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From ‘Medical Revolution’ to Techno-Politics: The Transformation of Chinese Medical Teams in Zanzibar

September 12, 2023

From ‘Medical Revolution’ to Techno-Politics: The Transformation of Chinese Medical Teams in Zanzibar

Yidong Gong

Mnazi Mmoja Hospital. Source: Yidong Gong.

Overlooking the deep-blue Indian Ocean, the white Arabic-style buildings of Mnazi Mmoja Hospital (MMH) evoke the ‘One Thousand and One Nights’ flavour of Stone Town, Zanzibar’s capital, some 70 kilometres off the coast of Dar es Salaam, Tanzania.

MMH, the name of which literally means ‘one coconut’, is a government-run tertiary referral hospital serving the nearly two million people of Zanzibar. Inaugurated in 1896, when the country was a British protectorate, by the Sultan of Oman, the hospital was initially established with six Asiatic wards and nine African wards, plus a European wing added in 1924, so that patients could remain racially segregated during their treatment.

In 1964, after the Afro-Shirazi Party assumed power and won independence for the Zanzibar Archipelago, the islands united with mainland Tanganyika to form the United Republic of Tanzania. Later, MMH was renamed V.I. Lenin Hospital, reflecting the state’s pro-socialist leanings. This name was retained until the late 1990s, before the hospital resurrected its original name.

In the summer of 2011, I was in mainland Tanzania and Zanzibar, working with Chinese medical teams and medical representatives from a Chinese pharmaceutical company. Like many hospitals in southern Africa at that time, MMH was suffering from the chronic emigration of experienced doctors and nurses to foreign countries, even though the President of Zanzibar, Ali Mohamed Shein, formerly an anaesthetist at MMH, had promised to raise the pay of health workers. In the 2000s, even the secondary care tier was provided almost exclusively by MMH. This explained why the hospital was overcrowded with patients and inadequately staffed.

My informants told me that doctors devoted more time to their private clinics than to their services at MMH. Even some high-ranking officials at the Ministry of Health had their own private clinics. The personnel shortage partly explains what Kue Young (1986: 132), a Canadian scholar of indigenous and community health, describes as ‘the multiplicity of foreign nationals from both the East and West jostling for an opportunity to help’. At MMH, the list of foreign experts was long: Egyptian dentists, Japanese physiotherapists, Chinese medical teams (wearing white coats with their red national flag, which made them stand out), and so on.

The popularity of global health volunteer projects was another factor making MMH an attractive destination for foreign doctors and medical students (Sullivan 2018). Because of the peaceful environment in Zanzibar and the charm of Stone Town on the Indian Ocean coast, a variety of short and long-term medical volunteering placements had been arranged at the hospital. For example, Go Volunteer Africa, a non-profit travel operator, framed volunteering in Zanzibar as ‘affordable, low-cost and budget friendly’, claiming that ‘the volunteer opportunities in Zanzibar are meaningful and life-changing both to the volunteer and to the host community’. When I was there, there were several Scottish, Australian, and German medical students and volunteers at the hospital, who were required to ‘donate’ US$70 to the hospital every week as part of a program contracted by a commercial company.

As a result, the hospital became a battlefield where different medical teams fought to assert their own expertise. During my stay at the hospital, all surgeries were suspended for a week due to the presence of a team of doctors from Turkey who were performing demonstration surgeries. The Chinese doctors regarded these surgeries—mastectomies and scar rehabilitation—as ‘simple cases’, and applied to set up a specialised theatre to perform more complicated procedures.

Various foreign donors also developed reform packages for the hospital and the health sector in Zanzibar in general, such as the Five-Year Strategic Plan and Zanzibar Health Care Worker Productivity Study compiled by the US Agency for International Development, the Health Sector Support Program implemented by Denmark’s Ministry of Foreign Affairs, and the Hospital Service Package in Zanzibar produced by a Netherlands-based development organisation. In such a crowded context, this essay tracks the transformation of Chinese medical aid in Zanzibar and calls for a blend of technical expertise and primary health care to respond more effectively to local medical needs.

