and stones and the fabrication of bricks. Additionally, wetlands are used as sources of water, for example to wash clothes or vehicles, or feed livestock, and in some cases also for cooking or even drinking. To a lesser extent the activities taking place in wetlands include the harvesting of papyrus for the making of mats or as a simple roofing material, and the collection of herbs and medicinal plants. In the literature on wetlands, especially from international organizations like the Ramsar Convention,6 the recreational value of wetlands is frequently listed. Wetlands are often described as particularly beautiful natural sites that are attracting (regional) tourism (cp. Dixon/Wood 2003: 118; Smardon 2009: 2-3; Ramsar Convention Secretariat 2013: 9-10). While this without any doubt holds true for many wetlands across the globe, it does not apply to the wetlands in the Namulonge area. With the data I collected in the area I cannot verify this 6 The Ramsar Convention is an intergovernmental treaty, providing the framework for the conservation and sustainable use of the world’s wetlands. The treaty was initially drafted and signed in 1971 in Ramsar, Iran.

4. Kampala’s urban fringe: Socio-economic dynamics and transformations

point, and as far as I can tell the local population does not value wetlands for their aesthetic appeal or their recreational value. In some cases, however, the swamps have had a meaning in the ancestral cults of the Baganda, or can be sites that carry special histories or locations where memorable events took place. The GlobE-Wetlands project was designed around the assumption that wetlands in East Africa hold a large potential to meet the growing demand for arable land and can play a significant role in obtaining food security in the future. Wetlands in East Africa lie largely idle, and thus hold a so-far unreleased potential to boost agricultural production (Becker 2015: 347). While that doubtlessly holds true for many wetlands in the rural hinterland of Uganda, it does not apply so much for the peri-urban environment of Namulonge and other places in Kampala’s fringe. Here, wetlands are increasingly being used for various income generating activities, and people rapidly unlock the economic capabilities of swamps in many ways. In that regard, the urban fringe serves well to observe the underlying dynamics and consequences of altering these ecosystems. Unlike in other countries in East Africa, where the use of wetlands is highly structured and controlled (as for example in Rwanda; cp. Ansoms et al. 2014: 244-45; Treidl 2018: 83-84), and homogeneous (as on the Kilombero f lood plain in Tanzania, which is largely used for rice and maize production; cp. Kato 2007: 6-7), the use of wetlands in Uganda seems to be rather unregulated and heterogeneous. A diverse range of crops is cultivated in wetlands, and as outlined above, wetlands are valued for a multitude of different purposes. Also ethnically the population in the research area is diverse, as are the socio-economic backgrounds of the households in the region. As Uganda is a member of the Ramsar Convention on wetland protection, having signed the treaty in 1988, its wetlands ought to be protected as vulnerable ecosystems. Although in theory this should restrict people from using wetlands for agricultural purposes or mining, in practice we see a different picture (Kalanzi 2015: 162). Wetlands in central Uganda are to a large extent in use, and few people are aware of the policies and laws regarding wetland protection. Only in very rare cases did my informants speak to me about these laws, and when asked they mostly claimed not to know of any such regulations. In my opinion there are three important underlying factors at stake here. First of all, it is probable that wetland users were reluctant to talk to me about restrictions on the use of wetlands, possibly fearing I might talk to authorities about these issues, or not wanting me to write about their activities and present them to a larger audience. Except for the rather obvious suspicions towards me, I became aware of another factor that might explain the discrepancy between theory and practice regarding the use of wetlands. In Luganda, the most prominent language spoken in central Uganda, wetlands are referred to as either ekisenyi or entobazi, depending on their characteristics, especially with regard to hydrology. While an entobazi is a f looded swamp, typically a shallow body of water, ekisenyi describes a moist, muddy area

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that is not f looded with water for most of the year (cp. figures ten and eleven). It is worthwhile noting that an ekisenyi can be cultivated while an entobazi is typically not arable. Through draining it is possible to convert an ekisenyi into an entobazi. Additionally, landownership plays an important role in the way wetlands are being seen and used. In contrast to state-owned swamps, large areas of the Namulonge wetlands are in private ownership and therefore being used (or rented out for use) by their owners. What can and should be done with such wetlands is, at least in the eyes of the local population, not for the Ugandan government to decide, but is rather subject to the interests of the owner – in this case, private landholders. Landownership and land tenure in central Uganda is complicated. In order to understand the current increase of wetland utilization in the urban fringe, one has also to look at the related dynamics with regard to shifting land rights and access to arable land. In the following paragraphs I outline the tenure systems in central Uganda and specifically look at the area between Namulonge and Kiwenda where I did my research. Moreover, as I will argue, one has to look back into the colonial past of the country in order to fully understand the implications of the complex land-tenure system in the country. Figure 10: Example of an “entobazi”; picture by author (lef t) Figure 11: Example of an arable “ekisenyi”; picture by author (right)

Land ownership and land use The tenure system in central Uganda is complex and confusing – and not only to outsiders – and has repeatedly been a source of conf lict over the last century or so. With their system of indirect rule, the British introduced individual land rights and ownership into Buganda, and consequently established a land market. This has divided Uganda’s population into landowners and tenants, and created the foundations for a class-based society. As I will lay out in more detail later on, the Ugandan tenure system has been repeatedly reformed over the years, often in or-

4. Kampala’s urban fringe: Socio-economic dynamics and transformations

der to strengthen the rights of the landless. However, evictions of occupants, the lack of access to land, and the associated social and political implications have repeatedly been the cause of conf lict and protest. Today, maybe more than ever, land tenure and ownership are contested all over sub-Saharan Africa, and acquisitions of land and “land grabs” on the continent have been increasingly discussed both within and outside of academia (cp. Berry 2002: 640-648; Lund/Boone 2013; Peters 2013: 545-46). It is worthwhile to note that in the case of central Uganda, these problematic land acquisitions are not an entirely new phenomenon, nor are they exclusively externally driven as is the case elsewhere in Africa (Van Leeuwen et al. 2014: 103-04). Instead, as pointed out before, contestations over land must be understood in a historical context, taking into account the colonial legacy left by the British, and the political upheaval of the post-independence era in Uganda.

Structural adjustment: the 1998 Uganda Land Act After the gradual reduction of tenure rights of many land occupants over the course of the 20th century, the issue of land reform has been a pressing one and was much debated in the 1990s, within and outside of the Ugandan political arena (Coldham 2000: 65; Deininger/Ali/Yamano 2008: 594-597). Eventually this led to the Ugandan Land Act of 1998, which legally recognizes four tenure systems. The act transformed the Ugandan land law and cleared the way for the formal recognition of property rights over customary land and the issuing of land titles. Customary land can now potentially be formalized and converted into freehold. Additionally, the Land Act strengthened the rights of squatters and the landless (Joireman 2007: 470). Whereas the improved land-use rights of the poor are certainly a positive result of the long-overdue land-rights reform, the underlying agenda was however rather informed by the efforts to build the foundations that would give way to economic development. Throughout they heyday of neoliberal structural reforms in Africa during the 1980s and 90s, it was considered to be common sense among economists that secured land rights would not only lead to increases in investments in land, but also raise the land prices and stimulate economic participation – eventually resulting in economic development. This gave way to land reforms in many African states, encouraged by institutions like the World Bank (Berry 2002:652-53; Deininger/Binswanger 1999: 247-49; Deininger/Ali/Yamano 2008: 593; Manji 2001: 329). The ideas formulated by Hernando De Soto formed much of the idealistic framework of the structural reforms. Diana Hunt, who has critically assessed the implications of De Soto’s ideas for the 1998 Uganda Land Act, summarizes that “the key to economic development in the West has been the estab-

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lishment of a formal, comprehensive, generally accepted and generally accessible system of property rights documentation” (Hunt 2004: 173), which eventually allowed for the production of surplus value through the facilitation of transactions. The legal recognition of property rights in the so-called global South should pave the way to roll in economic development in a similar way as it did in the West some centuries earlier. In Uganda, like in many sub-Saharan African states, tenure reforms have also spurred debates on development and political organization, as well as on the standing of the poor (Boone 2007: 558). While the structural changes with regard to land rights in Uganda are in many ways similar to the tenure reforms elsewhere in Africa, the Ugandan Land Act incorporates four tenure systems into the national law. In the government document it is stated that “all land in Uganda shall vest in the citizens of Uganda and shall be owned in accordance with the following land tenure systems – (a) customary; (b) freehold; (c) mailo; and (d) leasehold” (The Land Act, chapter 227, Part II).

Colonial legacies: the introduction of mailo land Unique to the Ugandan case is the so-called mailo land, a tenure system the roots of which lie in the rushed agreements between the British Administration of the Ugandan Protectorate and the Baganda regents and principal chiefs at the turn of the last century.7 Although concerned with matters beyond land settlement, a fundamental part of the 1900 Buganda Agreement was Article 15, in which land tenure was discussed (West 1972: 17; Mair 1933: 199). 8 Henry W. West, who wrote extensively on land tenure in central Uganda, emphasizes the rushed and shortsighted manner in which the agreement was set up: “Notwithstanding the haste in which the negotiations were conducted and the lack of research into the wide field covered by its terms, and in spite of the amateurish and ambiguous manner in which it was drafted, this quasi-treaty was to be the 7 The term “agreement” is somewhat euphemistic, as it implies mutual consent among the negotiating parties. In the context of the British colonial encounter in Uganda it is decidedly unjustified to assume fair negotiations, not at least because of the unequal bargaining position of the involved parties. The whole idea of representatives of the British Empire bargaining over the political fate of the Ganda people (or any other population that was subject to colonization, for that matter), can only be regarded as highly absurd and wrong. For an elaborated analysis of the colonial legacy in Uganda see Low’s book “Fabrication of Empire” (2009); for the colonial past of the continent see Mamdani’s much-cited book “Citizen and subject” (1996). 8 The 1900 Uganda Agreement mainly served to grant the British Administration the right to levy taxes, and defined the administrative and juridical functions of the Kabaka – the king of the Baganda. Cp. West (1965) and Mugambwa (1987).

4. Kampala’s urban fringe: Socio-economic dynamics and transformations

basis of relations between the British and Buganda Governments for more than fifty years.” (West 1972: 16-17) While West confines his comments to the period of validity of the treaty of 1900, it is safe to say that some of the effects of the 1900 agreement outlived its abolition in 1955, and can still be felt today (Reid 2017: 160). With the 1998 Land Act the mailo land, once established by the British colonial administration in Uganda, became part of the officially recognized Ugandan tenure systems and, as I will describe, still has its effects on today’s land markets in central Uganda. The 1900 Buganda Agreement materialized under the initiative of a certain Harry Johnston, who, acting on behalf of the Queen of England, was instructed to “restore ordered civil administration and to make the Protectorate more nearly self-supporting […]” (West 1972: 15). He had the land surface of the Buganda kingdom estimated at 19,600 square miles (hence the name mailo land), to then apportion parts of the land among the British Uganda Administration and the Kabaka and his notables as well as Baganda chiefs and other minor parties. A total of 958 square miles were appointed to the Kabaka, his Regents, county chiefs,9 and other members of his court. Another 8,000 square miles were divided among 1.000 chiefs, who already occupied their estates, that were estimated to be eight square miles in average.10 Furthermore 1,500 square miles were set aside for forest reserves. Smaller portions of the land were allotted to missionary societies and reserved for government stations, totaling to 10,600 square miles. The remaining 9,000 square miles were considered “waste and uncultivated land” (West 1972: 17; Kiwanuka 1972: 295-298) and declared Crown Land, vested in the government of the Queen of England. After independence in 1962 it became public land, and remains so up until today (West 1972: 15-18; Fortt 1973b: 69; Mugambwa 1987: 254-256; Coldham 2000: 67). As mentioned earlier, during the neo-liberal restructuring in many African states during the 1980s and 90s, tenure reforms and the associated individualized property rights were seen as essential step to pave the way for economic development. Only if property rights were recognized and formalized, went the argument, 9 Of the authors cited here, only Henry West defines the term “chief” more clearly. Writing on precolonial rights of control over land, he distinguishes between “two main groups of great chiefs, the bataka or hereditary heads of the kinship groups, […] and the bakungu and batongole who were respectively territorial governors and benefice holders” (West 1972: 11-12; accentuation in original). For a more detailed account of the raise of chieftaincy in the Buganda kingdom, and the role of Baganda chiefs towards the end of the 18th century, see Kiwanuka (1972). 10 Johnston distributed the mailo land based on estimations. In the end 8,430 square miles were declared private mailo, to be divided among 1,000 people. However, as some authors point out, the number of people named on the allotment list was in fact over 4,000, rising to 4,138 by 1921 (Fortt 1973b: 69; West 1965: 11).

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could land markets develop (Boone 2007: 566-570; Musembi 2007: 1457-1460). A number of authors, however, point out that a land market had already appeared in the Buganda region with the introduction of the mailo land at the turn of the 20th century (Barrows/Kisamba-Mugerwa 1989; Fortt 1973b: 66-68). In 1933 the anthropologist Lucy Mair wrote about the consequences of the 1900 Buganda Agreement in her article about Baganda land tenure: “The fundamental change brought about by the Uganda Agreement is independent of individual rights and wrongs, and much more far-reaching. It consists in the introduction into Buganda of an entirely new conception with regard to land tenure – the conception of land as a private possession at the complete disposal of an individual owner. The concurrent adoption of a money economy brought with it the idea of land as a source of profit through leasing or sale”. (Mair 1933: 199) The Buganda treaty transformed former chiefs into landlords, and consequently rendered the people who occupied the land tenants. They only possessed user rights over the land they occupied, and were not legally recognized owners of the ground itself. Occupants had to introduce themselves to the owner and define the property they used, which is still today called a kibanja – a kind of leasehold. Van Leeuwen et al. point out that the introduction of mailo land and the distribution of land titles by the British can be considered one of the first cases of land-grabbing in Uganda (2014: 109). As it appeared, owners of private mailo land soon began to transform the busuulo, a form of labor obligation of peasants towards their chief, into a cash payment, which they varied at will and increased significantly over the years. Heavy protests from the landless, who demanded a return of their land-user rights, eventually led to the enactment of the so-called busuulu and envuujo law in 1928. In order not to return to the former system of land rights, the British Government saw itself forced to interfere by introducing a law which protected tenants from eviction and fixed the annual rent price at 10 Shillings (West 1965: 20-22; Fortt 1973b: 70-71). The established land market in central Uganda quickly expanded. Okuku writes that “the large original mailo estates were broken up and the number of owners has, through inheritance, gift and sale, greatly increased” (Okuku 2006: 16). According to West in 1967 the number of registered mailo land owners had risen to 120,607 (from an initial 4,085 allotees in 1900), adding an estimated 60,000 unregistered holdings of heirs and other beneficiaries (West 1972: 196). The mailo tenure system, exclusive to central Uganda, continues to exists today, and at present the number of mailo land titles is supposed to be as high as 250,000. While there are relatively few landowners, i.e. people who possess a land title, most people in Buganda, and the majority of my informants are tenants on the basis of

4. Kampala’s urban fringe: Socio-economic dynamics and transformations

the kibanja system, which grants them and their inheritors permission to occupy and use a specified area of land (Ahene 2009: 3; Huber et al. 2018; Okuku 2006: 8). Typically, a person in search of land buys his kibanja rights either directly from the owner himself or from a current kibanja owner. Traditionally the tenant would introduce himself to the owner by giving him a kansu, a long, white costume typically worn by the Baganda on festive occasions. However, nowadays the equivalent amount of money is given as an introduction gift. The two parties then agree on a busulu and the tenant is given the rights to use the land, ideally in the form of a written agreement. These rights can then be transferred to others, and can also be inherited. The introduction to the owner of the land remains important, however. Once the owner has agreed to occupation of his land, he can only evict inhabitants if he proves that he has plans for further use of the land, and if he reimburses the money the tenant has put into the development of the land (for example through the construction of a house or the planting of a garden) and offers the tenant an equivalent place to build a house and sustain his living. Alternatively, the tenant and the owner can come to an agreement, whereby the kibanja is normally decimated and the tenant is given full ownership rights over the remaining parts, typically the part the tenant (and his relatives) stays on and, if applicable, the burial grounds of the tenant’s kin. Mostly it is the parts used for cultivation or cattle-keeping that the tenant loses control over. Several authors point out that the mailo system inherently causes conf licts over land – and thus contradicts the structural adjustment goals of the 1998 Land Act to diminish poverty and stimulate economic growth by establishing a free land market in Uganda. The overlapping interests in and claims to land of owners and occupants potentially stif le the development of the respective areas. Moreover, confusion about the rightful ownership or occupancy of land is common, especially among migrants who move into the Buganda area from outside and purchase a kibanja or an occupied plot of mailo land. While landowners cannot make the land productive, as the tenants are lawfully protected from eviction, the occupants on the other hand are reluctant to invest in the land as they are not its titled owners (cp. Coldham 2000: 66; Deininger/Ali/Yamano 2008: 596-97; Huber et al. 2018; Joireman 2007: 469; Okuku 2006: 15-16). Kibanja-owners in central Uganda often perceive their access and user rights to their land as fragile. As I will show with selected case studies in chapter seven, owners of a kibanja are indeed increasingly losing the access to arable land in the urban fringe. They are persuaded to agree to deals with which they lose the control over large parts of their kibanja. While transforming a kibanja into owned property is desirable, exceedingly few can afford to buy the property title to the land they use.

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Mailo land in Namulonge Whereas mailo land titles can thus be sold, transferred, and subdivided, permanent access to land remains out of reach for many. Land prices are on the rise and most farmers in my research area are struggling to acquire enough land to construct a homestead, let alone to cultivate a garden large enough to live off. On numerous occasions people explained to me that they had recently been deprived of their kibanja and that the owner had sold it off to an investor. The construction of relatively expensive houses and estates can be seen everywhere in Namulonge and the neighboring villages, and most of the new housing that is being built in the area is constructed on former kibanjas. In 2012 the former owner of the land in my research area, a certain Richard Ssemuju, passed away and bequeathed the land to his son, Charles Ssemuju, who in turn is now selling much of his property. Unfortunately, he refused to talk to me in person about the reasons for his efforts to release his land holdings, but the benefits are evident: while leasing a kibanja out to a tenant doesn’t bring the owner much wealth, selling the land off does. In the context of rising land prices in Kampala’s metropolitan area, the few landowners are blessed with tremendous wealth, much at the expense of the current occupants. In order to cope with the loss of land, many farmers try to make seasonal deals with landowners or other people who control land to use part of their ground for cultivation. Mostly both parties agree on a part of the harvest as means of payment, which is due at the end of the season.11 In other instances, I met people who use the vast areas of land of the NaCCRI institute. Much of the land is only partially under use, and especially the wetter areas of the land are often not occupied by the research institute. There is an agreement with the directorate of the institution that people who are employed by NaCCRI or NARO can be appointed a certain area of land for domestic use. In practice many people who are not employed by the research institute are also leasing land for agricultural purposes, or use it “illegally”. After the recent controversies concerning a possible land deal with Aamir Sabharwal the NaCCRI administration has announced its intention to intensify the controls in that regard; however, I haven’t witnessed any eviction of unregistered land-users on NaCCRI grounds so far.

11 In a way these type agreements bare an odd resemblance with medieval feudalism and unveil the power and class differentiations that stem from the possession of land.

4. Kampala’s urban fringe: Socio-economic dynamics and transformations

Health in local context In this book I am specifically concerned with conceptualizations of malaria among wetland users in central Uganda. To understand malaria in the local context will require one to broaden the scope of analysis to a certain extent and also look at regional health issues at large. The ways in which people make sense of malaria are inevitably also informed by the ways in which health and healthcare are organized and structured. In the following paragraphs I will, albeit brief ly, outline the health issues at stake in Uganda, in order to then go on to look at the organization and availability of healthcare in the region. I will thereby partly touch upon malaria as well. As a low-income country in the first phase of the demographic transition, characterized by a high birth rate and a f luctuating death rate, the burden of disease is predominately caused by communicable diseases, although non-communicable diseases are an emerging challenge. Uganda has one of the world’s youngest populations, with a slowly increasing life expectancy at birth, currently standing at 57 years (Haub/Gribble 2011: 4-5; WHO 2015). The leading cause of death is HIV/AIDS, followed (with a margin) by lower respiratory diseases. Malaria is currently the third most important cause of death in Uganda, accounting for roughly 20,000 of the annual deaths. It should be noted, that while the amount of deaths due to the three most important diseases (HIV/AIDS, tuberculosis, and malaria), had decreased by roughly a third over the previous decade, this drop has stalled. The infant mortality rate (IMR) is at 54 deaths per 1,000 live births, and the maternal mortality rate (MMR) has reduced to 320 deaths per 100,000 live births (WHO 2015). In the recent past Uganda has seen epidemic outbreaks of hemorrhagic fevers, most notably ebola and marburg viruses (De Vries et al. 2016: 162-163; Leach 2008: 5). In the urban areas there are recurring outbreaks of cholera and typhoid, especially in poor areas with limited access to improved sanitation (Bwire et al. 2013: 4; Isunju/Orach/Kemp 2015: 276; Murphy et al. 2017: 2). Malnutrition, especially among women and children, is a further relevant health factor in Uganda (WHO 2015).

Health care in Uganda This paragraph provides only a brief description of health care in Uganda, and at this point merely serves to set the context of the thesis. In the following chapter I will take a more thorough look at the health care options in Uganda. By using selected case studies I will illustrate which healthcare options are available in Kamapala’s urban fringe and how people make use of them. The Ugandan healthcare landscape is characterized by a range of different healthcare providers, biomedi-

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cal as well as others, and syncretic health models are common. While I will go into that matter in more detail in chapter five, some features will already be discussed here. In order to make sense of the research setting and the peri-urban environment in the context of which I look at malaria in this book, I deem it relevant to sketch a brief image of the medical landscape of Namulonge and its neighboring villages and trading centers, and outline its relevance for health issues beyond the malaria epidemic. It appears obvious to start the description of the medical landscape with the professionalized, biomedical healthcare services. Biomedical health care facilities in Uganda are characterized by their funding. Three different types of health care institutions can be distinguished: public, private, and NGO-funded and -organized (Boslaugh 2013: 481). Generally, however, the biomedical healthcare sector in Uganda is highly donor-dependent. This raises the question, whether the country can in fact autonomously set its national priorities with regard to health and defining the agendas of health interventions (Mukasa 2012: 6-7). Public health care in Uganda is generally free of charge; however, at the regional level it is typically very basic in its provision of services. Diagnosis and treatment of the most common and pressing health problems (HIV/AIDS, malaria, and tuberculosis) is however widely available, and, due to increased efforts to tackle the so-called neglected tropical diseases, driven by international agreements such as the proclaimed Millenium Development Goals, has improved significantly over recent years (ibid: 8). Public healthcare in Uganda works on referral basis, whereby a first evaluation of a patient’s case is made in low-level health centers, and complicated diagnoses are referred to higher-lever public health institutions. The health facilities are organized from the village level up to the parish, sub-county, and district level, with the Mulago national referral hospital at the top of the hierarchy (cp. Umlauf 2017a: 45). In Namulonge and the surrounding villages a Health Center III offers a range of essential health care services, most notably testing for HIV and malaria as well as antenatal care (cp. figure twelve). Patients with chronic diseases, such as HIV/AIDS, diabetes, and arterial hypertension are checked on special, regularly repeating clinic days. The health centers also dispense basic treatments upon diagnosis and when available. These are mainly generic medicines, such as broad-spectrum antibiotics, painkillers, cures against worms and other parasites, or combination therapies against malaria. Antiretroviral treatment is always wellstocked and distributed among HIV patients, according to national policies.

4. Kampala’s urban fringe: Socio-economic dynamics and transformations

Figure 12: Signpost of the Namulonge Health Center III, picture by author

Complementing the biomedical public healthcare, private health facilities offer a variety of therapies – in exchange for money. Throughout my research area drug shops were plentiful, commonly offering a range of drugs, aside of simple services, including rapid testing of one’s malaria status. Within the two main trading centers in my research area, Kiwenda and Namulonge, I mapped a total of 17 drug shops, as well as a larger medical center offering a range of health services. Also, a new medical center as well as two drug shops were opened in Kiwenda between my various visits to Uganda between 2015 and 2016, while another clinic closed in that time. Health insurance in Uganda is rare and expensive. Although there is a government incentive to promote Community Health Insurance, based on community-level finance-pooling, initial trials with target population groups are disappointing: the necessary fees are too high, and interest among the target groups remains low (cp. Basaza, Criel/Van der Stuyft 2008: 172-73; Dekker/Wilms 2010: 375). During my research I didn’t meet a single person insured against possible costs of ill health and the associated therapies, and the concept of health insurance was alien to most people I spoke to. However, over the last four decades the government has increased the spending on healthcare significantly. Nonethe-

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less, health facilities are mainly found in urban centers, and in the rural areas of Uganda access to healthcare remains a serious problem (Boslaugh 2013: 480). Most people I talked to would report expenses for health, along with the expenses for school fees, as the most important and challenging to meet. Often the wider social network is acting as a kind of insurance, so to speak, by covering the costs for the required treatment. Needless to say, more often than not only the most needed treatment is paid for. Still, I was surprised how in some cases rather poor families managed to free funds for relatively high treatment costs. As an alternative option to the costly scientific health care, people often turn to a range of other specialists and self-proclaimed experts in health related fields. Herbal medicine is on the rise in Uganda and a multitude of healers are offering remedies for a variety of ailments. Apart from being more affordable, the ratio of alternative practitioners in relation to the whole population is much higher than in the biomedical realm. While in the urban areas of Uganda 10,000 people share one scientifically trained doctor (the ratio is 1:50,000 in the rural areas), there is at least one alternative healer for roughly each 300 people. It is interesting to note that, although the number of alternative healthcare providers is much higher than in the biomedical sector, the number of patients that effectively turn to so-called “traditional” healers for medical treatment is not higher; on the contrary, from the data of the household survey that was carried out in the context of the GlobE-project, it appears that only a few people turn to alternative medical healthcare in order to treat a malaria infection.12 The range of alternative practitioners is wide, and names and definitions vary. Among the most common are herbalists, bonesetters, psychic healers, traditional birth attendants, faith healers, diviners, and spiritual healers (Weisheit/Male 2003: 1). Herbal medicine has a growing impact and has recently been recognized by the Ugandan ministry of health. In order to get an idea of the research setting, this brief summary of healthcare in central Uganda will suffice. In the next chapter I will elaborate more on the different health resources available to the people of Namulonge and also look more deeply into the processes that lead to a diagnosis of malaria as well as other diseases. I will also take a closer look at how the healthcare landscape has developed since independence, and how it is perceived on the ground. By means of a composite character case I will illustrate how patients in Uganda access healthcare. I argue that a systemic approach to the analysis of healthcare in Uganda is misleading, as the various healthcare facilities and offers are typically not perceived as being systematically structured, and neither is ill health commonly managed in a systematic way. 12 Out of 146 questioned households in the Busukuma sub-County, only one (0,7 per cent) stated to have treated the last malaria infection following the consultation and advice of a “traditional” healer. In chapter six I will elaborate more on the reasons behind this seemingly low quota.

