NEGOTIATING ABUNDANCE AND SCARCITY: HEALTH SECTOR REFORM, DEVELOPMENT AID ...

447 Pages·2011·3.45 MB·English

NEGOTIATING ABUNDANCE AND SCARCITY:
HEALTH SECTOR REFORM, DEVELOPMENT AID, AND BIOMEDICAL PRACTICE
IN A TANZANIAN HOSPITAL

By

NOELLE SULLIVAN

A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL
OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT
OF THE REQUIREMENTS FOR THE DEGREE OF
DOCTOR OF PHILOSOPHY

UNIVERSITY OF FLORIDA

2011
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© 2011 Noelle Sullivan

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To Tracy and Flynn

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ACKNOWLEDGMENTS
Dissertations are completed only after long journeys, with the support, assistance, and
encouragement of so many people. Many people in Tanzania, North America, and Europe have
had a hand in helping me think through the ideas that emerge in this dissertation. I have
benefitted from the gracious and unfaltering support of my advisors. Hansjörg Dilger has been
my Primary Advisor and Co-Chair. He has continually pushed me to expand and further clarify
my ideas, and provided continual and invaluable feedback on this project from its first
conceptualizations to the form that emerges on the pages below. Brenda Chalfin, my other Co-
Chair, has been a constant source of stimulating ideas, enthusiasm, and encouragement. Having
this special team of Co-Chairs allowed me to imagine a project that brought together the
complexities of healing with those of politics, bureaucracy, and transnational governance. They
have been unfaltering and invaluable mentors, continually inspiring me to explore
interconnections that have not always been obvious. Luise White has pushed me to understand
specific events in their wider and comparative contexts, and fostered in me a love for
ethnographies past and present. Her enthusiasm, imagination and insights continue to inspire me.
Maria Stoilkova urged me to think more deeply about how globalization, neoliberalism, and
politics impact my research, and enticed me to assert my ideas and arguments by challenging me
with important questions. I owe a special debt to Stacey Langwick, whose provocative courses
and mentorship early in my graduate career significantly shaped my intellectual approach to
biomedicine, science, Africa, epistemology, and notions of modernity. Although she is not on my
committee, I hope she sees her mark in the pages that follow. I am also grateful to Kendal Broad,
who gave me a foundation in feminist science and methodology, and was willing to share her
professional and personal perspectives on very complex issues. These mentors have been
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fundamental to my theoretical and practical training, and any disservice I do to their careful
guidance belongs to me alone.
For Kiswahili training, I am thankful to Masangu Matondo, who introduced me to
Kiswahili with a sense of humor, and to Rose Lugano and Charles Bwenge, who continued to
nurture and strengthen my language skills while at the University of Florida (UF). Lioba Moshi
first introduced me to Tanzania in 2004, and provided invaluable assistance during my return trip
in 2005. Her unfailing commitment to students and dry wit made my first weeks in Tanzania
incredibly rewarding. MS-Training Centre for Development Cooperation repeatedly offered me
training, lodging, and support in Tanzania over the years. A special acknowledgement goes out
to Yusta Mganga, Gaudentia Lwakatare, and Steven Ndosi. I would also like to thank the Chuo
cha Uenye Ulimavu, whose staff and resident families continue to inspire with their tireless
efforts to improve the lives of people with disabilities, and train them in skills that will allow
them to be independent.
In Tanzania, my most profound gratitude lies with the staff, patients, and caretakers of the
hospital where I worked, whose names cannot appear here for reasons of confidentiality. I was
welcomed to the place I call ‘Kiunga District Hospital’ as a researcher, but also as a member of a
team. The staff worked tirelessly under adverse conditions to build hospital capacity in the name
of treating the ill, and patients’ relatives were admirably involved in caring for not only their
loved ones, but also other patients in need. These caretakers continually assisted hospital
personnel in a way that was both remarkable and generous. I am humbled and grateful that the
staff, patients and relatives shared with me their joys, aspirations, frustrations, and sorrow—only
a fraction of which was able to spill out onto the pages that follow. The District Medical Officer
(DMO), “Dr. Saidi,” was always a gracious host, and his commitment to building the hospital
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was imaginative and moving. Being a researcher in the context of a hospital in Tanzania truly