The Staging of a ‘Medical Revolution’ in Zanzibar

After the 1964 revolution, most of Zanzibar’s Western European inhabitants left the country, including its medical specialists. To fill the vacuum, Abeid Karume, the first president of the newly independent country, solicited technical and military assistance, first, from Cuba and China, and then from the Soviet Union and Eastern Bloc countries such as East Germany and Bulgaria.

It was in 1964 that the Chinese Government responded to Zanzibar’s request by dispatching its first team of 14 doctors, from Jiangsu Province. This medical assistance persisted throughout the Cultural Revolution and, in 1970, the provincial government sent a second team to a new hospital constructed by China on Pemba, Zanzibar’s second-largest island.

From 1964 to the early 1990s, ideological justification remained central to the work of the Chinese doctors, as evinced in their later accounts of their time in Zanzibar over some 30 years. Recalling their experiences on the islands, the doctors often used phrases such as ‘crystallisation of friendship’ (友谊的结晶), ‘a medical revolution’ (医学革命), and ‘healing the wounded and rescuing the dying’ (救死扶伤) (Health Department of Jiangsu Province 2004).

A corner of MMH. Source: Yidong Gong.

An important characteristic of these Chinese doctors was their commitment to serving rural villages. For example, the Chinese teams adopted a circular system of medical treatment, with each member responsible for a designated area and spending from several days to an entire month in each village. At every stop, as well as treating patients, they would organise health education classes with an emphasis on disease prevention (Yu 1975). English Journalist Alan Hutchison reported how the Chinese doctors dispatched to Tanzania adapted themselves to local conditions in ways that reflected the Maoist idea of ‘serving the people’. In Zanzibar, Chinese acupuncture became so esteemed that islanders with a bad temper were told to visit the Chinese because ‘they even have a cure for that’ (Hutchinson 1975: 221–22).

In the meantime, China also had a marked influence on Zanzibar’s economic development. Chinese technicians advised the local government on reforms aimed at self‐sufficiency for the island, which fit with the socialist Zanzibarian Government’s strategy for nationalisation (Howe 1970). This effort was also evident in the healthcare sector. In 1968, Chinese medics helped V.I. Lenin Hospital establish a pharmaceutical workshop to produce essential drugs. According to Tanzanian media reports from that time now no longer available online, the workshop had capacity to produce 500,000 tablets for treating common illnesses every eight hours. Considering such extraordinary output, the local media praised China for helping Tanzanians to achieve self-reliance by imparting their knowledge to local doctors and nurses and enabling them to deliver medical services to those in rural areas.

Following the self-reliance strategy established by V.I. Lenin Hospital, Keko Pharmaceuticals and several other national pharmaceutical companies were established on the mainland of Tanzania in 1972 under the jurisdiction of the Ministry of Health and supported by the Chinese Government (Health Department of Jiangsu Province 2004). In 1997, Keko Pharmaceuticals was partially privatised, with the private sector owning 60 per cent of the shares.

Chinese medical staff in MMH’s pharmaceutical workshop. Source: Jiangsu Province Health Department.

Shifting Towards the Rule of Experts

The official discourse surrounding the Chinese medical teams began changing in the 1990s, with injunctions like ‘political enthusiasm’ gradually being replaced with ‘professionalism’—the symptom of a shift towards more streamlined technical programs. This reflected the realities of China’s market economy, as Chinese doctors were less financially motivated to serve in Africa. The 1990s even saw the withdrawal of some Chinese medical teams from Africa. Moving into the 2000s, Chinese medical teams were tasked with a new directive to help recipient countries upgrade their medical facilities and enhance capacity-building, including personnel training programs, as Chinese president Hu Jintao promoted China’s influence in Africa, Latin America, and other developing regions.

The twenty-fourth Chinese medical team to serve at MMH arrived in June 2011, comprising a urologist, a cardiologist, a general physician, a gynaecologist, an oculist, an otorhinolaryngologist, an oral surgeon, a radiologist, an anaesthetist, and an acupuncturist, as well as an interpreter and a cook. The team leader, Dr Lu, told me of their intention to ‘seize the opportunity and add new highlights’, including minimally invasive surgeries and the ‘Smiling Project’ (微笑工程), which involved surgeries for patients with a cleft lip or palate. Meanwhile, rehabilitating the hospital’s intensive care unit (ICU) was high on the Chinese medical team’s agenda. The ICU had been donated to the hospital in 1999 by the US-based humanitarian organisations Assemblies of God and Assist International, but it had been left dysfunctional after several machines broke down in 2010.

