N°3 Automne 2001
SANTÉ ET MALADIE : QUESTIONS CONTEMPORAINES
Els van Dongen
It is almost a decade ago since Ahmed and Shore have published their book “ The future of anthropology. Its relevance to the contemporary world ” (1995). The book asked some provoking questions : Is anthropology relevant to our lives today ? Does anthropology have anything to contribute ? Ahmed and Shore argue that after the “ crisis of interpretation ” anthropology has a “ problem of relevance ” and that the discipline is “ in danger of being marginalised and redundant unless it adapts to the changing world which now threatens to undermine its cherished theories, methods and practices ” (1995 : 15). The authors argue further that the anthropologist’s position as an expert presenting an objective account of native life is untenable, because the natives are likely to be educated, or as Frankenberg (1995) has put forward : “ The natives can speak for themselves ”. The possibility of making generalisations about a society are problematic since these societies have become increasingly heterogeneous, and because anthropology is challenged by other disciplines (media, culture studies, health sciences) or writers with anthropological interests.
Similar arguments are made by Moore and others in The future of anthropological knowledge (1996). These authors discuss the lack of politicalisation of knowledge production within the discipline (1996 : 3 and chapter 3) and focus on the differences of explanatory power within the discipline. They view anthropology as a range of different practices carried out in a variety of social contexts. Both, Moore (1996) and Ahmed & Shore (1995) stress the importance of knowing how anthropological knowledge is used (moral significance).
Kleinman (1995) has taken up the question of relevance for medical anthropology in Writing at the margin. He states that medical anthropology is at the margin of medicine and at the margin of anthropology. However, Kleinman continues, “ it is only at the margin that we can find the space of critical engagement…” (1995 : 5). He argues against the medicalisation of trauma and suggests that the main contribution of medical anthropology can make is the specification of “ how processes that make biomedicine effective as a technical rationality and strategy of social action so often become, under particular political and economic regimes, a barrier […] to improved health and good-quality health care ” (1995 : 17). He also suggests that anthropology can provide “ alternative ways of responding to human problems ” (ibid.). Like Moore (1996), Kleinman argues for a variety of approaches and the use of theoretical concepts as “ power ”, “ hegemony ”, “ resistance ”, “ social suffering ”, “ pluralism ” and “ change ”. For others (Singer, 2000 ; Johnson and Koss-Chioino, 2001) medical anthropology seem to suffer from the division between academic and applied anthropology, and between public health science and applied anthropology. For them, the discipline needs to be made more relevant, not by stressing the differences between disciplines with overlapping goals (to promote health and decrease illness and distress), but by focusing on commonalties with respect to different theories, methods and practices.
Violence as a focus for medical anthropology
In the last decade, the study of violence and its consequences became a focus of research for (medical) anthropology (for example Das et al., 2000 ; Nordstrom & Robben, 1995 ; Scheper-Hughes, 1992 ; Taussig, 1987). These works show that violence is not an event in particular countries or regions ; it is everywhere – in any country, in the prisons of dictatorial regimes, in the cities, in rural areas, in people’s houses. Besides, the experiences of violence are not restricted to war, upheaval or physical violence, neither is violence reducible to a fundamental dimension of human behaviour. The fear of older people to be robbed on the streets or to be accused of witchcraft, the anguish of women on the Cape Flats of Cape Town to be raped when coming home from their work, the fear of an Ethiopian villager to step on land mines, domestic violence, the fear of organ theft, the fear of a gang of youngster with guns in their hands ; it are mundane and not so mundane experiences of violence that people have to face. As Taussig (1987) pointed out, violence is “ slippery ” and escapes any explanation. Yet, it is a cause of human suffering and distress. Violence, Nordstrom and Robben (1995) believe, is “ a dimension of people’s existence, not something external to society and culture that ‘happens’ to them.” The temporary global developments are often seen as symptoms of a profound crisis, characterised by high risk, ruptures, chauvinism, xenophobia, nationalism and fundamental dislocation of people and social relationships. Kroker and Cook (1988 : 1) describe present modern cultures as “ panic cultures ” : “ panic sex, panic art, panic identity, panic bodies, panic noise, and panic theory. ” Many others have described the present world as a place where crisis, violence, globalisation and fragmentation lead to “ sequestration of experience ” which means “ that for many people, direct contact with events and situations which link the individual lifespan to broad issues of morality and finitude are rare and fleeting ” (Giddens, 1991). In short, the world seems to have become a pandemonium ; a “ wild ”, “ chaotic ” place.
The consequences of the pandemonium for health and well-being of people are so compelling that they push to the foreground scholarly and public attention, even to the point that critical scholars protest against the emerging “ trauma business ”, in which the “ jargon of democracy and civil society place a peculiar focus ” upon the victims of violence. In dealing with those consequences medical anthropology has come to the point that it cannot throw out the uncomfortable questions of the relevance of its theories, methodologies and practices.
