This essay is an attempt to explain the plight of one underdeveloped country and the reasons for such, as well as how Nebraskans can be of effective assistance in improving the lives of the folks there. Part one, presented here, explains the problems encountered in this country. Part two discusses how we may responsibly attempt to solve those problems.
I was interrupted from my sedentary activity on a hot afternoon in the Sons of Thunder Farm House when a young man of about 15 clanged the metal pipe that served as a doorbell. The clinic was closed, as the paramedic director was in Lusaka attending an HIV/AIDS course. I had met this teenager two years before, when I had visited his home in “the bush” to discuss his mother’s condition (HIV) and to check him to see if he had any evidence of disease. But I did not recognize him, as he had grown. He had the build of a typical rural Zambian, slender with no evidence of body fat from walking long distances each day and eating a limited diet consisting mostly of nsima (finely ground white corn boiled to a paste), the staple of Zambia.
He called my attention to his left foot, which was wrapped with a filthy rag. He removed the rag to reveal two nasty lacerations on his foot. He had been plowing in bare feet and must have cut himself on a stick or rock, so plentiful in the soil there. I had experienced plowing briefly with a plow and two oxen a few days previously, but I had boots on to protect my feet. It was hard work—so I knew I wouldn’t plan to quit my day job. Besides, my irregularly plowed rows left a lot to be desired.
I proceeded to wash the boy’s dirty foot in a bucket of water and then placed it under a faucet in the orphanage. I dressed the clean wound, hoping it would heal and not become infected. I declined to stitch it up, as I had no assistance and was concerned about closing a contaminated wound. He returned several times over the next week for treatment; fortunately, he did not develop an infection.
Throughout the time I was with him, I wondered why he was plowing in bare feet. I knew other farmers who did have shoes, but some were so badly deteriorated that they were of little value in protecting one’s feet. It was only after I returned to the U.S. that I discovered that my great-grandfather, who lived near Wilcox, Neb., also plowed without shoes, supposedly because he did not want to ruin his only pair of shoes—shoes that were to be worn to church. I began to think that there were numerous similarities between 21st-century Zambia and late 19th-century Nebraska. But I’m getting ahead of myself.
How I got involved
How did I get to this hot, dry mission station in rural Zambia, about 20 miles from Livingstone, a town not far from the world-famous Victoria Falls? Made famous by physician, missionary and explorer David Livingstone, the falls are now considered one of the natural wonders of the world.
As I neared retirement age, I began exploring activities to occupy my time post-retirement. One of the opportunities that excited me was in developing countries. I became involved with the International Section of the American Academy of Pediatrics, which introduced me to a Yale program that funded physicians to volunteer in developing countries. Fortunate to be awarded a Physician’s Scholarship in International Health, I was encouraged to work in a stable, democratic country with beautiful scenery and wonderful people—Zambia, in south-central Africa. Totally ignorant of African geography, like many if not most Americans, I agreed to spend six weeks at Livingstone, a city that was the capital in colonial days until Zambia’s independence in 1964, then Northern Rhodesia. North and South Rhodesia were named after Cecil John Rhodes, the entrepreneur and exploiter, for whom the Rhodes Scholarship at Oxford University is named. The Rhodesias eventually became colonies of Great Britain. The British were responsible for the development of much of the infrastructure in the region, which included railroads, roads, hospitals and schools. What was to become Livingstone General Hospital provided care for settlers from Great Britain and elsewhere, and the smaller nearby Batoka hospital provided care for the local native citizens.
Batoka Hospital currently houses the bindi ward (children’s ward), along with infectious disease wards and a tiny children’s “intensive care ward.” It qualified for such because a seriously ill child could be given oxygen but not a lot of other components for modern intensive care.
As a pediatrician, I was assigned to this facility and placed in charge, in spite of my lack of experience in tropical medicine. I had only treated three cases of tuberculosis, one case of malaria and one tapeworm during my 37 years of general pediatrics in Lincoln, Neb. The physician’s scholar who preceded me made rounds with me the first day, and thereafter I was on my own. The attending Zambian physicians were little inclined to assist me, in spite of the fact that we were supposed to work alongside of each other to share our knowledge and experience.
