BMC Infectious Diseases Reduction of Clostridium Difficile and vancomycin-resistant Enterococcus contamination of environmental surfaces after an intervention to improve cleaning methods

Brittany C Eckstein email@example.com
Research Service
Louis Stokes Cleveland Veterans Affairs Medical Center
10701 East BlvdClevelandOhioUSA

Daniel A Adams firstname.lastname@example.com
Research Service
Louis Stokes Cleveland Veterans Affairs Medical Center
10701 East BlvdClevelandOhioUSA

Elizabeth C Eckstein
Infection Control Department
Louis Stokes Cleveland Veterans Affairs Medical Center
10701 East BlvdClevelandOhioUSA

Agam Rao firstname.lastname@example.com
Department of Medicine
University Hospitals of Cleveland
10000 Euclid AvenueClevelandOhioUSA

Ajay K Sethi firstname.lastname@example.com
Department of Epidemiology and Biostatistics
Case Western Reserve University School of Medicine
10900 Euclid AvenueClevelandOhioUSA

Gopala K Yadavalli
Research Service
Louis Stokes Cleveland Veterans Affairs Medical Center
10701 East BlvdClevelandOhioUSA

Curtis J Donskey
Research Service
Louis Stokes Cleveland Veterans Affairs Medical Center
10701 East BlvdClevelandOhioUSA

BMC Infectious Diseases Reduction of Clostridium Difficile and vancomycin-resistant Enterococcus contamination of environmental surfaces after an intervention to improve cleaning methods
10.1186/1471-2334-7-61BioMed Central Page 1 of 6 (page number not for citation purposes) Research article * Corresponding author
Background: Contaminated environmental surfaces may play an important role in transmission of some healthcare-associated pathogens. In this study, we assessed the adequacy of cleaning practices in rooms of patients with Clostridium difficile-associated diarrhea (CDAD) and vancomycin-resistant Enterococcus (VRE) colonization or infection and examined whether an intervention would result in improved decontamination of surfaces.Methods: During a 6-week period, we cultured commonly touched surfaces (i.e. bedrails, telephones, call buttons, door knobs, toilet seats, and bedside tables) in rooms of patients with CDAD and VRE colonization or infection before and after housekeeping cleaning, and again after disinfection with 10% bleach performed by the research staff. After the housekeeping staff received education and feedback, additional cultures were collected before and after housekeeping cleaning during a 10-week follow-up period.Results:Of the 17 rooms of patients with VRE colonization or infection, 16 (94%) had one or more positive environmental cultures before cleaning versus 12 (71%) after housekeeping cleaning (p = 0.125), whereas none had positive cultures after bleach disinfection by the research staff (p < 0.001). Of the 9 rooms of patients with CDAD, 100% had positive cultures prior to cleaning versus 7 (78%) after housekeeping cleaning (p = 0.50), whereas only 1 (11%) had positive cultures after bleach disinfection by research staff (p = 0.031). After an educational intervention, rates of environmental contamination after housekeeping cleaning were significantly reduced.Conclusion:Our findings provide additional evidence that simple educational interventions directed at housekeeping staff can result in improved decontamination of environmental surfaces. Such interventions should include efforts to monitor cleaning and disinfection practices and provide feedback to the housekeeping staff.

Background

Patients colonized or infected with healthcare-associated pathogens often shed these organisms onto their skin and into the environment [1]. Although direct contact with patients is generally considered the major source for acquisition of pathogens on healthcare workers' hands and subsequent transmission to other patients, several recent studies suggest that contaminated environmental surfaces may also play an important role in pathogen transmission [2][3][4][5][6][7][8][9][10]. For example, we found that vancomycin-resistant enterococci (VRE) and Staphylococcus aureus were frequently acquired on hands of investigators after contact with contaminated objects such as bed rails and bedside tables in colonized patients' rooms [2,3]; daily disinfection of environmental surfaces in VRE-colonized patients' rooms was associated with reduced acquisition of VRE on investigators' hands [2]. In a medical intensive care unit, Hayden et al [4] found that enforcing routine environmental cleaning measures was associated with decreased VRE contamination on surfaces and healthcare workers' hands, and also with a significant reduction in VRE cross-transmission. In two other recent reports, control of VRE outbreaks has been attributed in part to implementation of a program of environmental decontamination [5,6]. Environmental decontamination with 10% bleach has also been associated with reductions in Clostridium difficile infections [9,10].

Beginning in 2002, our institution has experienced a significant outbreak of C. difficile-associated disease (CDAD) that has been associated with emergence of the recently described epidemic strains in the Cleveland area [ [11,12], and authors' unpublished data]. Despite control measures including contact precautions for patients with documented and confirmed CDAD and environmental disinfection of CDAD patients' rooms with 10% bleach, we continued to experience high rates of infection (~15 CDAD cases/1,000 patient discharges). Because we and others have demonstrated that frequently touched objects in patients' rooms may not be adequately disinfected by housekeeping staff [3,13], we assessed the adequacy of cleaning practices for CDAD rooms in our institution and examined whether an intervention would result in improved decontamination of frequently touched surfaces. For comparison, we also examined the adequacy of cleaning practices in rooms of patients colonized or infected with VRE because these rooms receive routine terminal cleaning after patient discharge.

Methods

Setting

The Cleveland Veterans Affairs Medical Center is a 368bed acute care medical facility. Patients with CDAD are placed in contact precautions until diarrhea has resolved. Two years prior to the start of the study, the infection con-trol department instituted bleach disinfection as a control measure for C. difficile. The housekeeping staff was inserviced on the C. difficile outbreak and the importance of their role in preventing transmission was emphasized. The housekeepers were instructed to use 10% bleach solution (Sunstorm, State Chemical, Cleveland, OH) for terminal disinfection of CDAD patients' rooms. Terminal disinfection was to be performed using a clean cloth or mop soaked in 10% bleach, and it was stressed that frequently touched objects such as bed rails, bedside tables, and call buttons were to be disinfected. Subsequently, the housekeeping staff was periodically contacted to reinforce the bleach disinfection policy.

