He was also skeptical of the expanding reach of the state and NGOs as they responded to Cyclone Jokwe. Why was it they distributed mosquito nets from house to house rather than allowing people to collect them at the hospital? he wondered. Why did they bring food aid directly to Curuhama rather than have the villagers pick it up somewhere? Equally suspicious was a cache of shovels and gloves the Red Cross had left in a nearby village. Mutumuara had never seen anything like it before.
The connection between cholera and the wave of distributions following Jokwe was, to him, obvious and indisputable: “They distributed mosquito nets to everyone, and four months later, this illness appeared,” he declared defiantly. How could one draw a different conclusion? “Not even fifteen days ago, they distributed more mosquito nets and I refused,” he ventured. “Tenho medo. I’m afraid, I’m afraid,” he said, repeating the phrase three times over. “If I feel I need one, I’ll go out and buy one.”
Momade Mutumuara spent two months in jail after taking part in the cholera-related violence that spread throughout Liupo in 2009. To him, the link between cholera and the Red Cross’s relief work after Cyclone Jokwe was obvious and indisputable: “They distributed mosquito nets to everyone, and four months later, this illness appeared,” he said.
Mutumuara was similarly suspicious of Passarinho, seen during the outbreak as a co-conspirator of the Red Cross volunteers—in part, of course, because the Red Cross used líderes comunitarios as liaisons to plan trainings and demonstrations. As a community leader, Passarinho had traveled to Inhambane, in southern Mozambique, for a special workshop with the government. When people in Curuhama asked about it, Mutumuara said, “He just said to us, ‘Don’t complain: when you see me eat rice, I’m eating my pen. When you see me eat cookies, I’m eating my pen’”—a swipe, as Mutumuara understood it, at illiterate neighbors like him.
Most telling of all, though, was Mutumuara’s response to the twelve bicycles given to Red Cross volunteers in Curuhama to assist with their work after Cyclone Jokwe, a subject he raised unprompted. “Could it be that the government only knows twelve people in all of Curuhama?” he asked. “Is that supposed to be help? If it’s help, it’s supposed to help everyone.”
This last gets at a fundamental question over the basic relationship of people in places like Curuhama with their government, which is to say, at best, almost none at all, and, at worst, a hostile one, with interactions perverted by patronage and bribery or run through with a kind of arrogance. In this context, a violent response to a public health campaign takes on a different sheen, as Joseph Hanlon writes in an essay called “The Panic and Rage of the Poor”:
Objections to chlorine may be scientifically unfounded, but reflect a well-founded social and political understanding. If a nurse or health post worker normally demands a bribe to provide proper treatment, why should they be trusted when they say they are giving chlorine free? If an arrogant NGO helps only a select few, why should it suddenly be trusted to help the poorest on a key health issue? If government actions have only led to increasing poverty and loss of jobs, why trust the government now? And if local chiefs and party secretaries have used their links with the outside to collect taxes and increase their own power, why should they be trusted to help now? The poor have every reason to ask if the sincere priests and health workers and NGO staff sent into rural areas are not just an attempt to build up trust so that the poor can be better exploited. And they have every reason to distrust the local leaders who ally themselves with the new outside exploiters.
In a time of hunger when people see no hope of improvement in their lives, perhaps the passive and violent resistance to putting chlorine in local water supplies should be seen as local people making a desperate attempt to regain some power; as a disempowered group finally taking a stand to defend its very lives.50
In 2002, a team of researchers led by the sociologist Carlos Serra undertook an ethnography of an even more destructive wave of cholera violence that swept across Mozambique in 1998–99. Serra called the resulting book Cólera e catarse, or “Cholera and catharsis.”51 In one exchange, in Memba, where residents had risen up to resist a water treatment campaign by Save the Children, a régulo explains their point of view as follows: “People ask the government to spray their cashew trees”—presumably to cut down on the losses from pests. “The government doesn’t do it, because they say it costs a lot of money. So then people start to question things: ‘They can’t spray our cashew trees, but they can find money for chlorine.’”52
Serra finds the roots of the mythology that drives cholera riots in a sweeping tableau of deprivation: bad water, agricultural pests, declining fisheries, literal hunger along with hunger for basic infrastructure like brick-and-mortar schools (as opposed to straw and mud), the arrogance and derision of public officials. The list goes on and on.
Out of all this, Serra argues, arises a potent symbolism hostile to the state and everyone who touches it. “It is not the State as such that is targeted,” he writes, “but the absent, non-dialoguing state, with no sustained contact with communities, incapable of giving up its demands for political loyalty in exchange for providing of basic services.”
Cholera is caused by the Vibrio cholerae bacterium, believed to have originated in the Ganges River delta, in India, and now endemic in more or less virulent strains throughout much of the world. Like new strains of influenza, or citrus psyllids, cholera has become an extraordinarily successful migrant in the age of world travel, finding a foothold in Africa in the early 1970s.53 With proper hygiene and/or immediate access to basic medical care (mainly rehydration), cholera is a preventable and highly treatable illness. But it can also prove fatal in the span of a few hours and spread incredibly quickly.
