What did we learn at the Inspiring Communities workshop?

This post originally appeared on reachoutconsortium.org.

We're featuring a guest post today, from Kate Hawkins on 'Inspiring communities in global health: Community Health Workers and Universal Health Coverage', an interdisciplinary workshop held at the Wellcome Collection on 12th June 2017.

By Kate Hawkins

On the 12 June 2017 the University of York’s Department of Politics and Centre for Global Health Histories held a fascinating meeting which explored the impetus towards the mobilization of communities in the definition of health policies and the delivery of care; and the role played by community health workers (CHWs) in this process. It was a chance to look backwards and get a historical view of the formation and adaptation of CHW programmes in different settings as well as looking at some of the more contemporary challenges and how these two things might relate. Three elements of the discussion stood out for me: religion, gender, and community and participation.

Religion

Recently I have been working with colleagues on a literature review on gender and CHW programming which is part of a larger paper. One of the things that struck me is the only papers that we found that made an explicit link between gender and religion were those from Muslim-majority countries. One can only speculate at the reasons for this. These papers tended to focus on how becoming a CHW increased women’s mobility in settings where they have traditionally stayed in the home and how this can be an empowering experience. They also point to the potential dangers of women breaking social norms and their vulnerability to attack and sexual assault by men when out and about in the course of their work. It may be due to our search terms, or the journals we are limited to, but I was surprised at the lack of papers where Christianity was at the forefront of analysis. As an atheist, I have had time to contemplate faith while at meetings on CHW programming that begin (and often end) with a prayer. The workshop was refreshing in that we heard new perspectives on how Christianity has influenced the conception and function of CHW programmes in different settings.

What became clear from our discussions is that Catholic and Protestant organisations have different models of mobilising communities, and attitudes towards them, which plays out in the design and functioning of CHW programmes. Ben Walker presented on Medical missionaries, Community Health Workers and NGOs competing and creating universal health care in Ghana between 1967-1983. Ben challenged the perception that the implementation of Community Health Workers was an entirely secular venture by describing the way in which missionaries and Churches in Ghana were involved in their formation. He tracked the changing attitudes amongst the Presbyterian and Catholic churches in Ghana across the 1950s to the 1970s in order to show how, whilst initially mission doctors and Ghanaian Christian health work prioritised a hierarchical relationship with local communities, reformations in mission theology in the 1960s shifted their practices. Particularly he emphasised how Vatican II, medical missionaries connection to local anthropologists and Christians studying at U.S. public health schools all encouraged community-oriented perspectives on how to incorporate Ghanaians into medical work.

We heard how Liberation Theology (of the type found mostly in Latin American countries) purposefully centred on the agency of communities and their active participation in overcoming socio-economic inequity. This essay by Paul Farmer describes how this approach underpins community health interventions in Partners in Health. We heard how in the Brazilian health system Catholic and African religions are integrated and this was central to the development of their model of health care. Community conceptions of what constitutes good health and wellness were what shaped the interventions provided, which is why homeopaths/herbalists are licenced providers of care. Polly Walker described how World Vision’s faith-based approach to development has evolved over the past 60 years, moving away from a provider-beneficiary relationship towards a model of transformational development and partnership (which reflects local ownership and definition).

Gender

REACHOUT was represented by Rosie Steege who reflected on some of the gender issues that have been raised as part of the work of the consortium and in her PhD research. She concluded that gender impacts upon CHWs in a multitude of ways and current CHW policies do not acknowledge the complexity gender plays ‘supply side’. This is a missed opportunity to promote gender transformative approaches at all levels of the health system. Her overall argument was that approaches on the ground are often governed by gender but not gender transformatory policies as a result they are sub-optimal.