Patients with VRE colonization or infection were included as a comparison group because they are currently managed with standard precautions and routine terminal cleaning is performed. According to the housekeeping staff, routine terminal disinfection was to include bed rails and bedside tables, but telephones, call buttons, and door handles were not cleaned unless they were obviously soiled. The disinfectant used for routine decontamination of patient rooms is Super HDQ Neutral (Spartan Chemical Company, Inc., Maumee, OH), which is a quaternary ammonium compound.

Pre-intervention assessment of cleaning practices

A prospective 6-week before-after study was performed to assess the adequacy of terminal cleaning and disinfection practices in rooms of patients with CDAD and VRE colonization or infection. All patients with known CDAD and VRE colonization or infection during the study period were considered for enrollment; however, only those patients who were discharged between 9 AM and 5 PM from Monday to Friday were included in the assessment of housekeeping cleaning practices. Standardized chart review was performed to collect information regarding demographics, medical conditions, and culture results. The hospital's Institutional Review Board approved the study protocol.

Baseline cultures of environmental surfaces were obtained within 3 days of patient discharge from the room. Six sites were cultured in each room, including the bedrail, telephone, call button, door knob, toilet seat, and bedside table. Two sterile, pre-moistened cotton-tipped swabs were applied directly onto the selected surfaces in a uniform fashion. For rooms of VRE-colonized patients, one swab was plated directly onto Enterococcosel agar (Becton Dickinson and Company, Sparks, MD) containing 20 µg/ mL of vancomycin and the other swab was placed directly into Enterococcosel broth (Becton Dickinson) containing 20 µg/mL of vancomycin. The plates and broth enrichment cultures were incubated for 48 hours at 37°C; broth cultures were then plated onto Enterococcosel agar con-taining 20 µg/mL of vancomycin and incubated another 48 hours. Colonies with unique morphology were subjected to identification and susceptibility testing in accordance with Clinical Laboratory Standards Institute guidelines [14].

For rooms of CDAD patients, the swabs were placed into an eppendorf tube and transferred to an anaerobic chamber within 1 hour of collection (Coy Laboratories, Grass Lake, MN). One swab was directly plated onto cycloserine-cefoxitin-fructose agar containing 0.1% taurocholic acid (CCFA-TA) and the other was placed into 300 µl of CCF broth containing 0.1% taurocholic acid and incubated for 48 hours prior to plating onto CCFA-TA. Plates were incubated for 72 hours at 37°C. Isolates were confirmed to be C. difficile on the basis of typical odor and appearance of colonies and by a positive reaction using Pro Disk (Key Scientific Products, Round Rock, TX). C. difficile isolates were tested for in-vitro cytoxin production using C. difficile Tox A/B II (Wampole Laboratories, Princeton, NJ), and isolates that did not produce toxin were not included in the number of positive cultures.

In order to assess the adequacy of housekeeping cleaning and disinfection practices, cultures of the same surfaces in the rooms were obtained after terminal cleaning was performed by the housekeeping staff, but prior to admission of another patient. Finally, in order to confirm the efficacy of 10% bleach for decontamination of C. difficile and VRE, one of us (B.C.E.) disinfected the same surfaces using a 10% bleach solution (Dispatch, Caltech Industries, Inc. Midland, MI). The surfaces were wiped with a cloth soaked with 10% bleach to provide physical removal of dirt or other substances and sprayed with bleach to ensure that the surfaces were thoroughly wet. The surfaces were allowed to air dry. Cultures were then obtained from the same surfaces.

Intervention and post-intervention assessment

After completion of the initial assessment of adequacy of housekeeping cleaning, the research team presented their findings to the housekeeping staff. Education was provided regarding the importance of environmental cleaning as a means to reduce transmission of pathogens. The importance of cleaning and disinfecting frequently touched surfaces was emphasized. In addition, the housekeeping staff was encouraged to provide input regarding measures that might improve their ability to perform adequate terminal cleaning. To assess the effect of the intervention, additional cultures were obtained before and after the housekeeping staff performed terminal cleaning of rooms of several patients with CDAD or VRE colonization or infection during the 10-week period after the intervention.

Statistical analysis

Data were analyzed using STATA 9.0 (StataCorp, College Station, TX). In describing the study population, continuous data were analyzed using unpaired t tests and categorical data were assessed using Fisher's exact test. In evaluating the effectiveness of the intervention, an exact McNemar's chi-square test was used to compare VRE and C. difficile culture positivity in rooms and on specific surfaces prior to and after cleaning by housekeeping staff. This test of significance was used to then compare culture positivity after cleaning by housekeeping staff and after cleaning by research staff.

Results

Pre-intervention assessment of cleaning practices

Prior to the intervention, we studied 17 patients with VRE colonization and 9 patients with CDAD. All of the patients were male. The average ages of the VRE and CDAD patients were 70.0 (range 42 to 86) and 63.8 (range 28 to 80), respectively. Of the 17 patients with VRE colonization, 5 (29%) were incontinent of feces, 6 (35%) had diarrhea, 6 (35%) were receiving antibiotic therapy, 11 (64%) were in multiple-bed rooms, and 4 (24%) were in an intensive care unit. Of the 9 patients with CDAD, all were in private rooms and were receiving therapy for C. difficile, 4 (44%) were incontinent of feces, and 1 (11%) was in an intensive care unit. Figures 1 and 2 show the percentage of positive brothenrichment environmental cultures before and after housekeeping cleaning and after disinfection with 10% bleach by the research team for VRE and C. difficile, respectively. Of the 17 rooms of patients with VRE colonization or infection on at least one of the surfaces surveyed, 16 (94%) had one or more positive environmental cultures before cleaning versus 12 (71%) after housekeeping cleaning (p = 0.125), whereas none had positive cultures after bleach disinfection by the research staff (p < 0.001). Overall, 72 of 102 total environmental cultures (71%) were positive for VRE before cleaning and 58 of 102 (57%) were positive after housekeeping cleaning. Housekeeping staff were effective in disinfecting bedrails (p =0.002) but not substantially so for other surfaces. Of the 9 rooms of patients with CDAD, 100% had one or more positive cultures prior to cleaning versus 7 (78%) after housekeeping cleaning (p = 0.50), whereas only 1 (11%) had a single positive culture from a toilet after research bleach disinfection (p =0.031). Overall, 30 of 54 (56%) total environmental cultures were positive for C. difficile before cleaning and 24 of 54 (44%) were positive after housekeeping cleaning.