Cholera first appeared in Mozambique in a Maputo hospital ward in 1973.54 It was a tiny outbreak—five cases and one death—but by year’s end, cholera had surfaced in half the country’s provinces, affecting eight hundred people. Abetted by war, drought, and massive population growth, it would spread throughout the country over the next two decades.
Between 1980 and 1991, the aggregate population of Mozambique’s largest cities doubled as fighting in the countryside drove people to the security of urban centers. The plumbing was not ready for them; the incidence of cholera over the same period tracked neatly with population growth.55 This was the same trajectory cholera followed in nineteenth-century Europe, as it spread along waterways and railways that connected the booming population centers of the industrial revolution. “As [cholera] arrived in the mushrooming towns and cities of a society in the throes of rapid urbanization,” writes the historian Richard Evans, “it took advantage of overcrowded housing conditions, poor hygiene and insanitary water-supplies with a vigour that suggested that these conditions might almost have been designed for it.”56
By 1991, one survey of Mozambique’s piped water systems—already few and far between—found that 80 percent had no way of treating the water that traveled through them.57 In the country-side, drought disrupted an already precarious water supply: rivers and wells dried up. New wells had to be dug, sometimes in areas already dotted with latrines.
During the first months of 1992, while negotiators were hammering out the terms of a peace deal to be signed in Rome that year, a cholera outbreak in Tete Province was on its way to infecting more than thirty thousand people and killing seven thousand.58 Cholera continues to be a major problem in Mozambique: in the decade ending in 2015, there were more than fifty thousand cases and five hundred fatalities from the disease.59 Still, both the incidence of and the mortality from cholera have declined incrementally since the late 1990s, suggesting both hygiene and sanitation and access to treatment during emergencies have improved.60
“Overall, the tendency is toward fewer diarrheal illnesses,” Francisco Sumbane told me. Just how much is hard to say. Sumbane is a WASH engineer with the Swiss organization Helvetas who has worked on sanitation in northern Mozambique since 1979. In Cabo Delgado, he to
ld me, “you could look at the statistics and think that a whole community is without latrines, even though everyone has one.” Official figures on sewage and latrines kept by Mozambique’s public works ministry don’t include unprotected (i.e., uncovered) wells and traditional latrines, making it hard for organizations to get an accurate picture of practices on the ground.61 Distribute large cement disks used to cap so-called improved latrines, Sumbane said, and you might return months later to find them used as washboards for doing laundry.
Alternately, drill a well in a community where there’s only a precarious living to be had from the soil and no technical or financial support for agriculture, Sumbane said, and it could soon outlive its usefulness. “There are some places [in the countryside] where you’ll find pumps that are very isolated, with no houses nearby,” he said. “The people have moved: you could be building WASH infrastructure every year for new communities.”
Even in areas where people stay put, he said, “The population is growing faster than the level of services being provided.”
Sãozinha Paola Agostino, who was chief medical officer for the provincial health department in Nampula when we met in 2012, told me then she believes the incidence of cholera-related violence is diminishing too, though it’s not something the government has studied directly.
In Nampula, the provincial government and its nonprofit partners have accelerated hygiene education campaigns using pamphlets, workshops, and radio spots. “The population must understand the pathology,” she said.
But the contours of the problem go beyond the scope of the Ministry of Health. “We will not be the entity to solve these problems,” Agostino said. “You can’t say that people are doing this out of a lack of understanding, because violence happens in areas where there have already been efforts at sensitization.” Here, Agostino seems to be caught up in a fallacy that assumes that education efforts are effective. The core issue isn’t whether information on cholera is available, but whether it’s credible.
On a second trip to Mogincual during the rainy season in 2016, I visited Iaué, a community a short ride from the district seat in Liupo, and the one that suffered the heaviest losses in the debacle that followed the cholera unrest in 2009.62 Seven men from Iaué were among those who died in the police station that March, having been arrested, in the police’s version of the story, for doing “night patrols” and stealing a motorcycle belonging to a Red Cross volunteer while they blocked the road.
Many people in Iaué, it turned out, had been to a WASH workshop put on at the hospital in Liupo. The basic message on cholera they’d taken away from the event, in the words of a woman named Terezinha Momade, was that “this disease comes from filth, from not having a latrine, not washing your plates and pots. But,” she countered, “when our ancestors lived here a long time ago, they didn’t wash their pots and pans or their plates, but that illness never came. Now that hygiene has started to show here—everyone has latrines, everybody cleans their house—that’s when cholera comes. Well, where does it come from? If they say this illness comes from a lack of hygiene: we always keep our homes clean with hygiene, and it still comes.” When people made this comparison for the health workers giving the presentation, Momade said, they were told, “You can’t count on old logic.”
Terezinha Momade, center, and her neighbors in Iaué remain skeptical of the hygiene and sanitation workshops they’ve attended at the hospital in Liupo. “When our ancestors lived here a long time ago, they didn’t wash their pots and pans or their plates, but that illness”—cholera—“never came.” Seven men from Iaué were among those who suffocated to death in the holding cell in Liupo in 2009.