tested my anthropological training. Importantly, it also tested me as a person, and the staff’s
pragmatism helped ease these dilemmas. Ninawakumbuka sana.
I must also acknowledge the warm welcome I received from ‘Kiunga’ District Council,
and all of the councilors and staff that took time out of their busy schedules to talk to a
researcher and allow me to attend their meetings so I could understand the way the health
department intersects with other community concerns.
There were many people in Tanzania who provided my family and I with friendship,
support, and laughter. First among them must be Baba and Mama Simon and their children
Simon and Catherine, who invited us into their lives and provided us with daily sustenance and
companionship. Tunawashukuru sana, na tunawakumbuka kila siku! Claus and Trine Heim, and
their children Camilla and August, as well as Stefan and Christiane Völk and their children
Nielson and Tilmann, were constant friends and playmates—they literally came to our rescue on
numerous occasions, and so literally, this dissertation would not have been possible without their
timely and selfless assistance. I must also thank Jesper Mogensen and Lidet Wolde, who
provided us with shelter, sometimes for long periods of time—not to mention amazing meals and
good company. Jesper Bosse Jønsson was always source of inspiration and humor. I am grateful
I was in the right time and place to meet Charles Llewellyn, and his wife Deborah, who were
constantly hospitable and entertaining hosts, and have continued to support me in my work.
Bernard I. Sefu, Mama Gertrude, Joho, and Sophia Moshi provided stimulating conversation and
friendship. We owe a special debt to Diamond and Diana Carvalho, and their daughter Sophie,
with whom we shared many great meals and even more laughter. I am quite certain Diamond and
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Tracy will drag each other to the top of Kili one of these days! I would also like to thank Irene
Rwegalulira for her assistance in transcribing interviews.
Tanzania’s Ministry of Health and Social Welfare (MoH) deserves special thanks. Due to
their kind invitation, I was able to mine the MoH library as I attempted to reconstruct a history of
the health sector, and many officers took time out of their very busy schedules to tell me their
personal stories, and the stories of the departments within which they worked. Within the MoH, I
am particularly grateful to Dr. Faustin Njau, who not only agreed to an interview and provided
additional information via email, but also graciously permitted me to attend the Joint Annual
Review of the Health Sector meeting in 2008. Dr. Bjarne Jensen also took out so much time to
share his experiences with me, both within and outside of Tanzania. I would also like to thank
Dr. Z. A. Berege, for providing me with letters of introduction to the district hospital where I
worked.
This research was supported by a Fulbright-Hays Doctoral Dissertation Research Abroad
fellowship, for which I am very grateful. Tanzania’s Commission for Science and Technology
(COSTECH) provided research clearance for this study, and Dr. A. Mvungi of the Department of
Sociology at the University of Dar es Salaam was my sponsor. I must also acknowledge the
support of Drs Ruth Meena and Rose Mwaipopo, as well as Mrs. Mabel Kaaya. Special thanks
must also go to the American Embassy in Dar es Salaam.
I presented some of the ideas contained in this study at two workshops: the first,
“Institutions, Collaborations, Power: Workshop on Hospital Ethnography” at the University of
Sussex, UK, and the second, “Urban Health in Sub-Saharan Africa” in Bamako, Mali. I would
like to thank the organizers, as well as all of the participants for the fruitful conversations we
shared, which have left important imprints on my thinking. I am also thankful to Claire Mercer,
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Lisa Richey, and Stefano Ponte for their comments and insights at the African Studies
Association meeting in 2009. Although I had been following her work for several years, I finally
was able to meet Claire Wendland in 2009, and our continued exchanges to date have leave a
profound impact on my thinking. Her impact on the pages that follow is clear, and I look forward
to future collaborations.
The foundation in anthropology I received at the University of Victoria as an
undergraduate has left its mark on me. I am especially grateful to Patricia Spittal, whose work
first inspired me to become an anthropologist, and to Eric Roth and Lisa M. Mitchell, who honed
my interests in the intersections of health and technology. At the University at Albany, I am
thankful to Iris Berger, who helped strengthen my thinking and writing while a master’s student.
The University of Florida’s Department of Anthropology and its Center for African
Studies (CAS) have provided me with a very happy academic home. They have been constant