For both C. difficile and VRE, broth enrichment cultures yielded about twice as many positive cultures than the direct plating method. All cultures that were positive by direct plating were also positive by broth-enrichment. For C. difficile, the number of colonies recovered by direct plating onto CCFA-TA plates was low (median, 3; range, 1 to 25 colonies). In contrast, many of the VRE cultures that were positive by direct plating yielded high levels of organisms that were too numerous to count; Figure 3 shows an illustration of gross contamination of a call button with VRE after completion of cleaning by housekeeping staff.

Intervention and post-intervention assessment

As noted previously, the intervention was initiated with a presentation of the initial culture findings at a housekeeping staff meeting followed by discussion of factors that impacted their ability to perform thorough cleaning. The housekeeping staff expressed concern that the time permitted for terminal cleaning was not adequate and that there were often significant delays before they were notified that a room was ready to be cleaned. The hospital administration agreed to allow the housekeeping staff additional time for terminal cleaning (30 minutes/room) and the nursing staff was asked to provide more rapid notification of when rooms were ready for cleaning. The housekeeping staff also expressed concern that the cleaning agents being used might not adequately kill the pathogens. We therefore performed in vitro studies on a laboratory bench top to assess killing of C. difficile spores and VRE by the cleaning agents used in our hospital. Freshly-prepared Sunstorm bleach, Sunstorm obtained from housekeeping carts, and Dispatch bleach efficiently killed an inoculum of ~10 6 colony-forming units of C. difficile spores or VRE in 10 µl of phosphate-buffered saline that was allowed to air dry on the surfaces; the contaminated surfaces were disinfected and cultured in the same manner as described for the environmental surfaces in rooms. Super HDQ disinfectant killed VRE but not C. difficile spores (data not shown).

After the intervention, the housekeeping staff agreed to apply 10% bleach solution to disinfect frequently touched surfaces (e.g. bed rails, bedside tables, call buttons, telephones, toilet seats, door handles) in rooms of CDAD patients using a spray bottle. The surfaces were then Culture plate showing gross contamination of a call button with vancomycin-resistant Enterococcus (VRE) after comple-tion of cleaning by housekeeping staff Figure 3 Culture plate showing gross contamination of a call button with vancomycin-resistant Enterococcus (VRE) after completion of cleaning by housekeeping staff. The patient was a 68 year-old man with Clostridium difficile-associated disease and VRE intestinal colonization. A sterile, pre-moistened cottontipped swab was applied to the surface of the call button and directly plated onto Enterococcosel agar containing 20 µg per mL of vancomycin. The same call button yielded C. difficile by broth enrichment culture.

Percentage of positive environmental cultures for vancomy-cin-resistant Enterococcus (VRE) before and after housekeep-ing cleaning and after disinfection with 10% bleach by the research team Figure 1 Percentage of positive environmental cultures for vancomycin-resistant Enterococcus (VRE) before and after housekeeping cleaning and after disinfection with 10% bleach by the research team. Seventeen rooms of patients with VRE colonization or infection were cultured.    allowed to air-dry. In addition, without prompting from the research team, the housekeeping staff elected to incorporate this method of bleach disinfection of commonly touched objects into their terminal cleaning practices for all patient rooms in our facility. Although there were initially concerns that bleach might cause damage to surfaces in the rooms, no complaints regarding such damage have been reported. In addition, interviews with the housekeeping staff were conducted, and no complaints related to the application of bleach were reported.

To assess the effect of the intervention, we performed environmental cultures before and after housekeeping cleaning in rooms of 10 patients with VRE colonization or infection and 10 patients with CDAD during the 4-month period after the intervention. Eight (80%) rooms of patients with VRE colonization or infection had one or more positive environmental cultures before cleaning versus 0 (0%) after housekeeping cleaning (p < 0.001). Nine (90%) of rooms of patients with CDAD had one or more positive cultures prior to cleaning versus 2 (20%) after housekeeping cleaning (p < 0.01). The Infection Control Department currently meets monthly with the housekeeping staff to provide feedback regarding culture results and to maintain awareness of the importance of environmental cleaning as a means to control healthcare-associated pathogens.

Discussion

Two years prior to our study, the infection control department instituted a bleach disinfection program as a control measure for C. difficile. The housekeeping staff was inserviced, and it was stressed that frequently touched objects such as bed rails, bedside tables, and call buttons were to be disinfected. Despite the initial intervention and periodic reminders of the policy, we found that frequently touched surfaces in rooms of patients with CDAD were often contaminated after terminal cleaning and disinfection by housekeeping staff. Similar results were obtained in rooms of patients with VRE colonization or infection. An educational intervention was well-received by the housekeeping staff and resulted in modification of cleaning practices and improved decontamination of frequently touched surfaces. Our findings provide additional evidence that simple interventions can result in improved environmental decontamination in healthcare institutions.

Our experience also demonstrates that environmental cleaning interventions should include some means of monitoring the efficacy of decontamination with feedback to the housekeeping staff. Such monitoring of cleaning performance has been recommended in recently published guidelines from the Centers for Disease Control and Prevention and the Society for Healthcare Epide-miology of America [15][16][17]. Although our intervention included environmental cultures, less labor-intensive methods of monitoring cleaning practices may also be effective. For example, Carling et al [13] used an invisible fluorescent marker to monitor cleaning practices; feedback to housekeeping staff led to a sustained improvement in cleaning of surfaces. Hayden et al [4] performed environmental cultures, but also observed cleaning practices and provided feedback to housekeepers.