Gender was also a focus in the presentation by João Nunes (Department of Politics, University of York) on CHWs in Brazil. He described CHWs as simultaneously vulnerable and empowered and in part this is because a big percentage of them are women (98% in some states). CHWs are often precariously employed with short term contracts, underpaid, and seen as disposable members of the health teams. They experience occupational health problems, such as trauma, stress, and physical injuries. João described how the community health programme is deeply heteronormative. Women are chosen as CHWs as men are not allowed to go into people’s homes unaccompanied, reflecting dominant conceptions of what is ‘appropriate’ for men and women. He relayed an anecdote where a member of staff recounted, ‘we have one male CHW but he is a homosexual so that is alright’. Heteronormative structures are very much present in many of the CHW programmes that I have seen – in anything from the way that households are defined, to assumptions about women’s caring responsibilities and natures, to CHW attitudes towards clients who break norms related to sexuality such as having children as teenagers - but they are rarely remarked upon. It would be great to see further analysis of this area.

Group discussion focused on whose ends are served by pushing women into positions where they are vulnerable to community violence and other forms of harm. I have long wondered why there is not more discussion about workplace health and safety in relation to CHW programmes. Employers have a responsibility to those who labour for them whether their workplace is an operating theatre or a doorstep.

Community and participation

In the CHW world there can be a tendency to posit communities as benign and all community participation as positive. Yet conversations at the workshop pointed to some of the limits of CHW programmes and how good intentions within drives for community health could have negative unanticipated consequences.

An excellent presentation by Karina Kielmann (Institute of Global Health & Development, Queen Margaret University) described how relationships and provider/client interactions are key to the delivery of HIV interventions through CHW programmes. She talked of how pre-existing social bonds can be instrumentalised by community health programmes and these can have negative consequences. For example, the creation of ‘expert patients’ to support adherence to ARV treatment in Malawi weakened horizontal links between peers and therapeutic solidarity as their positions were professionalised. In Zambia, the professionalisation of home based care practices meant that CHWs were less involved in physical care and did not support households through the provision of food. As their traditional role transformed people felt surveilled and policed by CHWs who were thought to adopt a berating attitude and meddle in household affairs through their treatment adherence practices.

Emma-Louise Anderson (University of Leeds) presented a paper on dependent agency and the limits of community mobilisation for democratisation and equity. Based on work in Malawi and Zambia (both countries which are extremely aid dependent in terms of their HIV programmes) she described how networks of people living with HIV and the support groups that followed from them are considered potential mechanisms to foster equity. However, in these settings aid recipients are ‘dependent agents’ who are constrained by exclusionary informal networks, donor recipient relationships and patronage politics. This is not to say that they were powerless and there were many ways in which structures were subverted, for example, through 1) the outward performance of compliance, such as using human rights language without a commitment to their realisation for all; 2) extraversion, or making dependency obvious so that it is advantageous in terms of additional resources; and 3) resistance below the line such as using euphemisms, stretching rules, and dragging feet. Nevertheless, community health in this environment has undermined the solidarity, accountability, transparency and the trust needed for democracy. It has led to the exclusion of certain groups and the pitching of different communities against each other. CHW interventions need to better understand the behind the scenes ways local people are enmeshed in unequal power hierarchies and social obligations if their programmes are to be successful.

In other conversations, we discussed how regimes of expertise and practice take up and then discard community members as the popularity of CHW programmes ebb and wane. One participant described CHWs as the ‘handmaidens’ for opening up markets for Western drugs as part of a global trend that is moving away from community care towards biomedical interventions.

The workshop was an excellent opportunity for academics from different backgrounds and disciplines to come together and share. I am hopeful that it will lead to fruitful collaborations in the future.

The organizers gratefully acknowledge the support of the Department of History and the Department of Politics at the University of York, and the support of the Wellcome Trust.

Global Health Histories: Engaging policy to promote transparency and equity

By Sanjoy Bhattacharya, Professor in the History of Medicine at the University of York Department of History, Director of the Centre for Global Health Histories, and Head of the WHO Collaborating Centre for Global Health Histories.
The historiography of international health after the Second World War is now rich and extremely well populated. And yet, significant sections of this body of work remain stubbornly and peculiarly focussed upon the views and actions of relatively small numbers of people within North America and Western Europe, even when the events and activities being described relate to regions and countries far afield. The biggest problem is that this body of work is rooted in unmoving assumptions about the importance of a small set of nations in the post-war era and insufficiently tested presumptions about their dominance over the negotiations that led to the creation of new post-war institutions (such as the United Nations). Post-war agencies are, in turn, described simplistically, where their Europe- and USA-based headquarters are presented as all powerful and capable of dictating the actions of representatives all over the world. Furthermore, this is done with suspiciously limited research, with almost no attention being paid to the birth of regional and national branches of UN organisations and their intricate negotiations with governments of newly independent, assertive countries who were willing to invest heavily, both financially and through new international alliances, in the modernisation of health, science and technology.