Medical anthropology has always been a means, not an end. For many medical anthropologists it is a means for social ends ; i.e. improvement of the health situation and well-being of people, improvement of patient-doctor communication, empowerment, problem solving, culture-sensitive implementation of health programmes. Its critical branch asserts “ that its mission is consciously emancipatory and partisan : it aims not simply to understand but to change culturally inappropriate, oppressive and exploitive patterns in the health arena and beyond ” (Singer and Baer, 1995 : 60). Others have stated that “ the study of how people in a particular society see and deal with illness provides a privileged and sometimes even indispensable means for understanding that society ” (Fainzang, 2000) ; in this case medical anthropology is a means for anthropology. There should be no doubt about medical anthropology’s commitment to injustice, inequality, repression or human suffering. For scholars like Scheper-Hughes (1992) and Taussig (1987) it is a duty to speak out against injustice one encounters.
The study of violence and its consequences by medical anthropology has examined the processes through which violence is produced and consumed. Most ethnographic accounts show how everyday lives of people are transformed by violence. In these cases, the relevance of medical anthropology is that the discipline is able to show “ how people engage in the tasks of daily living, re-habiting the world in the full recognition that perpetrators, victims and witnesses come from the same social space ” and that they “ analyze not only the explicit acts of bodily harm that occur in violent conflict but also the more subtle forms of violence perpetrated by institutions of science and the state ” (Das et al., 2000 : 2). It is the study of everyday lives of “ ordinary ” people, who will have to deal with the disappearance of taken-for-granted contexts, distorted social relationships, mistrust, uncertainty and changed cultural structures that makes medical anthropology relevant. However, to my knowledge little attention has been paid to a particular group in violent societies : the older people. The reason is not clear. In general, the study of old age has occupied a marginal place in medical anthropology. Yet, this study is relevant for several reasons. Firstly, a substantial part of the world population consists of older people (< 55 years). Secondly, older people are often “ good observers ” of their society. I will ground my discussion about relevance of medical anthropology in the problems that older people in the townships on the Cape Flats and in the centre of Cape Town experience with everyday violence and the accessibility of health care, because they seem to occupy a similar social position as the anthropologist : “ at the margins ”. They are part of what is seen by outsiders as violent and amoral places, but they are “ pilgrims through life ” (Bauman, 1992), having changed their social position when immigrating to cities or other countries, having their position altered again by violent regimes, and once again when their neighbourhood became “ place of chaos ”. These changes meant profound changes in feelings of self and changes in identity. Their lives seem to be fragmented by racism, discrimination, violence and poverty, and yet, they have managed and still manage to make sense of their lives.
There is a parallel with the anthropologist, although the latter mostly do not have to live permanently under similar conditions as the older people do. Ahmed and Shore (1995 : 20-21) have pointed out that in multicultural and fragmented societies “ classical ” anthropological fieldwork seems impossible, because there are no “ simple and remote societies the essence of which could be grasped after a year or two of fieldwork ”. “ Modern ” anthropology too, it seems to me, is often characterised by fragmentation and partiality of fieldwork. In societies with a high prevalence of crime and violence, fieldwork is even further fragmented ; the traditional practice of going into the field became untenable, not only for the safety of anthropologists, but also for the safety of the research participants. The partiality of anthropology’s “ toolbox ” may have consequences for theory and methodology. However, despite this partiality and other constraints, I will argue that medical anthropology can make an important contribution to the knowledge of contemporary worlds by studying the lives of older people under violence. Anthropology, notably by its methods participation and in-depth conversations is particularly suited to bring subjective experiences of people, which are also social experiences (Geertz, 1973) near.
Angelina, Constance and the others. Ordinary lives in violent times
Things beyond common human understanding can happen in the townships. When I was in a hospital, I heard a ninety two years old grandmother who was raped by her fourteen years old son. He also robbed her pension money to buy some drugs and beer in the shebeen. She was infected with HIV. Cynical minds would say : we share everything…, thereby referring to Ubuntu. Grandchildren can be kidnapped by gangs and older people might be robbed, while they are standing in the queue to collect their pensions… These events show that the lives of older people are firmly connected to what happened in the South African society.