Our study has several limitations. First, only one hospital was included, and our findings may not be applicable to all institutions. Second, we monitored the effect of the intervention on cleaning practices for only 4 months for the purposes of the study. However, we intend to continue ongoing monitoring of environmental disinfection practices because we believe that such monitoring will be essential to maintain compliance. Third, molecular typing was not performed to confirm that the organisms recovered from surfaces were genetically related to isolates recovered from the stool of patients occupying the rooms. Fourth, although bleach is required for disinfection of CDAD patients' rooms, it should be noted that non-sporicidal disinfectants are equally effective for elimination of other pathogens (i.e., the improvement in disinfection of VRE by housekeeping is likely attributable to improved performance and would have been achieved with agents other than bleach). Fifth, our disinfection method was performed after patients were discharged from the rooms and included spraying of bleach solution onto surfaces; wiping with a soaked cloth is preferred if patients or healthcare workers are present to limit exposure to bleach. Finally, we have not included an assessment of the impact of the intervention on rates of CDAD. Such an assessment will be performed after monitoring rates of CDAD over a longer period of time.

Conclusion

Frequently touched surfaces in rooms of patients with CDAD or VRE colonization or infection were often contaminated with these pathogens after terminal cleaning by housekeeping staff. Simple educational interventions directed at housekeepers can result in improved environmental decontamination, but these interventions should include efforts to monitor cleaning practices and provide feedback to the housekeeping staff. the manuscript. DAA contributed to the study design and assisted with cultures and data collection. ECE contributed to study design and assisted with the intervention. AR assisted with performance of cultures and data collection. GKY contributed to study design and assisted in editing the manuscript. AKS performed the statistical analyses and assisted in editing the manuscript. All authors read and approved the final manuscript.

positive environmental cultures for Clostridium difficile before and after housekeeping cleaning and after dis-infection with 10% bleach by the research team

Figure 2
2Percentage of positive environmental cultures for Clostridium difficile before and after housekeeping cleaning and after disinfection with 10% bleach by the research team. Nine rooms of patients with Clostridium difficile-associated disease were cultured.

table Phone Call button
PhonebuttonToilet

Door handle

(page number not for citation purposes)
AcknowledgementsThis work was supported in part by an Advanced Research Career Development Award from the Department of Veterans Affairs to CJD.Competing interestsThe author(s) declare that they have no competing interests.Authors' contributionsCJD conceived of the study, participated in drafting the manuscript, and edited the manuscript. BCE performed the cultures and data collection and assisted in draftingPre-publication historyThe pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2334/7/61/prepub
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International Journal of Health Geographics CAALYX: a new generation of location-based services in healthcare

Open Access
Maged N Kamel Boulos
Faculty of Health and Social Work
University of Plymouth
Drake CircusPL4 8AAPlymouthDevonUK

Artur Rocha email@example.com
Location Based Information Systems, Information and Communication Systems Unit
INESC Porto
Campus da FEUP, Rua Dr. Roberto Frias, 3784200-465PortoPortugal

Angelo Martins email@example.com
Location Based Information Systems, Information and Communication Systems Unit
INESC Porto
Campus da FEUP, Rua Dr. Roberto Frias, 3784200-465PortoPortugal

Manuel Escriche Vicente
Telefónica Investigación y Desarrollo
Parque Tecnológico de Boecillo
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Corscience GmbH & Co. KG
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Martin Braecklein firstname.lastname@example.com
Corscience GmbH & Co. KG
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John Nelson firstname.lastname@example.com
Department of Electronic & Computer Engineering
College of Informatics & Electronics
University of Limerick
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Gearóid Ó Laighin
Department of Electronic Engineering
National University of Ireland
Galway, GalwayIreland

Claudio Sdogati
Dipartimento R&D
COOSS Marche Onlus
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Dipartimento R&D
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Angela Jobes
Synkronix IIIncorporation Ltd
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Mark Kinirons
Department of Ageing & Health
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International Journal of Health Geographics CAALYX: a new generation of location-based services in healthcare
10.1186/1476-072X-6-9BioMed Central Page 1 of 6 (page number not for citation purposes) Editorial Mark Kinirons -email@example.com * Corresponding author
Recent advances in mobile positioning systems and telecommunications are providing the technology needed for the development of location-aware tele-care applications. This paper introduces CAALYX -Complete Ambient Assisted Living Experiment, an EU-funded project that aims at increasing older people's autonomy and self-confidence by developing a wearable light device capable of measuring specific vital signs of the elderly, detecting falls and location, and communicating automatically in real-time with his/her care provider in case of an emergency, wherever the older person happens to be, at home or outside.

Background

Back in January 2003, we explored the concept of 'location-based health information services', and presented it as a new paradigm in personalised health information delivery [1]. Since then, location-aware applications and services, and location-sensitive mobile devices have undergone major improvements, and have become more widely available and less expensive [2]. These rapid developments have made their use in mission-critical tele-care and healthcare delivery significantly more prevalent today than it was in the near past [3]. A recent conference workshop, Locare '06, was fully dedicated to the subject of 'location-based services for healthcare' [4].

The year 2007 has been described as 'the year of Global Positioning System (GPS)-enabled mobile phones' par excellence [5,6]. In fact, mobile phones lend themselves very well to location-based technologies, as David Sym-Smith cleverly notes: "Prior to mobile phones, the most common opener to a telephone conversation was 'How are you?' Today, on a wireless phone, more conversations open with 'Where are you?'" [7] Such GPS-enabled mobile phones (GPS-enabled cameras and other gadgets also exist) will not just enable millions of people to collectively annotate the Earth in ways never done before [8], but will also open many other exciting and much needed location-based service possibilities and opportunities. On such an opportunity is perfectly exemplified in CAALYX [9]. CAALYX aims at increasing older people's autonomy and self-confidence by developing a wearable light device capable of measuring specific vital signs of the elderly, detecting falls, and communicating automatically in real time with his/her care provider in case of an emergency, wherever the elderly person happens to be, at home or outside. Specifically, CAALYX's objectives are:

What is CAALYX

• To identify which vital signs and patterns are most important in determining probable critical states of an elder's health;

• To develop an electronic device able to measure vital signs and to detect falls of the older person in the domestic environment and outside. This gadget will have a geolocation system so that the monitoring system may be able to know the elder's position in case of emergency (especially outdoors);

• To allow for the secure monitoring of individuals organised into groups managed by a caretaker who will decide whether to communicate events identified by the system to the emergency service (112); and

• To create social tele-assistance services that can be easily operated by the users.