“Usually malaria is one of the conditions that is over reported because I think it’s a money maker for people operating private businesses. But here we are not after money, we are after offering a service.” Interview with Jonathan, clinician at the medical ward of a flower farm in Mairye, November 15, 2016 “Yes it’s a problem, this idea of coming to the pharmacy and saying: ‘I want Coartem’ – ah ah, with me you have to test first. By the time [that person] comes to a health unit, he is already badly off. But if he had come earlier to be tested, he wouldn’t have wasted a lot of money and time.” Interview with Dr. Nathan, clinician in Namulonge, November 4, 2016

5. Providing malaria treatment: Different forms of healthcare in Uganda Natayi had a rough night. Her 18-month-old son Ssenyondo kept her awake for a good part of the early morning. He was obviously developing a sickness; his forehead felt hot, he was bathed in sweat and struggled to get back to sleep. “Malaria”, was Natayi’s first guess – he would get over it. After preparing breakfast next morning, she would pick some omululuza on her way back from the well, where she filled the jerrycans. Her mother had taught her how to pound the leaves and mix them with boiled water. The bitter infusion was hard to swallow, but that only proved its efficacy. If she was to be lucky, she hoped, she would find some of the fruits of the kaselo shrubs, which she could add to the mix, and to make sure, she’d add some leaves of the omwetengo bush that stood their backyard. Although

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Natayi’s mother used omwetengo to treat stomach pains and ulcers rather than fevers, Natayi was sure it could not hurt. She sometimes took it herself when she had a headache, and thought it worked wonders. Ssenyondo cried when she fed him the lukewarm medicinal brew, but as she had anticipated, the self-made medicine seemed to work. Around midday, when she was preparing posho and boiling a pot of beans, her son was again up and playing with the neighbor’s kids. He ate well too. But Natayi’s relief was premature. Already in the afternoon Ssenyondo was burning hot again, squirming in the cloth wrap in which she was carrying him on her back while she was walking to her family’s field to complete the weeding she had started that morning. She put down Ssenyondo in the shade of a tree, where he fell into a fretful sleep while she was attending to the beans she had planted a month earlier. Later that day, again at home, she tried again to give her son some of the brew she had prepared earlier. The baby ate little, and slept fitfully that night. Natayi was still not worried. Nonetheless, she had asked her husband to buy some pills from one of the drug shops in the trading center. After all, chemical medicines are stronger than the local herbs, everyone knew that. When her husband returned later that night, at around ten, she had already dozed off. He was out, meeting some friends and drinking malwa – cheap, locally-made millet beer. While in the center, he had bought three Panadol tablets from a small medicine shop along the main road. Still that same night, Natayi snapped one of the pills in half, pounded it into a powder and dissolved in some water, which she then fed to the baby. The shop assistant in the pharmacy had advised her not to exceed the dose of half a pill, three times a day, and recommended that she see a medical doctor if there was no improvement within the next two days. But, as it seemed, at least for that night, the pills did their job. Though still feeling hot, Ssenyondo slept fairly well for the remainder of the night. Next morning Natayi repeated the Panadol treatment, and added a little of the content of a yellow capsule that was left from the last time her husband had been ill. This time Ssenyondo threw up, and did not keep in any food, milk or water for the rest of the morning. Instead he was visibly agitated, and cried for the better part of the morning. Although Natayi started to feel concerned about the well-being of her son, she was still hopeful that he would soon feel better, and did not suspect a serious disease. All too often she had seen feverish and sick children already. Ssenyondo’s two older siblings had experienced worse episodes of sickness, and after all they had both recovered eventually. Only Ssenyondo’s older sister had once been sick with a serious cough, accompanied with worsening fever. The doctors at the health center had said it was a bad sickness, calling it an English name she could not remember. In the end she was given a prescription for expensive medicines, urging her to not delay the treatment. Natayi could not read, and even if she had been able to, the doctor’s scribbles were impossible to decipher any-

5. Providing malaria treatment: Different forms of healthcare in Uganda

how. It was a costly treatment, containing of at least twenty green capsules and some smaller tablets, which had to be taken for an entire week, three times daily. Her husband had to borrow money from his brother in order to pay for it, but the treatment proved to be effective and Ssenyondo’s sister had soon improved. For a moment Natayi had feared Ssenyondo might have caught the same disease, but he did not cough at all – so she ruled out that option. By midday, to Natayi’s relief, the boy was drinking again without throwing up. But Ssenyondo’s body temperature remained high, he was restless, and she found him shaking. Her neighbors advised Natayi to consult Mukyala Sofiya, who lived a kilometer down the road. Mukyala Sofiya had once taken part in training set up by the health administration in Wakiso, Natayi’s neighbor remembered, and knew something about medicine. After lunch Natayi dodged her plans to fetch water and do the laundry and instead took her baby son to visit Mukyala Sofiya. Mukyala Sofiya, a middle aged woman, was not home when Natayi arrived at her compound, but two young boys who played around on the compound were sent to fetch her. Meanwhile, Natayi waited under the shade of a mango tree, chatting with a young woman of about her own age. Mukyala Sofiya, as it appeared, was indeed trained by the Wakiso district government and subsequently recruited to join the village health team in Balita. In this capacity she was appointed to monitor the medical and hygienic conditions of households in her village, and authorized to give medical advice to people, make an initial medical assessment, and refer patients to health centers and hospitals. Furthermore, the government had equipped her with malaria test-strips and a box of Coartem pills, a highly effective combination therapy against malaria. After about half an hour Mukyala Sofiya arrived, accompanied by the two boys who had rushed to find her. Carefully she listened to Natayi, who told her how her son had developed a fever, how she had tried treating him with the typical herbs and even Panadol, but that he was not responding to the treatment and instead lost his appetite, threw up, and was visibly worsening. She said, she suspected it was malaria, but was surprised that it did not go away as in most of her previous encounters with the disease. Mukyala Sofiya agreed with Natayi’s suspicion, but added that she could not know for certain until a test confirmed it. Ssenyondo cried loud when Mukyala Sofiya pricked him with a needle which she had first, wearing rubber gloves, uncomfortably uncapped after disinfecting Ssenyondo’s finger with an alcohol swab. After applying a drip of the baby’s blood to the testing device and adding the buffer f luid, they had to wait some fifteen minutes until the result would be shown. Natayi tried to soothe Ssenyondo, who wouldn’t stop crying – he was visibly unwell. Eventually the test confirmed what they had suspected already: two lines had appeared on the the test strip, one indicating that the test had been successfully run, the other showing the presence of malaria antigens in the tested blood. Mukyalya Sofiya said the boy would need a

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course of treatment with Coartem tablets, but was not sure whether she still had enough left in her stock to supply Natayi. In the worst case Natayi would have to go to the public health center; there they surely would have Coartem in stock. Natayi did not like going to the public health center, and avoided it as much as she could. In her experience one always had to wait for long hours until one was seen by a doctor or a nurse, who were then mostly impatient and unfriendly. And although the health center advertised its services as being free of charge, they usually just gave out prescriptions or referred patients to another hospital. The staff of the health center would say that they currently experienced stock shortages, but everyone knew that the doctors actually stole the public medicines and sold them from their private drug shops instead. In her opinion (and that of many others she knew) going to the public health facilities was mainly a big waste of time. Her experience with Mukyala Sofiya confirmed this once more. The only thing she did was test the baby and confirm what Natayi had suspected already – Ssenyondo was suffering of malaria. But instead of providing the right medicines, Mukyala Sofiya only referred Natayi to the health center. If she had known that beforehand, she could have gone there without the detour via Mukyala Sofiya’s place. Back home Natayi discovered that Ssenyondo had developed diarrhea. The wrap with which she carried him on her back was spoiled, and Natayi hurried to do the laundry she had wanted to do earlier in the first place. This would delay the entire program of the day; they would have a late supper tonight and Natayi would probably not have time to rest that day. Meanwhile Ssenyondo started crying again, his forehead was hot. When Natayi’s husband came home at around six in the afternoon, she prepared him a bath and told him about her experience with Mukyala Sofiya, and how she had advised Natayi to go to the public healthcare ward to get Coartem for the baby. She explained how she hated going there and how she saw no use in it in the first place, asking her husband to buy Coartem from the trading center. Her husband went to check on Ssenyondo, felt his warm body and agreed with Natayi that something had to be done. As supper was late anyhow, he went to the center right away to get the recommended antimalarial drugs. He returned with two tablets of Fansidar instead of Coartem. “The pills you requested”, he said to his wife, “were three times as expensive, and so I bought these,” showing her the Fansidar tablets. “The man at the drug shop told me they are also very effective against malaria, and were until recently also used in the public hospitals until Coartem was around. And with Coartem, you have to keep taking pills for three days, but with this one, two tablets are enough” One tablet was the dosage the chemist recommended for babies of Ssenyondo’s age and weight, best to be taken after eating and with plenty of water; to be sure, however, he recommended adding another pill 24 hours later. Natayi worried about whether her son would eat and keep down the water, but luckily, although Ssenyondo barely ate and did

5. Providing malaria treatment: Different forms of healthcare in Uganda

not drink much, he did not throw up the pill either. And to Natayi’s great relief, the next morning Ssenyondo already seemed to be better; he had only woken up once in the night, and appeared to be much calmer now. His temperature had gone down as well, and by the end of the day Ssenyondo was up again, still weak but walking around the compound, watching his brother and sister playing with the swing that their father had hung in the jackfruit tree in their yard. The relief did not last long. Only a day after Natayi had administered the medication, Ssenyondo fell ill again, lying sweating and crying in the bed next to Natayi. He had again developed a fever. Moreover, Natyi noticed his belly had swollen on the left side of his body. What was wrong with her son? She wondered if the dosage of Fansidar had not been sufficient. Did he need more drugs? Was Coartem the stronger medication? Natayi asked her husband if he could leave her some money so that she could go to the drug store that day herself to buy more medication. Her husband, however, objected, saying that he doubted whether Coartem or any other chemical drug would help the situation. “What if it’s a disease which cannot be cured with the bazungu medicines?”. He suggested Natayi should visit Namwanda Kabandu, an elderly lady in Sitabaale, who was known for her knowledge of eddagala elyekinansi, the herbs, roots and barks that were used in Baganda medicine. So, that day Natayi took a boda-boda to go and visit Kabandu. Namwanda Kabandu was an old widow, staying in an equally old and rundown house, into which she admitted her clients. Natayi felt a little uncomfortable. While she had heard of Namwanda Kabandu before and knew the house, she had never visited the woman, and neither had she consulted her medical expertise before. When she arrived at the house, a man received her on the compound. After she brief ly explained her request, the man disappeared into the house, coming out only a few minutes later, saying that Kabandu would see her shortly, and that she should wait inside. Natayi was led into a dark room, and directed to take a seat on a worn-out mat on the ground. While she was waiting, Natayi looked around: a few torn posters depicting biblical scenes and Jesus Christ, as well as a rosary were pinned to the wall; in one corner stood some sacks, while in another she saw a pile of unwashed dishes and a blackened kettle. At the other end of the room she saw a small cockroach disappearing into a crack in the wall. The room felt damp. After Natayi had waited for what felt like a long time, Namwanda Kabandu entered the room, wearing an old red Gomezi, the festive dress typically worn by Ugandan women. Kabandu greeted Natayi and asked her what she had come for. Natayi hurried to explain that her son had been ill for a few days, and that she had tried to treat him with omululuza, as she expected the child to suffer from malaria, and later with tablets, but that his condition had only got worse. She emphasized the vomiting, diarrhea, and the enlarged abdomen. Namwanda Kabandu listened patiently and then requested to see the baby.

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The widow felt the boy’s body, ran her fingers over the child’s belly, and weighed him in her arms. She then asked Natayi whether she had been to the health center or an eddwalilo, a clinic? Natayi replied that since Ssenyondo had not been responding to the any treatment, she suspected that the child was suffering from a disease which could not be healed with modern medicine. That’s why she had come here to seek for advice. Namwanda Kabandu pointed out that she was not a mganga, a “witch doctor”, as they are often referred to in English, but that she knew of herbs that were stronger than the omululuza and more effective than most of the chemical tablets that one could buy. To her it did not seem that the child was suffering from a local disease, but instead needed stronger drugs. Disappearing again into the adjacent room from which she had come, she ordered Natayi to wait. She soon returned with a plastic cavera, a bag, in which she had compiled a mixture of different dried herbs and barks, ground into a powder. The substance was dark, almost black in color, and had a moldy smell. Namwanda Kabandu instructed Natayi to mix a tablespoon of the powder into a cup of boiling water, which she should then give the child to drink; three times a day, until the fever had disappeared. Before she handed Natayi the bag with the medical mixture, she said the medicine was not without a price. As Natayi, had only 4,000 Shillings left, and still needed to pay a boda-boda to get home, she was sold the medication for just 3,000/= UGX. “Because you here for the first time,” Kabandu said, “and because I want you to come back”. As soon as she was back at home she put a kettle on the stove and prepared the medicine as instructed. The infusion had a brown color and a strong, bitter taste – Natayi shivered after tasting a small sip. Of course Ssenyondo did not like the concoction either; it was difficult to feed him the medical drink. The boy was visibly ill, had a pale complexion, and was shivering, although his skin felt hot. Natayi anxiously hoped the mysterious medicine Namwanda Kabandu had given her would finally improve her son’s condition. After all she had tried, these herbal mix should now finally bring about an improvement. By now Natayi was convinced that her son was not suffering from malaria, at least not the ordinary type. He would have been better by now, and it was a long time since she had last seen a child so ill. Ssenyondo was not even crying much anymore, most of the time just lying with his eyes closed, yet restless at the same time. Natayi kept applying the herbal medicine for one-and-a-half days until she gave up. She did not see any improvement in the baby’s condition and, to her shock, in the late morning of the following day she saw her son convulsing. Ssenyondo’s arms were trembling while his head jerked sideways, his eyes wide open, but with an absent stare. Natayi immediately knew something was wrong, that her son was in a serious condition, and all of a sudden she was beset with the crippling feeling that Ssenyondo might be in deadly peril. She switched on her phone

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and rang her husbands phone, anxiously hoping for him to call back. It was not until she had rung his phone another three times that she finally got the call-back she was waiting for. Natayi’s husband excused himself from his work and rushed home as he had promised. There he found Natayi, visibly distressed, with their son in her arms. Ssenyondo seemed to be asleep; he looked calm. However, as Natayi explained, once in a while his entire body would cramp and shake in uncontrolled movements. It seemed as if he was possessed, driven by an outside being. This called for the musawo omuganda, the mganga. Why had they not seen it before? Why had they not read the signs? There was a spiritual healer in Balita, not too far from where Natayi and her family stayed. Everyone knew the place, the bushy compound, with its shrines and grass-thatched huts. Natayi had never consulted a mganga before, but friends of hers had. Balita’s witchdoctor, as the baganga are referred to in English, was not one of the famous ones. He was not one of the likes of Musawo Muluuli, who was known across Buganda and practiced somewhere in Katwe. But he did not charge as much either, and consulting a mganga was an expensive endeavor on itself. Natayi’s husband called his brother in order to request some money – payment was delayed and the cash money they were left with was certainly by far not enough to pay the doctor. But in such emergencies one could always count on the family to help. It was Natayi’s brother-in-law who convinced them not to consult the mganga but instead to rush to the health unit at Bugema University, two hills further down the road, a fifteen minutes boda-ride away. After the worried phone call he had promised to drop by, to see the boy’s condition for himself. He had experienced similar symptoms with two of his own children, and had learned the hard way that a mganga could not do anything in such cases. His second son had passed away at only four years of age, suffering from similar convulsions. It was then that he learned that it was musujja gw’en sili, the mosquito-fever, that could cause such symptoms. A disease which they treated at the health center and in the modern hospitals. A disease that killed people. At the health ward of the Bugema University the nurse in charge did not hesitate for a moment when Natayi and her husband, together with their son, were finally called into the consultation room. Natayi was just describing the boy’s symptoms when Ssenyondo’s body began jerking again. The nurse requested to have the baby handed to her and called for her colleague to bring a basin of cold water. She stripped the boy naked and started to dab his body with his shirt which she had soaked in the water. “It’s to cool down his temperature”, she explained, and continued to say that Ssenyondo was suffering from malaria. “I don’t even have to do a test; this is a very clear case. Why didn’t you come earlier?” she barked. “You will have to stay here tonight”.

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Ssenyondo was given an injection and put on a drip. The nurse explained that he had a severe case of malaria, and that the convulsions were a typical symptom of the cerebral stage of the disease. The boy was given quinine injections, and had a good chance of getting better; however, the nurse continued, he would have to be kept under surveillance and would be admitted to the hospital; Natayi had to stay with him. In the end they had to pay a hefty bill, covering the hospital admittance, the expensive injections, and the consultation. Moreover, the healthcare ward at Bugema University was known to be rather expensive. But Natayi’s brother-inlaw assured them that they delivered excellent medical care. He was proven right: Ssenyondo was recovering. Already after the first night in the hospital he was visibly better. His temperature normalized, the jerking body cramps had stopped and he was now resting, noticeably calmer than only some hours earlier. Natayi felt relieved. All the fears that had taken hold of her in the last days now gradually released their grip and she too, felt exhausted, yet calm and happy that her son had overcome his malaria infection. The above description of Natayi’s struggles to find a cure for her son’s malaria infection is fictitious; she is a composite character, compiled from the many accounts of health-seeking I collected and my observations and notes that I took when doing fieldwork on malaria in central Uganda. It has to be noted that during my fieldwork I did not witness such a lengthy search for illness relief, and if I had, I would have interfered at some point for ethical reasons, motivated by my medical understanding of medicine and, most importantly, malaria. The several stops on Natayi’s health-seeking journey, and her considerations, fears, and assumptions, her evaluations and attempts to find a cure to her baby’s maladies have, however, been reported to me in lengthy interviews, conversations, and observations during my fieldwork in central Uganda. The story of Natayi serves to introduce the reader to the vast range of health services and medical facilities available to patients in the region. Moreover, the vignette gives an impression of the omnipresent practices of self-medication. Also, underlying the composite character are the various understandings of the expression “malaria”, which is at times merely used as an umbrella term for various maladies, but in another context referring to the parasitic disease that is described in biomedical books. In other instances, patients prefer to use the Luganda word musujja to refer to the feverish symptoms. To a certain extent, the imaginative case does also represent the nonlinear way in which treatment is often sought. This, I argue, is an important point, as it refutes the notion that health-seeking occurs in homogeneous, recurring patterns, as is inferred in the models of healthcare systems that were popular in the Medical Anthropology of earlier decades. The systematic approach by which scholars in the 1970s and 1980s have attempted to categorize healthcare provision

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and health-seeking does not do justice to the often context-related approaches to healthcare and highly individualized experiences of illness.

Self-medication and individualized conceptions of health Healthcare, against the common assumption, does not start with a doctor’s advice or the administration of drugs, but begins at the individual level. It is here that healthcare and health-related activities are usually initiated and evaluated, and where choices regarding the consultation of specialists are made. Kleinman notes that in most cases it is not health professionals who organize healthcare for patients. Instead, “[…] lay people activate their healthcare by deciding when and whom to consult, whether or not to comply, when to switch between treatment alternatives, whether care is effective, and whether they are satisfied with its quality” (Kleinman 1980: 51). Much like Natayi did for her son, people evaluate their bodies, their well-being and their health status themselves and decide, based on earlier experiences, the advice of family and friends, and the available options, what steps to take in order to change that health status. This is not only the case for central Uganda, but holds true everywhere in the world. Neither is the search for healthcare always straightforward, but instead often rather a trial-and-error approach, which is constantly subject to evaluation and new considerations. In Uganda, as in most areas around the globe, most cases of illness are at least initially handled individually, mainly at home. Self-medication with both biomedical and alternative or herbal medicines is widespread in Uganda, and the often precarious financial situation of households shapes the way in which illness and disease is handled. For example, like Natayi, most people have at least a rudimentary knowledge about a handful of herbal remedies and make use of them to cure uncomplicated diseases – a much cheaper and often quicker way to handle disease. Also an illness is diagnosed as a disease at the individual level. Based on earlier experiences with illness and healthcare, as well as the experiences of the wider social network, people form an opinion about their health, the possible causes of their illness, and the appropriate treatment. Economic, religious, environmental, political, and social factors also inf luence these decisions. In the following chapter I will come back to these points, and illustrate in more detail how health-seeking decisions with regard to a malaria infection are formed. Decisions regarding the activation of healthcare also ref lect individual ideas and knowledge about disease and its causes. After all, actions are based on earlier experience and readily available knowledge of individuals and their social network. Popularization and appropriation (and for that matter also simplification) of biomedical terminology is commonplace. Nevertheless, with regard to malaria in its biomedical definition – musujja gw’en sili – almost everyone in Uganda agrees that it is transmitted by

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a mosquito and needs to be treated with “white man’s” medicine.1 This, however, does not imply that the unspecific malarial symptoms (i.e. fever, nausea, headache, vomiting, and diarrhea) are in all cases interpreted as such. Instead, as I have shown in chapter two, the English term “malaria” is appropriated into vernacular Luganda to describe just that: a still undiagnosed, unspecific, feverish sickness, for which there are various treatment options. As I have outlined, and to my initial confusion, the term malaria is laden with various definitions, depending on the situational context in which the term is used. “Malaria” can refer to a set of rather unspecific symptoms, while in another context it signifies a dangerous disease, with all the implications attached to it. Sometimes, people chose to speak about a malaria infection in Luganda, using the word musujja, which simply means “fever” in English, yet in another conversation it might remain unclear what musujja refers to in biomedical terms. Malaria is not necessarily a clear-cut term in the biomedical realm either. There are five different forms of human malaria parasites to begin with, each causing a slightly different set of symptoms, and, more importantly, having different health implications for the diseased. For fully grown adults, most forms of malaria are usually not potentially fatal; only the falciparum strain is life threatening when it develops into a severe, cerebral form. While chronic forms of malaria are usually fairly curable, occasionally even with common herbal remedies such as the local omululuza (Vernonia amygdalina), complicated cases of plasmodium falciparum can only be effectively treated with powerful, modern combination therapies (Greenwood et al. 2005: 1491). Furthermore, from a biomedical perspective, feverish symptoms cannot be convincingly attributed to a malaria infection unless it has been confirmed with the help of a diagnostic test, preferably a microscopic blood smear analysis, but in rural Africa increasingly through rapid diagnostic tests (RDTs). In the context of the re-initiated campaign to roll back malaria, the increasing affordability and availability of test strips, and the threat of rising drug resistance, Uganda adopted a policy of confirmed, rather than presumptive, treatment of malaria cases. At least on paper, only a positive test result should grant a patient access to antimalarial treatment; however, the adoption of the policy has so far not led to a decrease in ACT-prescriptions (MoH 2014: 34-35; Beisel et al. 2016: 2).2 Also, I would argue, diagnosis of malaria prior to treatment is usually only 1 The Luganda term for malaria caused by plasmodial parasites, musujja gw’en sili, literally translates to “fever of the mosquito”, attributing fever to the infectious bite of a mosquito. 2 Due to increasing resistance of malaria parasites against chloroquine, Artemisinin-based Combination Treatments (ACTs) have become the most widely adopted first-line treatment of choice. In Uganda the combination of artemether-lumefantrine, better known under the brand name “Coartem”, is the common ACT prescribed in public health facilities since 2004 (Yeka et al. 2012: 190; Greenwood et al. 2005: 1491). However, in private-for-profit facilities the much cheaper chloroquine or other outdated treatments remain available and often are the drug of choice of peo-

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a requirement in formalized healthcare facilities, and in consequence, it is only through formalized healthcare that people suffering from malaria are in fact diagnosed according to biomedical standards. While in informal, private-for-profit facilities, malaria diagnosis through the application of an RDT has become quite cheap, it still adds to the treatment costs. Instead, most people chose to diagnose a febrile illness as the disease malaria/musujja without prior diagnostic tests, but based on the observations of the illness symptoms. While I myself have so far been lucky never to be struck by malaria, most Ugandans have suffered from a malaria infection at least once in their lives, and I’ve collected many accounts of illness experiences. Generally speaking, people don’t need to rely on blood analysis, and claim to safely be able to diagnose a malaria infection themselves. When accessing either biomedical or the alternative healthcare, it is usually in order to access treatment, not to receive a diagnosis. This, however, does not imply that people always diagnose a malaria infection correctly, and neither is the search for treatment always a straightforward procedure. Ill persons often spend a considerable time switching between different forms of healthcare, following what appears to be a system of trial and error. In her insightful article on the experiences of Ugandan patients, Hanne Mogensen reminds us that health-seeking is often a long process. “In the course of a sickness episode people move back and forth between self-medicating with herbs and pharmaceuticals; visiting local herbalists, diviners, and other kinds of specialists; visiting public health facilities of difference [sic] sizes; and visiting private clinics and pharmacies in the trading centers.” (Mogensen 2005: 214) She further emphasizes this claim when it comes to the health of infants and small children, who are prone to infections and often ill, in many cases for longer periods. She writes that parents… “[…] may seek treatment for diarrhea at the health unit one day and then interpret diarrhea as part of a larger constellation of symptoms that one chooses to discuss with the diviner the next day. No sharp distinction is made between symptoms treated with biomedicine and symptoms treated in other ways, and the public health care system continues, in spite of its turbulent history and many shortcomings, to play an important role in the ongoing process of seeking health care.” (ibid: 214) Mogensen’s quote already suggests that health-seeking is by no means a systematic endeavor, and thereby affirms the earlier mentioned critique of the model ple in search for medication in order to treat their malaria infection (Rutebemberwa et al. 2009: 47; Umlauf 2017b: 454).

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approach to healthcare and reminds us once more of Lewis’ (2007: 37) claim that people might have various understandings of an illness and disease that, to an outsider’s eye, can at times be contradictory or conf licting. When it comes to the evaluation of the healthcare options and the initiation of further steps in the process of treatment-seeking, there are a multitude of factors at stake. As I will show in the following chapter, these include earlier experiences with healthcare, illness and disease, as well as the experiences of the wider social network. Financial and socio-economic reasons play an important role, especially among poorer parts of the population. In some cases, religious or cultural views can be of importance. Geographical and ecological factors at times inf luence the decisions of ill people in search of remedies, as do political dynamics at various levels.

Mapping healthcare In his inf luential first book “Patients and Healers in the Context of Culture” (1980) Arthur Kleinman presented his model of a healthcare system. The model, so the idea goes, should be applicable to healthcare systems around the world and throughout history, and facilitate the comparison of healthcare and its organization across cultures, while grasping the many interrelated healthcare activities holistically. In his book, Kleinman viewed medicine as a cultural system of symbolic meanings, similar to the then common ways to analyze language, kinship, or religion, and regarded the healthcare system as part of social reality, ascribing a clinical reality to the social realm of illness and clinical care (Kleinman 1980: 24, 35-45). At its time the book was groundbreaking for the sub-discipline of Medical Anthropology, and up until today it is much cited, not only in the work of (medical) anthropologists. However, as hinted at above, over the years Kleinman’s systemic approach to healthcare has not gone without criticism. Indeed, one might argue that in general models do imply a certain simplicity that does not do justice to the complexities of social lifeworlds. What is more, rarely is healthcare organized to the extent that the systematic connections of the structuralist and functionalist models suggest. Even Kleinman himself, after rereading his book some fifteen years after its initial publication, wrote that he now is “[…] uncomfortable with the style and even the preoccupations of “models”, ethnocultural or other, which imply too much formalism, specificity, and authorial certainty […]” (1995: 7). Recapitulating the unease associated with speaking about specificities of a certain culture or society that has struck anthropologists since the postmodern turn,3 medical anthropology is also, increasingly, struggling with concerns about ascribed assertions about 3 For example, when speaking in general terms about the moral economy of the San, or Baganda culture.