Post apartheid, violence, social relations and older people
Before 1994 the South African State committed systematic violence against black and coloured people. The consequences of political upheaval, oppression and economic manipulation for many people were a dramatic rupture in social relationships and family life, loss of homes, kin, poverty, etc. This, in turn, has profound implications for the social relationships within the historical-colonial defined groups, and it is often stated that colonialism and apartheid have led to recent violence. It has also led to disbelief, cynicism and disappearance of cultural values and norms. For example, the ideology of intergenerational contract has been powerful in African societies. Cattell (1997) has described this intergenerational contract as a lifelong exchange relationship between grandparents, parents and grandchildren. Møller and Sotshongaye (1999) pointed out that rapid urbanisation and modernisation, as well as disruptive effects of labour migration and harsh apartheid laws had deteriorating effects on intergenerational and family relationships. The value system Ubuntu is met by people with cynicism or irony when they speak of everyday life in which crime became a rife. Older people have a harsh life in the townships. Many support an entire family with their pension money for which they will have to be in a queue every month for hours. Older people often suffer from “ indirect ” consequences of violence. It was very painful to meet a 76 years old woman who was almost on her knees and asked for domestic work, because she had to support her six grandchildren. The mother of the children, her daughter, was killed on a Saturday night out. The grandmother had no money to pay the school fees for the children. “ I can do everything, ironing, washing, cleaning, I need this job ”. Other older people are taking care of young children, whose parents died of AIDS. Hilde, sixty two, took care of 52 children from seven in the morning until five o’clock in the afternoon. She had three foster children, because “ their mothers had no money and ran away ; they were desperate ”. She cooked meals for the children and taught them Xhosa, Afrikaans and English. She runs a braai at the main road of Mfuleni to earn extra money for the children. “ The government gives me a little money and the mothers pay twenty rand a month. It is too little money, but if I don’t keep the crèche, the children will be in the streets and become criminals ”. Other older people have united themselves to “ run their own business ”, because “ at home, they are not abused, they are abused here (at the community centre), financially and mentally ”. The older people of Mfuleni came to the community centre several times a week. They had a meal at the centre and could talk, play, sing and be together without the sorrow of having to take care of children and grandchildren. This centre was run by younger people, who took decisions without consulting the elderly, although they were part of the committee that had to be consulted. One day, the elderly were told that there was no money left to run the centre. So, then they decided to try to sustain the centre themselves : “ Because we have decided as old people, we will stand for our rights until we go down to the grave ! ”
The South African state has been thrown into turmoil by the 1994 turn. Previously excluded populations are now involved in new forms of political and community practices. Associations, like the elderly centre above, The New Women’s Movement, politicised movements of ex-freedom fighters, Kgotla’s and so on, stood up for their interest and would fight everyday violence. They were sometimes supported by the government or international governmental and non-governmental organisations. The use of violence by police was denounced ; neighbourhood-watches and “ active citizenship ” were mobilised by the need to confront people’s fears. Security groups in the townships would take care for “ safer streets ”. However, the preoccupation with security could not prevent upsurges of criminal and political violence. The dynamics of violence were difficult to capture. A medical anthropologist may do fieldwork in the health care centres of the townships or in the hospitals of Cape Town. The image that emerges will be one of a chaotic, “ wild ” and dangerous society in which people are physically and mentally injured. Newspapers confirm this image by publishing photos and stories of missing persons, murdered people, raped women and abused older people. The anthropologist goes into the field and may witness the violence or talk about it with those who experienced it. The question is if narratives about violence — either written as an eye witness report or as an ethnography — are able to convey the suffering and traumas of people. And, if they do, what do they tell us about the dynamics of violence ? Is it violence of the young against the old, men against women, grandchildren against grandparents ? Most of the older people in my study have stated that after 1994 “ the blacks are fighting against themselves ”. But what does this everyday violence mean ? Is it “ terror as usual ” (Taussig cited in Scheper-Hughes, 1992 : 220) or has it become an institution of social control, which threatens the sanity of people and distract people’s attention from essential malpractice and failures of the state ? To examine how violence works and the effects it has on the health of people, medical anthropology must not limit itself to research in health care centres, or actual situations of people. Everyday lives and the historical dimension must be included.
To illustrate this, I will sketch the lives, reflections and experiences of two older people in Khayelitscha, a township on the Cape Flats, Western Cape Province. These older people have lived under apartheid, were forced to migrate to the urban areas, and many of them have lived in poverty.
Angelina was 74 when I met her during my fieldwork in Cape Town. She was one of the older people I work with in my research on older lives and remembrance. Angelina was born in Paarl where her parents worked at a farm. When she grew older, she worked there too : “ We used to plant, we worked with grapes, planting carrots ”. Together with her parents, she moved into Cape Town. She got married : “ Can you remember how you met your husband ”, I asked her. Angelina answered : “ He just grabbed me and went to tell my mother that she must not look. He has taken me as his wife. Llomala ”. She only stayed three months with her husband and got pregnant. She left him with nothing else than an old dress. She gave birth to her son at her mother’s house and got assistance of a person of the Salvation Army. She had to work for her son, her mother and herself in a “ white man’s house ” where she did housework, cooking and looked after the children. She liked her work and the people. After twenty one months her husband came to get his son. Angelina never saw her son again. When he was an adult, he died in a car accident in Kukuletu (another township on the Cape Flats). He had children “ of different women ”, Angelina told me, but neither of them visited their grandmother, except her granddaughter : “ She came once and she is not aware where I am. They did not come anymore. That hurts me ”. Apartheid had worried her. To illustrate what it had meant for her, she told a story : “ I was going to work and then this lady came. I said to her : O, that dress is nice. I was looking at a white lady. Then the lady said : You cannot praise me for that. But it was a nice lady and a nice dress. She got crossed. A policeman came and asked : Why did you look at that lady ? The lady didn’t like me looking at her. The man asked : What are you looking ? I said : O, she got a nice dress. The man said : You can go today, but those things mag nie (are not allowed). That was bad… ” At the time of our conversation, Angelina lived in an old age home. She was very scared of young people, who were “ cruel ” and “ killing one another and all those things ”. When she walked in the street, she always had the feeling that “ someone would grab ” her. Even in her house, she was afraid that someone would come in. Her windows and doors had iron gates, which were carefully locked when she was inside. For Angelina, history repeated itself ; she was still afraid to be “ grabbed ”.
