Offline: Africa—the incarceration of a continent

Abstract

What is the future for Africa? A bleak case is made powerfully by Tim Marshall in his book Prisoners of Geography (Elliott and Thompson, 2015). His premise is that the land on which we live shapes us all. “The physical realities that underpin national and international politics are too often disregarded”, Marshall writes. Geography explains the why of nations. It is the “decisive factor in the course of human history”. That truth is the reason geography is ignored by those concerned with improving health. It doesn't match our belief that knowledge is a more important determinant of human progress than inanimate landscapes. But Marshall contends that nature is far more powerful than any person. Africa has poor natural harbours for modern shipping. Its rivers can't support trade. Thousands of languages have prevented one unified culture from making an impression on world affairs—”The exchange of ideas and technology barely touched sub-Saharan Africa for thousands of years.” European colonialists drew lines on Africa's map that suited their own interests, a legacy that continues to impede Africa's advance even today: “Many Africans are now partially the prisoners of the political geography of Europeans.” Marshall gives persuasive examples to prove his case. The Democratic Republic of the Congo, a Belgian colony from 1908 to 1960, is (thanks to “the imposition of artificial borders”) too weak to be more than “the most under-reported war zone in the world”. Ethiopia's construction of the Grand Renaissance Dam may trigger a water war with Egypt. Nigeria's mismanagement of natural resources, not least its oil reserves, has worsened not ameliorated the country's inequities. Although many African countries have made gains in health, most remain constrained by their geographies and colonial histories. Last week saw the conclusion of WHO's annual Regional Committee meeting for Africa. The reports presented in Addis Ababa told a very different story from the one presented by Marshall. African countries projected a vision of industrious and successful agency. Solving the challenges of health security; learning lessons from the Ebola virus outbreak; advancing women's, children's, and adolescents' health; ending tuberculosis; defeating HIV/AIDS; controlling viral hepatitis; achieving sustainable development; creating a public health emergency fund; regulating medical products; protecting health and human rights; improving disaster risk management; ensuring healthy ageing; prioritising oral health; seizing the opportunity of eHealth; strengthening health information systems; exploiting traditional health; building human resources for health; and launching a new Centre for Disease Control. All of these programmes were embedded in a plethora of global and regional strategies, implementation plans, multisectoral actions, frameworks, and progress reports. It was an impressive manifesto of activity. And this was the work of only one international agency. If one assembled the contributions made by all governments, multilateral bodies, civil society organisations, the private sector, and health professions, one would discover a continent characterised by energy and hope. But what value are energy and hope if the natural and historical barriers to Africa's progress seem so insurmountable? When Matshidiso Moeti was elected Director of WHO's African Region in 2014, she launched what she boldly called a “transformation agenda”. She identified people as the most important ingredient for success. She was right. And yet it is among its people that Africa has been badly let down. The lack of sustained and credible political and technical leadership across the continent is enabling geography to defeat human creativity and ingenuity. The astonishing fact is that no major political figure since Tony Blair (remember his Commission for Africa, launched in 2005) has sought to take Africa seriously. Africa does not need to be permanently incarcerated by its geography. But the continent's release from its natural prison depends on outstanding leadership. Take one example: the leadership of WHO itself. In less than 5 months, WHO's Executive Board will select up to three candidates to succeed Margaret Chan as Director-General. As the campaign begins in earnest, now is the best moment the world has had for a decade to make Africa what it should be—global health's most pressing political priority.