These academic attitudes seem to me to be deeply entrenched in present-day notions of the hierarchies of specific nations, races, languages and educational backgrounds, and their supposed worth in the creation of the so-called post-war policies of internationalism and consensus. Such predetermined notions of pre-eminence are then fed back to inform assessments of past experience, which has helped to entrench deeply problematic assumptions. These trends are often promoted and sustained by cosy relationships between historians, other medical humanities experts, social scientists, and the officials of government and international agencies that they are writing about. The resultant lack of analytical independence, which has limited scholarly criticality and reduced the commitment to study situations and contexts in all their complexity, has stymied more democratic and realistic assessments of the intricacy of health programmes on the ground.

Indeed, very few academics have dared challenge these historiographical trends by publicly discussing the factors underpinning them, perhaps for fear of isolation from the established, high profile and powerful academic networks that have considerable say in publication, grant making and prize selection processes. Sadly, and to compound problems for those seeking to promote the adoption of a wider and more equitable analytical frame, many elements of such academic formations have, for some time, become far too comfortable about quoting work authored by friends in their network. Exacerbating the problem, these scholars do not read widely enough, refuse to study non-European and non-contexts in their own terms, and rarely carry out research in non-European languages or, perhaps more importantly, working with academics with the necessary skills, creating exclusionary and harmful hierarchies of academic worth. All of this goes a long way in helping to explain why several academics choose to focus on a small number of historical actors’ ideas and reports on how others responded to them, rather than the numerous, complex processes wherein a set of recommendations, from new specialist agencies associated to the United Nations would be discussed, negotiated, reworked, implanted and reshaped both regionally and nationally in wide-ranging ways.

Therefore, we have a situation where histories purporting to describe the impact of the ‘Cold War’ on international and global health projects consider it sufficient to describe debates and discussions between representatives of the USA and the Soviet Union on the basis of extremely narrow research (generally, for example, by focussing on US government reports on the USSR’s representatives’ arguments and positions, with no effort being made to study Soviet papers, in Russian, on these negotiations). Similarly, histories of the worldwide eradication of smallpox – widely regarded as the 20th century’s greatest achievement in international public health, interpretations of which continue to be considered in policy and academic circles, and presented as proof of the WHO’s ability to offer ‘global’ leadership – choose to focus on the roles played by small groups of people. In doing this, these bodies of work ignore or downplay ideas, activities and work carried out independently in important contexts such as India and the People’s Republic of China. This trend is particularly inexplicable, considering that these regions had significant populations, large and well-established administrative frameworks, were marked by great cultural and social diversity, wielded great regional political importance, and were regarded as important politically both by the USSR and USA, and the international alliances they spawned, at different historical junctures. That these attributes and determinants in South and South East Asia have been considered largely unimportant by generations of academics is a powerful indicator of the damaging nature of US- and Euro-centric scholarship about the birth and expansion of international health after 1945.

The WHO is not, and has never been a monolithic organisation, and many of its workers in offices around the world have shaped international engagements in health in significant ways. From this perspective, the support that the WHO Global Health Histories initiative has received from within many quarters of a complex organisation is unsurprising; many of its officials have recognised and supported the initiative’s ability to promote inclusivity, and collect information transparently and collaboratively. As these open-minded and democratically-inclined WHO officials work with talented academics from all over the world, who are united in seeking to study the widest range of voices and actions to develop intricate and realistic historical mosaics of internationalism in health, they create new forms of discussion and debate that mobilise and support new coalitions for equity in health. This inter-sectoral cooperation does not, of course, go unopposed within the complex maze of the structures of international and global health programmes. There are, for instance, those who seek to ensure the dominance of the English language in health research and its communication. However, as major health problems persist, leading many thoughtful and independent analysts to increasingly query the overshooting of targets and budgets in major programmes such as Global Polio Eradication Initiative, and the barriers created by the unwillingness of UN- and US-led initiatives to use multi-lingual research to properly understand and engage local populations threatened by new pandemic emergencies (Ebola being a good case in point), the imperium of those seeking to promote work in the English language and then label this as being the most important for all future responses everywhere is being challenged. The unmistakable shifts in the world’s political and economic orders are an important contributory factor and new international alliances, such as the BRICS nations, are becoming assertive in unprecedented ways.