Constance was also a woman who participate in my study. She was 82 years old and lived, like Angelina in Khayelitsha. She had a bad health and suffered from severe asthma. She had two explanations for her illness. The witchdoctors had told her that she caught Umsi wezube, the smoke of the thunder, when she was around the mountains in Transkei to pick up grass for the mats that her mother made to earn the living for herself and her children. The other explanation is that her asthma is caused because her mother suffered from umwbat alala, a fever of which many people in her village died. Her mother was so sick, that Constance was taken away. She could not “ drink from her mother’s breasts ”. When Constance was a young girl, she lived with her mother and four brothers and sisters in Transkei. They were poor. Constance married with a man who came to work in Cape Town. She stayed behind and sometimes travelled to the city, to her husband : “ for the children…trying, to task, to task, to task ”. Her greatest sorrow was not to get children. She had one miscarriage and did not get pregnant again. Her husband came to Transkei every holiday. Before he came home for the last time, he had spent one month in the hospital, because he had TB. He died at home. Constance was, after the prescribed mourning period, forced to go to Cape Town, because she had to take care of the belongings of her husband. When she had to fetch her pension, she had to travel to and fro Cape Town every month. She decided to live in the city. Constance too illustrated her memories of the time of apartheid with a story : “ I experienced little bad things, because at that time I stayed in Transkei. But when I came to visit my husband, I had to go to the magistrate and ask for a permit to come here. When I came here, I had to show the permit. That was written for three months only. So, I was allowed to stay here for three months. Just imagine. There was a place before you got into Cape Town, there was police. The bus was stopped and then we had to get out to show our permits. […] In train stations we were not allowed to sit on the bench on which was written “ for Europeans ”. If you had done that you were in trouble. […] So, at one day, as I said my husband was sick with TB, I came here. When I arrived at my auntie’s place, my auntie was staying in Langa. In the afternoon I took a little child with me and we went where the men were staying. […] There came a policeman and he said : Where is your permission ? We said that the permission was at my auntie’s place. […] He wanted six rand cash and then my husband gave the policeman that money… Even when I said that I had come to see my husband, he was sick,… he didn’t care. They didn’t care, they took the money. It was very bad at that time ”. Constance believed that in post-apartheid times are better. But she also thinks that now “ the blacks are fighting, killing one another ”. She had fear, because somebody could come to her and say : Ndiniki imali yakho!, we want money, or we kill. Constance thought that young people were “ rude ”, “ naughty ” and “ silly ”. She added : “ There were no minds like this in that time ”, meaning that when she was young, children obeyed their parents and went to school.
The big political events, the resistance and struggle were not the main themes in the stories and reflections of the older people. None of them was involved in political activism or resistance ; on the contrary, they told that they had tried “ to stay away from it ”. Like a man of 73 stated : “ I was never involved in the struggle for freedom. I didn’t know the point. You know, before you engage yourself in any activity you must first know the direction of the head (intliko). This struggle didn’t have any direction ; it was just hutshu, hutshu, hutshu ”. They told about the sorrows and “ ordinary ” suffering in periods of illness of themselves and family members, divorce, the immediate consequences of labour migration, loneliness at old age, and poverty. They told how they maintained their health or took care of their illness, which was according to the older people in my study not “ an easy thing to do ” because when they needed specialised care they had to travel a large distance to the city where the hospitals were.
Their stories almost sounded “ banal ”, something “ older people always complain about ”. The transformations of the stories, first into older people’s narratives and then into ethnographic accounts, had imposed order and reason on what had been experienced as chaotic. Lives lost absurdity, because “ inasmuch as violence is “ resolved ” in narrative, the violent event seems also to lose its particularity ” (Young, 1988 : 15). There was a difference between narratives about the past and those of the present.