CAALYX considers three main areas of development: the 'Roaming Monitoring System', the 'Home Monitoring System' and the 'Central Care Service and Monitoring System' (Figure 1):

• The Roaming Monitoring System intends to monitor unobtrusively the older person when carrying out his/her daily activities in an independent way, both in the home and outdoors. Several vital signs besides falls will be measured and automatically communicated together with his/her geographic position to the Central Care Service in case of emergency, so that a rescue unit can be dispatched in a timely manner.

• The Home Monitoring System intends to extend the monitoring in the home environment, integrating other monitoring devices and sensors, as well as to integrate home automation devices in the system. Another important aspect is the support for video communication and VoIP (Voice over IP) using the TV set, which can also be used for remote monitoring and service-provision. This platform opens new possibilities for on-demand services for the elderly, like grocery shopping, cleaning, housekeeping or gardening, and periodic consultation with the doctor or personal caretaker. A key goal is to ensure social inclusion through the provided technology, e.g., video conferencing with friends and relatives, and ensuring local events awareness.

• The Central Care Service and Monitoring System will receive alerts from subscribed elder persons. The caretaker will evaluate whether received alerts need to be communicated to the emergency service (112), in which case the geographic position and data about the likely type of emergency (fall, stroke, etc.) will be provided to the emergency service, so that a suitably equipped emergency team may be dispatched in a timely manner to the patient's location. Besides this service, video-communication with the home environment will be provided to attend to the older person's demands. Other possible services include reminders to take pills, activity and scheduled visit reminders, e-visits, etc.

CAALYX uses a bottom-up design approach with full user representatives' involvement to satisfy final and intermediate user needs. Further details about CAALYX, including a typical Case Study illustrating the above functions in everyday use, are presented in the online public project presentation [10].

Why CAALYX?

Other tele-monitoring projects either send location information without much or any details about the current medical status of the user, e.g., the Columba Bracelet, a GPS-enabled bracelet permitting the localisation of Alzheimer patients if they get lost or become disoriented [11], and location-tailored health information services('push services') [12], or send detailed information about user's medical status without any knowledge about their location, e.g., M2DM -Multi Access Services for Telematic Management of Diabetes Mellitus [13], and MobiHealth [14]. However, to be able to offer to users proper help during emergencies wherever they might be (including incidents in which patients are unconscious or unable to adequately describe their location for any reason), a service would ideally require both detailed information about user's current medical status and details of the user's current location in order to dispatch a suitably equipped emergency team to the patient, and that is exactly what we are developing in CAALYX. This is helped by the fact that CAALYX does not rely on fixed fall sensors installed in one place (at home), like infrared fall detection sensors or cameras (computer vision) that are physically tied to, and configured for, an older person's residence and need to first learn about his/her daily routine movement, but uses novel wearable fall sensors (featuring integrated accelerometers and gyroscopes, developed at the University of Limerick, Ireland and at the National University of Ireland, Galway, Ireland, an affiliate of the University of Limerick for the purposes of this project). These wearable sensors accompany the older person anywhere they go, together with an outdoors' GPS solution. The latter will CAALYX system diagram build on the industrial expertise and strengths of one of the project partners, Corscience GmbH & Co KG, Germany, in developing tracking systems (Figure 2) [15].

It is noteworthy that location sensitivity/awareness is now an FP7 (EU Framework Programme 7) trend/"requirement" for 'personalised health status monitoring' projects [16], so CAALYX and a few other projects like EmerLoc [3] are quite ahead of others in this respect.

Current issues and limitations of the locationbased/GPS features in CAALYX and some possible workarounds

Failure to establish a GPS fix in difficult environments

The geo-positioning module in CAALYX might fail to establish a GPS fix when operating in some urban can-yons/foliage/coated windshield environments, and indoors/inside buildings (e.g., inside a shopping mall). One possible workaround would be to develop (as part of a follow-on project) a more comprehensive and robust geo-positioning solution for mobile older people, combining multiple geo-positioning technologies to cover locations where conventional GPS alone would fail. Such a hybrid, "intelligent" solution should be able to automatically and transparently select and switch between multiple geo-positioning methods as appropriate/necessary to ensure uninterrupted location functionality. Other geopositioning technologies to consider in this regard besides conventional GPS include:

• Assisted GPS (A-GPS) and A-GPS over the Internet: can speed up the time to first fix in difficult environments

Corscience mobile GPS tracking system Figure 2 Corscience mobile GPS tracking system. Diagram showing the main components of Corscience mobile GPS tracking system.

[17]; the area of coverage can also be extended by eliminating the need for downloading the ephemeris data directly from the satellite, which requires a higher signal quality than tracking alone; • Galileo Positioning System: will not be fully rolled out until 2010. The Swiss company u-blox have recently announced the release of their first receiver for the European Galileo Positioning System, which will also use the signals of the American GPS satellites [20]. It is expected that Galileo will provide an enhanced coverage over the current GPS, higher positional accuracy, as well as better availability, making it possible to work in urban canyons and even in small buildings.

Privacy issues

Location capability poses service providers with the challenge of responsibly handling consumers' personal privacy [1]. This is particularly important with 'tracking services' that continuously monitor and log user's location, like Wherifone, an American location-tracking service for the elderly and children [21], and other live tracking services using technologies like the GpsGate Server [22]. Such services raise many privacy concerns and questions; for example, "If a consumer service allows one party access to the location of a second party, should that second party be notified when this location information has been provided?" [23] However, CAALYX's approach to location information privacy is different. CAALYX is an extensible user health monitoring platform that uses GPS as to support that function (health monitoring) and for emergency handling. Thus CAALYX is not continuously tracking older people, or continuously communicating their location in real-time with the central monitoring station. There are a number of reasons for this. Firstly, allowing the data logger (a mobile smartphone that users carry on them) to collect the data rather than continuously stream it to a remote server means that expensive bandwidth is saved. It is also far more power-efficient than a system that has to continuously transmit data and pick up real-time geo-graphic information via GPS, a paramount feature in any handheld device. But most importantly, it means people will not feel as if their every move is being watched. Location information is only sent when required during an emergency or when an alarm is raised. As such CAALYX has the potential of setting the standards and providing a 'modus operandi' or 'best-practice' model for wireless location privacy in mobile, location-intelligent/enabled ehealth services.