I struggled through this six-week experience of a lifetime. I signed 20 death certificates, many more than I had signed in my previous 37 years. Many of these came in dead or near dead. Others suffered from chronic diseases that remained undiagnosed for lack of effective laboratory assistance and consultation. The staff tried hard with limited support. Often the limited radiologic equipment was nonfunctioning, laboratory tests were slow to be returned and medications unavailable. The physicians were poorly motivated to assist, passing the time at the hospital until the tour of duty was completed, after which they could move on to Botswana or other settings where the compensation was more favorable. According to “The Economist,” of the 600 physicians trained in Zambia since independence in 1964, only 50 have remained. After independence, some of the infrastructure that had been developed was not maintained. The hospital often did not have water on a regular basis. A consultant engineer related to me that the original water purification system in Livingstone was well designed, but clean water was not always assured because of this absence of care (something that is also true in some parts of the U.S.).
Many of the children admitted to the hospital were severely emaciated. They may have been brought to the hospital because of fever and serious infections, but the malnutrition that had suppressed their immune systems gave additional reason for admission. Anemia was quite pervasive and exacerbated the illnesses that were present. Malaria, diarrhea, meningitis, pneumonia and unusual infections secondary to what we now know was HIV (human immunodeficiency virus, the virus that causes Acquired Immune Deficiency Syndrome, or AIDS) were common. Although it was gratifying to treat and help these children recover, one began to question whether or not many of these conditions were preventable—the answer, of course, was yes.
I became friends with a local physician who cared for children without charge in an orphanage near Livingstone. During a visit to the physician’s clinic, I met the orphanage director who invited me to consult on a premature infant who had chronic diarrhea and was gaining weight poorly. I visited the orphanage, located on a 10,000-acre farm and mission dedicated to teaching native Zambians improved farming skills. I encouraged the director, an American who was a licensed practical nurse, to continue her course of management, and the infant did recover, only to die of malaria a few months later. However, I was able to tour the farm and believed that here was an opportunity to improve the lives of rural Zambians who were extremely poor, living on around a dollar a day, well below the world poverty standard of $1.25 per day.
Through a series of events involving Lincoln East Rotary and Rotary District 5650, a collaborative relationship developed to assist the folks at the mission, named Sons of Thunder. In the Bible, Jesus refers to James and John as the Sons of Thunder because of their impulsive and aggressive nature. The Sons of Thunder facility is located about 25 kilometers from Livingstone near the highway to Lusaka, the capital of Zambia today. The original vision of the mission was to “feed Africa physical and spiritually.” Currently, there is an orphanage, a school, a medical clinic and a struggling agricultural program.
How did Zambia become the seventh poorest country in the world?
During periodic visits to Zambia over the past five years, I have often pondered why a country similar to south-central Nebraska failed to develop, whereas the fields of much of Nebraska are so green and productive. In the late 1800s, my great-grandfather (whom I referred to above) had to take his family back to his native New York for several years because of drought. Of course, as late as the “dirty thirties,” as we all know, no crops were raised at times. Irrigation followed, which magically converted the land to the cornucopia that it is today.
Nevertheless, the differences between Nebraska in years gone past and Zambia today go far beyond water. Some of the answers are provided by Jared Diamond in his book “Guns, Germs and Steel.” Several fundamental points emerge from Diamond’s book. Modern civilization developed in temperate zones across China and the Middle East, then spread to Europe. Primarily because agriculture developed in these areas, allowing a few individuals to provide food for many, the opportunity to develop written language, the wheel, medicine, mathematics and other essential components of modern civilization was made possible. It was only when the Dutch and others settled what is now South Africa that modern agriculture came to the area. Because it was a temperate climate, crops that had been grown for thousands of years in Europe and other similar regions took hold here. This is similar to what took place in the Americas (although certainly Native Americans had domesticated many grains and crops). Europeans were able to produce these crops in greater quantities over time. The Dutch farmers, or Boers, were hard-working, severely religious folks who read the Bible literally to the degree that they believed their “covenant with God” was to subjugate the natives like he had told the Israelites to slay the Hittites. They had the weapons (Guns) that enabled them to move into the land occupied by the Zulus and other African groups. The former were a formidable opponent but no match for the Boers and their technology. As is so vividly described in James Michener’s book, “The Covenant,” the English and other colonists settled the land and, over time, moved north to what became the Rhodesias. Eventually, Zimbabwe (Southern Rhodesia), Zambia (Northern Rhodesia) and Mozambique (formerly a Portuguese colony) became the breadbasket of Africa. This was largely due to the colonists who had the technology, capital and understanding of modern agriculture. At the same time, it was due to the hard work of Africans on the land. The combination of the two made productive agriculture possible.