Moreover, the Chinese team felt increasing competition from the West in terms of expertise and technology, Dr Lu said. In July 2011, US Secretary of Health and Human Services Kathleen Sebelius inaugurated a new HIV care and treatment centre for advanced HIV management at Mnazi Mmoja Health Centre in Dar es Salaam and visited MMH in Zanzibar. That same year, President Shein promised that his government would reform the health sector with a focus on acquiring ‘modern equipment’.

The MMH eye department. Source: Yidong Gong.

Chinese medical teams, too, increasingly used advanced technologies and equipment to treat patients in Zanzibar. In August 2009, the Chinese Government invested 1 million RMB (160,000 USD) to establish an eye centre in MMH with high-tech equipment. Dr Geng, a Chinese eye doctor, reported that as most of the equipment and facilities had been manufactured in Japan and the United States, ‘the quality was guaranteed’. In 2012, the Chinese Government allocated an extra 200,000 RMB (32,000 USD) to upgrade the eye centre. In this context, the hospital was becoming increasingly technologised and shaped by the rule of experts and techno-politics (Mitchell 2002).

The Chinese doctors believed that technology and expertise were important instruments for transforming the perceptions and practices of Zanzibarian doctors. One reason for their confidence was that they had come from Suzhou, an economically developed city in China, which enjoyed medical expertise superior to that of many other regions in the country. They were disturbed to discover on arrival that much of the hospital’s equipment, as well as its fixtures and fittings, was either makeshift or outdated. High-temperature disinfection was unavailable and there was no airconditioning in the operating theatres. The Chinese doctors often compared the medical facilities in Zanzibar to what they had experienced or heard about before China introduced its market economy in the 1980s. As one doctor said to me: ‘Looking back 20 years, China may have been more backward than conditions here at MMH.’

The neonatal unit at MMH. Source: Yidong Gong.

The Department of Obstetrics and Gynaecology is a big unit at MMH with as many as 12,000–14,000 deliveries annually, but at the time of my visit, the in-hospital maternal mortality ratio was high, at 401 per 100,000 live births (Herklots et al. 2017). Pointing to a blackboard at the entrance to the department, Dr Hou, a Chinese gynaecologist, told me that, in 2010, more than 250 of the 10,000 pregnant women who entered the department had been diagnosed with purpura, a disorder characterised by clotting in small blood vessels. In comparison, she said, the occurrence of purpura in Suzhou was less than 10 in 10,000 women. She added that the rate of postpartum haemorrhage was 20 per cent—10 times higher than that in China. There were only 40 beds in the department and many women going into labour had to share a bed or even lie on the ground.

In response to these conditions and the constraints on facilities, the Chinese doctors introduced new rules for their staff, such as requiring them to wash their hands with disinfectant before and after surgery. Dr Lu promoted the use of channel tubes in the urology department—a practice that, according to him, had originated in Europe and the United States.

Also, the once well-maintained primary healthcare services on the island were increasingly being replaced with reliance on surgery and medication. For example, one of the acupuncture wards at MMH had been absorbed into an ophthalmology and otorhinolaryngology theatre and nicknamed the ‘Sea View Theatre’.

A Chinese dentist reads a patient’s dental X-rays. Source: Yidong Gong.
A Chinese eye doctor performs surgery. Source: Yidong Gong.