Conclusions and future directions

Europe is about to face a significant social change, brought about by an unprecedented demographic change: the ratio of older people to the entire population is steadily growing, while the ratio of younger age groups, especially the working population (including healthcare workers) is shrinking. This demographic trend makes it difficult to foresee how Europe will find enough people to take care of its older population, without a major change in traditional older people's care methods. The role of ehealth in facing such challenges will be very significant. In fact, leading health informatics think tanks like Professor Enrico Coiera are anticipating a total "reinvention" of healthcare by the year 2020, as the already significantly strained national health systems face the increasing needs to treat proportionately more people, with more illness, using relatively less tax money and fewer healthcare workers [24].

In this context, CAALYX represents a unique and much needed mobile, location-based (geo-aware) e-health service. Older people's autonomy (duration of independent living) and self-confidence can be greatly increased by wearing a light device that can measure vital signs, detect falls and location, and automatically raise an alert to their care centre in case of an emergency. Other tele-monitoring projects either send location information without much or any details about the current medical status of the user, or send detailed information about user's medical status without any information about their location. However, to be able to offer users proper assistance during emergencies wherever they might be (including incidents in which patients are unconscious or unable to adequately describe their location for any reason), a service would ideally require both detailed information about user's current medical status and details of user's current location, and that is exactly what CAALYX is offering.

To further improve service safety and reliability, the CAA-LYX design team will be looking at a 'technical contingency plan' to deal with problematic situations and locations when/where, for example, geo-positioning/getting a GPS fix using standard GPS is not possible (perhaps consideration will be given to using some form of 'Assisted GPS' in such cases) and/or when communication http://www.ij-healthgeographics.com/content/6/1/9 between the older person and a central CAALYX monitoring station is lost for some reason (e.g., bad network connection or technical fault in remote server). Future followon services should have enough embedded "intelligence" to be able to automatically deal with such situations and switch to a suitable alternative plan.

Other possible future directions include developing value-added geo-services for niche markets; for example, for Alzheimer's patients a geo-reminder service can be developed based on Ludimate's Geo-minder [25] to help with their short-term memory problems. The current version of CAALYX offers essentially the infrastructure for creating such services, and some non-mobile/non-location-based reminders, e.g., daily drug reminders at home, will be included in the pilot. But a location-based reminder to assist Alzheimer's patients could be something like "When I pass supermarket, remind me to buy vegetables". Then upon arriving at the marked location, the mobile phone can play an alarm and display a stored text note or a voice note previously associated to that location. This is far more superior to simple time-based reminders, as it also considers the location-based context.

Figure 1
1CAALYX system diagram. Diagram showing the main components of CAALYX (WLD = Wearable Light Device).

•
WiFi Positioning System (WPS): SiRF and Skyhook have recently announced a hybrid GPS/Wi-Fi (WPS) location solution [18]; • Rosum TV-GPS: a TV based positioning solution with potential enhanced support for dense urban areas and inside buildings (currently only available for the North American/NTSC market) [19]; • Cellular positioning: offers a very wide coverage even in indoor situations while lacking the precision of satellite based navigation systems; and

Publish with Bio Med Central and every scientist can read your work free of charge"BioMed Central will be the most significant development for disseminating the results of biomedical researc h in our lifetime." Sir Paul Nurse, Cancer Research UK Your research papers will be: available free of charge to the entire biomedical community peer reviewed and published immediately upon acceptance cited in PubMed and archived on PubMed Central yours -you keep the copyright Submit your manuscript here: http://www.biomedcentral.com/info/publishing_adv.asp BioMedcentral International Journal of Health Geographics 2007, 6:9

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CAALYX (Complete Ambient Assisted Living Experiment, 1st January 2007-31st December 2008) is a two-year project partially funded by the European Commission (EC) under the Sixth Framework Programme (FP6 -contract number IST-2005-045215 -in response to Strategic Objective: eInclusion Call 6). The total EC contribution to CAALYX is €1,850,000.00 Euros. The project has a total of eight participants in six European countries: Telefónica Investigación y Desarrollo, Spain (Coordinator), Instituto de Engenharia de Sistemas e Computadores do Porto, Portugal, Corscience GmbH & Co KG, Germany, COOSS Marche Onlus, Italy, University of Plymouth, United Kingdom, Guy's and St Thomas' Hospital (NHS), United kingdom, Synkronix Ltd, United Kingdom, and University of Limerick, Ireland, with the National University of Ireland, Galway, Ireland, who for the purposes of this project, is an affiliate of the University of Limerick.
(page number not for citation purposes)
AcknowledgementsThe CAALYX project (Complete Ambient Assisted Living Experiment) is funded by the Commission of the European Union as part of its Sixth Framework Programme (IST-2005-045215).Authors' contributions
Location-based health information services: a new paradigm in personalised information delivery. M N Boulos, Int J Health Geogr. 22Boulos MN: Location-based health information services: a new paradigm in personalised information delivery. Int J Health Geogr 2003, 2:2 [http://www.pubmedcentral.nih.gov/articler ender.fcgi?tool=pubmed&pubmedid=12556243].