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culture-specific medicine and the related knowledge, practices, and etiologies. Roland Littlewood raises the question of whether “[…] any medical system which we might observe [is] to be found in the minds of individual members of that community, or is it merely our convenient way as external observers of collecting together and describing health- and illness-related practices? Whose systematization produces the system, the locals’ or that of the ethnographer?” (2007: ix). As the example of Natayi shows, individuals do indeed have multiple ideas about the causes and treatment of certain illnesses and diseases, but these notions do not necessarily have to be incorporated into a system of etiology, treatment, and diagnosis (Lewis 2007: 31). While it would be tempting to make sense of the multifaceted landscape of health services through the structure provided by an explanatory model, such an approach would not do justice to the complexity and individuality of treatment-seeking. The example of the composite character Natayi and the story of her seek for treatment shows that healthcare is not as clearly structured as one might wish to think; neither is it accessed in a systematic manner. Healthcare in Uganda, like elsewhere, is diverse and multifaceted, and goes beyond the realm of Western biomedicine. The offers for medical therapy and diagnosis are broad and range from so-called “traditional” practices, rooted in localized understandings of health, to interventions orchestrated by large, transnational health programs. 4 Especially with regard to malaria, the number of treatment options is vast. So are the perspectives people have on illness and disease, and the way they make sense of their (ill) health. Which treatment options people choose, and how they evaluate their health status, is subject to a multitude of factors, not only in Uganda but everywhere around the world. In the following paragraphs I will take a closer look at the various health-related institutions and medical facilities in central Uganda and in my research area in particular. As we will see, the political upheavals of independent Uganda, as well as the larger economic context of post-colonial Africa, had a lasting effect on the forms of healthcare available in the country, and are crucial to the understanding of healthcare and treatment-seeking today. Also, how different forms of healthcare are to be categorized, and the conceptualizations thereof, might not always be self-evident, and require further discussion.

4 Referring to medicine as “traditional” is problematic. By labeling medical products and practices as “traditional”, they are distinguished from a so-called modern, scientifically founded biomedicine, and implicitly ranked as less advanced. Also, the term fixes the associated body of knowledge in the past, not doing justice to the changes and adaptions that make alternative medicine part and product of modernity, and a contemporary practice. Elisabeth Hsu points out that it commonly appears as if the First World is considered to have complementary and alternative medicines, whereas in the Third World one often speaks of traditional medicine (Hsu 2012: 195) – a narrative that is revealing of the Western self-conception, especially with regard to the medical landscape.

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Healthcare in Uganda: Historical Perspective The Ugandan political landscape since independence has not always been stable as it has been over the past decade or so.5 Most readers will know of the political derailing during the regime of Idi Amin in the 1970s, which left a lasting mark on healthcare (among other sectors of public life), from which the country is still recovering today. To fully understand today’s healthcare situation in Uganda, it is necessary to take the political upheaval of that time into consideration. Much of the health sector in today’s Uganda, most importantly the private sector and for-profit health services, developed out of the aftermath of the deterioration of the public health sector under Amin, and the subsequent efforts by Museveni’s NRM government as well as global development politics to revive the country’s economy and decentralize the public sector (Adome/Whyte/Hardon 1996: 15; Jeppsson/Okuonzi 2000: 275-276). The health sector prior to Amin’s rise to power in 1971 has been described as “one of the best government health care systems in Africa” (Whyte 1992: 165), with “[…] health services far superior to many other developing countries” (Scheyer/ Dunlop 1986: 28-29). The high standard of the healthcare at that time can be attributed to several factors. Uganda had a fast-growing economy, mainly based on the agricultural sector, exporting coffee, cotton, tea, and later also tobacco and sugar. This allowed for relatively large spending in the health care sector with a strong policy development, which was linked to the country’s economic strategy. The expansion of not only hospitals, but also health posts and dispensaries in rural areas, integrated into a well-staffed health service network, and the focus on curative rather than preventive health measures ref lect the good reputation of Ugandan health care at that time (Scheyer/Dunlop 1986: 25-29). Moreover, there was a constant supply of highly educated health workers and medical professionals, graduating from the – at that time – prestigious medical school of Makerere University6 and, more importantly, the government could offer them an attractive salary (Adome/Whyte/Hardon: 1996: 9-10).

5 To some Ugandans it might sound derisive to speak of political stability in Uganda. Since the beginning of Museveni’s long-lasting period of political rule, the northern region of the country has been torn apart by civil war for more than twenty years, and the local population has suffered tremendously under the atrocities of both rebel troops and the government’s army. It is hardly ten years since fighting ceased, and the marks of war are still omnipresent. With regard to healthcare, one would have to tell a considerably different story for that part of the country. For a compelling insight into the complex matters of the conflict I recommend Sverker Finnström’s ethnography “Living with Bad Surroundings” (2008) and Chris Dolan’s book “Social Torture” (2009). 6 Prior to the political crisis in Uganda during the 1970s and 80s, Makerere University was widely famed for its high standard of education and regarded as “the best university […] between Cairo

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Things changed considerably after Amin took power in 1971. Shortly into his regime, he ordered the so-called “Asian community”, the Indian minority that had settled in Uganda after the British had employed them to construct the East African rail network, to leave the country, and forcibly evicted those who resisted him. With the Indians left an important part of the country’s commercial and technical sector, which in turn led to economic chaos. Soon other, foreign as well as Ugandan health professionals left the country and its economic and political havoc, among them an increasing number of Ugandan physicians, seeking jobs abroad. To make matters worse, the economy further deteriorated and agricultural exports declined. The government’s health expenditures also fell, as they couldn’t keep up with inf lation. Needless to say, drugs became scarce and the capacity of the Ugandan public healthcare facilities plummeted, while the population’s health status was thrown back to the state it had been in some three decades earlier (Scheyer/Dunlop 1986: 29-32). One of the important consequences of the breakdown of health services under Amin and the short-lived transitional governments thereafter was the rise of the private-for-profit medical sector in Uganda, which developed out of the frail state of the public health services. First of all, due to the breakdown of the public healthcare sector, church missions played an increasingly important role in the provision of healthcare, especially outside the urban centers, since they were less prone to the economic and political disruptions. What’s more, as pointed out before, the low wages in the public health sector made it unattractive for health workers to remain in the country. The ones who remained had to find additional sources of income in order to sustain a living, mostly by setting up private practices. Up until today it is hard to make ends meet relying on a government salary alone, and in addition to their work in government facilities, it’s common for health professionals in Uganda to offer their services in private clinics, drug shops, or dispensaries. As a consequence of the rise of private-for-profit health care, biomedical healthcare became inaccessible to those people unable to afford the services offered in the private sector (medication, diagnosis, and consultations). Many had to rely on self-management of their sickness or alternative healthcare options (Mogensen 2005: 213; Adome/Whyte/Hardon 1996: 10; Whyte 1992: 165-166; Jeppsson/Okuonzi 2000: 279; Macrae/Zwi/Gilson 1996: 1097). With Museveni taking power in 1986, Uganda entered a period of gradually increasing stability and a piecemeal recovery from the shocks of the Amin period and the political turmoil thereafter. With the regained political constancy, the quality of healthcare began to increase. The recovery of the public sector, especially in relation to healthcare, is in large part also rooted in the increasing attention and the Cape” (Enns 1986: 54). While still one of the outstanding universities in East Africa, it sadly lost much of its prestige over the collapse of the public sector during the Amin regime.

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from outside donors, aid programs, and the World Bank’s policy of structural reforms throughout sub-Saharan Africa. A good example of the regained efficacy of the public healthcare sector is the government’s response to the ravages of the HIV/AIDS pandemic, which hit Uganda hard. Museveni’s NRM was quick to realize the magnitude of the threat, and acknowledged it publicly. As a result, Uganda adopted a national program to target AIDS, and eventually managed, as the first country worldwide, to reverse the trend of increasing new HIV infections. It was the f lexible, multi-sector approach, with strong integration of foreign donors, and later also NGOs, which not only formed the powerful response to the spread of HIV, but also gave shape to the organization and provision of healthcare in general in Uganda (Whyte 2014: 4-7; Kuhanen 2008: 301-302). Uganda’s orchestrated response to HIV/AIDS in the 1990s can be regarded as a precursor of the now well-established health programs that are characteristic of the country’s public medical sector: donor-dependent public-health approaches that operate on an international scale. The recent efforts to target malaria are no exception to this. With the rise and fall of Amin, Uganda’s professional medical landscape had changed considerably from its time after independence. As a result of the breakdown of the public sector, private healthcare facilities, such as clinics, medical laboratories, pharmacies, nursing homes, and drug shops mushroomed all over the country, leading to what Adome, White and Hardon call “a lively health business” in Uganda (Adome/Whyte/Hardon 1996: 15; Whyte 1991: 130). One important aspect of the privatization of healthcare is the increase in drug availability, as well as the demand for biomedical medication, and the individualization of healthcare. Authors have also pointed out the strong links between the public, and the informal “for-profit” healthcare sectors. Many, if not most, health specialists working in the public sector run a private health business to top up their income (Whyte 1992: 170). With the start of neoliberal structural reforms, the health sector in Uganda underwent considerable restructuring in the early 1990s. Jeppsson and Okuonzi (2000: 276) stress that the health-sector reforms in Uganda, unlike in other African countries, was part of an overall reform of the public sector, with the main goal of decentralization of the government and liberalization of the economy. The reform of the health sector appears never to have been of central concern in the plan to restructure the public sector. Nonetheless, the reforms had a large impact on healthcare in the country. Mainly, so the authors continue, the reform transferred much of the administrative tasks as well as implementation with regard to service provision from the MoH to the district level, where district health teams have been set up. Meanwhile, the policy development, quality control, epidemic management, and the training of human resources remained in the hands of the ministry. Furthermore, the reforms facilitated a better integration of the formal

5. Providing malaria treatment: Different forms of healthcare in Uganda

private healthcare sector, including church missions and hospitals run by NGOs (Jeppsson/Okuonzi 2000). In 2001 president Museveni kept his promise made during election campaigns, and abolished the user fees for access to healthcare. Up until today, basic public health care in Uganda is, at least in theory, free of charge. Yet costs arise due to frequent medicine stock shortages and bribery of the health workers (Mogensen 2005: 213; Umlauf 2017a: 78-79). As has become apparent over the last few paragraphs, the public healthcare sector in Uganda is very much confined to the provision of biomedical healthcare. Only recently has the government made attempts to formalize and integrate alternative healthcare options by recognizing and registering healers and doctors working with herbal medicines. It is, however, important to note that biomedical healthcare in Uganda is not exclusive to the public healthcare sector. Rather, it “[…] is divided between state, non-governmental organizations, faith-based organizations and not-for-profit facilities; private hospitals and clinics; and medicine sellers who operate from drug shops, grocery stores and market places” (Hutchinson et al. 2015: 52). Also, so the authors write, are the boundaries between the formal and the informal, the public and the private not clear cut, and medicines, techniques, and persons move across these borders. As the vignette leading into this chapter has shown, the medical landscape in Uganda, as elsewhere, is diverse, and ranges from professionalized and regulated biomedical health care to alternative medicine, and includes self-medication practices based on individual experiences with disease, health, and healing. In order to understand how a disease like malaria is understood and dealt with, I argue, one must take a look at the forms of medical care that are available to patients. In the following paragraphs I will therefore elaborate more on the different forms of healthcare in my research region, distinguishing between formalized forms of healthcare and the non-institutionalized types. Furthermore, I will go into the localized and individual understandings of medicine and healthcare that are important for the analysis of self-medication and the routes along which healthcare is accessed.

Formalized healthcare Formalized healthcare is comprised of the organized and institutionalized medical professions. Mostly, these consist of biomedical healthcare provision; however, alternative or complementary medicine can be part of the professional sector as well. The most prominent examples of professionalized forms of medicine outside the biomedical realm are certainly Chinese and Ayurvedic medicine (Kleinman 1980: 54). In the case of Uganda, alternative healthcare providers are, as of recently, incorporated in the national health policy as so-called “traditional and

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complementary medicine practitioners (TCMPs)” (MoH 2010: 5, emphasis added). It should be noted, however, that the Ugandan Ministry of Health does not further specify which medical knowledge classifies as “traditional” or “complementary”, and fails to distinguish between different types of alternative medicine (for example the vast range of indigenous medical knowledge or Chinese or Ayurvedic medicine). However, none of the indigenous alternative or herbal medicine is as of yet professionalized, despite the call from the National Traditional Healers and Herbalists Association to open a hospital specialized in alternative healthcare, as well as having regulations for the production and quality of herbal medicines, in order to streamline the field (WHO 2001: 36-37). Other than that, Chinese medicine7 is an officially recognized and regulated form of medicine, which can be found in the major towns – though not, however, in the peri-urban zones of my research area (Hsu 2009: 115). Biomedical healthcare services can be found in three different sectors: (1) the public healthcare sector, (2) private-for-profit healthcare facilities, and (3) faithbased institutions and hospitals. Public healthcare is hierarchically organized on a referral basis, from so-called village health teams (VHTs) at the lowest level, up through Health Centers numbered I-IV (HC I-IV), to hospitals at the top level (see also the opening vignette, in which Natayi was recommended to consult the VHT, and avoided going to the public HC III for medical advice). Apart from the main referral hospital Mulago (of ficially called the Mulago National Referral Hospital) in Kampala, there are two regional referral hospitals (one in Mbale, in Eastern Uganda, the other in Gulu, Northern Uganda) and twelve smaller hospitals at the regional level throughout the country. Furthermore, there are a total of 143 smaller hospitals in the country, of which 66 are state-run (Boslaugh 2013: 481; Umlauf 2017a: 45-46). In areas where public hospitals are scarce, patients are referred to private hospitals and health facilities. Public healthcare in Uganda is regulated by the MoH, which in turn delegates many of the responsibilities concerning planning, monitoring, and implementation to the district level and the so-called district health teams (Jeppsson/Okuonzi 2000: 279). In the area of my research, just outside of Kampala, around Namulonge and the surrounding trading centers and dispersed settlements, there is a public HC III, equipped with a basic outpatient department (OPD; cp. also Chapter four, Figure twelve). Furthermore, each village or trading center has a VHT, whose members work on a voluntary basis. In case of medical emergencies or other, more complicated cases, patients are referred to the next Health Center IV in Kasangati, some 10 kilometers away (complicated medical cases which cannot be taken care of at the HC IV are of course directly referred to one of the hospitals in Kampala).

7 Or rather, as Elisabeth Hsu points out, a “drastically simplified” version of it (2009: 114).

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Apart from the government health center there are private facilities that provide biomedical healthcare. Here it makes sense to differentiate between profit-oriented health businesses and the rather service-oriented ones. With respect to the latter, the health center of the nearby Bugema University (a private university owned by the Adventist church), and the facilities of the foreign-led Xclusive Cuttings f lower farm are noteworthy, as these health wards are subsidized by their respective carrier organizations.8 The rest of the landscape of biomedical healthcare providers is shaped by an array of small to medium-sized, privately-led businesses, in form of medical centers, health posts, maternity wards, drug shops, dispensaries, and clinics. It is precisely through these small, private businesses that most of the biomedical healthcare is offered and accessed. These private-for-profit facilities are regulated and formalized through the MoH and the government at the district level in that they must be registered under, and run by a recognized healthcare professional, and are required to report their medical cases. However, many of the smaller clinics, drug stores, and dispensaries are in fact evading regulations. The private-for-profit sector is the most important source of biomedical medicines for most Ugandans, and I am not alone in the observation that the evasion of government regulations enables many patients to acquire treatment which would otherwise not be affordable for them (cp. for example Hutchinson et al. 2015: 52-54; Umlauf 2017a: 74; Whyte 1992: 167-170). To discard self-diagnosis and self-treatment through private-for-profit drug sellers as a problematic practice alone would be overlooking the fact that these medical businesses grant patients responsibility over their own health and enable them to act upon and manage their ill health autonomously (cp. Whyte/Van der Geest 1988: 4-5). Aside from biomedical materia medica, alternative healthcare serves a similar function. In the next paragraphs, I will take a closer look at alternative and complementary medicine in central Uganda and elaborate more on the ways in which it is accessed.

Informal healthcare While biomedical healthcare is comprised of organized, regulated, and institutionalized health professions, backed by bio-scientific and physiological findings, complementary and alternative medicine is usually not, and consists of a variety of components. Also, in comparison to biomedical healthcare, the boundaries of 8 In my research area there are two flower farms (cp. figure 19), one of which runs a company health post that grants employees and their families access to healthcare and drugs subsidized by the company. The services are open to outside patients as well – who, however, are charged for the full cost of their treatment.

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alternative healthcare are less defined, and vague. Sometimes it is difficult to tell what falls within the medical realm and what lies outside of it. For example, one might consult a mganga for a vast range of problems, most of which have little to do with medicine. The issues for which one consults a so-called musawo omuganda, a cultural Baganda doctor, mostly deal with altering one’s fortune, cursing one’s adversaries, or manipulating one’s social environment. On the other hand, some ailments which could be considered health-related from a biomedical perspective are perceived as being caused by evil spirits, summoned by a mganga, and need to be countered by witchcraft. With regard to the biomedical understanding of malaria, it is mostly the symptoms associated with a grave, cerebral infection that are locally associated with spirit possession. While “malaria” itself cannot be treated by a mganga or musawo omuganda, they are considered essential actors when it comes to exorcism as they know ways to communicate with ancestral spirits. It becomes apparent then, that with regard to alternative medicine there is a vast array of healthcare options: from self-proclaimed specialists to highly sophisticated herbalists, the basawo owekinansi; from so-called witch-doctors and diviners to health workers who set up a private practice; from midwifes and bonesetters, who make use of generations-old knowledge, to healers whose work is rooted in religious doctrines. In some cases, providers of healthcare are not exclusively working in the medical sector, like for example a bonesetter I met, whose income mainly stems from farming and roasting chicken; only on request does he help with fractures or sprained limbs. In other cases, people don’t see themselves as actors in the healthcare system, like a midwife I repeatedly visited (and who was introduced to me as an expert on herbal medicines): she didn’t regard herself as a medical expert, and claimed to merely possess knowledge of plants and their healing qualities, which she inherited from her mother.9 Yet in other instances, it is debatable whether the work of a folk practitioner is only of a health-related nature. In Uganda, spiritual healers, baganga, or so-called “witchdoctors” are consulted for many problems, many of which are not related to health in any aspect. As already mentioned before, much of the biomedical care and medicine is of fered in an unregulated, non-bureaucratic manner, essentially making it part of unregulated, complementary medicine. Especially with regard to malaria and the biomedical pharmaceuticals that are commonly used for its treatment, it makes sense to view many of the private drug shops, clinics, and dispensaries as part of alternative or complementary healthcare, rather than a domain of formalized and regulated biomedical healthcare. While on paper, 9 In fact, it is questionable whether the term “midwife” is fitting in this case at all. After all, the term is borrowed from the biomedical sphere of healthcare, and, more importantly, the person in question does not claim this title for herself. What is more, much of what she does would not be considered midwifery in the biomedical understanding of the term, but rather antenatal care.

5. Providing malaria treatment: Different forms of healthcare in Uganda

drug shops and the like need to be registered and should thus be regulated and organized, Hutchinson et al. note that only “[a] minority of the drug shops are formally registered and licensed by the government […]” (2015: 53). Furthermore, drug shops often function in a space, that Chandler et al. describe as “liminal” (2011: 941), as they are at the same time legitimate providers of medicine and health care, while doing so illegally. There is a considerable overlap between formalized, biomedical forms of healthcare and alternative or complementary forms. In some cases, most prominently with private-for-profit health businesses, it is not entirely clear what kind of healthcare certain health services and practices are associated with, and there is considerable movement of people, medicines, and practices from the formalized parts of the healthcare landscape into the informal and alternative ones. Especially medicines are moving from the formalized realm into the informal domain, as does the according terminology for both treatment and disease. As indicated above, many of the private-for-profit drug shops can be better conceptualized as informal healthcare providers. Various trajectories exist, along which biomedical medicines are appropriated, individualized, and reinterpreted. With the f looding of biomedical materia medica into African markets this holds true more than ever (Whyte/Van der Geest/ Hardon 2002: 8-9). Some routes lead biomedical pharmaceuticals into the domestic sphere, such as when patients do not complete the prescribed treatment regimen, and stock the remaining pills for eventual future illness episodes. Especially with regard to malaria, the free drug dispensations at the public health-centers lead people to acquire antimalarial medication as a prophylactic for future malaria outbreaks. This is a point which underlines the commonality of malaria: it is always good to have malaria treatment at home, as the next illness episode could strike anytime (Umlauf 2017a: 80; 2017b: 454). Often the meanings attributed to medicines, and the ways they are made sense of, change considerably. An illustrating example is that of an old woman who was introduced to me as an expert on medicinal plants. On one occasion while I was visiting her, she lamented about her weak health and complained about her painful joints. She showed me a plastic bag in which she collected all kinds of pills and capsules that she had been given or prescribed to treat earlier illnesses. Unfortunately, said the woman, she had run out of “yellow pills”, the ones that relieved the pain in her aching legs. While she had no idea about the name of the specific pharmaceutical, she distinguished medicines by their color or form. In a similar way, biomedical terminology is popularized and used for alternative or complementary medicines, while slightly changed in meaning. Here, an excerpt of an interview with a self-proclaimed specialist in herbal medicines is illustrating. I will call him Dr. Ntabazi here:

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Matian van Soest: “Can I ask you what this powder is used for?” Dr. Ntabazi: “It’s called Omubaluka,10 it works on pressure and un stable hearts. You drink one spoon. You can either boil [it] or mix [it] with cold water and drink.” MvS: “Does it work against high or low blood pressure?” Dr. N.: “Both. Here in Africa we don’t specify, as long as it is pressure. […].”11 This short interview-excerpt shows how the medicines Dr. Ntabazi sells are specifically tailored to cater for common non-communicable, chronic diseases, such as hypertension, which are currently increasing all over Africa. My differentiation between hyper- and hypotension was seemingly unimportant to Dr. Ntabazi. I, however, think this ref lects the ways in which biomedical terminology is adapted and incorporated into localized forms of healthcare, outside of the biomedical realm. Another example is best illustrated with photos I took at a bi-monthly event I attended several times (cp. figures 13-18). Parishioners of the Adventist Church of Lwero, a neighboring district to Busukuma, offer their knowledge of the curative qualities of medicinal plants in villages and trading centers in the area. Once every two months they visit Namulonge, where I carried out my research, and invite people to help them prepare medicinal concoctions and brews that are then complemented with dried herbs and barks, to cater for the specific needs of the attending patients (cp. figure 16). Attendees are asked to bring a jerrycan full of water as well as some firewood, in order to provide the basics for the preparation of the brew. The present basawo, the doctors, as they are referred to by the patients in Luganda, supply the medically active ingredients for the brews (cp. figure 17). Typically, during such an event, guests and patients arrive bit by bit during the morning hours, and start by heating water in big kettles, to which the basawo then add a mixture of selected barks and herbs. Each guest, after emptying her or his jerrycan into one of the kettles, then places it in the line of canisters already formed by earlier arrivals (cp. figure 18), but not without first listing the name of the ailments that one needs a cure for on the side of the can. Figure 14 depicts an example of such a jerrycan, showing, in Luganda, the names of the following diseases: pulesa (derived from the English “pressure”, translating to “hypertension” or the associated symptoms); sukali (translating as “sugar”, in this context referring to the biomedical diagnosis 10 Omubaluka is derived from the Lugandan verb okubaluka, meaning “to explode” in English. 11 The interview was conducted in both Luganda and English, switching between the languages. In favor of better comprehensibility, I left out the parts in Luganda and instead paraphrased the translations of my assitant. Interview conducted on May 25, 2015.

5. Providing malaria treatment: Different forms of healthcare in Uganda

“diabetes” and the symptoms associated with the diagnosis); alusa (derived from the English “ulcer”, commonly used to refer to “stomach ache”); okulya (English “to eat”, here referring to a general “loss of appetite”); amagulu (translates to the English word “legs”, in this context referring to “joint pain”); and finally kifuba (translating to “cough”). The consultation and dispensed medicine is expressly free of charge, and the doctors act on the basis of their religious conviction. One of the basawo explained to me: “Here God has come to treat his people. So it’s not a market where you can sell your things. We only accept if you bring us things for free, such as food to eat, or you donate transportation for us to come. Giving some things for free that’s what we allow as appreciation of our work, but [we don’t offer our medicine in] exchange for money. We don’t collect money, and we [do not run a] business. […] Everything is free. It is a day that God has given to you to be around and receive treatment.”12 There are countless more examples of the ways in which biomedical terminology infiltrates alternative healthcare from the biomedical sector, and is there reconfigured to describe common sets of symptoms and illnesses. One could also argue that the copying of biomedical terminology is used in order to better compete with Western pharmaceuticals and the related practices, and to demonstrate an authority and expertise that is typically associated with professional medical personnel (Hutchinson et al. 2015: 56-57). At first sight, the above examples of the syncretic and multifaceted informal healthcare domain in Uganda do not refer to the problem of pandemic malaria that is the subject of this book. I have documented cases of treatment for pulesa, diabetes management, and antenatal care. I have highlighted the role of spiritual healers in the facilitation of rituals in order to cope with socially shaped inf lictions, and I have pointed out herbalists offer free consultations to patients, based on their personal faith and moral conviction. None of these practices are examples of specific malaria treatment, at least not in the biomedical sense. However, as I have argued in the second chapter of this thesis, there is a considerable discrepancy between the biomedical term and its implications with regard to disease etiology, diagnosis, and treatment, and the local conceptualization of malaria/musujja/ fever. The word “malaria” is often used as an umbrella term to cover the range of unspecific symptoms that are associated with the disease. As I have pointed out, the popularization of biomedical terminology often ref lects the seemingly vague definition of diseases and their symptomatic articulations. Coming back to the opening vignette of Natayi’s management of her son’s malaria infection, the example shows well how the interpretation of the disease 12 Interview conducted on October 11, 2015.

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is subject to change, re-evaluation, and the constant monitoring of the evolving symptoms. Malaria/musujja/fever does not necessarily have a clear, straightforward solution, but requires careful consideration based on the specific circumstances in which the disease unfolds. Natayi has consulted the help of various medical specialists, put her own ideas about illness treatment to use, and changed her opinion about the gravity of the situation based on the observation of the symptoms. In the process of curing her child’s illness she crisscrossed through the labyrinth of healthcare suppliers until her child’s condition finally improved. As I will show in more detail in the following chapter, the diagnosis in the biomedical sense is often not that important. My impression of the management of disease among my interlocutors was often that of a symptom-based treatment. Patients (or caretakers) often have their own opinions about the causes and sources of their symptoms. Healthcare professionals, whether healers, medical doctors, baganga, medicine-sellers, or the knowledgeable neighbor, are consulted in order to treat the disease, not so much to diagnose it – the diagnosis has happened already, when making the decision to consult a medical specialist. This is in stark contrast to the practices in biomedical healthcare, where prior diagnosis determines the choice of adequate treatment. Especially with regard to the policies recently put in place by the Ugandan Ministry of Health, which make malaria testing mandatory before the prescription of antimalarial medicine, this discrepancy between the popular and biomedical understanding of disease treatment can lead to conf lictions – for instance when the test result is negative, and does not qualify the medical personnel to hand out the desired antimalarial medication. Moreover, as René Umlauf points out in his book on the diagnosis and management of malaria in Uganda, and as I have documented during my own research in the public health center of Namulonge, the unspecific diagnosis of malaria/musujja/fever, as it is commonly understood by patients consulting the public health sector, requires the medical personnel to carefully communicate the possible reasons for a negative test result and retranslate the biomedical understanding of the diagnosis, including its implications for treatment and disease management, back into the popular vernacular (cp. Umlauf 2017a: 112-115). In the following chapters I will go deeper into the ethnographic material I collected, in order to shed more light on the factors that inf luence the handling of a malaria infection, paying special attention to the economic and environmental aspects of healthcare and treatment-seeking. This, as I argue, will lead to a better understanding of malaria and the ways it is dealt with in central Uganda, and probably elsewhere in East Africa. Especially in the light of the resurgence of major political efforts to roll back, and even eradicate malaria, it makes sense to critically review the top-down approach of the programs and integrate the perspective of people on the ground. While the associated medicalization of malaria is based

5. Providing malaria treatment: Different forms of healthcare in Uganda

on good reasoning, it also simplifies the ways malaria is dealt with on the ground. On the one hand, in order to achieve substantial progress in the treatment and control of malaria, biomedical malaria medication needs to be integrated into the complex lifeworlds of the people who suffer its consequences. On the other hand, the biomedical sector must appreciate the advantages of informal healthcare services, which cater to the demand for etiologies and conceptualizations of health that go beyond the positivistic understanding of the body and its workings – arguably a phenomenon of the postcolony and an articulation of the failed promises of modernism (Geschiere 2017: 281-290; Whyte 1988: 217; Whyte/Van der Geest/Hardon 2002: 111-12). Underlying the increasing use of alternative medicine, so-called “traditional” healing methods, and the rising popularity of spiritual and religious healers, I would argue, are the same processes and mechanisms that can explain the upsurge of “occult economies” in South African and elsewhere on the continent (cp. Myhre 2017: 181-83).As Comaroff and Comaroff (1999) have shown, the use of and demand for magical means and metaphysical explanations are the result of a dialectic interplay between the analytic categories of the global and the local in the context of all-encompassing globalization and the related neoliberal exploitation of the African continent.