Until recently, Zimbabwe continued to be extremely productive, but the sudden forced removal of white farmers there by the government and vigilantes since 2000 has contributed to the horrible situation in that country. The cronies that were given the land knew little or nothing about farming and did not engage in agriculture. As a result, the economy of Zimbabwe collapsed, resulting in serious difficulties for nearly everyone in the country. In 2003, I met a couple who had moved to Zambia because of the turmoil. They were raising beautiful crops (tobacco) along the Zambians side of the Zambezi and told me no crops had been raised on their Zimbabwean farm in two years.
There are limited numbers of animal and plant species that can be domesticated. For example, there were no such animals in sub-Saharan Africa. Zebras are too “ornery” to be modified over many years to function like horses. Although cattle have been introduced to the region, they do not fare as well as indigenous species because of disease. Historically, they are an important component of Zambian agriculture but require care such as “dipping” into insecticides to free them from parasites. Of course, this requires funds that may not be available.
Ancient Zambians survived by hunting and gathering. They were able to earn their livelihoods by hunting the indigenous animals and gathering nutritious and medically important plants. Eventually, they became agro-pastoralists, who may have supplemented their diet with hunting. There are few animals left to hunt, in part because of overkilling of fauna in order to survive. Wildlife also died out due to disease such as rinderpest. Maize was introduced into Africa from the Western hemisphere, probably by the Portuguese, but because it is so dependent upon ample water, a successful crop is not always possible in this arid climate. Indigenous crops such as sorghum and millet are more drought-resistant and have potential for better nutrition, but are less palatable and are out of favor with the Zambians. Besides, much of the land is not arable, in any event.
The population growth, discussed in more detail below, has surpassed the ability of the land to produce enough food, especially with the small farms and gardens that are most common. Half the population lives in cities, as the hard life in the village has led young people to flee in hopes of finding work. They seldom find employment, and some of them engage in less desirable pursuits to survive. It is speculated that the population growth may be related to the medications brought by the colonists and others to treat serious disease, as well as to the need for larger family sizes to meet agricultural labor demands.
More recently, the reliance upon maize (corn) has led to malnutrition, especially in young children who are low on the totem pole for food. I am told that the first president of Zambia, Kenneth Kaunda, encouraged the farmers to raise maize, I suppose in hopes that it could be exported; but it is not the best crop for the dry savannahs. Zambians love their nsima, finely ground white corn that is placed in boiling water and made into a kind of paste. Unfortunately, maize is low in lysine, which is an amino acid necessary to form a complete protein, and for infants and toddlers this can impair their growth and immune status.
With much adversity, the Europeans were able to be successful at farming, and even after independence in 1964 when many white farmers left the country, the Zambians maintained the agricultural economy, which included the raising of cattle. The government established cooperatives that provided seed corn and fertilizer for the poor farmers. After about 10 years, the economy collapsed, partly due to the drop in the price of copper, which was one of the main sources of its gross domestic product. It has never completely recovered from this. Drought lasting 10 to 15 years and HIV are additive factors in this crisis. As a result, Zambia, like many an African country, is highly dependent upon economic support from the developed world for survival.
Some Zambians charge that the reason farmers do not adapt more effective methods is because when folks have run out of food and are starving, the government and nongovernment organizations (NGOs) come to the rescue with grain. Robert Hitchcock, Ph.D., formerly of the University of Nebraska-Lincoln’s (UNL) anthropology department, has related to me that when food is brought in to a starving population, production drops off the following year. For these and other reasons, the “Green Revolution” so successful in China, Pakistan, Mexico and India has not been extended to sub-Saharan Africa.