Location-based Services and Geo-positioning -Items about location-based services, especially in relation to health and healthcare. Location-based Services and Geo-positioning -Items about location-based services, especially in relation to health and healthcare [http://caalyx.eu/ index.php?option=com_weblinks&catid=13&Itemid=23]

EmerLoc: Location-based services for emergency medical incidents. I Maglogiannis, S Hadjiefthymiades, 10.1016/j.ijmedinf.2006.07.010Int J Med Inform. in pressMaglogiannis I, Hadjiefthymiades S: EmerLoc: Location-based services for emergency medical incidents. Int J Med Inform 2006 in press. doi:10.1016/j.ijmedinf.2006.07.010

First Workshop on Location Based Services for Health Care -Locare'06. November Innsbruck, AustriaFirst Workshop on Location Based Services for Health Care -Locare'06, 28 November Innsbruck, Austria [http:// www.locare.org/]

Businessweek -Europe, results?search_query=Nokia+GPS+N95&search=Search] 7. Navigation in 2007: It's Much More Than Maps (David Sym-Smith, Directions Magazine. Takes to Location-Based Cell ServiceBusinessWeek -Europe Takes to Location-Based Cell Serv- ice [http://www.businessweek.com/technology/content/oct2006/ tc20061013_164404.htm] 6. Nokia N95 [http://www.youtube.com/ results?search_query=Nokia+GPS+N95&search=Search] 7. Navigation in 2007: It's Much More Than Maps (David Sym- Smith, Directions Magazine) [http://www.directionsmag.com/ article.php?article_id=2379&trv=1]

Second Life Future Salon Brave New Virtual Worlds: Presentation Slides v1.0 for 'Accelerating Change. Second Life Future Salon Brave New Virtual Worlds: Pres- entation Slides v1.0 for 'Accelerating Change 2005' [http:// slfuturesalon.blogs.com/second_life_future_salon/2005/09/ brave_new_virtu.html]

CAALYX Web portal. CAALYX Web portal [http://caalyx.eu/]

The Columba Bracelet Permits the Localisation of an Alzheimer Patient in the Event of Their Getting Lost or Becoming Disoriented (News Release. The Columba Bracelet Permits the Localisation of an Alzhe- imer Patient in the Event of Their Getting Lost or Becoming Disoriented (News Release, 16 November 2006) [http:// www.prnewswire.co.uk/cgi/news/release?id=184581]

HealthCyberMap Customisation. HealthCyberMap Customisation [http://healthcybermap.org/ ip.htm]

M2DM. M2DM [http://www.labmedinfo.org/research/m2dm/m2dm.htm] 14. MobiHealth [http://www.mobihealth.org/]

Corscience -Tracking systems. Corscience -Tracking systems [http://www.corscience.de/en- tracking-systems.html]

FP7 Objective 188.8.131.52 -Personal Health Systems for Monitoring and Point of Care diagnostics. Internet A-GPS. 9Slide 9: FP7 Objective 126.96.36.199 -Personal Health Systems for Monitoring and Point of Care diagnostics [http:// fp6uk.ost.gov.uk/documents/lsgb/ Diane_Whitehouse_Challenge_5%20_%20London%20_DW.ppt] 17. Internet A-GPS [http://www.gpspassion.com/forumsen/ topic.asp?TOPIC_ID=47602]

SiRF Teams with Skyhook Wireless To Deliver GPS-WiFi Hybrid To Accelerate Location-Based Services. php?duty=Show&id=16422&trv=1] 19. Rosum TV-GPS. SiRF Teams with Skyhook Wireless To Deliver GPS-WiFi Hybrid To Accelerate Location-Based Services [http:// www.directionsmag.com/press.releases/ index.php?duty=Show&id=16422&trv=1] 19. Rosum TV-GPS [http://www.rosum.com/rosum_tv- gps_indoor_location_technology_overview.html]

First Galileo receiver upcoming. First Galileo receiver upcoming [http://www.yournav.com/con tent/n/225/First_Galileo_receiver_upcoming.html]

Wherifone. Wherifone [http://www.wherify.com/wherifone/seniors.html] 22. Online tracking -GpsGate Server [http://franson.com/gpsgate server/]

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Cultural nationalism in Mashingaidze Gomo's A Fine Madness

Rodwell Makombe firstname.lastname@example.com
Department of Media
Language and Communication at Durban University of Technology
DurbanSouth Africa

Department of Media
Language and Communication at Durban University of Technology
DurbanSouth Africa

Cultural nationalism in Mashingaidze Gomo's A Fine Madness
3B369DB83A2363D2FC147C7B58E292A110.4314/tvl.v51i2.7anti-colonialismanti-imperialismcultural nationalismneocolonialismresistance
Cultural nationalism in Mashingaidze Gomo's A Fine MadnessFor many years, African countries have struggled to develop an ideological framework that suits the dynamics of the African context.From the writings of literary artists to those of political figures such as Kwame Nkrumah, the call has remained consistent: Africa needs to formulate its own path of development and disentangle from the tentacles of colonialism and neocolonialism.While négritude, as a cultural movement, was a direct response to the impact of Western civilisation on Africans in the aftermath of colonization, Gomo's A Fine Madness may be read as a response to the West's dominance in the neoliberal global order.It interrogates the relationship between Europe and Africa in light of persistent war and instability in Africa, particularly in the Democratic Republic of Congo.Like négritude, Gomo's work advocates the promotion of African ways of doing things politically, economically and culturally and shuns neocolonial relationships of exploitation.Adopting an anti-imperialist position, A Fine Madness holds the West responsible for fuelling conflict in some African countries for commercial gain.The article interrogates the concept of cultural nationalism as it has been appropriated in Gomo's work.Focusing on selected poems, the article argues that A Fine Madness is a militant intervention in African politics, and a voice of resistance to the obtaining neoliberal global order.

Introduction

Every struggle for liberation is a struggle for cultural freedom.Thus, resistance to colonial/neo-colonial domination is, in many ways, resistance to the culture of the coloniser.From the writings of literary artists to those of politicians, there has been a concerted effort in Africa to recover and promote cultures that were annihilated by colonialism or simply to find a cultural framework that is suitable to the African context.Writing about cultural nationalism in the aftermath of colonization, Abiola Irele notes that négritude appears as the culmination of the complete range of reactions provoked by the impact of western civilisation on the African, and of the whole complex of social and psychological factors that have gone to form black people's collective experience of western domination.Its roots lie far down in the total historical experience of the black man in contact with the white (Irele 322).The cultural nationalism exhibited by the négritude movement had two facets.On one hand, there was a negative gesture of refusal, a denial of an imposed world-order attributed to the white coloniser, and the wish for a cultural 'differentiation' which gave rise to a nascent political awareness, or a nationalist consciousness.On the other hand, there was a recasting of foreign and indigenous elements into a new cultural structure, which offered new possibilities of self-expression (Irele 323).The ideals of the négritude movement are relevant to this article because they provide a background to the cultural nationalism exhibited by Gomo's poetry.As it was during colonialism where Africans were drawn into the cultural world of the European but kept in a secondary position, in the neoliberal global order, Africans continue to occupy a secondary position in an economic system whose balancing scales are tipped in favour of the West.