As their representatives within the UN work ever harder to ensure that their voices are heard and the contributions of a wider range of countries is recognised as major, new health initiatives are rolled out, it may well be that conditions will be created for a more equitable, non-US and non-Eurocentric historiography, based on careful research in multiple languages. The election of the first ever WHO Director General from Africa, on the basis of a vote that involved all national member states, represents an important and, hopefully, lasting shift that will promote complex, open-minded engagements between policy managers, academic allies and target populations. However, to thrive and make an impact, any reforming agenda needs to avoid the pitfalls of what it displaces: the imposition of select nationalisms on deeply international bodies; racially informed superiority complexes and attendant hierarchies of worth; and the denial of sufficient space to describe and assess a multiplicity of voices from the regions and countries. If such reforms are to empower future generations of scholars, allowing them to come up with innovative new research in unfettered ways, then resultant socially-, culturally- and politically-sensitive historical work is much more likely to be able to engage those involved in delivering health and development policy around the world on a day to day basis.

Made to measure: Data in the movement for primary health care

In the run up to the 101st Global Health Histories seminar ‘A world that counts?' Contexts of health: Information for Health, we're considering the data issues present in our work on the 'Local Bases of Global Health’ project. What was the role of data in the global movement for Primary Health Care (PHC); who was responsible for data collection; and how was data used? Dr Alexander Medcalf considers such issues below.

Global Health Histories Seminar 101: 'A world that counts?' Contexts of health: Information for Health’ will be streamed live online on Thursday, the 22nd of June starting at 12.30pm CEST (11.30am GMT).

Data and information collection was viewed as a vital component in improving health after the Second World War. It became an important issue for the nascent WHO; the first Director General Brock Chisholm recognised the ‘growing need for quantitative data, not only to provide comparable information on the health of populations, but also for the adequate planning of health programs and for the sound evaluation of results’. The Organization’s early annual reports displayed the extensive systems adopted for collecting and disseminating information and health statistics. In 1951 for instance, a conference on morbidity statistics was held in Geneva in connexion with a meeting of the Expert Committee on Health Statistics, and a training course for statistical coders was held at the WHO’s headquarters. Regional courses in vital and health statistics were held in the South-East Asia and the Eastern Mediterranean Regions, and surveys of the existing methods of collecting and compiling statistics were made in various countries.[1]

Whilst the WHO’s work priorities shifted in the 1970s to promote Primary Health Care (PHC), the interest in data remained constant. The 1978 Declaration of Alma-Ata at the International Conference on Primary Health Care outlined PHC as comprising ‘essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and country can afford’.[2] Information was seen as vital to success, and the gathering and analysis of data was envisaged as an integral part of PHC programs to help monitor and evaluate health programs, identify pressing health problems, and build up a comprehensible picture of the health needs within communities. A joint report by the WHO and UNICEF specified that the planning and management of PHC programs depended on the ‘right kind of information’: data collection should be kept to a minimum by identifying only relevant information. ‘Timely’ and ‘useful’ were the main watchwords.