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Figure 13: Filling the jerrycans, foto by author

Figure 14: Jerrycan prepared to be filled, foto by author

5. Providing malaria treatment: Different forms of healthcare in Uganda

Figure 15: Waiting for consultation, foto by author (lef t) Figure 16: Preparation of medicinal herbs and barks, foto by author (right)

Figure 17: Musawo during consultation, foto by author (lef t) Figure 18: Jerrycans lined up to be filled, foto by author (right)

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Figure 19: Cabbage field in wetland, foto by author (lef t) Figure 20: Wetland-field prepared for planting, foto by author (right)

Figure 21: Gerald‘s brick-workshop in the wetland, foto by author (lef t) Figure 22: Clay-mining pits filled with rain water, foto by author (right)

Figure 23: Using the wetland as a washing-bay, foto by author (lef t) Figure 24: James’ fishpond, foto by author (right)

“You know, there at the government health centers it takes time, you sit on a chair waiting for a very long queue. At times men have things to do. Many are business men, they have deals. So for them waiting in a queue is a waste of time. That is why they don’t want to go to [public] hospitals, they just go to clinics and buy drugs” Interview with Mukibi, a farmer in Kiwenda, November 12, 2015 “What I mainly know about herbal medicine is that it cures all forms of sicknesses at once as compared to the chemical medicine that heal only that specific disease […]” Interview with the herbalist Mukyala Sofyia, October 24, 2016

6. Coping with malaria: Facets of health seeking I got to know Mary at an event organized by the Adventist church community in Namulonge (cp. chapter five). Promoting the healing power of plants, in both medicine and diet, the church regularly invites two basawo to Namulonge, in order to “pray together and cook medicines”. The event is open to everyone interested, under the sole condition that one has to bring firewood and water in order to be able to brew the base solution to which later specific medicinal plants are then added. Typically, the cooking starts in the early morning hours and continues until well into the afternoon. Participants arrive bit by bit, tossing their fetched wood on the prepared pile, and pouring water from their jerrycans into one of the kettles ready to be stoked up. After adding their jerrycan to the queue of other attendee’s containers, new arrivals join in cutting bark, chipping wood, melting soap (which is then mixed with herbs), or just chit-chatting with other guests (cp. chapter five, figure 15). Once the preparations are finished, the basawo invite everyone to join their prayers, after which they give a short introduction to the procedure before

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the consultation starts. One of the two herbalists monitors the filling of the jerrycans (cp. chapter five, figure 13), while the other sees patients in the privacy of a consultation room. There patients tell the doctor about their complaints, based on which the musawo adds selected herbs and plants to the ground brew that has been filled into the containers. The relaxed atmosphere of these cooking events, taking place once every two months, gave me a good chance to talk to the participants. As there was plenty of things to do, I could make myself useful and meanwhile have conversations with the participants about their anticipations, their motivations to come to the event, and their ideas about herbal medicines. In some cases, I got invited to pay people a visit at their respective homes to continue our conversations away from the cooking event, in the privacy of their homes. Mary was one of the participants whom I visited more often. I first met her at the second cooking event I visited. At that occasion, I introduced my research intentions to her and explained why I was particularly interested in the motivations behind the preparation and use of herbal medicines. As the busy atmosphere around the preparation of medicines and the consultation of medicines did not allow for a private conversation, we decided to continue our talk on a different day at her place. When I met Mary she was in her late 50s, a widow, living on her own in a rented room in the trading center of Namulonge. She took care of her grandchild, while her daughter – the mother of her grandson – was living in town. The little money she had at her disposal came from her children, who would once in a while send her some so she could pay her rent and meet her everyday needs. She also maintained a field on the slopes down towards the forest swamps between Namulonge and the bordering village of Seeta, where she cultivated sweet potatoes, beans, and some maize. As she told me, she was suffering from chronic hypertension, “pressure” or “puleesa” as it is commonly referred to in Luganda. Before I met her she had been going to the local health center for more than a year, where she received treatment to manage her hypertension. Every two weeks she was supposed to show up for check-ups and to receive the next batch of medication. Living in the trading center, the HC III was not far away. Still, she complained, it took considerable time to go there. The center would usually be crowded on treatment days, and it would take hours of waiting until she was seen by a nurse. Meanwhile her condition had not shown signs of improvement – she claimed. It was against this backdrop that she considered attending the medical events organized by the Adventist herbalists. An acquaintance of hers from church told her about it, and spoke wonders about the medicines. Indeed, Mary told me, she felt better since she had quit the biweekly consultation at the health center and started attending the Adventist gatherings. The medicines she receives from the basawo at these events prove to be effective. From each meeting she comes home with two 2-liter jerrycans of medicine, enough to get her through the time until the following

6. Coping with malaria: Facets of health seeking

cooking event takes place. Initially Mary used the medication solely to treat her hypertension, but as she learned more about the cooking events, and talked to the people she met there, she began requesting other ingredients as well. As she told me, she finds the medicines useful to treat her grandchild, who frequently falls sick – “malaria” she says. While I believe that the child she looks after is often ill – malnourished and exposed to simple living conditions, like too many other children of its age in Uganda – I doubt whether Mary and I have the same understanding of the term malaria. The case of Mary is a good example of the broad meaning of the term in the local vernacular, including the inherent conceptualization of the disease and its implications. From Mary’s perspective, the potion prepared by the Christian herbalists serves as a panacea, treating and preventing all kinds of symptoms she associates with malaria.1 Most of all, however, it helps to cut the costs of treatment, giving relief to a household that is struggling to survive. Form a biomedical perspective the herbal concoctions brewed under the guidance of the Adventist doctors are problematic. With unknown ingredients they must be considered risky, as nothing is known about proper dosage or side effects. Also, being stored for several weeks, it is probable that mycotoxins have developed in the medical concoction. And while there are a number of plants in Uganda that are known and used to counter the effects of a malaria infection, none of them will cure a complicated case of cerebral malaria. Talking to a medical doctor running a private clinic in Namulonge, I asked about his opinion on herbal medication. While he did not refute their medical efficacy, he mentioned concerns about their interaction with other drugs, and said that he had seen patients with affected liver functioning, which he attributed to the uncontrolled application of herbal medicines. From the perspective of patients that are attending the Adventists’ medical consultations, these herbal concoctions are considered medicines in their own right, advertised by someone who has a reputation as an expert. While they might not be as effective and convenient as industrially produced pharmaceuticals, these herbal medicines are nonetheless a way to treat everyday ailments, and allow for a certain autonomy with regard to the management of disease and responsibility for one’s own health. Moreover, compared to the private-for-profit sector and the outlets of biomedical medications, the events organized by the Adventist

1 In a round of Q&A at one of the cooking-events, the musawo explained to one of the patients how her medicines could be applied to treat various ailments: “[…] This medicine treats a lot of diseases. Let’s say Omululuza, you may know it only [to treat] fever [musujja], but someone else may tell you that they take it when they feel some hurting bones. You find that one herb can treat maybe four diseases. Now for this medicine you just give to the patient to take and you leave the rest to the almighty God to do the healing.”

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community guarantee cheaper access to medical products (Whyte/Van der Geest 1988: 4-5). Seen in this way, the use of herbal medicines, all too often described as “traditional”, is in fact very much an outcome of our post-modernistic times, and a visualization of globalized inequalities and the domination of a for-profit pharmaceutical industry. With the commodification of health, and the increasing use of materia medica to treat disease, there is a growing demand for affordable drugs (Whyte/Van der Geest/Hardon 2002: 79). Mary, who treats her grandchild’s malaria with a herbal concoction she obtains from healers of the Adventist church, is a good example thereof. She resorts to these medication as they seem to work for her, albeit to treat an entirely different ailment. Nonetheless, this gives her trust in the expertise of the church doctors: when the medication she takes to treat her hypertension works as guaranteed, why should not the promises for the malaria treatment hold true as well? The jerrycan she brings home after every gathering of the Adventists does not cut into her small budget. Put in that way, the herbal brew is simply a convenient way to treat her grandchild’s “malaria”. Like Mary, there are many others who join the weekly cooking events. The promise of effective and free medicines is hard to resist. In this chapter, I want to take a closer look at the ways in which smallholders access different kinds of malaria treatment. As the above vignette already shows, there are a multitude of factors involved when it comes to health-seeking and the choices that are made when treating a malaria infection. Gender, class, income, religion, social networks, ideas about malaria, and earlier experiences with the disease, to name but a few aspects, all play a role in the ways in which patients deal with malaria and how they treat it. Furthermore, as the above example of Mary illustrates, disease does not constitute a moment of crisis in itself, but rather happens against the backdrop of endemic poverty. Following the argumentation of Henrik Vigh, who calls for the conceptualization of crisis not as episodic but rather as an endemic state of disorder, I argue for an analysis of health-seeking in the context of crisis, rather than understanding disease as crisis in context (Vigh 2008: 7-8). Living in a single-female-headed household, and taking care of her grandchild without a stable income, Mary struggles on a daily basis, not episodically. There certainly are ups and downs, and better days shift into worse. In general, however, Mary has little capacity to plan ahead, put money on the side, or look far into the future. The management of disease and access to healthcare is therefore always an additional burden, even with chronic conditions such as Mary’s hypertension. With an acute disease such as malaria, health-seeking can become an emergency undertaking, demanding improvisation and a clever response. Storing a supply of the free herbal panacea allows her to better cope with emergencies, such as the “malaria” of her grandson. Mary’s story of her quest for medicines bears an odd resemblance to the case of HIV/AIDS patients in Tanga in Tanzania, who attend in their thousands events

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hosted by an Evangelical pastor who claimed to have found the cure to their disease. Based on his religious authority, the pastor has given hope to his patients who have turned to him in medical crisis. In his analysis of the medical authority of the pastor in Tanga, Dominik Mattes points out that the medical landscape is often characterized by an array of different actors, interconnected, entangled in complex ways, and opaque to most outsiders, also, or especially with regard to their therapeutic expertise: “Scientific evidence of certain healing practices is often not available, while for many it is also not fully comprehensible or simply not relevant. Patients’ health seeking behavior may thus be informed by mainly pragmatic calculations but could also be a search for meaning and more profound redemption in a situation of permanent – not only medical – crisis. Healers and prophets – be they self or externally constructed – will remain important figures and avenues for troubled persons in these troubled times.” (Mattes 2014: 188) Arguably, an important aspect of access to healthcare and the availability of treatment is the related costs. Treating a malaria infection can be an expensive undertaking – depending on the type of healthcare, the kind of treatment, and its efficacy against malaria. While Kamat (2013: 102) reminds us that it would be simplistic to reduce health-seeking to financial considerations alone, one has to consider the financial aspects of malaria treatment as well as the malaria infection itself in order to understand why the death toll from malaria is still so high. How people make sense of ill health is also, at least in part, related to their financial background. As I laid out in chapter five, the ways in which people move between the different healthcare options and diagnose a disease is by no means straightforward, and is typically characterized by a trial-and-error approach. This kind of health-seeking, as I will argue here, is in large part determined by the financial capacities of the affected person and her or his social network. In the following paragraphs I shed light on the costs that can arise in treating malaria. Using selected case studies, I illustrate how financial aspects determine the health-seeking of patients and how a malaria infection is diagnosed and evaluated. As I show, one has to incorporate factors such as control over money, gender, class, access to land, and landownership, as well as a household’s income and spending into the analysis of health-seeking with regard to malaria. Of course, health-seeking cannot be entirely explained with financial factors alone. Countless researchers have convincingly shown how a multitude of factors inf luence health-seeking, from the perception of one’s medical condition, through ideas about medicine, medical syncretism and pluralism, to spiritual or metaphysical convictions (cp. Hausmann-Muela et al. 2002; Hausmann-Muela et al. 2012; Williams/Jones 2004; Langwick 2007; Mattes 2014; Brown 1997; Kamat 2006, 2013).

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However, as Lock and Nguyen (2010: 9) remind us, cultural factors are all too often overemphasized in Medical Anthropology when it comes to the analysis of medical practices in local context, neglecting the economic and political factors that are shaping health. In light of this I want to take a closer look at the costs that can arise with the treatment of a malaria infection.

Costs of biomedical malaria treatment Uncomplicated malaria is a fairly easy disease to treat. However, as I have shown in chapter two, increasing parasite resistance against common, cheap, and once highly effective antimalarial medication, as well as the constraints of healthcare provision in many low-income countries, increasingly complicate the treatment of malaria. Nonetheless, the chances of successfully curing an uncomplicated, clinical malaria infection in East Africa are still fairly good. Patients usually do not have to be admitted for in-patient care in a hospital, health ward, or private practice, and can apply a three-day cure with a combination of antimalarial drugs at home, typically in the form of orally administered pills. These modern first-line malaria drugs are distributed free of charge through public hospitals, health centers, government dispensaries, and, for sick children, even by village health teams. The same ACTs, as well as older, less-effective, but cheaper antimalarial medication, can also be acquired at private-for-profit medicine outlets. In line with the multi-actor Roll Back Malaria (RBM) partnership,2 access to these drugs is, however, regulated through prior blood analysis, usually via common and readily available RDT-tests, also distributed free of charge through the aforementioned public healthcare bodies (Beisel et al. 2016: 2; MoH 2012: 36-41; Umlauf 2017a: 73-74). With severe malaria, the case is entirely different. Complicated malaria cases, often the consequence of either delayed or incomplete treatment application, or plasmodium parasites’ drug resistance, poses a number of challenges. Patients that show symptoms of an advanced malaria infection are in a precarious health state, usually facing an acute, life-threatening condition. Severe anemia, dehydration, and in bad cases, the typical convulsion symptoms associated with the so-called “cerebral malaria” require admission in order to apply quick intravenous treatment to counter the dangerous onset of the disease induced by the falciparum parasites. These treatments are also provided by the government – or at least they should be. In reality things often look different, and lead to the accumulation of costs that often pose a serious financial burden to poor households that face financial struggles on a daily basis. 2 For a comprehensive overview of the discourse on anti-malaria measures and the politics behind the RBM campaign see Packard (2009).

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To start with, people need to get to the health center in order to receive free treatment. As I have described in chapter five, in comparison to the private health sector, the number of public health facilities is negligible. For many, the journey to the health center is a long one – too far to be traversed on foot, certainly when suffering from the grave symptoms of a full-blown malaria infection. These travel costs can rise further when the patient needs to be admitted, and/or is referred to a higher-capacity health facility. Furthermore, bribery and illicit drug sales are reported to be commonplace in public health centers.3 Overall, the public healthcare sector suffers from a bad reputation, and is said to be chronically understocked and understaffed. Indeed, all too often a visit to the health center means long waiting hours, and the majority of the patients are given a drug prescription instead of free medication and are referred to a private drug shop in order to buy the missing medicines. An informant of mine accurately commented: “[at the health center] they’re good at giving Panadol”, referring to a generic of Paracetamol, the well-known painkiller, that does little apart from granting temporary relief from pain and raised body temperatures. The cynical comment ref lects the general opinion of public healthcare in Uganda. While patients expect to be given the needed medication to treat their ailments, they are often fobbed off with simple painkillers and sent to the pharmacy to buy the needed cure. The criticism is certainly justified, at least to a certain extent: based on my own observations in the HC III many patients, often after testing negative for malaria, are indeed given a dose of painkillers and a prescription for other drugs. On the one hand, health workers are pressed to treat their patients’ illnesses – after all that is what sick people come to the health center for. On the other hand, the government’s policy is to only prescribe antimalarial drugs after a malaria infection has been confirmed by means of a blood analysis. Patients, however, usually do not come to the health center for a diagnosis, but rather for treatment. Instead of sending their patients home empty-handed, health workers often give out Panadol to treat the reported symptoms. Expensive antibiotics or other medication used to treat febrile illnesses are often out of stock.4 This, however, does not hold true in cases where a patient has a confirmed malaria infection (at least, as far as I can tell, in the case of the Namulonge HC III). Coartem, the common first-line Arthemeter/Lumefantrine combination therapy against malaria, is always well stocked and dispensed when needed. However, in many cases 3 While a number of people I talked to complained about these issues, I never observed these practices myself. 4 In some cases, the HC III lacks the laboratorial capacities to diagnose the cause of the fever symptoms. Rather than referring the patient to the next-level health unit, doctors often prescribe antibiotics based on suspicion in order to avoid sending the patient away empty-handed, and to avoid complaints.

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patients who come in with suspicion of malaria test negative and are in the end discharged with a three-day course of Panadol, a broad-spectrum antibiotic, and a prescription for additional drugs.5 Aside from the public health facilities, the private-for-profit healthcare sector provides a range of malaria diagnostic and treatment services, and out- as well as inpatient care. Here costs arise, as private healthcare relies on a classic business model, where customers pay for the provision of services. Although the costs as well as the treatment ought to be regulated by the government’s health policies, the reality proves different. Against the backdrop of growing drug resistance and international pressure to tighten the regulations on drug distribution, antimalarial medication should only be prescribed after clinical malaria has been positively diagnosed, either by microscopic blood smear analysis or by means of RDTs (Beisel et al. 2016: 2; Hutchinson et al. 2017: 1-2; Umlauf 2017a: 73-78). However, testing is mostly offered as a separate service, the costs of which are invoiced at the patient’s expense. Moreover, in cases of a negative test result, patients will still demand treatment for their health complaints, the provision of which can significantly drive up the incurred costs. Taken together these factors can explain well why many medical professionals in the private sector chose not to be too particular about the regulations formulated by the Ugandan government and international bodies like the WHO. Insisting on prior blood analysis would exceed the budget of many people in search of malaria treatment, who would then go to look for alternative options, all too often the next-best drug shop or private clinic. In order not to miss out on business, the common procedure among small, private medical facilities is to dispense antimalarial drugs on demand, rather than by necessity. Although counseling and medical education are usually performed faithfully in most drug shops and clinics,6 antimalarial drugs were regularly sold without prior testing, and not necessarily as full-dosage courses (cp. Hutchinson et al. 2015: 49). A clinician of one of the small medical clinics in Kiwenda explained to me: “I often experience that: the person comes in and complains about malaria. After you explain to him that we have to do a test to verify [if he is in fact suffering of 5 Out of a total 5,241 malaria tests carried out at the Namulonge HC III between November 2014 and October 2015, 3776 (72 per cent) were negative (1,433 suspected cases were confirmed positive, while 27 tests were invalid; there were 5 cases of missing values in the dataset; cp. chapter two, figure three). 6 This claim is solely based on my observations in the private healthcare sector in central Uganda, and should therefore not be taken as a fact. The situations I observed had a certain potential for observational bias, and it is easy to assume that health workers behaved in an exemplary manner in my presence. Still, in conversations with those health workers all of them seemed to be well aware of the purpose of the government regulations.

6. Coping with malaria: Facets of health seeking

malaria], he tells you: ‘doctor, I don’t need to test, I don’t have money.’ So you just have to go on and dispense medicines.”7 At the time of my research, the costs for a common first-line, antimalarial combination therapy for an adult were around 5,000/= to 15,000/= Ugandan Shillings (UGX), roughly between 1.60 € and 5.00 €.8 Commonly this consisted of three daily doses of Coartem (or another modern artemisinin-based combination therapy like Artesunate) for a period of three days. Blood analysis by means of instant tests cost round about 5,000/= UGX as well. At the public health centers, doctors would commonly prescribe Panadol (or any other form of generic Paracetamol) to be taken alongside the malaria medication, in order to bring down the fever and relieve the pain. On the private market the costs of Panadol were very cheap, around 200/= to 500/= UGX per dose. However, the purchase remained optional and many patients chose not to buy additional medication, trying to keep the costs as low as possible. In more severe cases of malaria, the prices for treatment rise drastically: while simple malaria can be diagnosed and treated for around 20,000/= UGX (less than 7.00 €), the costs for in-patient care can easily rise to around 150,000/= UGX and more (around 45.00 €). The second-line treatment most commonly used in private healthcare facilities is chloroquine, typically administered via an intravenous drip, separated into three doses. While Quinine itself costs only a fraction of the price of the common, contemporary combination therapies, it is the necessary materials as well as the necessary expertise that drives up the costs. Sterile cannulas, infusion bottles, saline solutions, and materials for dressings are costly, and so is the admission into a clinic. A nurse or any other medical specialist has to apply and monitor the drug administration, clean bedding has to be provided, and the patient needs at least basic care.9 Moreover, not all clinics and drug shops offer intravenous drug treatment, simply because they lack the space for an in-patient unit. In cases where such second line treatment is needed, patients are usually referred to a larger clinic or medical facility, of which there are still plenty in the area of my research.10 However, the larger medical facilities are usually also the more expensive ones. Offering a broader range of medical services, and being staffed with better-educated medical personnel, they enjoy a good reputation – a reputation that allows them to charge more. 7 Interview conducted on November 11, 2016. 8 The exchange rate between Euro and Ugandan Shillings at the time of my fieldwork was about 1:3,000. 9 In most cases, family and/or friends look after their relative or friend and provide food, company, and care to the patient. 10 In Namulonge and Kiwenda, the two most important trading centers in my research area, there were nine private medical facilities that had a basic in-patient unit.

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While the treatment costs of 20,000/= UGX for an uncomplicated malaria case can pose a considerable financial obstacle for many households, the 150,000/= shillings that are to be paid to cure a complicated malaria infection are a serious economic setback for most smallholders and petty traders. In order to avoid costs for medication, patients often seek for cheaper treatment first, before they opt for the expensive biomedical healthcare options. As I have outlined in chapter five, the way through the jungle of healthcare options is usually anything but straight. Often it starts with the application of simple herbal remedies, and only if these do not prove effective do people resort to biomedical treatment options. In order to keep costs low, testing is avoided and antimalarial or antipyretic medication is bought based merely on suspicion rather than on a confirmed diagnosis. Often the correct dosage is ignored, or, in order to save on costs, cheap but ineffective medicine is bought. In cases of a malaria infection this can lead to the development of severe and life-threatening symptoms that have to be treated urgently, which drives up the treatment costs significantly.

Malaria treatment outside the biomedical arena The options for malaria treatment rise further if one includes the many treatment choices outside of the biomedical realm. As I have argued earlier, the local understanding of malaria differs considerably from the biomedical one. When one talks about the costs of malaria treatment, it then is inevitable to also look at the treatment that lies outside of the biomedical realm which is consulted by many patients who seek to cure their malaria/musujja infections. As Susan Whyte already noted thirty years ago, since the introduction of biomedicine into countries of the “global South”, there has been an increased demand for medicines, biomedical as well as other (Whyte 1988: 217). The popularity of medicines can be attributed to a shifting of therapy from the public arena into the domestic domain, as it allows for treatment independent of a practitioner, thereby granting people responsibility over their own health (Whyte/Van der Geest 1988: 4-5). There are plenty of different treatments available, and the variation in terms of costs, efficacy, properties, applicability, and accessibility is large, and constantly changing and growing. Compared to biomedical medicines, other forms of treatment are far more differentiated in terms of materiality, presentation, and application. It is therefore difficult to paint a complete picture of the entire landscape of alternative antimalarial medicines. However, during my research I got to know a good number of frequently used remedies and talked to healthcare providers who offered alternative therapeutic measures, as well as patients who made use of alternative healthcare. In the following paragraphs I will present some of the most

6. Coping with malaria: Facets of health seeking

common drugs and methods I came across and discuss them in terms of their benefits and drawbacks. To begin with, the knowledge of basic medicinal plants is widespread. Most people I asked could name a number of commonly found plants, which can be applied to treat fever, headaches, or nausea. Many households even keep such plants on their compounds, to have them close in case they are needed. The most widespread herbs used against malaria were Omululuza11 and Sele.12 Usually the leaves or f lowers of said plants are infused and drunk like tea. The benefits are evident: no costs arise, and the medicines are conveniently collected and easily prepared. Aside from the bitter taste, there are few to no side effects – so I was assured. In terms of efficacy, most people I spoke to claimed the plants would work well to cure mild symptoms. Indeed, the antimalarial effect of some of these plants has been affirmed by various scholars. For example, Challand and Willcox (2009: 1235) attest a moderate clinical efficacy of the plant Vernonia amygdalina (which in Luganda is called Omululuza) in the treatment of uncomplicated malaria in adult, semi-immune patients. Aida et al. (2014: 588) as well as Andrade-Neto et al. (2004: 638) claim the same for, among numerous others, the roots of Bidens pilosa, in Buganda known as Sele. Antimalarial medication based on herbal ingredients is also increasingly industrially produced and commercially sold. There are a range of medications that are mostly based on the plant Artemisiae annuae and its derivatives, a long-known antimalarial plant in Chinese medicine (Hsu 2009: 112).13 The range of products and manufacturers varies widely, and so does their appearance. Most commonly, however, they are sold in the form of a powder or drops that are to be dissolved in water, and are used as a prophylactic rather than to treat an acute malaria infection. These drugs are sold in supermarkets, drug shops, in markets, or by vendors on the street. While this type of medication typically does not differ much in price from its biomedical equivalents, the herbal content is usually emphasized and advertised. Natural ingredients as well as the lack of side effects are used as selling points for herbal medicines, aspects that point out a growing skepticism towards chemical pharmaceuticals (Ekor 2014: 1). Herbal medicines are also frequently advertised on television, and more importantly, on the radio, a media channel that most people use. On market days one often finds herbal medicines sold at stands along the roadside in trading centers, and every now and then medicine sellers pass by the trading centers by car, advertising their products as they drive 11 Lat.: Vernonia amygdalina. In the text I refer to these plants using the Luganda terms. 12 Lat.: Bidens pilosa. 13 In fact, most first-line treatments used against falciparum malaria today are based on derivatives of artemisinin, the active antimalarial substance found in Artemisiae annuae. So, for example, is Coartem, the go-to medication in public health facilities in Uganda (Hsu 2009: 121).