Diamond uses the metaphor “Steel” to describe technology that has been developed in “advanced” cultures. The failure to develop and implement innovative technology is one of the three reasons that Zambia is in the state that it is. The Zambians are largely descendants of the Bantu people, who had skill in ironwork, but in general the technology did not move beyond the making of simple tools and weapons. Unless a culture has a method of producing enough food for all, individuals will not be able to have the time to develop an advanced civilization.
The next factor, “Germs,” provides us with the third reason for the plight of the Zambians. The climate is one reason that infectious disease is so rampant in sub-Saharan Africa. This is especially true of malaria, which is transmitted by mosquitoes that propagate in the pools of water that collect in the rainy season. Malaria was quite prevalent in Europe and the Americas but was eliminated by the overliberal use of DDT; but only recently have this and other insecticides been used to attempt to quell this major health problem in Zambia. Until David Livingstone, physician, missionary and explorer, brought quinine and other medications with him that enabled him and subsequent explorers to travel into deep Africa, even then it was with much difficulty. There may have been innate immunity to malaria and other diseases that developed over thousands of years, but as tribes were moved out of their traditional locales, new diseases to which they lacked immunity would invade them. Likewise, when invaders came with diseases such as measles and smallpox, the locals could be devastated. (This, of course, happened to Native Americans as well.) The native population may have lived in areas that were less likely to have mosquitoes, and when moved to less desirable locations by the colonists, they became likely to contract malaria. The construction of the Kariba Dam displaced 57,000 Tonga, for example.
Although the diseases of Africa slowed the northward movement of Europeans, eventually their superior technology enabled them to survive in the new land. However, there is another issue that compounds the problem of disease. In recent times, medications and immunizations brought from the developed countries have enabled many to survive when they may not have done so prior to this time. As a result, the population in Africa has soared. In 1964 at the time independence, the population was around 2.5 million. Currently, that figure has soared to 11 million, in spite of HIV/AIDS. As a result, villagers have moved to land that is less fertile and where clean water is less available. Thus, water-borne disease is also prevalent. I saw the results of this at the bindi ward in Livingstone, where children with severe dehydration due to gastroenteritis were brought in, many of whom died. It is not uncommon to see wells that are not protected from animals to be contaminated by such when they are drinking from the water source. Again, these deaths were the impetus to me to seek ways of prevention in Zambia.
Diseases caused by worms are common. One example is that of hookworm, which is contracted from the soil and can cause anemia because of blood loss from the worms migrating through the body and attaching to the intestinal wall. Recently, we tested 50 orphans for anemia and found that half of them had mild to severe anemia. The diet, which is lacking in iron, may well have been a contributing factor. Children and some adults lack shoes or prefer not to wear them, and thus this barrier to the germs is not present.
Another parasitic disease is schistosomiasis or “bilharzia,” which is contracted from water that contains the parasite and invades through the skin. The lack of latrines allows for this to happen, as the folks may relieve themselves wherever convenient. In times past, when the villages dispersed or they moved periodically, this may not have been a problem.
I would be remiss not to include HIV/AIDS as a major health problem in Zambia, as well as much of Africa. The incidence of HIV positivity is about 16 percent by recent estimates. It is probably higher in the populous areas. This has a severe effect on children, as parents have died and the traditional approach of the extended family in caring for all children is no longer viable. Grandparents and close relatives have few resources to provide for these kids and, as a result, there are estimated to be one million orphans in Zambia. These children often come to orphanages extremely emaciated or disease-ridden, demonstrating the lack of food in their villages. This is a financial burden to the country, now met by outside caring organizations. Unfortunately, orphanages are poor places to raise children unless care is taken to promote optimal emotional and physical development. One of our goals is to prevent the need for children to need to be sent to orphanages
In summary, Guns, Germs and Steel can partially explain why Africa never reached the level of civilization that occurred in other areas of the world. However, other reasons that have led to the failure of these wonderful people to improve their lot in life are corrupt government and misguided efforts to help by Western organizations. The poor transition from colonial domination to independence provided little opportunity for adequate experience in governance and training of those involved in leadership. Some would also mention that there is a culture of things “happening in God’s time,” which is not helpful in providing the materials and strategies for a successful modern society. For example, if a hospital needs medicine for a severely ill child, most of us would want to “speed God up” a bit to see that the child would get it today. (Medicines were commonly not available at the Livingstone General Hospital during my stint there.)