Although this was the aspiration, the collection and usage of data played out differently in countries and communities around the world. We get a glimpse of some of the experiences and responses in a series of articles which appeared in the World Health Forum in the mid-1980s,[3] a half-decade after the start of many PHC programs. In ‘Information for Health Development’, Paul Freund and Katele Kalumba argued that in many cases health systems data was unavailable, and that which existed was of ‘doubtful value’. One problem was that health information systems ‘imported from developed countries overemphasises the role of curative care in combating disease, reflecting little of prevention or other health maintenance inputs’. In some cases data collection was not so timely, with a lapse, as long as 4-5 years in some cases, between collection and the compilation and publication of results. In ‘Look, listen and learn : preparing the ground for primary health care’, Shirley Buzzard warned that where there were no clear objectives for data collection a ‘shotgun’ approach was used – asking a little about everything but not much about anything. Data collection had indeed become a part of PHC programs, to identify common health problems, but questionnaire replies frequently confirmed what was known already; that poor housing, low income, ineffective water supplies and sewage systems led to poor health. More damagingly, survey taking could give the impression that people were being listened to and steps taken to address their complaints, expectations which might later be dashed if the surveys were not followed by action. Logistical problems, such as the lack of stationery and questionnaires and inefficient mailing systems, also stifled efforts

More damagingly, whilst some program planners tended to overlook existing sources of data which might have helped avoid duplication of efforts, others overlooked the input of the communities they intended to help. Worryingly in the context of the wider aspirations of the Alma-Ata declaration, some surveys involved little or no participation from community members.

The articles also reflected on some of the responses developed to deliver better data for improved health, and agreed unanimously on the necessity of community involvement in planning and collecting data. In ’Gathering information for health’ Evangeline Suva reported that the ‘few and simple tools’ used in lay reporting in Manila provided a clear picture of the health scene and helped people to be self-reliant in health matters. The articles by Freund and Kalumba and Buzzard suggested that children should not be overlooked as potential data collectors as they were keen and dedicated observers. In addition to questionnaires, Buzzard advocated using anthropological approaches including participant observation, life histories and interviews, because they provided data as well as identifying community belief systems that affect behaviour. Life histories could reveal critical information for maternal, child health and family planning programs. She suggested that ‘listening may be one of the most important skills a health promoter can develop’.

Involving community did not just result in more relevant and useful data but also helped inspire a deep-seated concern for health issues. Freund and Kalumba detailed how, in Zambia although intended for monitoring and evaluation, community participation in data collection created linkages between CWS, schools and health centres united in a common purpose. Involving children in data collection was practical and logical, but also helped spark an interest in the health of the community from an early age. The overarching conclusion was that listening to local concerns and involving communities in the planning, collection and analysis of data provided a better way forward regardless of the country or region.

This is just a brief snapshot of the conclusions drawn from a small sample of programs, but sets out some interesting considerations when looking at the aims of data analysis, the problems of collection, and how these were overcome or worked to the advantage of communities in the 1970s and 1980s. Towards the end of 2016, to mark Universal Health Coverage Day the WHO launched a new data portal aimed at tracking progress towards universal health coverage (UHC) around the world. The portal shows where countries need to improve access to services and where they need to improve information. At the launch the then WHO Director General Dr Margaret Chan said that ‘Any country seeking to achieve UHC must be able to measure it…Data on its own won’t prevent disease or save lives, but it shows where governments need to act to strengthen their health systems and protect people from the potentially devastating effects of health care costs’. (www.who.int/mediacentre/news/releases/2016/portal-universal-health/en/). This marked a very twentieth century response to a decades-old preoccupation.


References:

[1] Work of WHO 1951, 4.

[2] The Declaration of Alma-Ata, 1978.

[3] Shirley Buzzard, ‘Look, listen and learn : preparing the ground for primary health care’, World Health Forum 6:4 (1985); Paul J. Freund & Katele Kalumba, ‘Information for health development’, World Health Forum 7:2 (1986); Evangeline Suva, ’Gathering information for health’, World Health Forum 7:4 (1986)

'A world that counts?' Contexts of health: Information for Health, Global Health Histories Seminar 101

Do join us live online for Global Health Histories Seminar 101: 'A world that counts?' Contexts for Health, Information for Health' on Thursday, 22nd of June 2017 (12:30 pm CEST). Broadcast live over the internet, via webinar: http://www.euro.who.int/ghh

In today’s world, an enormous amount of information about our life (and death) is being recorded as data. Health is no exception. We are surrounded by numbers, from statistics on well-being and quality of life to epidemiological data that can help fight disease and even predict epidemics. In fact, a recent UN report about mobilizing the data revolution to support sustainable development describes our world as “a world that counts”.
However, there are many important social, political, and cultural factors that influence the process of collecting, producing, analysing, and managing quantitative data. This panel discussion will explore the cultural contexts of data and the powerful potential for (and possible pitfalls of) ruling the world by numbers.