Violence, young and old and “ the good times ”
The older people in my study were very concerned about today’s violence of younger people. They spoke about bad relationships between parents and children, and the lack of values and norms. Although few of the research participants were actual victims of violence, all of them had fear to be robbed, or worse. All of them knew other older people who were victims of violence and some of them said that during apartheid there was no such violence. Although many excellent studies showed that the relationships between family members have been disrupted by the effects of state violence (cf. Reynolds, 2000), this was not directly worded in the stories of the older people. It was told indirectly in narratives about the problems with registration, consequences of labour migration and separation of children and spouses. The older people did not directly mention state violence and its consequences as the cause of the recent violence. They were anxious and the danger came from within the communities and from outside. In case of violence within the communities, they often blamed “ television ”, “ drinking ”, “ drugs ”, “ too much freedom ”, “ parents having no time for their children ”, and unemployment, thereby pointing vaguely to what Giddens has mentioned “ modernity ” (Giddens, 1991) and Falk has pointed out as “ the consuming body ” (Falk, 1994). Other elderly blamed others from outside the communities or even from outside the country. Veronica, a woman in her seventies, lived in Woodstock, a central part of Cape Town. She “ thinks everyday of what can happen ”. She told : “ We live in this fear because they are bombing, they are just bombing. And there is a lot of burglary in the houses. And there is a lot of rape. […] I have been living here in Woodstock, it is not the people that come from here. […] It are the others that come and do. ” Similar accusations were made by older people in townships as Khayelitsha and Mfuleni. It were the militant branches of political organisations, like the Pagad, the refugees from Angola, gangs from other townships or even the older people themselves who were responsible for the violence and misfortune that people experienced in their daily lives. Older people sometimes were accused of witchcraft and this eventually would lead to burning the house of the older person, beating or even killing . The older people (and others too) thought that those others were “ barbaric ”, “ wild ” and chaotic. For some, the daily world seemed a pandemic cruel world. Joseph, an older man who lived in Khayelitsha, did not want to die in Cape Town, because, like he said, “ I don’t want to be buried in this hell ”. In Cape Town people responded to violence from particular political, social and economic standpoints, which made it difficult to grasp for example the situation of older people and the veracity of the stories they told.
However, my study seem to approve other studies that showed how older people have reasons to worry about intergenerational relationships and their position in society (cf. Glanz, 1991 ; Keikelame & Ferreira, 2000 ; Møller & Sotshongaye, 1999). Both, the studies of Glanz and Keikelame and Ferreira showed that older people are victimised and suffer from different forms of abuse. Møller and Sotshongaye showed that respect for older people suffered due to rapid urbanisation, modernisation, labour migration and apartheid laws. However, the elderly sad memories and recent anxiety were countered by other memories of those times. Angelina told : “ I was working … for Mrs McKinsey. It was quite nice. […] And they liked me too. When their mother was away, the children came to me. Supper, breakfast, oh, it was quite nice. […] He (the child she took care of) took me as mother. That was nice. Yes … white people. ” Of course there were exceptions, but it looked to me, that the older people — men and women — remembered the time that they worked in the houses of the “ white people ” as one of the best periods in their lives, together with times of their youth in Transkei or Ciskei. The older people’s positive experiences of the past suggest a similarity with to the outcome of a study of the Institute for Justice and Reconciliation in Cape Town  among 3500 people, which shows that one third of the black population in South Africa thought that despite abuse during apartheid, the idea of apartheid was good. Racial sentiments seem to be alive, especially in rural areas. The study mirrored the disappointment of people in South Africa in the changes of the country. Many people had the feeling that their lives are not improved. They were concerned about criminality and unemployment. They were worried about the problems with transport to health centres and shops. They were concerned about the long waiting hours in health centres. In these cases, the memories of the older people of the ‘good days’ in the past would fall in fertile grounds. On the other hand, those positive memories may be viewed as signs of “ internalisation of European epistemology about themselves ”, which has superimposed “ new values on their past ” (Makoni, 2000 : 243), and — in turn — may be countered by the sentiment which is worded in Coetzee’s Age of iron ; the older people left the initiative to the younger generations to struggle. Meštrovic has worded this entire collage of accusations, rumours, fear, emotional eruption, etc. as follows : “ repackaging of quasi-historical emotional vestiges from the past ” (1995 : 255). The questions are : Why have no studies on older people in South Africa highlighted this positive appreciation of the past ? What does it mean for the social relationships between historical defined groups ? What is the role of these emotional remembrance for popular sentiments and social memory ? What is the meaning for identity-making in the “ new society ” ? Why do those memories play a minor role in history making ? In the case of South Africa many stories are part of public (social) memory because of the work of the Truth and Reconciliation Commission, but also many others continue to circle in society’s backwaters. Therefore, to answer these questions is not a simple task. Focusing on one particular group may blur the complexity of the variety of ways in which violence affects people and the ways it is experienced. It may conceal the often hidden everyday rhetoric on violence that hangs over the research field like a fog and covers deeper problems.