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through the villages. It must be added, however, that while some of these industrially produced herbal remedies are thus available in the urban fringe, they are far more accessible in town, where a whole assortment of them are on offer, even in most supermarkets. It was my impression that herbal medications were not the preferred choice of malaria treatment among my respondents, certainly not as a prophylactic measure to prevent a possible infection. Aside from commercially sold herbal drugs, there are of course treatments provided by alternative healthcare professionals. Depending on the type of doctor, this includes a variety of services, ranging from the simple dispensation of medication, to consultation, advice, examination, ritual, and spiritual treatment, or any combination of the mentioned. The services are provided by healers, herbalists, self-proclaimed doctors, midwives, so-called “witchdoctors”, and occasionally even people trained in the biomedical sector, like drug-shop owners or clinicians. The associated costs, one might guess, vary greatly, and depend on a number of factors: What are the complaints? What type of treatment is one looking for? What kind of professional advice is one seeking? What are the patient’s financial possibilities? The reasons why people consult alternative health specialists are diverse as well. Mostly, some authors argue, it is the cultural proximity of local healers that is valued (cp. for example Goodman et al. 2007). Often alternative healthcare specialists come from the same community as their patients and are known among their clients. The social gap between them and their patients is not as large as is the case in the public healthcare facilities. Furthermore, as I have described in chapter five, the choice of healthcare depends also to a great extent on the type of symptoms one wants to treat. Most, if not all the people I talked to seemed to know very well what kind of disease malaria, musujja gw’en sili, is, and how to treat it best – with “the white man’s medicine” (eddagala ezungu). This finding was also confirmed by the outcomes of the household survey that was carried out by socio-economists working in the GlobE project. The data indicate that among the targeted households in my research area there is little doubt about the cause of malaria: almost 86 per cent of the respondents related malaria to an infectious mosquito bite.14 A similar percentage of people named the common antimalarial drugs, including contemporary ACTs, as the go-to treatment against a malaria infection. But when combined with the qualitative data I collected, it becomes apparent that “malaria” does not always have to be understood according to the 14 The question was semi-closed-ended, and formulated as “What can cause a malaria infection?” with several possible answers, including a blank field. Up to five answers were possible, the sequence of which was tracked. Of the respondents, 79.5 per cent gave mosquito bites as their first answer. Including subsequent answers, in total 86 per cent of the respondents related malaria to an infectious mosquito bite.

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biomedical definition. When translated into Luganda as “musujja gw’en sili”, the “mosquito fever” (as was the case in the survey), there is little doubt about what one is talking about. Nonetheless, the expected health implications that are associated with the term, and the ideas about adequate treatment might still diverge from the biomedical understanding. The English term malaria, however, offers more room for ambiguity, and can be interpreted in different ways. As a farmer I met in a local explained to me: “Fever [musujja] is fever [musujja]. It’s the doctor to decide which fever you are really having, [and whether it] is it malaria or typhoid […]. Until they do the test we always generalize it as ‘malaria’.”15 What conclusions are drawn in the end, and how one decides to treat malaria, then, is open to a number of factors. In the case studies I present, financial aspects play an important role in this. However, in some cases the symptoms are not clear, and a child showing the typical convulsions associated with an advanced case of malaria is perhaps haunted by ancestral spirits, rather than suffering from malaria – and thus brought to a ritual healer. In the following paragraphs I will present three cases of residents of the Namulonge area with whom I talked during my research. I will shed light on the ways in which they deal with an (assumed) malaria infection. The four cases show different aspects of the struggle with ill health and a suspected case of malaria, and illustrate some of the aspects that determine health-seeking. By taking a closer look at how poor households deal with malaria and its financial burden, we can better understand how sickness is perceived and evaluated, and how decisions concerning health-seeking are made.

Peter The first case I want to present is that of Peter’s household. I have already introduced Peter earlier in this thesis, as he was what some might call my “key informant” (Sanjek 1993: 13). Living with him and his family for a large part of my research, I gained a good impression of their ways of dealing with ill health. When asked about his professional identity, Peter would describe himself as a rice farmer. This, however, is only one part of the story. As Peter did not possess land, he relied on seasonal leaseholds in order to cultivate rice down in the swamps. The upland plots he was allowed to use around the homestead of his grandmother did not allow for the cultivation of rice. In fact, I did not get to know Peter as a farmer at all. He was employed by a colleague of mine from the University of Bonn, who ran a long-term field-experiment on rice cultivation in wetland areas. Peter’s job was the coordination of the fieldworkers, and the agricultural maintenance of 15 Field notes from April 29, 2015.

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the research plots. Earlier experience as a fieldworker for the Japan International Cooperation Agency (JICA) in similar field experiments with rice plants qualified him as candidate for the GlobE experiment; his outgoing and trustworthy personality did the rest. As I got to know Peter better, I came to know more about his background, his earlier work experiences, and his aspirations. Like many others in and around Namulonge, Peter only completed primary school;16 there was simply not enough money for further education. His mother died when he was still young, and Peter and his brothers grew up under the guardianship of their grandmother (the mother of Peter’s father). As is often the case with custody, Peter and his brothers were an additional financial burden for their grandmother, and schooling played its role in that. Peter spend much of his childhood helping out around his grandmother’s house, rather than at school. Nonetheless, he managed to learn a good deal of English, which opened a lot of doors for him, as it allowed him to find work at the nearby NaCRRI farm. Like most people in rural Uganda, Peter knows how to cultivate a field. Most people engage in farming to a certain extent. Often wrongly termed “subsistence farming”, this kind of small-scale agriculture adds to the household income. However, throughout my research did I not find a household that relied on farming alone. In just the same way, Peter’s household income stemmed from various sources. Peter worked at various places throughout his life. Farming was always an essential part of his income, but rarely did he rely on farming alone, and he generally took every opportunity he could to earn some money. At times he worked day jobs, for example helping out with the leveling or the harvesting of a wealthy neighbor’s field. On another occasion, he found a job at a poultry farm owned by Ugachick, a Ugandan fast food chain, who run one of their ranches not too far from Namulonge. For much of his working life he had been hired for agricultural fieldwork and had acquired a fair share of expertise on rice cultivation. Before I met him, he told me, he had been in between jobs. Anxious about his future income, he leased a plot of land in the swamps, made it arable and planted rice. While his income comes from all kinds of sources, mostly earned as a laborer, Peter considers himself a farmer. This perspective on his profession seems, to me, to ref lect his aspiration to gain a steady and good income. From his work on larger farms, he sees how people can make a profitable income from agriculture. Moreover, he understands what it takes to cultivate a field, from the process of clearing the land until the harvest. And Peter is certainly very well connected in Namulonge; he knows where to seek help, and from where to borrow materials. Agriculture could very

16 In fact, many people, especially of the older generations, did not even complete primary school education, if they went to school at all.

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well become his main source of income, except that he lacks the land resources to make it profitable. At the time I was introduced to Peter, and throughout my stay in Uganda, he worked in said research project, which provided the lion’s share of his income at the time. The job secured him a daily wage of 20,000/= UGX, paid once a week, as a lump sum for six working days. As the coordinator of the fieldworkers he earned twice as much as the coworkers he supervised. While in the local context he earned a fairly good salary,17 it still is shockingly little regarding Peter’s household expenses: Peter’s income had to provide for his wife and their three children,18 plus the child of his father-in-law’s wife, who lived with Peter’s family for a while, resulting in a per capita income of just about 20,000/= UGX/week (roughly €4). Peter insisted on sending his children to a private school, for which he had to pay fees. In his words, the public schools are “useless”, and he wanted to make sure his children would speak better English than himself. This, he was sure, they would not learn in a government institution. The schooling of his children was Peter’s first priority, but by no means his only one. Next to this, he and his family needed to be fed, dressed, and taken care of. The house he had built some years before I met him was never completely finished; the walls lacked plastering and the f loor had no pavement. On top of this came unexpected expenses, travel costs to a funeral for example, when some member of his extended family had died, or money for a new mobile phone when the old one broke. Lastly, and this is my main concern, come the costs for healthcare – an emergency expense in all cases: Peter’s precarious financial situation makes it difficult for him to plan ahead and prepare for medical eventualities. Peter, as he says himself, finds it hard to handle money responsibly. Usually it goes as soon it comes. When he receives a larger sum of money he usually spends it quickly, depending on his current needs and those of his family and their household. While Peter surely knows how to, as Ugandans jokingly say, “enjoy life” or to “eat money”, I do not want to give the impression that he squanders his money. On the contrary, I think Peter shows a good amount of foresight in the way he spends money and plans ahead – as well as possible – for upcoming bills and expenses. The case is rather that living on the bare breadline there is always something that money can be spent on. I had the impressions that the priorities for spending the money shifted almost on a weekly basis. New shoes for his children, charcoal for the kitchen, maize f lour for posho19 in order to prepare the daily meals – something always cropped up. Towards the second half of my fieldwork period, Peter 17 Salaries of 7,000/= UGX for a day’s worth of hard fieldwork are not uncommon. 18 Peter and his wife had a fourth child in 2017, when I was already back in Germany. 19  Posho, a doughy porridge made from corn flour, is a cheap staple food all over East Africa, in Uganda typically eaten with beans.

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made plans to construct an annex building on his small kibanja, with a shop premises from which he planned to sell rice – a strategy to add another income to his household. Even if such buildings are usually never constructed all at once, and instead gradually grow whenever there is money, Peter needed to save in order to buy the bricks, then the cement, and later the iron sheets for the roofing, and the frames for windows and doors. Whenever he had a larger amount of money at his disposal, for example when the payment of salaries had been delayed and he finally received the salary for several weeks’ worth of work at once, Peter would make a down payment at the local hardware store. In periods of little income, Peter and his family prove to be good at “hustling” through the dry spell. Simple food, limited meals, and no costly diversions, until the money comes in again. When a medical emergency hits during such a period of shortage, it demands a good deal of improvisation to make it through. It is at this point that I want to take a closer look at the health-seeking behavior of Peter and his family. During my time at Peter’s I witnessed periods of ill health at various times. Mostly it was the children, who fell ill with fever, f lu, and coughs. Twice, however, his wife was struck by malaria. In both cases, the treatment was delayed and led to hospital admission of his wife. On one of the two occasions Peters phone was “f lashed” by his wife: a quick call to a phone, too short to be picked up by the receiver, but long enough to be noticed and understood as a request to be called back. Mama Paulo, Peter’s wife, called in to say she was ill, feeling cold and suffering from a terrible headache: “malaria” she said, using the English term, as Peter confirmed to me later. In fact, she had already felt weak in the morning when she went to the garden to harvest sweet potatoes. The symptoms got worse, and she said she had barely made it back home, where she finally lay down. Via mobile money, Peter sent her 5,000/= UGX, instructing her to go to the nearest drug shop to get medication. When he got home at night, Mama Paulo was lying on a mat in the hall, obviously suffering. She had not taken any treatment as she felt too weak to walk to the trading center. Sending a neighbor was not an option either, as she had no cash money, only the credit on her mobile money account. Peter went to Kiwenda later to get some pills. Fansidar or Artefan is what he wanted, as it is a little cheaper than Coartem, the recommended combination therapy sold to treat malaria. As the first drug shop did not have the wanted medication on stock, he tried a second one until he found what he was looking for. As the fever struck Mama Paulo again the next morning, Peter finally decided to bring her to the health ward of the nearby Bugema University, a private University two trading centers further down the Zirobwe road, where they tested and admitted Mama Paulo to be treated for malaria. She had to stay for 24 hours, during which time she received three doses of chloroquine via a cannula. In the end the total costs added up to 125,000/= UGX.

6. Coping with malaria: Facets of health seeking

The story of Mama Paulo’s malaria infection is interesting for several reasons. Firstly, it shows who is in charge of money and implicitly says much about the gendered aspects of health-seeking in Uganda. As Mama Paulo did not have her own, regular source of income, she was dependent on her husband. This is not so unusual, even outside of Uganda, and not very different from cases I know for example from Germany. However, in the context of poverty it has far-reaching consequences with regard to access to medical care. In the case outlined above Mama Paulo was not able to take action herself and get access to treatment on her own terms. Access to healthcare for women and their children (in Uganda, as in most places, it is typically the mother who is taking care of her children) is often in the hands of the breadwinner who brings in the money and controls it. Without cash-money at hand, women can often only rely on the public health facilities in order to access medicines. This fact also becomes apparent when one looks at the patients arriving to the public health centers where medical care is free of charge: it is mostly women waiting for consultation with a doctor, not men. There are a number of possible explanations for this imbalance. The first impression might be that women are simply more susceptible to malaria than men. That holds true only to a certain extent. While the probability of contracting malaria through an infectious bite is the same for both sexes,20 pregnant women are more prone to develop severe anemia, and thus also more likely to be in need of professional help (Reuben 1993: 474-475). Furthermore, as I have explained in chapter two, the unequal gender distribution might also be rooted in the fact that women in general go to the health center more often than men. During antenatal care women are screened for all kinds of infections, and doctors as well as nurses are alert to detect malaria sooner rather than later, thus also quicker to test women at the slightest sight of symptoms. What is more, because women often have more experience with public healthcare, they might also have a more positive stance towards the health center and maybe even know some of the staff. Time constraints are a further reason that might explain why men are less likely to go to the public health center for treatment. Buying treatment from the private healthcare sector is simply much quicker than waiting long hours at the public health ward. However, when I asked for explanations, doctors as well as patients, both from the private as well as from the public sector, mentioned money constraints as one of the first reasons for this phenomenon. Women often simply do not have access to the money needed to go to private health facilities, buy treatment on their own, or use treatment outside of the public sector. Unfortunately, I lack comparative quantitative data from the private health sector to back my point. While the biomedical sector indeed keeps these kind of 20 Due to their occupation and nightlife, men even tend to be more exposed to infectious mosquito bites than women.

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records, there are just too many private healthcare institutions that offer malaria treatment to cover all the possible options. Furthermore, as I have pointed out earlier, antimalarial drugs are often sold without prior testing, thus biasing the statistical records. And lastly, even if the necessary data were available for the desired time frame, it is unrealistic that I would have been given permission to review the medical records of all the private health facilities. Nonetheless, my observations from the private healthcare sector, as well as the interviews and conversations I had with professionals working in that sector, seemed to underline the assumption that the number of male clients in the private sector was indeed higher than at the public health center in the area. The case of Mama Paulo illustrates this quite well. While her husband is out working, she remains at home to take care of the daily household chores, the garden as well as the children. At times Peter leaves money behind so she can go to buy cooking ingredients or other daily necessities. Mostly, however, Mama Paulo does not dispose of money when her husband is away, making it difficult for her to act on medical emergencies. This situation is shared by many women who do not have an own source of income, and rely on their husband’s income. By the time I completed my fieldwork in Uganda, the construction of the annex to Peter’s house had advanced to such an extent that Peter could make use of the shop premises, and he did indeed start a retail business for rice. When I completed my fieldwork in Uganda he was still experimenting with prices and was looking for reliable sources from which to purchase larger amounts of rice. On my last visit in early 2018, however, I was glad to see that he now has a small business running that Mama Paulo takes care of when he is away. While it does not bring enough revenue to run the household, it does help them to get through the aforementioned dry spells and, most importantly, gives Mama Paulo control over some money.

Gerald On one of my strolls through the wetland behind Kassambya I met a group of three young men, working on a field planting and harvesting Nakati,21 a local leafy vegetable similar to the spinach I knew from Germany. The field was relatively large, measuring around “two acres”, as one of the boys told me, using the old British area measure, common in Uganda.22 A merchant from town used the area to grow these delicate vegetables and cater for the markets Mpererwe and Kalerwe, suburbs on the way to downtown Kampala. He was on the lookout for wet21 Lat.: Solanum aethiopicum. 22 One acre equals roughly 4,000 m2, adding up to a field size of little less than a hectare.

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lands for the obvious reasons, as these were usually fallow and provided enough water to supply vegetables throughout the year. Apparently he maintained more fields elsewhere, growing greens and passion fruits, high-demand goods on the city’s markets. The merchant himself rarely showed up on his fields, and rather had them maintained by cheap laborers – among which were the three boys, one of whom was Gerald. Gerald, 19 years old, stayed in Namulonge. He had completed primary school education, although he graduated late, as he had dropped out of school intermittently. His father never could (or wanted to) pay for his secondary schooling, and so he stayed at his mother’s house for most of his youth. By the time I met him, he had moved to the trading center, where he rented a small room for himself, his wife, and their baby child. Relying on small jobs for an income, he struggled to make ends meet. Considering their exposure to wetlands, I asked Gerald and his co-workers about malaria in relation to the farming job the three young men did. That, so they claimed, was not a problem – they had not been ill for years. This was not too surprising, as malaria is mainly a problem of children or other vulnerable groups, such as pregnant women, elderly people or people with a weakened immune system. It was only after we had changed the topic, and began talking about their boss, and how he had selected the wetland for agriculture, that Gerald told me about his recent illness period. As it appeared, Gerald had been struck by malaria not that long ago, a serious infection that had him admitted to the HC IV in Gayaza. He fell ill about three months before I met him, ignoring the chills and headache, and joining his colleagues on the Nakati-field. As he told me, he feared being replaced by someone else if he did not show up for work – not an unreasonable apprehension, as there are plenty of people looking for jobs, willing to do whatever it takes to gain just a little salary. Ignoring his symptoms was at some point no longer possible, and Gerald collapsed under the shade of some trees close to the Nakati-fields. His colleagues rushed him to the local health ward, where he was referred to the HC IV in Gayaza, the next public health center that had an inpatient unit. “That one was heavy” Gerald recalled, “plus-plus malaria, they said”. The chloroquine treatment Gerald received was effective and, most importantly, free of charge, as he was consulting the public health-care sector. A few days later he was back in the swamps, weeding the Nakati-fields. As I mentioned, Gerald told me about his malaria experience in the context of a conversation about his boss. It came up as I asked about the working conditions of the three men, and whether they felt exploited. Although they earned next to nothing, and labored under hard conditions, all three of them defended their boss as being a good guy, and assured me they were happy they could work for him. In order to prove his point, Gerald told me the story of his recent period of ill health.

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Not only did he keep his current job, but also did his boss paid for the transport to both health centers, the HC III in Namulonge and the next-level referral unit in Gayaza. While the kind of fieldwork Gerald is doing is a good example of the horrific labor situation that I brief ly mentioned in chapter three, I do not want to make a point about Gerald’s working conditions, nor do I want to judge his boss’s actions. There are two other aspects of Gerald’s story that I’m concerned with in this chapter: first of all, the mention of his very recent illness with malaria was somewhat surprising. After all, I had just asked him and his colleagues whether they thought malaria was a problem related to their work in the wetlands, to which they responded that they had not been hit with malaria in a long time. Only later in our conversation, seemingly incidentally, was the grave period of malaria mentioned. Secondly, the story struck me as an apt example of the financially precarious situation Gerald was in, and a good illustration of how malaria can disrupt the fragile livelihood of a young family in Uganda (and probably elsewhere in the world). Gerald was never in serious danger of losing his life, I suppose. If his boss had not paid the boda-boda that brought him to the hospital, someone else in Gerald’s social network would have. Nonetheless, the sheer thought of him ignoring the malarial symptoms out of fear of losing a badly-paid job underlines the financial pressure he is under. My puzzlement related to the coincidental mentioning of the recent sickness could probably be best explained by a lack of interest in my questions on the part of the interviewees. Why elaborate on something that seems irrelevant, and which prolongs an exasperating conversation unnecessarily? But I think there is more to it. Of course, I inquired as to why Gerald had not mentioned his malaria when I asked about it earlier. The reason, so I was told, lay in the ambiguity of the term malaria, which, as I have shown at various points in this book, is bestowed with a meaning different from the biomedical understanding of the term. “Malaria” can mean a lot of things: fever, headache, f lu, exhaustion, sickness. And it can have a lot of causes: spoiled food, bad water, dust, or bad smells. While it is thus a collective term for a range of health issues, it is typically not used to describe a possibly life-threatening disease. It is an everyday complaint, which does not need particular mention. Musujja gw’en sili, on the other hand, is a serious disease, with a defined cause, that can cause grave symptoms. In this regard, the confusion about the term, rooted in rushed translation on my side, can help explain the initial neglect of my question about the occurrence of malaria. As for the second point, concerning Gerald’s financial situation, his story is telling with regard to the significance of income for the way in which people deal with ill health. Gerald’s example is not the only instance of that kind that I witnessed. In the context of my research project I recall being shocked a number of times about the endurance with which some employees pushed through poor

6. Coping with malaria: Facets of health seeking

health, without permitting themselves and their bodies a break. Having a job that provides a more or less regular income is not a given for many, and risking it by showing a poor work ethic would be reckless. Admitting to illness is therefore simply not permissible, as it means risking one’s job, which would entail worse consequences than sitting through work suffering from a simple f lu. But what if it is not just a common cold? The dependency on one’s job simply does not allow one to elaborate much on that thought. Especially malaria is prone to be confused with a common inf luenza infection, due to its unspecific symptoms. Fever, headaches, sore muscles, and possibly sickness are common symptoms that can be attributed to a number of diseases. What’s more, among otherwise healthy adults in endemic areas, a malaria infection, even with the aggressive falciparum strain, does commonly not develop into a life-threatening disease. Partial immunity, which develops under prolonged exposure to infectious mosquito bites, protects adults fairly well. Seen in this light, the decision to go to work rather than to the next health center becomes a more reasonable one. Regardless, dependence on an income has an inf luence on the ways in which people deal with ill health and the choices they make with regard to preventive, or precautious measures.

Mukyala Nakakande Looking for experts on herbal medicines used for malaria treatment, I was introduced to Mukyala Nakakande, a woman, 49 years of age residing in Seeta, one of the villages around Namulonge. Living in a large mansion, she was clearly from a wealthy background. And indeed, as I learned over the course of our interactions, her husband, like many people in her extended family, has a successful career. Muykala Nakakande’s husband and his larger family are landowners. As I was told, the great-grandfather of Nakakande’s husband was given a good portion of land by Kabaka Daudi Chwa II as a reward for his service as a soldier in the East Africa campaign of World War I. In contrast to most other residents in central Uganda, the family could claim a large piece of land as their property. “We own more than 50 acres; it stretches all the way down to the swamp and over to the other side”, Maukyala Nakakande said to me while pointing in the direction of their fields, not without a certain pride. On the land her husband maintains a mango plantation and employs a good number of workers who do the manual labor for him. I never got to know the exact size of their premises, and am not sure whether 50 acres (about 20 hectares) was indeed a correct indication of the area of their land, but from what I saw and heard from others, the properties of Nakakande’s family are indeed vast. The land has earned the family a good amount of money, enough to send the children to university. One of Mukyala Nakakande’s brothers-in-law is

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a renowned doctor with private practice in Kampala, the other one works for a real estate firm in town. One of her sons was supposed to complete his studies at Mbarara Medical School in 2016, while the other was making his first professional steps as a lawyer. Her daughter had married and moved to England. At least, so I was told. I cannot verify these claims as I never got to know her wider family in person. Regardless, from the family’s reputation in the area and from what I could tell from the size of her house and the way she presented herself to me, she was indeed not struggling to make ends meet. Over the course of my research I met several times with Mukyala Nakakande. I talked to her about my interest in herbal medicines and wetlands, and she willingly shared her knowledge with me and invited me to come back. At one point she even sent Mzee Ssenyondo, a man in his late 50s who worked on the family’s farm, to accompany me into the swamps to collect a list of medicinal plants for me in order to show me how to apply them. Although Mukyala Nakakande seemed to know quite a lot of medicinal plants she does not use them herself. When I asked her if she would treat herself with the plants she had shown me, she chuckled: “Me?! No, I don’t take [medicinal plants]. They are very bitter; I don’t like them.” As became apparent over the course of our conversation, he mother had taught her a lot about the medical efficacy of certain plants, and she indeed knew much about their uses and benefits. However, when she would fall ill herself, she did not resort to herbal medicines in any case. She pointed out the convenience in application of chemical drugs. A little perplexed, I was wondering why, during all of our conversations, she had been advocating medicinal plants, if in the end she seemed to be rather dismissive of them. I asked her if people approached her for advice on medicinal drugs. Apparently she sometimes recommends herbal medicines to people working on the farm: “why should I spend money [on medicine], yet I know there is medicine here that I can give them?” she asked rhetorically. However, the fact that Mukyala Nakakande, despite being knowledgeable in the field of herbal medicine, would not use her own plants should not surprise me all too much. After all, several of her family members were trained biomedical doctors, and, I assume, suspicious of the use of herbal medicines for the treatment of a malaria infection, as treating malaria with herbal medicines risks complicating the disease further. What’s more, while the earlier described case of Mary shows how the increasing use of herbal medicines is an outcome of contemporary dynamics, herbal medicines are nonetheless often associated with the past, and seen as pre-modern, if one will, sometimes even discarded as primitive. Commonly, alternative medicines are referred to as “traditional” or “cultural”, and thereby linked to a domain that is all too often regarded as outdated or unsophisticated. If one can afford it, biomedical healthcare is preferred because it is more reliable, more convenient, and linked to a certain set of practices and expertise

6. Coping with malaria: Facets of health seeking

that are assumed to be modern. There is no need to go into the “bush” to collect it and it does not need to be prepared before it can be applied. The only drawbacks of biomedical pharmaceuticals that Mukyala Nakakande could name were the side effects of some types of medicines and the risk of overdoe. When I asked her from where she would obtain her treatment, she complained about the desolate state of Seeta, the village she lived in: there was no way to get biomedical treatment here, as there was simply not a single drug store, let alone a clinic. Indeed, Seeta is not a “trading center”, as they are called in Uganda, a conglomeration of shops and markets, mostly along a road that makes the center accessible to merchants. Seeta is a dispersed settlement, with mud roads and small paths connecting the single houses. Close to the local councilor’s house a woman sells the most basic of daily necessities from a small stall, but otherwise Seeta is comprised of little more than some fifty or so houses. The closest health facilities, private or public, are located in Namulonge, a 45-minute walk away. Normally Mukyala Nakakande would be treated in town, either by her brother in law, or, as recently, in Mulago hospital where she had eye surgery. In emergencies, or when she needs to have certain medication, she consults Dr. Nathan, a doctor who in 2014 set up a private practice along the road entering Namulonge. Mukyala Nakakanda, having a wealthy background, does not have to be f lexible in the way she deals with ill health. Unlike other people I met, she can easily reject medicinal plants and avoid the public healthcare facilities. She is related to medical doctors, and wealthy enough to afford biomedical therapies when she needs them. For her, accessing healthcare is not subject to careful consideration and evaluation, but instead a rather straightforward process. Money is apparently not among the most important factors. Her comfortable financial situation allows her to worry relatively little about health – certainly about such everyday ailments as malaria. In light of this, the way malaria is perceived and dealt with, people’s access to treatment, and the considerations that go into the activation of healthcare are all subject to class as well. In stark contrast to the cases I presented before, Mukyala Nakakande did not have to worry much about money, where it came from and where it would go to. For her, health expenses were rarely an emergency issue, and her health-seeking behavior did not unfold against a background of constant or prolonged crisis. Moreover, how money is valued, and the implications that the presence or lack of money has with regard to health become evident in the ways in which Mukyala Nakakande spoke to me about medicinal plants. She valued them as part of the rich cultural heritage of the Baganda, and cherished her inherited knowledge about herbal remedies as a symbol of her mother’s wisdom. At the same time, however, she was dismissive of the efficacy of the natural medicine as a treatment for serious diseases such as malaria.