More details available via https://www.york.ac.uk/history/global-health-histories/events/ghh-seminar-101/

Vital Statistics: The problem of exploring the burden of Non-communicable Disease (NCDs) in Sri Lanka, 1950-2000

In the run up to Global Health Histories Seminar 101: 'A world that counts?' Contexts of health: Information for Health’ (https://www.york.ac.uk/history/global-health-histories/events/ghh-seminar-101/) we are taking a look at the health data issues present in the work of our colleagues on the ‘Local Bases of Global Health’ project. We asked Dr Margaret Jones, a research fellow at CGHH, to reflect on her work on Sri Lanka.

My research on primary health care policies in Sri Lanka in the period 1950-2000 (https://www.york.ac.uk/history/staff/profiles/jones/) has entailed an exploration of the burden that NCDs have imposed on the health services of the island and its population. The demographic and epidemiological transition that Sri Lanka underwent in this period arising from declining death rates, increasing life expectancy, a decline in infectious disease and an ageing population, brought NCDs to the forefront of the island’s disease burden.

NCDs therefore form a significant part of the primary health care story. But a major obstacle, for both contemporaries and historians, to assessing the significant problem that NCDs presented is the lack of reliable and extensive statistics on the morbidity and mortality from the most common ones – heart disease, cancer and diabetes. Throughout this period the reliability of mortality and morbidity statistics generally cannot be taken for granted but finding information on the prevalence of NCDs presents a particular challenge. The health authorities made little attempt to collect data on NCDs, quite reasonably focusing their constrained resources on the far more pressing problem of infectious diseases. The mortality and especially the morbidity NCDs caused remained almost entirely undocumented. Extensive statistics on the special campaigns against the infectious diseases – malaria, tuberculosis, leprosy, filiariasis and VD - for example, appear assiduously in annual medical reports, health bulletins and the weekly epidemiological reports issued by the Health Department. But data on NCD morbidity could only be obtained from hospital admission records. Sri Lanka, alongside other developing countries, did not have the resources to collect population-based morbidity statistics.

As awareness of NCDs developed from the 1980s onwards the annual health bulletins pointedly and repeatedly highlighted this knowledge gap, noting that hospital records were the only source of data on morbidity, and that they could therefore present only a partial picture of the burden. There was no data, as for example the 1992 Annual Health Bulletin explained, on those who “were admitted to Ayurveda and private hospitals, and the large numbers who were attending the outpatient departments of Government medical institutions, dispensaries of private practitioners and offices of Consultants”. Furthermore, “the private sector comprising of western and traditional medicine, accounts for 55 per cent of the patient load which is mainly outpatient management”. Added to this there was the factor of self-medication, facilitated at this time as highlighted in this Bulletin by the “laxity of the Cosmetic Devices and Drugs Act which permits the purchase of a wide range of drugs without professional prescription”. The Bulletin concluded therefore that, “the morbidity load, as indicated by statistics obtained from Government hospitals is only the tip of the iceberg”. (Annual Health Bulletin Sri Lanka, Colombo: Ministry of Health, 1992).

The result is that the burden of NCDs was largely invisible for much of the period of my study and it was only as the demographic and epidemiological transition in Sri Lanka took hold that attempts were made to make them visible. But, still determined by the lack of resources, this could only be done through population surveys varying in size, population profile and geographical coverage. These surveys have, however, led one contemporary to talk of an “explosive epidemic of NCDs”(Premaratne, Amarasinghe and Wickremasinghe, “Hospitalisation Trends due to selected non-communicable diseases in Sri Lanka, 2005-2010, Ceylon Medical Journal, 50:2, June 2005). In terms of epidemiology NCDs are now being given due prominence in the health policy landscape and increasing attention is being given to assessing their true prevalence in order to facilitate the implementation of effective policies to reduce the threat they pose.