Anthropological writing and fieldwork
The writings of an anthropologist always mean a selective narrowing of possibilities of explanations. To state that anthropology may give voice to — in this case — the experiences of older people of South Africa (i.e. Cape Town, i.e. the Cape Flats) would be a hyperbole and arrogant. The relation between writing and people’s experience has always been problematic. Besides, the act of writing about violence is not a straightforward matter. “ For Spivak, research and representation are irreducibly intertwined with politics and power. The anthropologist who proclaims to “give voice” to those less able to do so, warns Spivak, is often little better than postcolonial discourse refashioned for a postmodern world ” (Spivak, 1988 in Nordstrom & Robben, 1995 : 11). So, I am reluctant to say that my study “ gives voice ” to the lives of older people. Yet, I believe that fieldwork, anthropology’s showpiece, can make an important contribution to the understanding of people’s lives under violent circumstances. However, it is often constrained by power structures, danger (real or imagined), or historical relationships between the anthropologist and informants. It is not always danger or threat for the anthropologist. Sometimes, the anthropologist has to do things that go against the grain to protect his informants. For example, when we — my research assistant and me — were on a farm to talk to the older people, we met Auntie Sanne, sixty seven years old, in the kitchen of her boss’s house. She was ironing and had agreed to talk about her life. We sat on the chairs at the kitchen table, but Auntie Sanne stood against the kitchen sink. We asked her if she would like to sit down. “ Mag nie ” (that is not allowed) she answered. She had no choice than to stand in the house or to sit on the dustbin, although she felt “ vernederd en afgehou ” (humiliated and rejected). We could sit on the chairs, because “ that is different ”. We could have insisted, but what would have happened when her boss had come in ?
“ Close the doors, we are approaching the township ”.
Ethnography of health in places of anxiety
The townships on the Cape Flats in the Western Cape province, and the rural areas around Cape Town were an obvious choice for my research on memory, well-being and contribution to the communities of older people. This region is characterised by a sharp increase of rural to urban migration from the 1940s until now and the number of elderly people living in urban areas is increasing rapidly. Although there is much research on the problems of older people living in urban areas (Sagner, 1997 : 13), there is still a general lack of studies relating to the role of older people in the South African society after 1994 and their social and cultural contribution to “ the new society ”. There is also a general lack of anthropological studies on health and illness of older people.
Life on the Flats
The Cape Peninsula is one of the fast growing urban areas in South Africa and is known as an area where “ crime and violence have taken on “ epic ” dimensions and have changed life on the Flats in ways that was not thought possible ” (Baderoon, 2000). Much has been said about crime and violence in South Africa and about how to solve the problems. During the episodes of my fieldwork I could read the daily news about crime and the comments upon it. In the newspapers, the statistics of increase (and eventually decrease) of crime were published and I collected numerous personal narratives of those who became the victims. The discourse on crime was moral and stereotypical and simplified the problem. It tended to confirm racist stereotypes by focusing on “ black criminality and violence ”. The fear of crime lurched itself through the city and the rural areas around ; it showed itself in space and behaviour of people. People struggled to understand the processes that had lead to this violence, but cynically the public discourse on crime and violence had led people’s attention away from severe problems like unemployment, poverty, disease and many other structural social conditions in which violence occurred. This did not mean that one should not take people’s fear seriously. Violence was an immediate reality.
When anthropologists want to do fieldwork in such situations, they are kindly advised to stay away from “ troubles ” and to avoid taking sides or to become involved in conflicts. In the case of this particular field it is not recommended to stay overnight in the townships. How to behave in such situations is a topic over which little is written in anthropological manuals.
One may simply shy away from everyday violence and continues the research as it was planned. But to shy away from the fear and anxiety of others is the most difficult thing to deal with in the field. I was faced in an obtrusive way with those fears and anxieties in the Cape Peninsula, where the process of social polarisation due to violence and crime had reached an acute phase. When I drove to Khayelitsha with a colleague, a friend or a friend of a friend, I was advised to lock the car door, if it was not locked electronically. When I wanted to spend time in people’s houses, I had to honk before people opened the gate. The rattling of keys and chains accompanied my visits. The sound of keys and chains was already familiar to me, because I have worked in the closed wards of a psychiatric hospital. In those places the doors were locked to “ keep people inside ” ; here the doors and gates were locked to “ keep people outside ”. The image of myself, driving in a car with locked doors, staring outside to the people who walked home or tried to sell something at the traffic lights, and they staring inside the car became a symbol of the social relationships between different groups in the Peninsula society, and of the partiality of “ modern ” anthropological research. These events forced me to change my focus of research ; instead of focusing on remembrance alone, I decided to focus on the everyday lives of older people. Many local researchers in CT go to the health centres or other places in the townships “ to do their business ” and return to their homes or the university in the late afternoon or at night. However, it is possible to stay in people’s houses ; but it may be difficult to move around freely. Community leaders will have to decide whether the anthropologist may live in the community in one of the townships. Sometimes, they will refuse because, as they say, the safety of the people is under fire when an anthropologist stays. Or, they may ask substantial help from the anthropologist, which she cannot give.