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As I have shown in this chapter, people deal with a malaria infection in different ways. This depends on a number of factors, but more often than not money is an issue. How much one can afford to spend on healthcare determines to a great extent how one accesses it. But of course, there is more to it. As self-diagnosis and treatment is common practice, the way in which one accesses healthcare, and what one is willing to spend on it, depends also on the symptoms one experiences and the way in which they are interpreted. Is this a serious malaria infection or just a heavy f lu? Especially with regard to children, this can be difficult to tell, and is subject to constant re-evaluation. In many cases is it mistaken to assume that people have false ideas about the graveness of their medical condition or the implications of their actions. Instead, it is the ambivalence of the disease and the understanding of it that can help to explain the course of their treatment-seeking. I argue that an assumed malaria/musujja/fever infection, poses a serious financial burden to households. The people I talked to were well aware of the costs of medical treatment, which decisively inf luenced their way of dealing with ill health. With this I do not intend to entirely rule out other factors in the analysis of health-seeking behavior, and I recognize the sometimes diverging and pluralistic ideas of medicine, health, and, most importantly, cure. However, I do think that often poor communities in Africa are denied expertise about health in general and biomedicine in particular. Especially when it comes to malaria, people are in fact generally well educated about its origins and the options for treating it. The decision to opt for treatment outside the biomedical sector is often made for financial reasons. Because of its degree of formalization and technological complexity, biomedicine is not only highly effective, but also commercialized and exclusive to solvent customers. Opting for biomedical healthcare to treat a malaria infection, although probably the safer and more effective choice, is also the more expensive one. Mary, whom I introduced at the beginning of this chapter, put it poignantly: “Herbals are cheap; you can get them even when you have no money which is not the case with the chemical medicine. Herbs are easy to get; almost every home has grass and trees. […] When you go to a [public] hospital, they will [make you wait]. But we people who are average, we cannot afford big clinics, we have to go to government hospitals where you can spend an entire day [without seeing] a doctor.”23 In the following chapter I will take a closer look at the economic exploitation of wetlands in the region, and link these ecological changes to the malaria epidemic in Uganda’s urban fringe. As I have already pointed in chapter four, introducing the setting of the research, the ongoing dynamics regarding land tenure lead to an increasing use of wetlands for economic means. With the case studies presented 23 Interview conducted on October 10, 2015.

6. Coping with malaria: Facets of health seeking

in this chapter, I have highlighted how the precarious economic situation of my interlocutors shapes and determines their health-seeking and their ways of dealing with malaria. In the next chapter I will show in more detail how these activities are linked to the occurrence of Anopheles mosquitoes in the region and are likely to further exacerbate the malaria problem in the future decades. As people are entering wetlands in order to eke out an income, access to malaria treatment and the occurrence of the disease are interlinked.

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“There was an entobazi [between Namulonge and Balita and the people dug channels which transferred the waters into a river. This was to enable them do farming in the swamp.” Interview with Mzee Kisito, a retired farmer in Balita, May 17, 2015 “The good thing about wetlands: you can be cultivating there even during the dry season. You can cultivate greens, cabbage, tomatoes [there]; even when the sun shines, you can get good yields.” Interview with Tusabe, a farmer in Kassambya, September 8, 2015

7. Agriculture in the urban fringe: The ambivalent role of wetlands Wetland agriculture and mosquitoes Moses was reluctant to talk to me at first. I had met him on one of my strolls through the wetlands in my research area. At the beginning of my research, not knowing many people, I intended to use these walks through the swamps as a strategy to meet people who made use of wetlands as a site for agricultural production and to get an impression of the activities that took place in wetlands. Equipped with wellingtons, “gum boots” as they are called in Uganda, my assistant and I fought our way through the muddy soils – an inhospitable environment, with its high grass and wide trenches that were difficult to cross. In hindsight I wonder what my assistants thought of me when I proposed to them that we might take these strolls through the wetlands. In their polite manner they would not refuse to join me on my research endeavors, and accompanied me wherever I wanted to go, despite the fact that the wetlands were not exactly a pleasant field site. Without any particular business in the swamps one would rather stay out of a wetland. Especially for me,

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a muzungu, it was highly unusual to be seen in a swamp. As I soon realized, my attempts to get to know the area’s wetlands raised suspicions among the people I met. What business would I, as a white person, have here? Did I want to buy land? Did I plan an investment in the area? Did I maybe cooperate with the government? As mentioned in my brief description of wetlands in Uganda in chapter four, these ecosystems are protected biotopes that are excluded from agricultural uses. Usually they are considered state property and thus exempted from private or customary tenure. Having recognized the environmental and ecological value of wetlands, the Ugandan government seeks to preserve them from degradation (Mafabi 2018: 808-09). Regardless of this, many wetlands are in fact profoundly used already, especially in the proximity of town where land resources are increasingly becoming scarce. The high production potential of wetlands makes it probable that this trend will further intensify in the future, as the population pressure continues growing and with it the demand for arable land (cp. for example Behn et al. 2018: 250-251). The people who make use of wetlands for agriculture or other money-generating activities usually do operate in a legal grey area. While wetlands are largely fallow areas that do not belong to a particular person, they are tempting places that can be used for the washing of cars and clothes, extraction of building materials such as sand, clay, and papyrus stems, as a source of water, the planting of fields, as well as the construction of fish-ponds. Since wetlands are typically not owned by a private landowner, there is no one who claims his exclusive user-rights. Although the Ugandan government has put in place a wetland surveillance unit and delegated to the local district governments the responsibility for implementation and observation of the policies put in place, the state itself rarely enforces the wetlands’ protection (Kalanzi 2015: 161), and during my time in Uganda I did not hear of anyone who was forcibly evicted from a wetland by a state authority. With non-enforced wetland policies, the laws regarding the do’s and dont’s for wetlands remain an optional guideline for the proper use of these ecosystems. The misleading definition of wetlands further underscores the ambiguity of policies with regard to marshlands. The National Policy for the Conservation and Management of Wetland Resources applies the same broad definition of wetlands as established by the Ramsar convention in 1971: “an area where plants and animals have become adapted to temporary or permanent f looding by saline, brackish or fresh water” (Ministry of Natural Resources [MoNR] 1995: 6). This definition does not comply with the local terminology for wetlands (ekisenyi and entobazi), which differentiates between at least two different types of wetlands. Moreover, the boundaries of a wetland are not always clear, as they shift depending on the season and the rainfall. Which areas are in fact protected is thus often unclear. With the misleading and unclear regulations with regard to wetland protection and land tenure, people react suspiciously to the appearance of a stranger.

7. Agriculture in the urban fringe: The ambivalent role of wetlands

Moses was no exception. When he heard that I was interested in wetlands as a student working on a doctoral thesis, he told me that he didn’t know anything of interest to me. I carefully explained that, since I met him in his field in the middle of the swamp next to Kassambya, I would of course like to talk to him about his ideas about wetland agriculture, the risk of malaria in the region and his views on the linkages between his agricultural activities in marshlands and the occurrence of mosquitoes. While I respected his refusal to talk to me about wetland agriculture, I asked him why he thought he had nothing valuable to tell me. It turned out that Moses was worried that my writing on the agricultural uses of wetlands would draw the government’s attention to the ongoing activities in the area around Namulonge, and might eventually lead to consequences for him and other farmers who used wetlands as a resource for their income. The names of the people I cite are of course pseudonyms. With regard to the use of wetlands that I describe in this thesis, I do not think that I deliver previously unheard news to the environmental agencies in Uganda. As I have described in chapter four, all it takes is a drive over the tarmacked road from Kampala to Namulonge to see all kinds of agricultural and other activities taking place in the wetlands bordering the street. The transformation of wetlands into arable land is therefore by no means happening secretly or kept out of the eyes of the authorities. Regardless of this, it should go without saying that I have no intentions to reveal Moses’ activities in the wetlands to government officials, nor do I intend to judge the ecological impact of his or his neighbors’ agricultural activities. However, in order to understand the problem of malaria in central Uganda and elsewhere, I am of the conviction that one has to take the modes of agricultural production into account. The occurrence of malaria in a particular place is often linked to the ways in which land is used and water is managed, and how the environment is arranged. This, as I will show in this chapter, is also the case for the urban fringe of Kampala and the type of wetland agriculture that can be found here. And, when looking at wetland agriculture in Namulonge, one has to take the peri-urban context, as well as the local land dynamics related to the urban expansion, into account.

Malaria and Agriculture Whether or not malaria is present in a specific region is dependent on a number of environmental factors. As a vector-borne disease, malaria only occurs when the habitats of humans and mosquitoes fall together and the life-supporting conditions for mosquitoes and parasites are met. This can explain why malaria is typically not found at high altitudes, as the temperatures are too low to sustain significant numbers of mosquitoes. Equally, in hot and dry regions, especially deserts,

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malaria typically does not occur, as mosquito larvae breed in pools of water. Furthermore, most malaria-transmitting Anopheles mosquitoes thrive better in humid weather conditions. In some areas malaria occurs seasonally, during and shortly after the wet seasons, when puddles of stagnant water have formed. With regards to the reproduction of the Plasmodium parasite within the mosquito host, warm temperatures are needed as well. With external temperatures below 14° C degrees the life cycle of the malaria parasite is interrupted in the salivary glands of the mosquito. In temperate regions, malaria therefore only occurred during the warmer months of the year (Dale/Knight 2008: 257-259; Service/Townson 2002: 63-65; Wielgosz et al. 2012: 1-9). As I have indicated earlier, in chapter two, the transmission of malaria is to a large extent shaped by human activities and the associated environmental changes (Packard 2007: 7-10). While there are a number of factors that shape the distribution of mosquitoes, and with it the appearance of malarial parasites, among the most crucial is agriculture (ibid: 15). It is suspected that malaria parasites affected human populations with the onset of the first agricultural revolution, approximately 10,000 years ago. Loretta Cormier emphasizes that the dawn of agriculture was a watershed event in the distribution of malaria, as it dramatically reshaped the relation between humans and primates, allowing plasmodial parasites to adapt to human hosts. “The advent of agriculture not only involved a change in the mode of human subsistence patterns but is also the starting point for a major shift in human relationships with the environment that have forever altered both human and wild-primate relationships with malaria parasites. Rather than humans moving nomadically to obtain resources, they began to become sedentary, domesticating plants and animals, altering the environment, and ultimately, changing the primate malarial landscape.” (Cormier 2011: 31) In order to thrive, malarial parasites need larger groups of settled individuals. The parasite develops in human as well as mosquito hosts, and is transmitted from one human to the other by the bite of the same mosquito. Therefore, before malaria can jump from one human to the next, three mosquito-bites are needed: one to inject plasmodial sporozoites into a human host, a second one to later ingest gametocytes into the mosquito guts, and a third one, by the same mosquito, to inject sporozoites into a new human host. In small populations, which are not settled, and don’t stay close to water sources, plasmodial parasites can hardly survive. However, with the dawn of agricultural societies, the conditions for malaria transmission were indeed increasingly met. Aside from the establishment of sedentary communities, the agricultural activities created favorable environments

7. Agriculture in the urban fringe: The ambivalent role of wetlands

for the development of mosquitoes, which became adapted to human blood meals (Müller 2011: 19). Apart from the significance of settled communities for the prevalence of malaria, agricultural land-users often create habitats suitably for the development of mosquito larvae. The reasons for this are rather simple: deforestation and the clearing of land, typically associated with the transformation of bushland into arable soil, expose the ground to sunlight. The exposure to the sun heats up the water pools and reservoirs which frequently build up as a consequence of agricultural activities, creating perfect breeding grounds for some strains of Anopheles mosquitoes. Anopheles gambiae and Anopheles funestus for example, the predominant malaria vectors in Uganda, lay their eggs mostly in temporary puddles of water, which are often found next to agricultural fields. Due to the abundance of water, wetland ecologies are particularly favorable for mosquito breeding (Dale/ Knight 2008: 257-58; Lindblade et al. 2000: 272-73; MoH 2014: 23; Munga 2006: 71; Service 2002: 326). The qualities of wetlands as a habitat for mosquitoes are rather obvious. Water is a prerequisite for the development of mosquito populations, and the nuisance of mosquitoes around swamps and marshlands is commonly known. Most of the academic articles on the links between agricultural practices and malaria, however, focus on upland agriculture. Nonetheless, Lindblade et al. (2000) have shown that the same applies for cultivated wetlands as well. In their study, the authors have looked into land-use and land-cover changes in the highlands of south-western Uganda to explain the recent malaria outbreaks in areas that were previously regarded as malaria-free due to their elevation. The clearing of the wetlands’ natural vegetation cover, most importantly the thick papyrus bushes that are typical of the swamps of tropical Africa, and the management of water in and around fields, creates conditions favorable for mosquito breeding (ibid: 268-269). While agricultural activities can exacerbate malaria prevalence and expose entire communities to infectious mosquito bites, agricultural development has, over the last 150 years or so, also significantly contributed to the eradication of malaria in many parts of the globe. Mechanization, upscaling, and the improvement of working and housing conditions of fieldworkers are some of the most important factors that explain the decline of malaria cases in much of North America and Europe during the 19th and 20th century. Agriculture has become significantly less labor-intensive, only a fraction of the people living in the so-called “developed” world are working in the agricultural sector. However, in much of the global South, most prominently in Africa, these developments in agricultural production have remained largely absent. In contrary, as Randall Packard argues, the dramatic expansion of tropical agricultural, linked to the growing demand from industrializing countries in the West, has only aggravated the malaria problem in

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the South, as it has never produced the capital needed for agricultural transformation (Packard 2007: 84-86). “Patterns of agricultural production in tropical and subtropical regions of Africa, Latin America, Asia, and the Pacific during the nineteenth and early twentieth centuries […] tended to be undercapitalized, used few technical inputs, relied on the extensive use of human labor, and were marked by significant inequalities in the ownership of land. […] In many regions, patterns of agricultural development failed to provide producers and their families with the resources needed to improve their conditions of living or reduce their exposure to infection. It thus prevented them from “growing out of malaria.” At the same time, in a number of places these patterns of production led to increases in the distribution and intensity of malaria transmission. While climate and the presence of highly efficient vectors contributed to the persistence of malaria, conditions of production played an equal if not greater role.” (ibid: 84) Building on the land dynamics I outlined in chapter four, I will show in this chapter that these conditions have not changed much in Kampala’s fringe, certainly not among the poorer part of the population who often remain directly dependent on farming. As we will see, in central Uganda, access to land and landownership is increasingly reserved for the aff luent minority, while poorer households are driven into the wetlands, where they often maintain a small field which they work with the hoe. Understanding why malaria continues to be an African problem, I argue, must include a perspective on the modes of production and the living conditions of the local populations, as well as the related ecological context.

Wetlands as economic resource Preparing my research proposal, I became acquainted with the literature on wetland agriculture, African land issues and the backdrop of pressing issues like population growth, climate change, and land acquisition. Wetlands, according to the literature, have a large potential to attenuate these issues, as they could be transformed into arable ground. The GlobE project, specifically designed to investigate how to best unlock the production potential of wetlands, held the title “Wetlands in East Africa: reconciling future food production with environmental protection” – clearly indicating the agricultural production potential of East African wetlands, especially with regard to future developments in the region. However, as I have already outlined, the agricultural use of wetlands in the peri-urban spheres of Kampala is by no means an endeavor of the future. Already people are resorting to wetlands in order to plant gardens and mine building materials. The urban fringes

7. Agriculture in the urban fringe: The ambivalent role of wetlands

are areas which are already affected by population pressure, and the wetlands to be found there are being used to cope with the lack of arable land in the city’s surroundings. In that regard, peri-urban spaces are highly suitable locations in which to research the future dynamics with respect to the transformation of wetlands into production sites and the expected economic exploitation of these ecosystems. Figure 25: Parts of the Mairye Estates and Xclusive Cuttings f lower farms, picture by author

The potential to transform wetlands into arable cropland lies mainly in their fertile, watered soils. But the abundance of water in the swamps creates conditions that are not favorable for all crops. Rice appears, of course, as an obvious choice for a field in the marshes. However, maintaining a rice field is labor-intensive. One has to bound the field to control the inf low of water, weeding is done in standing water, and once the crop is ripe, the field has to be guarded against birds. While the cultivation of rice is increasingly taking hold in Uganda, it still accounts for only a small part of the country’s agricultural yields. Cabbage, yams, maize and cassava are more popular crops that can be found in swamps and are more readily planted. Among the cash-crops grown in wetlands are the more delicate leafy vegetables, such as Nakati or Dodo, tomatoes, eggplants, and onions, which are often sold in the nearby markets of Kampala and its surrounding towns. Sugarcane is also commonly grown in wetlands, as it is needs abundant water to grow. The

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demand of Kampala’s larger hotels for Western crops like strawberries, broccoli, caulif lower, and salads is also catered to. Wetlands are suitable production sites for such agricultural products, as their steady availability of water allows for yearround production. In the Namulonge area I met two farmers who produced such crops, and came across several fields with strawberries. Furthermore, in Uganda industry-like f lower farms are increasingly popping up. Close to my research area there were two large farms located right in the wetlands, where they produced cut f lowers for the European and Asian market (cp. figure 19, and figure eight in chapter four). These kinds of large-scale agricultural investments are also playing an increasing role in the scramble for land in Africa, especially in the proximity to urban centers and their infrastructure. Arguably the most disrupting effect of agriculture to the wetlands’ ecosystem is the transformation of the fallow wetland into arable cropland. As I have already pointed out, in Luganda one differentiates between entobazi – a pristine, f looded marsh – and ekisenyi – the cultivable, dryer swamps. The former can be transformed into the latter by means of draining out the water through a central canal and slashing the typical, thick papyrus bush. In the Namulonge area, most wetlands are either temporarily f looded in the first place, or were already drained years ago. The thick papyrus swamps that are typically associated with wetlands are only found on the margins of my research area (indicated in dark gray in figure eight provided in chapter four). Nonetheless, these wetlands are also valued for their supply of reeds, clay, and fish. The ways in which wetlands are utilized are then by no means homogeneous, and neither are the user groups. While wetlands are an increasingly valued land resource for smallholders and provide a small income for poor households, better-off businessmen also invest in wetlands, especially in proximity to the town. The strawberry fields are a perfect example of this: the targeted market lies in the nearby city, and in order to access it, one needs good connections to the expensive hotels in the city – connections that require an advanced level of English language capacity, as well as f lexibility and mobility. Moreover, the presence of larger industries, like the f lower farm at the border to the Namulonge wetland, is a clear example of large-scale wetland utilization that requires a substantial amount of capital in order for the business to be set up. In much the same way as the users of wetlands are coming from different social backgrounds, wetlands are also used and utilized in various ways in order to generate an income or to provide the daily needed resources. Next to agricultural uses, there are a number of other activities that take place in wetlands. In the coming paragraphs I will elaborate more on the different uses of wetlands and the users’ motivations and aspirations with regard to wetlands (cp. figures 20 to 25 for examples of wetland uses at Kampala’s fringe).

7. Agriculture in the urban fringe: The ambivalent role of wetlands

Wetland mining Apart from their benefits as agricultural land, wetlands are valued as a source of building materials, most importantly clay. Digging below the fertile humus layer wetlands often feature a layer of thick, gray clay. Steven, a farmer I met in Balita, accompanied me on several of my strolls through the wetlands and explained the features of the swamps around Namulonge to me. On one of these walks he showed me how to dig up the clay. With the help of a hoe and a few well-executed slashes, it took him about two minutes to dig a thirty-centimeter-deep hole, enough to expose the clay-layer. As Steven explained to me, the clay can be used for a number of purposes. He sometimes provided clay for a woman who used it to form so-called emumbwa out of it – bars of dried clay enriched with a mixture of herbs and barks, used for a range of medical purposes.1 However, as Steven further told me, clay was much more valued for the production of bricks. While bricks in Uganda are usually made out of the red laterite soil, in East Africa known as “murram”, clay bricks feature better characteristics, and can be sold at a higher price. Pointing towards the newly built houses that mushroom along the borders of the Namulonge wetland, he said that clay bricks were something reserved for the rich. Whereas a classic murram brick is usually bought at around 50 to 100 Ugandan Shilling, clay bricks have a market price of 400/= UGX per brick. This form of wetland utilization at the urban fringe is thus a direct outcome of the redistribution of land in the region and the related surge in demand of high quality building materials. While the digging up the clay is a lot of work, moreover in an inhospitable environment, it does not require much material input or specific skills. Also, the production of bricks is quickly mastered and can be done with simple instruments. Considering the immense demand for high-quality building materials near the growing city, it is not surprising that the typical towers of stacked bricks ready for burning can be seen everywhere. For many, the production of bricks is an easy way to gain an income. The impact brick-making has on the wetland ecology and the implications that arise for the breeding of mosquitoes can best be illustrated with the case of Kayongo. In the opening vignette of this chapter I introduced Moses, whom I met at one of my strolls through the wetlands around Namulonge. After getting to know him better, he eventually introduced me to one of his friends, Kayongo, who 1 Emumbwa are a feature of Baganda medicine, and largely unknown outside of Buganda. One can find emumbwa for a range of ailments; mostly, however, they’re used as bathing supplement for newborn infants and for antenatal care of pregnant women. In order to be applied, the emumbwa is dissolved in water. This water is then either used for bathing, or drunk, depending on its purpose.

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ran a small “brick-factory”, as he put it himself (cp. figure 22). Although the term “factory” might be misleading, Kayongo indeed produced bricks systematically and with considerable effort and success. He even paid a young man who helped him with the production of the bricks. He had set up a makeshift fabrication hall, a wooden construction covered with tarpaulin, in which he formed the clay into perforated bricks, a special form of building blocks that are used as ventilation holes in walls. Kayongo used an old, rusty, manually operated press, which allowed him to cut three bricks at a time. On a good day, Kayongo could press almost 300 bricks, which were then piled up to dry and later stacked in order to be burned. Proudly, he explained the process to me in detail, pointing out the pitfalls such as low quality of clay, with a high amount of sand, or poorly pressed bricks, with locked-in air chambers. The biggest problem, however, was selling the bricks. Usually he only worked on demand, starting production after having received an order. As he described it, the process of selling his bricks to hardware stores was cumbersome, as they would usually only buy small numbers of ventilation bricks, and he had to transport his bricks from the wetlands to the trading centers – nearly impossible without a vehicle. Instead he hoped for customers who would pick up his product directly from the production site. The mining of clay is highly destructive of wetlands as ecosystems. The excavating that is done in order to reach the clay layer below the swampy soil leaves behind deep trenches, changes the soil composition, and mixes up the fragile ecological equilibrium of marshlands (cp. figure 21). Especially the trenches are of relevance to the presence of malaria, as they quickly fill up with water, providing perfect conditions for the development of A. gambiae larvae. Uncovered, the puddles are heated up by the equatorial sun, favoring the maturation of larvae into mosquitoes. What is more, as these puddles exist only temporarily, they are usually not populated by larvae-eating fish. Asked about the ecological consequences of his work, Kayongo had a different perspective than the one I have sketched out above. In his view, the clay mining was not an intervention into the wetlands ecology, as the water was still abundant. It was the farmers who, in his opinion, caused more harm by draining the wetlands and creating channels which dried up the farmland. “The water is still there”, Kayongo claimed, pointing towards the puddles behind his makeshift brick factory. As for the vegetation, he assured me that it would take only some months for it to recover. “When you come back after next wet season, you’ll see that it will be all covered again.” Hinting at the appearance of mosquitoes and the link to the puddles of stagnant water he created, I wanted to know his opinion on that topic. “Of course, you find many f lies down here in the lowlands” he shrugged, “but the bushy areas is where they hide.” While Kayongo clearly attributed the appearance of mosquitoes to marshlands, he did not see a link to his brick-making activities.

7. Agriculture in the urban fringe: The ambivalent role of wetlands

If anything, he was of the opinion that he rather helped to diminish the number of mosquitoes, as he cleared the wetland’s thick papyrus cover. Aside from the mining of clay and the brick production, there is the extraction of sand and stones. Especially in seasonal wetlands the soils are often sandy, and locally one can find pits of sand, just below the humus layer. While living in Peter’s house, I regularly used to walk to the NaCCRI research facilities, where I made use of the office facilities, kept my field notes, and charged my laptop battery. A shortcut led along the borders of a seasonal wetland, which branched off from the larger swamp bordering the research farm. Here a group of young men started to dig out sand. It was a major undertaking: the area had to be cleared of its bushy vegetation first. Thick, thorny bushes were covering the place. The activities lasted for a good three weeks until all the sand had been taken out of the swamp, leaving behind a cratered landscape. This happened during my first stay in Namulonge, and over the course of the research I repeatedly came back to the place to document the changes. It is astonishing how fast the vegetation recovers in the tropical spheres. Just a few months after the excavation had begun, the area was again covered with grass and shrubs. Nonetheless, the craters remained, filled with water as soon as the first rains had set in.

Fisheries Another activity that takes place in wetlands, although only to a limited extent, is the creation of fishponds. In September 2015 I witnessed a man from the neighborhood staking off a square of approximately six by three meters, close to the spring from which Peter and his family drew their water. Two days later the demarcated area had been dug out to a depth of about 80 centimeters, and by the end of the week, a shallow wall had been constructed around the hole. Interested in what was going on, I first asked Peter, who then introduced me to his neighbor James, who was responsible for the construction of what proved to be a fishpond. Just like Peter, James lived with his family in a house along the main road of Balita, a few hundred meters further down the road. Like Peter, James too occupied a kibanja that provided him with enough land for his house and a small garden with matooke-plants2 and cassava shrubs. But unlike Peter, his kibanja was not limited to the immediate surroundings of his house. Some years back, James had approached his landlord to acquire the user rights for a plot further down the

2 Matooke is a starchy banana variety, and one of the staple foods in central Uganda and elsewhere in the Lake Victoria basin. In Buganda the peeled fruits are steamed and eaten as a doughy porridge, accompanied with a sauce or stew.

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hill, just at the border of the swamp.3 Here he intended to grow rice, but never managed to find the time to clear the field and plant the rice. Instead he let the plot out to farmers like Peter, who were willing to invest the time and labor in order to make the land arable. When I was introduced to Peter, he had just planted a rice field on James’ kibanja. After harvesting Peter would pay two sacks of rice to James as rent. Although Peter would have liked to continue cultivating the rice field in the swamp near his house, James refused as he had decided to build a fishpond there instead, and to use the remaining part of the land as a field for sweet potatoes. Once built, fishponds don’t require much maintenance. Simply put, all it takes is waiting for the fish to mature, while feeding the fish once in a while. Of course, things are a little more complicated than that: one has to adjust the water level and check the water quality, keep off birds, snakes, and burglars, and control the fish population. But compared to the maintenance of a rice field, keeping a fishpond is relatively easy, and most of the time it remains untouched. Needless to say that a fishpond provides an excellent environment for mosquito larvae. Although some of the larvae might fall prey to the fish, not all of them will, and much of the time the pond lies idle anyhow, waiting for fish to be put in (cp. figure 25). Asking James about the mosquito problem, he seemed dismissive. If anything, the hazards related to fishponds had to do with snakes, who looked for prey in the ponds. While James confirmed that mosquitoes were more common close to the lowlands than on top of the built-up hills, he did not relate them to his ponds, and neither did many others I spoke to. What is written in scientific books about mosquitoes clearly differs from the views on the ground, where the complex link between mosquitoes, malaria, and humans is constructed differently, if at all. Moreover, as will become clear in the following paragraphs, the benefits of wetland agriculture outweigh the perceived threat of malaria.

3 This is a good example of the ambiguity and ambivalence of land regulation in Uganda, which I outlined in chapter four. While I have described earlier how wetlands are supposed to be protected by the Ugandan government and are excluded from the classic land-tenure systems, the example of James, that I lay out here, proves the opposite. In fact, the swamp below Balita is, at least in parts, owned as private milo land and can be leased out as a kibanja. This outlying arm of the wetland is only seasonally flooded and in Luganda referred to as an ekisenyi. As I was told by the local authorities at the Busukuma Sub-County Hadquarters, it was excluded from government protection.