A Growing Resistance to Foreign Experts

However, assistance from China was met with ambivalence by the hospital personnel. While some younger intern doctors and nurses expressed their gratitude to China for its help, others were reserved or even distrustful. A local diabetes specialist provides us with a good example of this mixed attitude. Born in Beijing’s Friendship Hospital in the 1960s, this doctor, Chinese colleagues believed, had a ‘deep affection for China’ thanks to her roots. Yet, after studying and living in Russia for almost 20 years, she had returned to Zanzibar because she believed the country should not rely on the ‘foreign community’, including its ‘old friend’ China:

I think it is high time that we stand on our own feet, because the [foreign] medical teams have operated for 40 years. Generally, they are good, but now we have to stand on our own. We have a lot of doctors. If the conditions are good, we can stand on our own. You know, it is true. Language, culture … it’s difficult to come just for one or two years. We don’t just treat patients, we talk. I think their [the Chinese doctors’] surgery is good. They don’t talk much. They just look and operate with the knives. Sometimes, the treatment [by Chinese doctors] does not go well. Much is about communication. It’s difficult for them to talk with patients. That’s why it is high time to be on our own.

MMH’s director was pragmatic. In an interview with me, he said:

The cooperation itself is like a living thing, it changes according to the times. The collaboration in the 1960s is not the collaboration today. There was much demand [from Zanzibar]. Things are changing. Technologies are changing … We have more doctors, more specialists, even as the counterpart of China. We are trying to fit into the new era. China changes a lot. China in the 1960s is not China today economically. We are seeking areas where we can make changes. We have operated the eye department … Even the composition of the team. They are more sophisticated than previously in terms of expertise

The director saw the Chinese medical services offered to MMH as a curative system, which shared certain features with the Western model:

The US are capitalists: everything is money. We are trying to make a balance. The training of doctors in the UK or US may be much more advanced, but when they go back, they are frustrated. You are trained in high-tech methods. [When] you go back, everything is different … Cuba is poor, but it is much better than the US in terms of medical care. The US is not the number one. It is not an issue of money, but of how well you use that money.

These statements by Zanzibarian medical personnel can be seen as conveying resistance to what Frantz Fanon (1983) described as a ‘sense of dependency’, which has lingered in postcolonial, neoliberal Africa, further marginalising the continent with respect to the contemporary world (Ferguson 2006). As such, Zanzibar has struggled between self-reliance and dependence on foreign aid.

Port of Zanzibar. Source: Yidong Gong.

Balancing Technical Expertise and the Moral Economy of Care

China’s medical interventions in Zanzibar are embedded in a postcolonial and post-socialist scenario, ‘with the remains of socialism lying thick and the surface patches of private practice still spreading’ (Iliffe 1998: 219). Zanzibar inherited a healthcare legacy with a colonial agenda. It has largely remained divided in its medical service provision: on one side of the spectrum, there is the increasing demand among the elite for the establishment of the ‘best’ care available; on the other is the neglect of basic healthcare services, which are not accessible to the disadvantaged. Since the 1990s, the international community has collaborated with the Tanzanian Ministry of Health and local partners to address critical health needs. As such, the political economy of healthcare in Zanzibar has given rise to the proliferation of global health programs.

If China’s discourse and practice of ‘serving the people’ originally offered Zanzibarians an alternative to the all-too-familiar colonial discourse from the early days of their political independence, this association has become ever more complicated, and feelings about it ambivalent, as the global health agenda has taken a more prominent role in shaping Zanzibar’s health sector.

Bidding farewell to the independent development of Chinese medicine in the 1960s and 1970s, Chinese agencies have since had to adapt to the new discourse that structures the Zanzibarian health sector. China has become increasingly integrated with a technocratic regime of medicine, which stands in contrast to the decentralised, comprehensive, and grassroots order that both China and Zanzibar had shared, or at least hoped to achieve, during the socialist period.

However, remnants of their common past of socialism and community-based values remain. While China is increasingly invested in technical expertise, it should capitalise more on its tradition of a people-centred approach to implementing global health programs.


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Yidong Gong is an Assistant Professor of Anthropology at New College of Florida, a public liberal arts college in the United States with a distinctive academic program that emphasises individualised learning. He studies how medical expertise and ethics influence biopolitics in transnational health care, and particularly their convergence and friction in Africa. His current book project examines China’s longstanding medical programs in South Sudan, which offer an alternative to the prevailing values of medical humanitarianism in regions marked by crisis or conflict.
New College of Florida


Volume 2, Issue 1, 2023