sources of financial, academic, intellectual and moral support. From CAS, I benefited from three
Fulbright-Hays Foreign Language and Area Studies Grants (FLAS), as well as several travel
grants. I am thankful for the continued support of Léonardo Villalón, Todd Leedy, Corinna
Green, Ike Akinyemi, Renata Serra, and Julie Silva. The Department of Anthropology gave me
numerous opportunities to teach, as well as a wonderful environment in which to learn. I would
like to thank Allan Burns, Ken Sassaman, Michael Heckenberger, Clarence (Lance) Gravlee,
Peter Schmidt, Peter Collings, and John Krigbaum for many stimulating exchanges, and for their
interest in my development as a scholar and teacher. Alyson Young has been a constant source of
friendship, advice, and support. My progression through the program would have been far more
tumultuous had it not been for the help of Karen Jones, Patricia King, Juanita Bagnall and
Pamela Freeman, whose commitment to the department, its faculty and students is unrelenting
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and remarkable. Special thanks must also go to Dan Reboussin and Peter Malanchuk, our two
African Studies librarians extraordinaires, whose passion for their work, undying support of
scholars, and uncanny ability to predict what people need is such a valuable gift.
I also owe many thanks to my fellow graduate students (past and present) in anthropology
and African studies. Becky Blanchard, Anna Brodrecht, Scott Cady, Sarah Cervone, Jean
Dennison, Lauren Fordyce, Jennifer Hale Gallardo, John Hames, Rachel Harvey, Angelina
Howell, Cara Jones, Carmen Alondra Laguer-Diaz, Alison Montgomery, Joost Morsink, Tim
Nevin, Meghann O-Brien, Gypsy Price, Alan Schultz, and Noah Sims and have all made my
time at UF so rewarding. I owe a major debt to Traci Yoder and Meredith Martin, whose untiring
support and friendship, not to mention editorial expertise, have been important in my
development as a scholar and person. I have also benefitted from friends who take me outside of
my academic world, including Karen Matthews, Kaitlin Earley, Sonny Assu, and Mireille van
Raaij. I wish to extend my gratitude to Parker and Jenni van Hart, and their children Madison
and Samantha, for providing my family and I with love, support, humor, honesty, good
friendship, and amazing meals.
As I reflect back on my life’s journey so far, I cannot help but be humbled by the grace and
love that my family has shown me, even when they did not understand what I was doing. They
have endured my absence from my Canadian birthplace for over a decade, but have always been
pillars of strength for me even from afar. It was a great gift to grow up knowing that regardless
of what I chose to do, I would have their support. In particular, my parents Guy and Shirley
Gentner and Stu and Doris Colquhoun have been stalwart enthusiasts, and have motivated me
with the passion and determination they demonstrate in their own lives. My sister Maggie
Russell, her husband Noah and their children Ethan, Kiera and Zack continually remind me of
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the importance of love, laughter, and joie de vivre. My brother Adam moves me with his
willingness to continually push towards his goals despite setbacks. My grandparents Tony
Wuitchik and Doreen Gentner remind me of the importance of getting the most out of life, and
finding respite in music. My aunt, Shelley Smirfitt, inspires me with her inexhaustible
perseverance in the face of considerable challenges. I regret that my grandparents, Bob and Lee
Colquhoun, and Cliff Gentner, and my uncle, Rob Colquhoun, did not live to see me finish this
dissertation. They have such an important impact on my life, and I carry their love with me
always.
Most of all, I want to thank my chosen partner of life, Tracy Sullivan. Tracy uprooted
himself and our son from a known life in Florida to a country he had never before seen. For over
a decade he’s been a constant companion and friend, and upon our return to Florida gave up so
much in order to be the physical, emotional, and moral support that I needed. He truly is what he
claims to be: a ‘spousal anthropologist.’ I am grateful for his presence in my life every day, and
no one has scarified more than him to ensure that this dissertation was completed. I am also
thankful for our son, Flynn, who so often of late has asked me, “Why do you go out and do that
crazy work?” Crazy, indeed. But watching him marvel at the world around him, I remain hopeful
that at some point the ‘why’ becomes a little clearer to him. I’ve been so blessed with his ability
to make me laugh and be silly. Some people feel rooted in places. I am not rooted in a place, but
rather in these two people. And so it is to Tracy and Flynn that this dissertation is dedicated. I
hope what they find in its pages honors their daily sacrifices.

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