7. Agriculture in the urban fringe: The ambivalent role of wetlands

Malaria and agriculture: local perceptions As I have repeatedly pointed out in this text, the local view of malaria is different from the biomedical understanding of the disease. In the local context the term “malaria” is frequently used to refer to unspecified ailments. Asking local farmers about the causes and effects of malaria, one has to be careful not to confuse the different conceptualizations that lie behind the term “malaria” and to be clear what one talks about. Regardless, mosquitoes are not only perceived as nuisance, but to a certain extent also as a potential health threat. Public health campaigns to inform and sensitize the population, mainly through media channels such as the radio and billboards, as well as school education, have created a certain awareness about the link between mosquitoes and fever. After all, the Luganda term musujja gw’en sili, the “mosquito fever”, puts fever symptoms clearly in relation to mosquitoes. Also, mosquitoes are linked to the occurrence of water and frequently described as a phenomenon of the rainy season. After the first rains in the short rainy season of 2015 had set in, Peter explained to me: “As we have received rains now, you will see white ants will be plenty soon”, referring to the male termites that leave their mounds in their thousands shortly after the first rains have set in.4 He added: “white ants, and mosquitoes.” Indeed, as James McCann vividly describes, the wet-dry seasonality found virtually across the entire continent has equipped the A. gambiae mosquito-species complex with a remarkable ability to endure dry spells and quickly multiply as soon as the rains begin to fall (2014: 146). Asking where and when mosquitoes appeared, wetlands, swamps and forests were among the most common answers. “You cannot be down in the swamps at night, there are too many snakes and mosquitoes,” I was warned repeatedly. Sitting outside after the brief, tropical dusk during the wet months, the clapping of the palm of a hand hitting at a naked arm or neck was a common sound, and sooner or later someone would complain: “ah, I am eaten alive.” To almost everyone I spoke to it seemed clear when and where one could expect mosquitoes, and it equally seemed common knowledge how one could protect oneself against their bites. Bed-nets are common in Uganda, although not always loved. Everyone who has once slept under a mosquito net will know the cumbersome ritual of tucking the net under the matrass before going to sleep. Furthermore, many people complain about the lack of ventilation under a mosquito net, and claim they sweat more during their sleep. More often than not, especially adults choose not to sleep under a bed net, either because its drawbacks outweigh the benefits, or because they do not regard the mosquito problem as too serious.

4 Roasted with onions or eaten fresh, they’re considered a delicacy across Uganda.

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Apart from the presence of water, the appearance of mosquitoes is linked to environmental attributes such as “bushy areas”, “uncleared fields”, and “disorganized compounds.” Generally, the occurrence of mosquitoes is seen as a sign of untamed nature, messy environments, and untidy homesteads. Mosquitoes f ly where humans have failed to impose order on the wild, or where they don’t take control of their environments. Whereas this view is not entirely congruent with scientifically informed perspectives on mosquito habitats, this explanation does contain elements that bear a striking resemblance to the analyses of the above-cited malariologists, historians, and geographers. They often point out that malaria must be seen as an outcome of a region’s ecology and the predominant modes of production (cp. Dale/Knight 2008; McCann 2015; Packard 2007). A well-kept homestead with a tidy compound leaves little room for the accumulation of water puddles. The water barrels with which rainwater is usually collected are covered, the jerrycans are closed with a lid, and the compound is clear of rubbish in which rainwater could accumulate. While a tidy household might help to diminish the breeding possibilities for mosquitoes, it does not, however, prevent the insects from f lying over from the neighbor’s homestead, or the swamp a couple of hundred meters further down the hill. Neither does the analogy of a well-maintained environment with few suitable biotopes for mosquito larvae apply to untouched nature – the so-called bush. Here it is mostly human interference that creates the conditions that favor mosquito breeding. It is astonishing how quickly mosquito larvae develop in stagnant bodies of water. I vividly remember finding a few larvae in my bathing water every evening. When living at Peter’s place I used to wash myself from a basin filled with water from one of the jerrycans that Peter used to store his water for home use in. While it is difficult to spot mosquito larvae in the murky puddles that remain from clay-mining, a bright, plastic basin provides the perfect background for seeing the small, worm-like creatures f loating in the clear water. They’re difficult to catch, as they hardly have any mass, and are easily washed away with the water that runs off of one’s hand. And while everyone knows these little larvae, hardly anyone – including myself – draws an immediate connection between the wormlike organisms submerged in water, and the f lying insect we know as mosquitoes. It takes a lot of patience, and preferably a laboratory-like environment to witness the transformation of a larva into a pupa and ultimately into a mosquito. I myself have only read about the mosquito life-cycle in books. And while I firmly believe that every mosquito has once developed out of a larva, I admit that the thought itself is a rather abstract one. No wonder then that among the people I met, not everyone draws that connection. At some point, the life cycle of mosquitoes and the parasitology of malaria is taught in biology class, but few of the farmers in Namulonge have been to school for long enough to witness that lesson.

7. Agriculture in the urban fringe: The ambivalent role of wetlands

Malaria campaigns and wetland agriculture As in most countries across sub-Saharan Africa and elsewhere in the so-called global South, agriculture remains the backbone of the Ugandan economy. According to the 2016 Agriculture Sector Strategic Plan released by the Ugandan Ministry of Agriculture, Animal Industry and Fisheries (MAAIF) “72% of the workforce and 87% of the working poor [are] primarily engaged in agricultural activities” (MAAIF 2016: 10).5 Uganda’s agricultural policy is thus aimed at modernizing agriculture in order to reduce poverty across the country and to boost the agricultural productivity. The promotion of food and nutrition security, as well as household incomes, is the main objective, with the ultimate goal to transform “subsistence farming into sustainable commercial agriculture” (MAAIF 2013: 26). Moreover, the government sees a large potential for the growth of the agricultural sector, which could mainly be achieved through the improvement of the agricultural production techniques. While malaria is mentioned brief ly in the agriculture policy, it is only in order to highlight the disease burden posed by malaria (MAAIF 2013: 20), not, however, in order to establish a link between the agricultural practices and the occurrence of mosquitoes. Analogously to that, in the Uganda Malaria Reduction Strategic Plan 2014-2020 the hampering effect of malaria on the agricultural productivity is highlighted, while there is little mention of other linkages. Only the limited involvement of the ministries for environment and agriculture in vector management is mentioned, in a brief sentence (MoH 2014: 33). Including the international campaigns and efforts to put an end to malaria, vector control is often limited to the spraying of insecticides and the provision of mosquito bed-nets; affordable and manageable measures – however, with limited results: insecticide resistance is widespread and has put a halt to the famous Global Malaria Eradication Campaign, sparked by the international enthusiasm and the belief in the technological advances of the 1950s. And while bed-nets provide important protection against mosquito bites, especially for children, they only work when they are in a good state, and well-maintained (all too often I have seen mosquito-nets with holes and tears). Moreover, a bed-net only provides protection against mosquito bites during the hours when one is sleeping. For many, bedtime is not until well into the night, long after the active hours of the mosquito have begun. As a health worker I spoke to put it: “They give out bed-nets in order for us to be protected against mosquito-bites; yet mosquitoes are f lying most in the evening, when I am having my supper, not at night when I’m in bed asleep.” Indeed, has there been a study that indicates changing biting habits of mosquitoes in the 5 While these numbers impressively show how agriculture remains an important source of income for many Ugandans, it does not reflect the fact that a household’s sources of income are usually divers and shifting. Rarely does a household rely on agriculture alone to sustain its livelihood.

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context of increased bed-net use: over a period of four years, surrounding a nation-wide campaign of bed-net distribution in Papua New Guinea, the human exposure to mosquitoes has been monitored. After an initial decline of biting rates, levels of exposure eventually resurged, with significant shifts in the mosquitoes’ biting behavior – the mosquitoes had started to bite before sunset now (Thomsen et al. 2017; cp. Ferreira et al. 2017).

Wetlands as last resort Earlier on in this book, in chapter four I introduced the mailo tenure system that is exclusive to the Buganda region, a relic of Uganda’s colonial past, which is an important factor in the distribution of land and landownership in the region. Understanding why people increasingly make use of wetlands, despite their inhospitable environments and their perils, I argue, must include the current land dynamics that are taking place in the urban fringe, and are reshaping the distribution of landownership, access to land, and wealth. Interviewing Mzee Kamya, a middle-aged man living in Nabalanga, about the importance of land and the current land dynamics, he commented that “people in Uganda without a [land] title cannot sleep!”, referring to the uncertainty that kibanja-owners are faced, as do not know for how long they can claim their rights to a piece of land. He told me that “land [in central Uganda] has become a business” and angrily added, “a nasty business!”6 As I have shown in chapter four with the example of Zion Estates, the real estate company that has bought up a chunk of land between Namulonge and Kiwenda (cp. figure nine, chapter four), land close to the city is increasingly sold to the growing, aff luent middle class in town. In turn, land resources for smallholders are getting scarcer. Legally recognized landownership is rare in Buganda and as I have described in chapter four, most people merely occupy a kibanja, claiming their rights based on the use of the land, and their investment in and development of the land. While the rights of kibanja-owners are legally recognized and theoratically untouchable, in the process of the land redistribution many people are faced with the loss of large parts of their kibanja. In exchange for titled landownership, and under the pressure put forward by the landowner, many people agree to give up their rights for the use of their kibanja, and return the land to the mailo owner. As a result, many families lose their agricultural land. In order to compensate the loss of cultivable land resources, many smallholders are drawn into the wetlands, an obvious choice, since the land is fallow and mostly free from conf licting land rights. 6 Field notes from November 13, 2016.

7. Agriculture in the urban fringe: The ambivalent role of wetlands

Isaac’s case serves as a telling example. Like many young and unemployed men in Uganda, he hired a motorcycle from a wealthier person in order to earn an income as a boda-boda-rider.7 I first met him as his passenger, and over the course of my stay in Uganda repeatedly made use of his services, and after a while I called him whenever I needed a ride and even hired him for entire days. Over time I got to know him better and we became acquainted. Isaac began to invite me to his place for meals, and introduced me to his family. When we met, Isaac was in his late twenties, living with his wife and son in a small one-room house on his wider family’s kibanja, located somewhat off the road in Namulonge. Isaac had built the house himself with his hard-earned money from the taxi services. His grandfather, Mzee Lwetute, being the eldest in the family, had allotted him a small plot next to the house of Isaac’s elder brother. On a typical day, Isaac would be at the boda-stage in Namulonge waiting for customers as early as eight o’clock in the morning. Although the taxis arriving in Namulonge from Kampala were usually still quite empty in the mornings, he explained to me that you could never know who needed a lift; every now and then he had made a day’s worth of money with only one customer who needed urgent transport to town. Depending on the day’s business, Isaac would not return home until well after sundown. Meanwhile, as is the case with many families, his wife would go to the garden in the morning, while managing the household in the afternoon. Although Isaac’s family lived mainly from his income earned with the motorcycle, the household depended also on the harvests obtained from the garden. Just like the plot Isaac’s house was built on, his father had also allotted him a sizeable piece of land on the kibanja in order to do cultivate a field where Isaac’s wife planted the usual crops: sweet potatoes, matooke, maize, cassava, and beans. With these staples coming directly from their own garden, Isaac’s meager income did not also have to provide for foodstuffs, but could instead be invested in other requirements. As is the case with households in Uganda, and probably the whole of Africa, agriculture remains an essential part of many people’s livelihoods. At the same time, I would argue, is it misleading to speak of “subsistence agriculture”, as is often the case in academic literature on Africa, across all disciplines. Most households will have to engage, in one way or the other, in commercial activities 7 In Uganda, motorcycle taxis are referred to as boda-bodas. According to an urban myth, they were once used to cross the Kenyan border quickly without needing to fill out the cumbersome paperwork needed for cars and trucks – hence the name. The motorcycle-taxis soon became a popular means of public transport, allowing for individual point-to-point transportation, off the usual bus routes, on paths that are inaccessible to larger vehicles, and enabling passengers to cut through the nerve-racking traffic jams of the big towns. Boda-boda riders typically do not own the motorcycle they ride, but hire it. The rental prices differ depending on the region and the owner of the motorcycle; in Isaac’s case he had to pay 140,000/= UGX at the end of each week.

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in order to buy fabricated and industrially produced products. Subsistence agriculture as such is, in my view, more of a myth than a fact, and a too simplistic a category to grasp the complexity and changing contexts that lead households to engage in agriculture. The term homogenizes a large group of farmers, who engage in agriculture for different reasons and to different extents. The dichotomy between subsistence and commercial farmer divides farmers into two groups and does not do justice to the often complex and shifting foci of production, and the increasingly diversified incomes that African livelihoods are built on (cp. Ellis 1998).8 Nonetheless, most households do maintain a garden, which for many serves as a safety net that helps them hustle through dire times. When I came to Uganda for the final fieldwork phase in October 2016, ten months after I had last left the country, I found Isaac as usual at the boda-stage under a large tree in the center of Namulonge. He was visibly happy to see me and greeted me warmly. He and his family were in good health and had been well over the last year. However, he told me, there had been unfortunate changes in the last months, and things had turned against him. As it turned out, he had “lost his land”, as he brief ly put it. He would explain it to me in more detail in the coming days, he promised, and would show me what had happened. Indeed, later that week he came to pick me up at the project house to meet his family, and to show me around his compound and the kibanja that I knew from earlier visits. Where his and his brothers’ garden used to be was now a cleared field, recently levelled by excavators. Once covered with lush green matooke-shrubs and the characteristic heaps of a sweet-potato plantation, the site now resembled a freshly ploughed field with the reddish brown color of the typical murram soils. The area had been sold to a real estate firm, Jumayi Estates in this case, who had prepared the grounds for the construction of roads and houses. Cemented posts marked the borders of the area, directly attached to the burial ground of Isaac’s family. “What happened?” I asked Isaac, already suspecting what might have been the case. I had already seen the opening of similar construction areas all around Kampala, including in the area around Namulonge, and had heard about Mr. Ssemuju, the wealthy landowner in the area, and how he was selling his land to real estate companies. And indeed, as Isaac explained, his grandfather, Mzee Lwetute, had been approached, first by one of Ssemuju’s administrators, then later by the owner 8 Skepticism towards the concept of “subsistence agriculture” is by no means new. Anthropologists and other scientists have long criticized the implicit oversimplification and dualism that comes with the concept. For example, Little and Horowitz (1987) point out the problematic implications of the distinction between subsistence and cash crops. Cousins (2011) critically scrutinizes the blurring qualities of terms like “smallholder” or “subsistence farming”, arguing that such terminology disregards inequalities and class-based differences between individual households that engage in agriculture on a small scale.

7. Agriculture in the urban fringe: The ambivalent role of wetlands

himself, in order to discuss a deal with regard to the kibanja that Mzee Lwetute and his family occupied. As expected, Mr. Ssemuju was looking for a way to free parts of his land from kibanja-occupation, thus approaching the tenants of the largest bibanja first. As Mzee Lwetute eventually told me himself, Ssemuju came with a lot of official papers, documenting the size of the kibanja, the rightful occupation by Lwetute and his wider family, and of course, proving the ultimate ownership of the land in the name of Mr. Ssemuju. The proposed deal entailed that Mzee Lwetute would give up his user rights to the southern parts of his kibanja, which were at the time used as agricultural fields, while he would be given an official land title for the remaining parts. In the end, and much to the regret of Isaac, his brothers, parents and uncle, Mzee Lwetute agreed. It should be mentioned at this point that Lwetute’s decision is not all that surprising, and I would even argue that there was not much to decide. First of all, being a “titled land owner” is a well-regarded attribute in Uganda, as probably in any place where the land-tenure system is confusing, and landownership is disputable – more so in central Uganda, where the British left a tenure system that deprived the majority of the population of their right to ascertained landownership. Living on (and from) a kibanja, one is merely considered an occupant of a plot of land. In this context, having one’s claims to land secured and documented holds a certain symbolic, as well as practical value. A land title is a status symbol. Occupying a kibanja guarantees user rights to the occupants, and an occupant cannot easily be evicted from his or, in rare cases, her kibanja. Owning the title to a plot of land does much the same: the owner can freely dispose of the land in question. While on the ground, then, not much changes – obtaining a land title merely changes the user rights into ownership rights – it transforms the occupant into a titled landowner, which can be regarded as a change of status. With the steady growth of Kampala, the land prices around the city are soaring, and few people can afford to buy the title to their kibanja. The ones who can are enjoying the status of a landowner. The practical value of this transformation lies in the fact that with a legally recognized land title, “nothing and no one”, as Lwetute put it, can question one’s access to land. Furthermore, although portrayed as a deal between owner and tenant – a voluntary agreement between the two parties as it were – it is questionable whether the arrangement is indeed based on mutual consent. I argue, that in the case of Mzee Lwetute and his landlord Ssemuju, there is reason to doubt that the trading in the kibanja-rights for a proper land title is indeed in the best interest of both parties. First of all, the agreement is usually made across a hierarchical divide, between a landlord and his tenant, the landowner being at the more powerful end of that gap. As is typically the case, certainly with regard to the landlord Ssemuju, owners of mailo land in Uganda are wealthy individuals. In contrast to the occupants of a kibanja, they own land resources. As I have described earlier in chap-

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ter four, mailo land was appointed to notables and chiefs, and then handed down from generation to generation, keeping the wealth in the family. This is not to say that a mailo owner’s lineage can always be traced back to the Baganda elite: over the years many so-to-speak “commoners” have acquired mailo land. Nonetheless, as mentioned above, buying land always implies the investment of a substantial amount of capital – something that only aff luent people can afford. In the case of Mr. Ssemuju, the major landlord in the Namulonge area, the land has been in the family for generations. On top of the hill, dividing the trading center of Namulonge and the village Nabalanga, surrounded by a large, park-like estate, lie the burial grounds of the family: impressive tombstones document the genealogy of the Ssemuju family, dating back to the beginning of the 20th century.9 In light of this, it is reasonable to ask whether the deal between Mr. Ssemuju and Mzee Lwetute was indeed in the best interests of both parties. It is fair to assume that Mzee’s decision was partly inf luenced by the intimidating status of his landlord. Arguing with people of a higher status is not always easy, not only in Uganda, and denying them their wishes even less so. Moreover, when status is at stake, power usually is as well. With regard to the deal between Mr. Ssemuju and Mzee Lwetute, the former certainly had the greater leverage. Withstanding a proposed arrangement brings the risk of losing more in the end. Even without considering the inf luence and authority that a figure like Mr. Ssemuju has due to his position as landowner, his wealth alone enables him to enforce a legal decision-making process. Mzee Lwetute just would not have the necessary money to bring the case to court or have himself legally defended by a lawyer. Finally, one must also consider that Mzee Lwetute’s decision was made on behalf of his wider family. He, as the oldest male representative of his family, is entitled (and burdened, one might add) with the responsibility of negotiating a deal with the landowner. The question of what he would leave behind for his sons and grandsons, as well as their security in terms of landownership, probably also played a role in his decision. If he had not agreed to the proposed arrangement, Ssemuju would most likely have tried again to negotiate a deal once Lwetute passed away. 9 While in Uganda the European system of a given name and a surname has been adopted from the British, both names are in fact given at birth. Among the Baganda the first name is usually a religious name, either Christian or Muslim, while the so-called surname is typically appointed at birth, selected from multitude of Baganda names, someties referring to special circumstances at birth (for example, Musisi is the name given to boys whose birth coincides with an earthquake, or Salongo to a boy who has a twin sister), or referring to the clan-identity (Ssenkubuge, for example, is a name exclusive to men from the Mpeewo clan, or Namutebi a name for women of the Mmamba clan). Rarely is the surname passed on to the next generation, and usually only among Baganda royals, or when a person has achieved fame or popularity – as is the case with the Ssemuju genealogy.

7. Agriculture in the urban fringe: The ambivalent role of wetlands

The entire family was disappointed with Mr. Ssemuju and the way he had handled the issue. First of all, the land-titling brought unexpected costs for the necessary legal procedures – the land had to be measured, documents had to be drafted, a notary public had to oversee the entire agreement, and finally a land title had to be issued at the district administration in Wakiso. All of this added up to a considerable amount of money, of which Mr. Ssemuju only agreed to pay part, and which Lwetute and Isaac felt had not been adequately addressed beforehand. Later in 2016 the disappointment grew when the real estate firm that had bought and cleared the land of Lwetute’s former kibanja encroached into the parts that were supposed to remain in the possession of the family. When I asked about the case Isaac showed me how, in his opinion, the border marks had been shifted a few meters into his field. Apparently the measurements carried out by the land company had shown that the land portion sold by Ssemuju extended into the fields that remained with Isaac and his relatives. Also, so I was told, Mr. Ssemuju refused to negotiate in that case and referred Mzee Lwetute to the land board to solve the issue legally. When I returned to Uganda for a brief visit in early 2018, Isaac told me that the local councilor had helped to settle the conf lict, and that there had been a compromise whereby the real estate company agreed to pay compensation for the lost land. However, Isaac complained, so far there only had been a first installment of 150,000/= UGX, and he did not expect the company to complete the promised payment. The case was particularly disappointing to Mzee Lwetute, who had known Mr. Ssemuju’s father and grandfather well. Lwetute spoke highly of Richard Ssemuju, the deceased father of the current owner, and said that with Richard the current situation would never have developed. While Richard Ssemuju in his time had already sold parts of his land and negotiated similar deals with kibanja occupants as was now the case with Lwetute and his family, Mzee claimed that Richard had always assured him that his kibanja was safe. “With the old Ssemuju this would have not happened, he would have not allowed Jumayi [the real estate company] to get away with this.” Lwetute told me, when we talked about the case of the land encroachment in 2016. Over the course of my research I collected several other stories that were similar to the case of Isaac and his family: people who had been deprived of a large part of their kibanja in return for the ownership rights over a considerably smaller part of their former premises. Applying the ideas of Lund and Boone, the kibanja system could be best grasped as a user-rights tenure principle based on occupation and labor investment, considering that occupants of land claim their rights based on their investment in and use of the land resources. However, we now witness a shift to a market-based tenure principle, in which former tenants become property holders, leaving them, however, with significantly fewer land resources (Lund/ Boone 2013: 7). The loss of the agricultural land is what poses a problem to many of the affected people. As Kamya, whom I cited earlier, put it: “Someone who is

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left with only half an acre, how is he supposed to support his family?”. While agriculture may not be the main source of income of a household, it is certainly an important one. Having a field or a garden that provides one with the basic staples for the everyday meal contributes considerably to the livelihoods of poorer households, and enables them to bridge periods of little or no income and compensate emergency payments or the like. Losing one’s fields also means losing one’s buffer in times of financial drought. In search for alternatives Isaac contemplated if he could get a field further down the hill, towards the swamps that separate Namulonge and Seeta, the next village to the West. He knew some of his colleagues who maintained a field there, and apparently there were still parts that remained idle. He said he would probably need to invest some days in order to clear the land of bushes and shrubs and make it arable, and he was wondering if he could afford to hire some boys to do that for him – after all, he had to be on the stage to pay the rent for his motorcycle. Isaac’s story is similar to those of many people I met in central Uganda for whom wetlands are the last remaining place for farming and the only option to compensate for the loss of agricultural land. Tusabe, a wetland-farmer from Kassambya, explained this issue to me in the following words: “Now the problem [is the following]: people used to cultivate on the upland before, when they still had a kibanja, when the land owners had not sold off the land to the rich. But now the rich have come and bought acres of upland, you see? For example, Kisito had [a kibanja of] four acres, and now [he] stays on a plot of 50 by 100 [feet], [while] the people who have a lot of money buy the land. So they bring the rich people to buy the land and you, who [remains with] nowhere to cultivate, you decide to slope down to the wetland. It’s because of these sales of land to the rich people.”10 The swamps are (mostly) excluded from mailo tenure and furthermore unattractive to real estate firms, as they are prone to f looding and require a lot of preparation before it is possible to lay a foundation. Furthermore, in the proximity of the city, the land prices are rapidly rising. For newcomers, acquiring new land sizable enough for a field is hardly possible. Of course, bibanja contracts are still made, and many people I spoke to had indeed “bought” a kibanja fairly recently. Especially the agricultural research institute and the f lower farms attract people from all over the country, as they offer working opportunities. After saving enough money to build a house, these workers often get a kibanja in the area, rather than moving back to their places of origin. These bibanja are, however, barely big enough to construct a house on, let alone to set up a garden that could sustain a household. 10 Interview conducted on Septmeber 8, 2015.

7. Agriculture in the urban fringe: The ambivalent role of wetlands

Here I want to introduce James’ case, which serves well to illustrate this dynamic. Originating from Lira district in the northern part of the country, he is ethnically a Lango. After completing school and a training program for security workers, he found work at a company which recruits security personnel for NaCCRI, where he worked as a night guard. His job required him to guard the gates and the laboratories of the research institute. When I met him, he was in his late twenties and had been employed by the NaCCRI institute for a good five years. While he complained about the often delayed and irregular salary payments, he considered himself lucky, as he enjoyed several benefits from his work on the NaCCRI premises. Like many of his colleagues, he had a garden on the premises of the research institute, and he was assigned a room in the staff barracks. And unlike most people in Namulonge of his age he could count on a more-or-less regular salary, a salary which allowed him to put some money aside and look to the future. Towards the end of my research, in the fall of 2016, James was transferred from his security company to the NaCCRI institute, which now employed him directly. The transfer came with slightly better wages and, most importantly, more regular wage payments and a fairly guaranteed position for the years to come. This promotion motivated James to get a kibanja at Sitabaale, a village on the next hill, opposite of the research farm. He knew people there and already had a plot in mind. The landlord knew of his aspirations and had agreed to sell him the kibanja rights; the only thing left was to pay the landlord the agreed sum (150,000/= UGX) plus the obligatory, and customary, kanzu dress in order to establish a proper relation between tenant and landowner. He would then start building his own house and, according to his plan, move in with his wife. The above vignette serves as an example to illustrate how the opportunities for work that exist in Namulonge and elsewhere in the peri-urban zones of Kampala attract people from other parts of the country who eventually settle in central Uganda. While their employment is the reason for their migration to the city, they usually do not have access to agricultural land.11 This is mainly for two, rather obvious reasons: (1) bibanja sizeable enough to allow for agricultural use are hardly sold anymore, and (2) they would be too costly for most laborers in the first place. Because agricultural land remains a valued asset, however, many migrants will look for possibilities to plant a garden anyhow, and are left with wetlands as a largely idle and undisputed land resource. Despite wage-labor being the main reason for relocation close to the city, for many farmland is an essential and valued resource. Although in the urban fringe hardly anyone is exclusively living from farming anymore, almost everyone still 11 Huber et al. (2018) describe similar constraints of the kibanja system experienced by migrants who are not familiar with mailo land and their associated rights and obligations as kibanja occupants.

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maintains a garden in one way or another – if one does not tend to it oneself, one pays people to look after it. This claim probably holds true for most of Africa, urban as well as rural: while subsistence agriculture has largely become a myth, agriculture itself is omnipresent and remains the single most important source of income for rural African households. It is an invaluable safety net for households with unsteady and diverse sources of income (Davis/Di Giuseppe/Zezza 2018: 65). Peter, whom I introduced as my “key informant” earlier in this book, enjoyed a fairly steady income, being employed as a fieldworker by my research project. On my last visit in the spring of 2018, the project was coming to an end, and with it his job as field assistant manager. He showed me his new rice field, which he had opened on the former fields of the project’s crop-yield experiments. The land was not to be used until the end of 2018, and Peter was quick to ask for permission to plant rice for one season. While he was confident that he would eventually find a new job at NaCCRI, he also knew that he would have to find a way to bridge the period of unemployment. Planting a rice field was thus a way to cope with the uncertainties that lay ahead of him. Lacking social welfare, and with little social security provided by the state or employers, people rely on their social networks and their land in order to sustain their livelihoods in difficult times.