When I stayed and spoke with people in their houses, family members were around and the neighbours often came in to listen and to observe what I was doing. Sometimes the atmosphere became heavy. People mistrusted me ; I was white, asking around, why ? What offer could I make ?
Mistrust, rumours and fear
In a focus group discussion with older people on a farm in Paarl, my research assistant and I had uneasy moments when at the start of the discussion a woman started to cry vehemently. She confessed that she was terribly worried and anxious about the violence. When we asked her if she had experienced a crime or abuse, she said “ no ”. She was worried about her children and grandchildren who were moved to Cape Town. I could have thought “ nothing special here ”. I had heard this kind of story many times before. However, this episode became a marker of a deeper problem. The farm owner was standing in the door opening. She had made available her office where the wages were paid and the administration of the farm was done. Probably, she felt the right to be there. We did not have the courage to send her away. She nodded in approval and when we discussed the older people’s health problems and a sixty five years old man told about his misery because his wife had Alzheimer, she interfered with the warning that he must not forget to tell us how helpful his neighbours were. The group discussion threatened to stop, but the owner went away and the older people started to narrate more freely. We were not able to grasp the precise nature of the social relationships on the farm, but we felt quite certainly that defensive behaviour, mistrust and suspicion for outsiders and for what the older people might tell shimmered in the office. Why should anyone be interested in the lives of people who lived their life on the farm ? What is going to happen with the stories ? This episode came on top of our efforts in the health centre. We have had to assure “ not to ask “ political ” and other “ difficult ” questions ” to the older people at the farms, because that would disturb the relationships of the centre with the farm owners.
The climate of mistrust and prudence is contaminating ; the knowledge of the rumours and gossips about the relationships between farmers and farm workers had made us suspicious and cautious. Maybe the old woman cried for other reasons ? Maybe the farm owner had structured the discussion before our arrival and instructed the older people what to say ? We might have observed what Baderoon (2000) has described as distraction from addressing the structuring social conditions in which violence occurs.
For an anthropologist, the rumours, gossip and urban legends about crime and violence which are ubiquitous in Cape Town, were difficult to deal with. What might be their meaning ? How to interpret ? It was difficult to separate rumours and imaginations from the daily events of crime and violence. It was often not possible to sift facts from fiction, because danger often prevented me from collecting field data personally. Gossip had several dimensions. The older people interviewed also complained about the gossip. They thought that it kept people in the grip of fear and suspicion. They also believed gossip separated people and set them against each other. Mama Bam : “ They say : Your sister doesn’t even cook for you, you know such rumours, the gossip, the gossip is in a lot of people, that’s why their lives are so changed. Nowadays, someone comes and is talking stories. Gossip and making hate ”. The social control by gossip was so large that older people feel forced to do things that they actually could not do. An old man, living in an old age home, told that he was very happy to be in the home, because his children and grandchildren were never satisfied about his support (financial support and care for his grandchildren). The neighbours meddled in the family affairs. The old man felt exhausted and abused and decided to leave his family and to live in the old age home.
The blurring of facts and fiction created a paranoia and hysterical fear that, like Scheper-Hughes (1992) stated, “ can be seen as a new technique of social control in which everyone suspects and fears every other ”. Rumours like the story of gang members playing soccer with the heads of their victims that went around in the streets of the townships kept people in the grip of fear. Older people did not move around freely. Although the older people in Khayelitsha and other townships did not speak about this “ hysterical fear ”, they told that, when they were walking in the streets, they were continuously looking over their shoulders. They were cautious and suspicious. Mama Bam’s narrative was exemplary : “ Taxi is no good, busses are no good . I just have to take it. If God doesn’t want you to get hurt, you will not get hurt. It’s a thing you can never run away from. […] My sister doesn’t like taxi and bus, she is going by train. Lots of things happen to the train. And I sit and worry and think. I wonder why those people (criminals) are working on the train. Sometimes, people cannot come home. Because the train doesn’t go. They take of your earrings, in the train and they point you with guns. I mean, nothing is safe. You must believe in God. Even you go by car, you pray for that car. You believe : God is with me and my car ”. Even in old age homes, the older people did not trust others, like volunteers. “ They drink and go to parties ”, an old woman whispered to me when two women in traditional clothes entered to assist with the preparation of a festivity, “ they don’t give me food, they eat it themselves ”. John, a seventy three years old man who lived in an old age home in Khayelitsha said : “ The way they live now, it is not the same as before. They live in a completely different era. This is the era of the murderers. Abanaluxolo : our sons now do not have peace anymore ”.
The older people interviewed shared the belief that when the younger people would “ go to church ”, they wouldn’t hang out in the streets and wouldn’t become “ criminal and rude ”. Joshua, seventy nine, said : “ Every youngster who stands at the corner I ask : Why are you standing at the corner ? God needs you. But they don’t say anything, they just stand there ”.