Five Lessons from the Archives of the History of Medicine in Ghana

CGHH PhD student Ben Walker recounts his archival fieldwork in Ghana, with tips for researchers

'Making Friends and Acknowledging People: Five Lessons from the Archives of the History of Medicine in Ghana' by B. B. Walker

Searching through the archives for material to put together a history of medicine in Ghana can be a challenge. Getting the right letter from the right person or physically locating the archive for example, can often involve a far greater effort than actually reading the documents themselves.

Unlike for histories of Europe and North America, Ghana’s historical record is not to be found in vast libraries of catalogued papers (though it must be noted, the Balme Library at the University of Ghana has an excellent stock of a wide range of government, media and academic publications). Its past is in people’s homes, in their funeral brochures, in church storerooms and in obscure corners of hospitals. This is not because Ghana is more ‘primitive’ but because it has not had the stable institutional capacity to maintain a full national archive since the years of its independence from British rule in 1957. Coups, economic collapses and revolutions have led to the loss of large swathes of written material.

The research may be more physically grueling but it is no less rewarding. Ghana’s records are a patchwork, but no less worthwhile or valid than any of the red ribbon-tied bundles one might find at the British National Archives in Kew. For those who wish to try it for themselves, here are five key tips:

1)     Get Signatures: To get into PRAAD (Public Relations and Archives Administration Department of Ghana) you will need a signature on an official archive document in order to be allowed in. This signature can best be obtained from a friendly academic colleague at the University of Ghana. It cannot be obtained from the British High Commission (yes, I tried). You may have the option to try to get the form in advance and have a Head of Department from your own institution sign it, although I cannot vouch for this route.

2)     Make Friends: Your best pathway to understanding anything about the country of which you are researching is to get to know the people and fellow researchers. Ghana is no different. My research would have been much more problematic had I not received help at every turn by incredibly kind Ghanaian academics, students, librarians, businessmen, solicitors, fashion designers, doctors and hoteliers. Not only will this likely facilitate your only access beyond the national archive storehouses, it will make the whole thing make far more sense and be far more fun.

3)     Interview, interview, interview: I conducted many interviews with many elderly Ghanaian doctors and clerics, each of them with their own surprising and important insights. Obviously the aim is not to take on their opinions as your own. Sometimes these interviews tell one far more about present concerns than about past ones. Nevertheless, actually talking to people involved is vital if one is to get a sense of what is beyond the written record, what has been hidden and what was never recorded on paper. By listening to the voices of individuals historians can counter the claims of the powerful to control the national past.

4)     Go West: Many of Ghana’s best-written historical material can be found in the UK and the US, even material after the end of colonialism. Copies were made and stored more effectively and systematically. As Jean Allman recently emphasised in her article on Ghana’s archives on the Nazi Pilot named Hanna, a history of Ghana requires travelling all across the world.[1]

5)     Tip and Acknowledge: Making friends with local librarians and taxi drivers, both of whom are vital to any good historical work often requires good tipping and payment. Buy gifts for those who help you out. Pay when you are given photocopies. Many of these people have little money. Don’t forget about their real lives beyond the archive. Secondly, there are terrible historical relations between European researchers and African communities because of broken promises in the pursuit of information. If you promise something, deliver it. If you publish something, send it to the people that helped you and of course, acknowledge them. Finally, don’t forget that you are a guest.

Overall, the value of the archives (whether in the sense that one might expect or not) to be found in Ghana far outweighs the difficulty of accessing them and connecting to their keepers. They can shed light on histories that have for too long remained disclosed, submerged in imperial and post-imperial narratives constructed from the records of the powerful. Whether or not you ever choose to study Ghana, the principle can be generalised. Attempting to uncover hidden histories matters if scholars are to continue confronting the assumptions of their audiences and to extend their own understanding beyond previous expectations. If we do not, we will continue to misunderstand, misinterpret and demean cultures and pasts which look unlike our own.

[1] Jean Allman, “Modeling Modernity:  The Brief Story of Kwame Nkrumah, a Nazi Pilot Named Hanna, and the Wonders of Motorless Flight.” In Peter Bloom, Takyiwaa Manuh, and Stephan Miescher, eds. Modernization as Spectacle.  Bloomington, IN: Indiana University Press, 2014, 229-43.