The ambivalent character of wetlands In this chapter I have elaborated on the links between mosquitoes, malaria, and agriculture, a relation that has already been known for a long time and discussed in academic literature across disciplines. The presented vignettes show examples of agriculture (and other income-generating activities) in wetlands, and the factors that increasingly draws people into the swampy valleys in order to cultivate crops. I have presented the growing cities as a force that drives this dynamic, as the prices for land rise and open up a lucrative market for the few landlords in the region. Furthermore, I have shown how institutions like the NaCCRI farm provide work opportunities and are pulling people from Uganda’s rural areas closer to the urban center. Despite the growing shortage of land resources in the region, agriculture remains important for many and provides a safety net for households with an unsteady income. Land can fairly easily be used to produce an income, be it through agriculture, mining, or the construction of rental houses. As Shipton aptly put it: “[…] people seek in land not just material satisfaction but also power, wealth, and meaning […]” (Shipton 1994: 348), reminding us, however, that “[…] land produces nothing without water, labor, capital, or all three.” (ibid: 348). Depending on one’s means to invest in the land, both in monetary terms as well as in terms of time and labor, land is a resource that renders the user independent of unreliable wages and economic f luctuations and, most importantly, awards the

7. Agriculture in the urban fringe: The ambivalent role of wetlands

user agency in the otherwise frustrating environment of lacking job opportunities and crippling unemployment. With regard to malaria, the ecological conversion of wetlands into arable land is playing into the relation between mosquitoes and humans, bringing the two agents closer together. In the first part of this chapter I have shown how the utilization of wetlands for agricultural and other purposes, is creating breeding grounds for A. gambiae and A. funestus, the most important malaria vectors in Uganda. There is an ambivalent character to wetlands, then. For the human population they are a valued base for agricultural production and, as I have shown, constitute an important part of the livelihoods, as they provide a much-needed safety net for otherwise vulnerable households. On the other hand, they provide a perfect habitat for mosquitoes, thus fostering the transmission of malaria parasites and exposing the growing population to the disease. It is easy to assume that in the decades to come Kampala will further expand and eventually engulf and absorb the area around Namulonge. The problems will be different then – arable land and malaria are not the main concerns in an urban context. While the hungry markets of the capital will have to be fed with supplies from the immediate surroundings, probably then located further north, around the trading centers of Zirobwe, Bombo, and Kalagala, the swamps of Namulonge will be populated with informal settlements, as we now find in the city’s poorer neighborhoods of Bwaise, Kawempe, and Namuwongo. Analyzing the development and growth of Kampala over the last century, Lwasa describes a segregation of the population by class. He writes that in the context of urban growth the residential areas mainly develop along the main radial roads that exit the city’s center. In the process of urban growth, he states, people with a higher income often buy up the land, “[…] pushing the poor further in to [sic] marginal areas, mainly wetlands.” (Lwasa 2010: 15). The beginning of these processes can currently be observed at Kampala’s fringe; in this chapter I have described a few examples. Whereas the agricultural exploitation of wetlands is an ecological transformation that is consequential for the distribution of malaria in the region, the encroachment into and urbanization of swamps plays out differently. The ecological changes in this case are of a more profound character, with drainage and pollution as the major factors that alter the marshlands’ characteristics, and are capable of transforming a swamp into a dryland. Driving towards the city, one can easily observe the spatial segregation of different income classes. As a rule of thumb: the higher the hill, the better the buildings that stand on its slopes, while the lowlands are often built-up areas with makeshift houses and huts. Wyrod, who carried out ethnographic research in Bwaise, one of Kampala’s notorious slum areas, aptly observes: “[a]lthough Kampala’s most attractive feature is its many hills, the majority of the city’s residents make their homes in modest communities in the city’s f lood-prone valleys.” (2016: 31). The canals that run through the valley bot-

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toms are essential, as they carry away the water and sewage, thus creating dry space for people and their houses. However, as Wyrod continues “[d]uring the two rainy seasons, the canals back up and spew sewage from surrounding hills onto Bwaise’s streets.” (ibid: 31). Indeed, each rainy season the newspapers are filled with reports about f loods in Kampala’s lowland neighborhoods. Especially when the latrines overf low and spill into the f lood, water-related diseases like typhoid and cholera easily spread. In this book I am mainly concerned with malaria in a peri-urban context, and I lack the ethnographic material as well as the expertise to say much about the f lood-related epidemics mentioned in the foregoing paragraph. And while the living conditions in the poorer neighborhoods of Kampala are doubtlessly harsh, and a health threat in themselves, cholera and typhoid are not the main problems faced by those communities. Nonetheless, it is worthwhile to take a look at the effects of the rapid urbanization, and appreciate the health-related effects of the ecological transformations that go along with it. Understanding and recognizing those dynamics might help to avoid future generations having to experience them – probably the generation of my informants’ children. As I pointed out at the beginning of this chapter, the peri-urban sphere can be seen as a precursor to developments that are yet to unfold in the rural areas of the continent. Appreciating the current dynamics with regard to the specific ecologies that affect health, livelihoods, and the common modes of production can help us to foresee and adapt to future challenges. Coming back to the malaria pandemic that is yet again at the focus of international health campaigns and the target of large donor organizations, the developments at Kampala’s fringe call for an integration of agricultural development into the attempt to roll back malaria, and urge the adaption of the respective policies and regulations.

“We need to rejoin the struggle by paraphrasing a political metaphor, that all malaria is local and is a complex tapestry of nature’s forces.” James C. McCann (2015: 120)

8. Conclusion History repeats itself. Just after the end of WW II, the newly established UN and the affiliated WHO, elated by recent scientific advances and political developments, kicked off an incentive to free the world of malaria. Unfortunately, however, the campaign failed. Today, much as in the past, malaria remains a major health threat virtually all across sub-Saharan Africa, and accounts for the bulk of today’s childhood mortality in much of the continent’s countries. One cannot help but wonder how this mosquito-borne disease is adamantly prevalent in Africa, while it has been successfully wiped out elsewhere on the world. In that spirit, the global community, led by Western donor agencies, humanitarian aid organizations and international health bodies, has once again declared war on the parasitic disease, promising to remove human malaria once and for all from the surface of the earth (Packard 2009: 53). But history never repeats itself in exactly the same way twice. Today, the war on malaria is fought in Africa. And while the optimism about the possibility of winning it bears resemblance with the hopes of the 1950s, we have learned not to bet on a single silver bullet, and instead to join forces and plan an orchestrated effort to tackle the problem at different sites simultaneously. Powerful modern antimalarial drugs, rapid new testing methods, vector-control measures, education and sensitization programs, and finally also the prospect of an effective malaria vaccine are all part of the international strategy to win the fight against malaria (Eckl 2017: 426-427). But will it work this time? Can the combined efforts of various actors, strategies, and measures finally lift the burden of malaria? Or is the campaign once more doomed to fail? Unfortunately, there is reason enough to be pessimistic. The proclamations about not only driving back, but eradicating malaria altogether were again formulated too hastily. The few weapons that prove effective in the battle are too weak. And although scholars around the world have pointed out why the attempts

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failed the first time, few seem to have listened to them. As it appears, the only lesson learned is that vector control alone won’t do the job – to win the war against malaria one has to fight on many fronts (Graboyes 2009: 2-3). But the opinions about appropriate solutions, and the nature of the problem, differ (Eckl 2017: 430). The political situation in many sub-Saharan African countries remains unstable, and in some cases it has even worsened over the past five years. Rural Africa, where the toll of malaria is the highest, until recently remained isolated, and cut off from essential infrastructure such as roads, electricity network and improved water supply. And although in the last two decades there have been massive investments in the development of the African hinterland, the progress is often only partial and localized, reaching only the parts with exploitable resources, while other areas remain isolated. Poverty burdens the continent now more than ever, and even basic healthcare remains out of reach for many, while inequality rises globally. Most importantly, however, the approach to malaria relief is still a topdown operation, thought up by actors in the west, far away from the disease’s perils. There is little regard for the localized circumstances that shape the disease, the site-specific ecologies, different socialities, and individual cultural backdrops against which malaria has to be understood – and against which an anti-malaria campaign should consequently be designed (Brown 2017: 483). As I have shown in the foregoing chapters, malaria is a social problem as much as it is a medical one, ecological as much as biological, shaped by individual behavior as well as political decisions, a product of local circumstances and global processes alike. Solving it will require the insights of social sciences as much as the natural sciences, and advances in pharmacology are as important as the understanding of the factors that shape the ways in which people cope with malaria. Scholars have shown how, throughout history, the distribution of malaria has been closely linked to ecological systems, and how epidemic outbreaks often occur in parallel to environmental change and disturbance. As Koch and McCann write, “[…] malaria is opportunistic, thriving on environmental change such as new local ecologies brought on by human settlement, economic change, and even political instability” (2010: 2). Changes in land cover, whether through agricultural production methods, settlement schemes, the construction of large-scale infrastructures, or the introduction or eradication of certain species, can all have far-reaching effects for the distribution of malaria parasites, mosquito vectors, and the distribution of the disease. Political instability, war, and poverty can equally lead to the spread of malaria, especially in regions where the disease is unstable and occurring seasonally. The data I have presented in this book show similar changes in the ecological system in the urban fringe of central Uganda. The increasing population pressure, combined with the unusual tenure system found in the region, provide a set of factors that have the potential to exacerbate the malaria problem in the region.

8. Conclusion

Agricultural production in wetlands will increase in future decades, certainly in increasingly urbanized regions, where arable land becomes a scarce resource. Moreover, as I have shown, factors such as the socio-economic background of the local population are important determinants for the way in which malaria is dealt with, and therefore shape the impact the disease has in terms of morbidity and mortality. The ecological and political surroundings provide the backdrop against which I have looked at malaria in central Uganda. At the beginning of the book I brief ly outlined the biomedical view on malaria and contrasted it with the local understanding of the term and its use. While, from a biomedical perspective, the term malaria refers to a disease with an unmistakable cause – which manifests itself, however, in rather unspecific symptoms – the local use of the term is somewhat the opposite. ‘Malaria’ in this context can have many different causes, and there are equally many ways to treat it. The symptoms on the other hand are fairly clear: fever – musujja. What is probably even more important is the fact that ‘malaria’ is often not regarded a deadly disease, but rather as a common ailment. I argue that the diverging ideas about ‘malaria’ are part of the reason why malaria remains a problem in central Uganda and elsewhere in sub-Saharan Africa. The conception of malaria as a harmless disease is part of the explanation for why self-diagnosis and self-treatment are widespread practices in Uganda and elsewhere in Africa. Ineffective measures and a lack of incentives on the side of private healthcare practitioners to encourage a malaria diagnosis are another part of the puzzle. This is not to say that the malaria problem is indeed so simple. Quite the contrary: as I have shown, malaria is a complex issue; that complexity derives from the interplay of a multitude of factors. There exist various conceptions of what malaria actually is, and of its causes, its treatment, and its dangers. Moreover, the disease is embedded in a changing environment, ecologically, socially, and politically. To illustrate the complexity of malaria I have presented selected cases I collected during fieldwork in Uganda. Especially the material discussed in chapter six highlights the multifaceted nature of malaria in the urban fringe. The ways in which the protagonists deal with malaria, their views on, and ideas of the disease, as well as their struggle to cope with it, make it clear that the biomedical perspective on malaria as a disease with a defined cause and a clear-cut diagnosis and treatment procedure is too simplistic and does not do justice to the interplay of a multitude of factors on the ground. Arguably one of the most significant factors that must be considered when looking at malaria in Uganda is the mismatch between the biomedical understanding of malaria as a lethal disease and the popular perception of it as an everyday ailment. This mismatch can help to explain the one-sided approach of biomedically informed institutions at various levels, from the global down to the local, to counter malaria, insisting on a technical solution to the malaria prob-

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lem. Moreover, the local conceptualization of malaria provides the context for the trial-and-error approach to treatment-seeking of sufferers in central Uganda. Malaria, as has become clear from the presented cases, is often not considered a major health threat, and thus is only dealt with as a medical urgency when the disease has reached an advanced stage. Furthermore, the access to treatment in Uganda, and probably in most places across the so-called global South, remains constrained by poverty, and are typically associated with high and often unforeseen costs. In places where the access to health care, biomedical or other, is restricted by the price one has to pay for it, it is inevitable that recommended types of treatment are disregarded in favor of (seemingly) cheaper options. Targeting an everyday disease like malaria in low-income countries therefore has to start with the provision of diagnosis and treatment at low or no cost. Only then is it feasible that drug resistance and the delaying of treatment-seeking are kept in check. This claim is not new, of course, and Uganda is a good example of a country which has taken this advice to heart. Biomedical treatment for the most pressing diseases, one of which is malaria, is available to the majority of the population at no cost. However, as I have shown, the public healthcare sector suffers a bad reputation and, at least at the urban fringe, where there are plenty of private-for-profit drug shops available, is avoided if possible. Many prefer to buy cheap medicines at private outlets instead of waiting long hours for a diagnosis at the public health ward – which, more often than not, ends with a referral to the private sector anyhow. The government’s incentive to regulate the market for antimalarial medication by making diagnostic tests mandatory is frequently undermined. Private healthcare facilities often sell drugs on request, without prior testing, as few patients are prepared to pay the extra costs for an RDT test strip. Here there could be room for adjustment: there is a need to subsidize RDTs beyond the public sector, making them available at no cost at private outlets as well. The hindrances to the testing and proper treatment of malaria are not only typical of Uganda, but can be observed in many countries across Africa, where healthcare is deregulated and inaccessible for many. Moreover, the problems are an illustrative example of the multifaceted nature of the factors that shape the malaria epidemic. Self-diagnosis and the related search for treatment (rather than the search for diagnosis), are a directly related to the ways in which malaria is perceived. Furthermore, testing and treatment-seeking provide one of the breaking points between the biomedical approach to malaria and the popular understanding of the disease. From a biomedical perspective the way to antimalarial treatment leads through prior blood-analysis in order to diagnose malaria (and rule out other infections as the cause of the symptoms). On the ground, however, testing is often seen as an unnecessary expense, which, in the end, usually does not change much – the fever is usually treated with medicine, either antimalarial or some other kind.

8. Conclusion

A highly localized aspect of the malaria epidemic in central Uganda lies in its political ecology. In the third chapter, describing the setting of my research, I highlighted Buganda’s unique mailo tenure system and the associated uncertainties for smallholders and land occupants. As I have shown, in the wake of urban expansion and the rapidly growing demand for land, smallholders and land occupants are agreeing to free up large parts of their agricultural land, in return for ownership of the remaining portion of ground. In the context of such developments, as well as the general high unemployment in the area, many people move into the wetlands to eke out an income, whether in the form of agriculture, brick production, mining of clay and sand, or simply as a valued source of water. There are various perspectives on this exploitation of wetlands. As I have argued in the introduction of this book, from the perspective of western academia wetlands are seen as the future food basket of East Africa – against the backdrop of climate change, population growth, and land grabs, wetlands hold a significant potential to feed the growing population of the region. However, the transformation of marshlands into arable land puts the delicate ecosystems under pressure and threatens their biodiversity. Accordingly, scientists are looking for sustainable ways to unlock the wetlands’ potential. Next to these outside perspectives, local stakeholders increasingly value wetlands as a last resort for economic production, as they are among the last remaining land available. With regard to malaria, wetlands play an ambivalent role, then, as they provide the necessary income for people to be able to access healthcare, while at the same time exacerbating the malaria epidemic by creating mosquito habitats. The described transformation of wetlands in central Uganda and the associated malaria epidemic is particular to the region, as it is linked to the specific tenure system in Kampala’s urban fringe. Nonetheless, the findings can be extrapolated to other countries, as well as other diseases. Rapid urban growth and exploding population numbers are not exclusive to Uganda, and neither are conf licts over land. Increasingly, scholars point out the problems associated with population growth and wetland encroachment, including, and sometimes especially, with regard to health (cp. for example Anthonj et al. 2017). In settings where ecological changes affect the management of natural water resources, as well as the supply of drinking water, health environments are likely to change with it – most significantly water-related diseases, one of which is malaria. While malaria strikes less frequently in built-up areas and is thus restricted to the peri-urban zones, it is diseases like cholera or typhoid that strike episodically in the informal settlements in the rapidly growing towns of the global South. Looking at Kampala, one can find the slums wedged in between the characteristic hills of the city, down in the valleys that used to be wetlands. Here, in neighborhoods like Kalerwe and Kawempe, the heavy rains of the long wet season frequently f lood the areas, lead-

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ing to outbreaks of typhoid and, in bad cases, even cholera (Isunju/Orch/Kemp 2015: 287-288). Not exactly a malaria problem, one might think, when looking at it through a biomedical lens. However, as I have shown, the way in which patients treat musujja is often not so much dependent on the type of disease as its symptoms. Or, put differently, what constitutes a disease on the ground is not so much its etiology as its articulations. This brings me to the final point of this research: the socio-economic side of malaria. How one deals with malaria in Uganda and how much of a problem the disease is for a household is to large extent dependent on the financial background of the sufferer. Health, disease perception, treatment-seeking and health risks are all also partly rooted in the socio-economic background of a person. In some regards this might be obvious. Most will know that quality healthcare is costly. Moreover, the perception of a disease and its risks is also highly dependent on one’s education, the media channels one consults, and the information one has access to. But as I have shown and repeatedly pointed out already, malaria is also related to one’s larger environment, and its ecology and its links to the provision of income. Wetlands in East Africa are increasingly becoming a fundamental part of the livelihoods of local households, their transformation and the linked health issues. Prognoses for the next 50 years or so point towards an increase in malaria in Africa. For example, climate predictions for the tropics foresee an increase of malaria in the coming decades. Rising temperatures and increased precipitation are expected to create conditions that allow for the spread of malaria even in higher-altitude areas which were previously malaria-free. Combined with the ecological changes that are likely to take place in the context of growing populations and increasing migration, the stage is set for devastating, episodic outbreaks of malaria with many fatal cases of sufferers who lack the partial immunity that comes with long-term exposure to infectious bites. Already today the first cases of this kind are being documented. James McCann’s fascinating accounts of devastating malaria outbreaks in the Ethiopian highlands are among these records, as he shows the complex interplay of climate change, ecological change, mosquito populations, and growing human populations (McCann 2014: 100-137).

Outlook I started the conclusion with an account of the renewed campaign to eradicate malaria. Linking back to the material that I presented in this book, I probably have to count myself among the skeptics regarding the success of the recent efforts. There is too little concern for the local circumstances that shape the epidemic, and the applied strategies are too standardized to work effectively in all of the differ-

8. Conclusion

ent settings in which malaria occurs. The call of experts from the social sciences, history, and geography to integrate ecologies and political dynamics into the understanding of malaria seem to remain unheard. Moreover, it appears ambitious to promise the eradication of malaria altogether. The factors that ensure the persistence of malaria across sub-Saharan Africa are of an entrenched nature, and hard to change. To make matters worse, in many places the situation is expected to further aggravate, with climate change creating wetter and warmer conditions, population growth raising the pressure on agricultural land, and poverty remaining widespread, with somber prospects for future generations. It might be overly optimistic to expect the total eradication of malaria in the foreseeable future, but a closer look reveals enough reason for cautious optimism regarding the containment of the disease. The story of malaria in the 21st century is not complete if one does not make mention of the slow but steady trend with regard to the declining malaria numbers of recent years. While this progress has now stalled, the overall situation has nonetheless improved considerably. Especially in sub-Saharan Africa the number of malaria-related deaths has been decreasing year by year. Moreover, while still far from satisfactory, there is ever more attention being paid to the contextualization of malaria. As mentioned above, scholars from various disciplines, most importantly historians, point out that, in order to be overcome, malaria has to be understood in an ecological, social, cultural, and political context, and cannot be conceptualized solely from a biomedical perspective (cp. Kamat 2013; Umlauf 2017b; McCann 2014; Brown 2017) Disciplines related to medical studies, such as Public Health, are, despite the justified critique, bringing the importance of a localized perspective on health-related problems under the attention of medical professionals (Webb 2009: 17). And last, but certainly not least, advances in medical research are promising. While we might still be years, even decades away from an effective, and most importantly, affordable vaccine against malaria, the research in that field has experienced a major push since the beginning of the 21st century and the first results so far look promising. And although parasite resistance against the new first-line combination therapies is becoming a problem, there are important and promising strategies to counter this development. An example would be the introduction and dissemination of point-of-care testing devices, which is slowing down the development of resistant malaria strains, and proves the importance and efficacy of cheap and simple instruments in order to fight malaria in countries with endemic poverty and deficient health infrastructures. Finally, I want to connect the work I have presented here to a larger research context, both within the field of (Medical) Anthropology and beyond. How is my own work connected to the relevant research agendas elsewhere and in other fields? How does my own work raise questions that could lead to further research? And how can it be placed within the current debates within the discipline? Espe-

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cially with regard to the above mentioned international efforts to eradicate malaria, it is justified to raise the question of what role anthropology could play in this campaign. Especially Medical Anthropology is known to be one of the more applicable sub-fields of the discipline. As medical topics are typically associated with some kind of a problem – usually some form of ill health – it might appear natural to formulate the findings in a solution-oriented manner. In fact, the insights of medical anthropologists have long been valued in cross-cultural health interventions, patient-practitioner relations, health policies, and other international (and thus intercultural) health campaigns. Given the above mentioned skepticism towards the international approach to malaria, it is of course justified to ask how my findings could contribute to a better implementation of a reduction of the malaria burden. There is a well-founded critique of the role of medical anthropologists as mere advisors to health professionals, policy-makers and health ministries, providing, so to speak, an analysis of the sociocultural backdrop against which health measurements are to be implemented. Along with the self-ref lective turn in the 1980s, scholars began to criticize the role of medical anthropologists as “cultural brokers” for biomedical healthcare providers and public health projects. Much as Anthropology’s role in the colonial endeavor was increasingly recognized, so too did medical anthropologists begin to critically assess their role in the establishment of biomedicine’s hegemony and the relation between patient and clinician (Campbell 2010: 77; Scheper-Hughes 1990: 190). In that regard I want to point out that I do not wish to advocate that social scientists, and more specifically anthropologists, should take on the role of advisors or cultural interpreters. However, there certainly is a need for social science research in global health and public health matters (Nichter 2008: 6-7). Although I think that the biomedical understanding of malaria, with its specific etiology, must be a central element of the strategy to drive back malaria, it is equally necessary to recognize the socio-ecological and cultural dimensions of the disease. And while the importance of qualitative data is increasingly being acknowledged, the attempts to produce such information, mainly in the disciplines such as public health, are limited to interviews and focus-group discussions, and lack the long-term engagement with informants and the holistic perspective that anthropological work typically entails. Moreover, the ref lexivity and critical self-assessment of the discipline are often lacking in other social sciences, leading to potentially questionable or problematic results. In light of this, the role of Anthropology in the efforts to roll back (and eventually maybe even eradicate) malaria is evident: as I have outlined in this chapter, there is a need to understand how malaria is seen locally, on a cultural, social, and political level. Especially the methodological approach of anthropological research – long-term engagement with patients on the ground, with special attention to the emic perspective on disease and healing – is highly suited to documenting how

8. Conclusion

malaria and malaria prevention manifest at the local level. These ethnographic findings can and must be used to formulate a critique of the biomedical-centered approach to malaria prevention, and these insights can be applied to develop a more holistic approach to disease prevention. In that regard Medical Anthropology certainly is one of the more applicable sub-fields of Anthropology, as the findings can directly feed into the design and intervention of healthcare promotion and facilitation (Lock/Nichter 2002: 9-10; cp. Eisenberg 2011: 100-116; Janes/Corbett 2009). The call for contextualized and tailor-made approaches to the malaria problem demand proposals as to how incentives to tackle the epidemic in a local context could look. What circumstances are we looking at? Where does a locality begin, and where does it end? Who is included, and who is not? And how to identify the relevant context? Looking at the dynamics that drive the malaria epidemic in central Uganda, the prevailing tenure system is the crucial factor. As I have shown, the mailo system puts kibanja occupants at risk of losing their access to arable land. With regard to the aforementioned questions concerning the locality of malaria prevention, the population in the proximity of growing urban centers is at risk. In the context of the urban expansion, it would make sense to strengthen the rights of the owners of a kibanja, and target them as an individual group. These are approaches that apply specifically to the context of central Uganda. Zooming out, we have seen that the agricultural exploitation of wetlands is a crucial element of human exposure to malaria. A more thorough protection of wetland ecosystems, preferably with the inclusion of local stakeholders, would make sense in order to better contain the spread of mosquitoes. Alternatively, a promotion of more sustainable agricultural practices, for example by raising awareness of the danger of stagnant water pools and the relations between mosquitoes and the pollen of maize plants, is theoretically a constructive incentive. This is an issue that concerns all communities that live close to wetlands in malaria-endemic regions, and can best be targeted in accordance with national agricultural policies and environmental protection strategies. With regard to the perception of the gravity of the malaria problem, the international strategy would need to increase the local popular appreciation of malaria as a serious health threat to children and pregnant women, and encourage testing instead of self-diagnosis. This will only be feasible when RDTs are disseminated freely in the private-for-profit sector. Moreover, health institutions, national as well as international, would have to appreciate this self-diagnosis and self-treatment as a way to cope with malaria in uncertain conditions, rather than condemn it as problematic behavior from the outset. With regard to future anthropological research on malaria it will be interesting to follow the coming attempts to tackle the epidemic, as well as the local manifestations of these efforts – especially changes with regard to drug policies, the implementation of new regulations concerning the distribution of antimalarial

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medication and diagnostic measures, and, hopefully in the not-too-distant future, the social and political effects of a malaria vaccine. These global health measures will need to be critically ref lected upon, a job that anthropologists are perfectly well positioned for (Nichter 2008, Janes/Corbett 2009: 149). Apart from that, science and technology studies offer promising perspectives on the technological aspects of the response to malaria that could produce promising insights (Hardon/Moyer 2014: 107-108; Nading 2015: 366). Furthermore, from a political ecology perspective, there is potential to further explore the relations between (changing) ecologies and disease, as well as the interplay between species, in this case mosquitoes, humans and parasites, but possibly also livestock and primates. This research outline is relevant beyond the malaria topic: within Anthropology there is an increasing interest in human-animal interactions (Kirksey/Helmreich 2010: 545), and while there are numerous ways in which human lifeworlds intersect with the realms of other species, health is arguably an important domain (Swabe 1999). The assertion that human life does not exist separately from non-human animals (Rock/Degeling 2016: 78) raises questions with regard to the factors that mutually shape and inf luence both animal and human health, and has led to the development of concepts such as One Health (Zinsstag et al. 2012: 107-108) and conservation medicine (Aguirre/Tabor/Ostfeld 2012: 5-6), and the integration of anthropological perspectives within increasingly multidisciplinary research contexts. Considering vector-borne diseases, as I have shown in this book with the example of malaria, it becomes apparent that the interrelation of humans and animals is of central concern: (re-)emerging diseases like dengue and malaria call for a new assessment of the shared environments of humans and mosquitoes (cp. Beisel 2015, Nading 2014). Furthermore, the interfaces between wildlife and domesticated animals are also affecting human lives. Control of wildlife populations, policies regarding animal husbandry, international trade agreements, and the livelihoods of farmers are all factors that fuel the discussion. Regarding human-animal relations and health, the importance of the social, cultural, economic, political, historical, and technological contexts of health and disease dynamics in an increasingly interconnected and rapidly changing world cannot be downplayed (Muehlenbein 2016: 407).

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