In all, older people on the Cape Flats had created a different kind of past than one would expect of people who have lived under state violence. This is related to how they have to deal with and remember the violence of the present. In “ Reconciliation and memory in postwar Nigeria ”, Last (2000) addresses the issue of memory of violence in local communities away from the public debate. The author distinguishes between “ watchers ” and “ bystanders ”. The latter have left the scene of violence. Last states that in Nigeria “ turning the head away is perhaps the strongest of social statements, much stronger than loudly arguing back ”. This may be true for the older people in Cape Town. However, their stories show the enormity of violence, not only state or criminal violence, but also the violence which is less visible ; the serious difficulties and constraints they have in their daily lives. Complaints of older people about Abanaluxolo do reveal the experienced reality of lives in the townships, as Cattell has shown : The older people’s complaints are “ not to be dismissed as “ just what all old people do ”, their complaints are strategies for assuring their physical security and reassuring themselves as persons in settings of rapid social and cultural change ” (Cattell, cited in Sagner, 1999 : 4).
Learning from older people : some final remarks
Traumas such as the experience of state violence or criminal violence surely affects people’s understanding of who they are, what to expect and in what kind of world they live. They colour expectations and worldview. Anthropological research on the Cape Flats make clear that the past state violence has more destroyed than the relationships between “ whites ” and “coloureds ”. It has ruptured intergenerational and gender relationships ; it has damaged cultural structures like Ubuntu. It has changed the meanings of hope and trust of people, etc. Anthropology is described as the discipline that seeks deeper understanding of the ideas and practices of a particular group by reconstructing their lives and worldviews. Then, the impact of experiences like those of the older people above must be reckoned with. A closer look at the daily lives and stories of older people, their worries and opinions may contribute to understanding of the world they have to live in. But what is the meaning and the relevance of “ deeper understanding ” when medical anthropology claims to understand traumatising contexts and the impact of violence on everyday life ? There is little doubt that one can learn a great deal by intensive listening. However, interpreting narratives, life stories, conversation or dialogues is a tricky business, because they have to be situated in social and symbolic contexts. Therefore, fieldwork (observation and participation) is indispensable. However, fieldwork in these social contexts is partialized. Often it is impossible to live and stay in the field, so that it is difficult to capture the totality of people’s experiences. But one can never hope to grasp everything. One has to work with “ bits and pieces ”, which are the components of a puzzle that will be for ever on the table of the anthropologist. The relevance of medical anthropology may be summarised with Morsy’s phrase, in which she stated that anthropology has to shift “ anthropological obsession with what is inside people’s head to a scrutiny of what is on their backs ” (Morsy, 1990 : 31). To a medical anthropologist this means a focus on human suffering, and pain that emerge from experiences of misfortune and reproduce cultural worlds (cf. Kleinman, 1995). On the Cape Flats, like in many other places where suffering is at stake in the daily experiences of people, the anthropologist cannot move away from involvement when confronted with needs and sorrows of people. Intrinsic to such an endeavour is that anthropologists cannot avoid moral and political entailments (cf. Das et al., 2000). To shy away from local moral worlds would mean that anthropology looses sight on powerful social and emotional processes that organise people’s experience.
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 In December 2000, a discussion on the “trauma biz” was held on The Transcultural Psychiary Discussion list, McGill University, Montreal. The reason was the work of NGO’s in war-affected countries like Sri Lanka and the psychiatric treatment of child soldiers, whereby Western models of PTSD and what to do about it are transported to non-western environments and cultures without concern for culture.
 Hazan made a similar point. He claims that the study of old age and older people enables anthropology to claim a unique perspective on the whole discipline, ‘a perspective anchored in the liminal position of the professional ‘stranger’ (1995 : 204).
 Ubuntu is not easily definable. It has been described as a world-view of African societies and a determining factor in the perception which influence social behaviour. The substantive Ubuntu means ‘humanness’ and its philosophy is reflected in the adage ‘Umuntu Ngumntu Ngabantu’, which means ‘a person is a person through other people’. Nowadays, Ubuntu is related to the South African Renaissance and considered as essential in the transformation of the society.
 SAR 540.
 In October 2000 the newspapers in Cape Town published articles on queuing when a seventy year old man died in the pension queue and laid two hours in the sun before he was removed. It was said that the man’s death spotlighted the fate of many - mostly poor - South Africans to spend long stretches of their lives in a queue. The older people who participated in my study also complained of long waiting hours at health centres and in hospitals.
 The kgotla is based on a traditional Xhosa structure consisting of a group of elders who act as a kind of tribunal. The organisation acts against violence in the community.
 She explained Llomola to me as follows : “He bought me. He bought me from my mother ”.
 Another township on the Cape Flats.
 See for example “Witchcraft deadly serious problem in South Africa”, Cnews, October 30, 1999.
 Volkskrant, Saturday June 16, 2001.
 In that period, there was a “taxi war” in Cape Town.