There was truth on both sides. Diarrhea writ large has been a scourge around the world for centuries, helped along by the “old logic” of going without latrines or antibacterial soap, or drinking untreated water. But to the people in Iaué, cholera was something different—diarrhea that could spread from village to village or rip through a neighborhood overnight, bringing quick and certain death. Both the disease and the quick population growth that made it so deadly had come to Mozambique within living memory. Even without access to a timeline of cholera’s spread in Mozambique, people in Iaué had made an important observation: cholera was actually a relatively new phenomenon in the region, virtually unknown in much of the country until the 1990s.
I’d been talking with Momade and a group of women under her porch while a hard rain fell outside. The group shook with laughter when I asked if they trusted the answer they’d been given at the hospital. “If you tell the truth,” Momade said, “you can go to jail.” Of course, they might have been misremembering the exact words, or misunderstanding their meaning in the first place, but the takeaway was the same. To them, the information they’d been given about cholera—or, at the very least, the messenger—simply wasn’t convincing.
Over time, cholera riots can be expected to wane along with the prevalence of the disease in Mozambique. But it is too soon to discern the future of either phenomenon: in the past, large outbreaks have been separated by intervals of as many as five or more years. Mozambique’s declining economic fortunes, high population growth, and vulnerability to the floods and droughts of a changing climate all serve to exacerbate the challenges the country faces in addressing the underlying public health needs.
The relative calm officials have noted among communities where violence has occurred in the past may have as much to do with the absence of cholera as it does with a shift in attitudes about the disease and the people working to prevent it.
While cholera violence is, of course, linked to the disease’s spread, it is also controlled by another mechanism altogether. Contagion, fundamentally, is about whom you believe, and for close to two decades, disenfranchised people in the remote areas and urban slums where cholera violence has taken root have often chosen to believe their peers and their lived experience rather than their government.
One tragedy of the chaos in Mogincual and Angoche is that the official response to unrest seems in some respects to have reinforced the underlying problem of government credibility.
A report by the Mozambican League of Human Rights (Liga dos Direitos Humanos) based on fieldwork done in March 2009 concluded that press accounts of the unrest left out crucial parts of the story. Cholera prevention efforts during the outbreak in Angoche, for instance, had been undertaken without knowledge of the local community leaders: “Some health workers were discovered in the middle of treating wells with chlorine. Having little information, residents of Sangaje [in Angoche] thought they’d discovered a plot to contaminate the water with a drug that causes cholera. The misunderstanding resulted in a popular protest against the health workers that led to a deadly response by the national police.”63
“In putting down the protest, police fired on unarmed citizens, resulting in an unknown number of deaths, and detained 38 people in the district jail.” According to the authorities, the report continues, only eight of those detained were involved in the related violence—police, the report concludes, believed from the start that members of the opposition, Renamo—were to blame, and acted accordingly, rounding up people involved in the opposition.
In Iaué, a man named Danilo Martín said his brother, his uncle, and his nephew were all killed in the holding cell in Liupo. Afterward, people from the village spent four days outside the police station there demanding that the government return their relatives’ bodies, only to be told they had been sent to Nampula for an autopsy.
Ultimately, Martín said, people from Iaué had to scrape together money to get to Nampula and transport the bodies home for burial themselves. But the autopsy results were never revealed.
“I don’t know how long an autopsy takes to deliver results,” Martín told me, nearly seven years later. “We never got a judgment or anything at all about why our relatives were killed. That’s why we blame the government,” he said. “We’ll never stop saying the government is guilty of some things, because i
t is.”
The UN voted to draw down the peacekeeping mission in Haiti in April 2017, a few months after acknowledging MINUSTAH’s role in the cholera epidemic there.64 The announcement coincided with another damaging revelation from the Associated Press, that UN soldiers had spent years luring children in Port-au-Prince into a sex ring, and that UN investigations into similar misconduct were often closed inconclusively.65 The formal rationale for the UN’s withdrawal was that after a presidential election in November 2016, Haiti was finally on a path to political stability—that MINUSTAH’s job, in other words, was complete. But many in Haiti took the news to mean the opposite, welcoming the UN’s departure as vindication after years of unheeded criticism.66
There’s been no evidence of similarly malevolent plots by NGOs or by the government in Liupo since 2009, but that hasn’t stopped each side from drawing exactly opposite conclusions from the cholera violence. For officers of the Ministry of Health in Nampula, the absence of further unrest in recent years is an indication that medical knowledge of the disease and its causes has increased. For the people in Iaué, the lack of closure on their relatives’ deaths at the Liupo police station is ample proof that you can’t safely speak your mind to the government; and for the people in Curuhama, the fact that cholera hasn’t come back since the Red Cross stopped talking about it shows they were right to defend their community against outside meddling.
Florencio Vasco, a nurse in Nampula who supervised a health post in rural Mogincual until the cholera violence of 2009, argued that education on hygiene should be integrated into primary school, a lesson learned year-round and beginning in childhood. “Sensitization cannot simply be during outbreaks, because then the population will begin to say: ‘Here comes the time for them to kill us,’” he said. “Children should grow up knowing how cholera is spread. As long as the population doesn’t understand the means of transmission of the disease, things will not improve.”
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