Cultural nationalism may be defined as the manifestation of the nationalist "sentiment" in cultural indices, which places emphasis on cultural symbols, ideas, beliefs and other artifacts and motifs shared by a group (Adedeji 432).Boyd Shafer (in Adedeji 432) defines nationalism as a sentiment which unifies a group of people who have a real or imagined common historical experience and a common aspiration to live together as a separate and distinct people in the future.Adedeji (432) further argues that in the African context, cultural nationalism arises out of the unique cultural history of the people of Africa, the colonial onslaught on the continent and the conscious attempt by certain individuals or groups to seek ways and means of satisfying their nationalistic aspirations through a programme that resurrects the African past.Gomo may not be advocating a return to an idyllic past, but his work bears out as a vicious attack on neo-imperialism in Africa.

Cultural nationalism tends to have specific objectives.Hutchinson (Ndlovu-Gatsheni 946) is of the view that 'cultural nationalism is a movement of moral regeneration which seeks to re-unite the different aspects of the nation-the traditional and modern, agriculture and industry, science and religion-by returning to the creative life-principle of the nation".Cultural nationalists therefore perceive of the nation as a product of history and culture and thus they seek to inspire 'love' of community, educating members of community on their common national heritage of splendour and suffering, engaging in naming rituals, celebrating cultural uniqueness, and rejecting foreign practices (Ndlovu-Gatsheni 947).While négritude as a cultural movement sought to resist colonialism and assert African values, Gomo's cultural nationalism resists neo-imperialism which manifests itself through unfair trade relations and the commercialisation of war in Africa.

Mashingaidze Gomo is a Zimbabwean writer who was involved in the DRC war of 1998 following the death of the Congolese dictator, Mobutu Sese Seko, and Laurent Kabila coming to power (Ngugi in Gomo 1).Born in Highfield in 1964, Gomo is the fourth in a family of eight.His father was a driver at Lobels Bakeries in Zimbabwe while his mother was a peasant farmer in Chihota village.Gomo spent the first early years of his life in Chihota, his parents' rural home.Although his mother only went to school as far as Standard Three, she believed in education and thus became a source of inspiration to the young Mashingaidze.After completing his Advanced Level in ˜˜ Harare, Mashingaidze Gomo joined the Air force of Zimbabwe as an apprentice and worked there for almost 23 years.When the Mozambican civil war of the late 1980s broke out, Gomo was part of the Zimbabwe National Army contingent that was deployed to assist the forces of the Mozambican regime.It was during this war that Gomo saw, first hand, the destructive nature of war.The Renamo insurgents "destroyed critical infrastructure from bridges and roads to electricity power lines".

The DRC war of 1998, in which Gomo also participated, attracted the attention of countries such as Namibia, Angola and Zimbabwe in the SADC (Southern Africa Development Community) region.Formerly known as Zaire, the DRC is a vast country in the Great Lakes region which has suffered a series of civil wars since independence in 1960 and the murder of its first premier, Patrice Lumumba, in 1961.Over the years, the civil wars have been centred on the control and distribution of the country's vast mineral resources.

In line with Ngugi's call for the recovery and promotion of African culture and languages, Gomo's work laments the mutilation of African cultural resources in the new global order.Perhaps the question is: what is new?A lot has been done by way of writing back to the empire and countering Western misrepresentations of Africa.According to Hovarth, A Fine Madness proves compelling not because its analysis of colonialism is particularly original but because its representation is engrossing and believable.Gomo makes the reader believe in his educated but otherwise ordinary soldier's earnest struggle to make sense of his circumstances (Hovarth 251).The genre that he chooses to package his ideas is also worth noting.In a review, Whittaker (44) describes A Fine Madness as "a kaleidoscope of notes and fragmentary diary entries, poetry and prose, factual descriptions and phantasmagorical flights of fancy".Most importantly, Gomo succeeds in "painting a visual tapestry of the heinous images that comes with war" (Otas 79).He even manages to wrest beauty from the punishing jungle, to sing songs of hope in a seemingly hopeless situation.Drawing from his experiences of the horrors of war, he passionately "reflects on the wider issues of colonial exploitation and the possibilities of a Pan-Africanist vision of the continent" (Whittaker 44).Far from being an original narrative, A Fine Madness resuscitates and rekindles a Pan African vision envisaged by thinkers such as Aíme Césaire in his Return to my Native Land.

In his book, Moving the Centre: The Struggle for Cultural Freedoms, Ngugi calls on formerly colonised countries to shun Eurocentrism and embrace alternative worldviews.His idea of "moving the centre" resonates with the narrator's call for Africa to draw from its rich cultural resources and desist from depending on the West.For example, in a poem entitled "Impeccable English and French" (54), Gomo's narrator harps on the idea of having one language across the African continent.Although the idea may seem far-fetched, it is inspired by the narrator's realisation that there are more similarities than differences between most African languages.The ˜˜ notion of "moving the centre" advanced by Ngugi also resonates with "Afrocentrism" which, as defined by Molefi Asante is "a quality of thought, practice, and perspective that perceives Africans as subjects and agents of phenomena acting in their own cultural image and human interest".The Afrocentric project includes an interest in psychological location, a commitment to finding the African subject place, the defence of African cultural elements, and a commitment to lexical refinement and to correct the history of Africa (Asante 1).Gomo's work may thus be read as an Afrocentric project that seeks to retell the African story.Afrocentricty, as Asante puts it, is a perspective that puts Africa at the centre.Ngugi affirms that "centredness is the basis of all knowledge and human development.A person must know where they stand in order to know in what direction they must proceed" (Ngugi Politics, 32).

The title of Gomo's book A Fine Madness is, in fact, a paradox.Madness is usually perceived as a deviation from the norm, hence to call it "fine" seems to be a contradiction.In this respect, the title is a statement of resistance, and subversion of European ways of conceptualising and representing the world.A Fine Madness is probably a celebration of an alternative modernity-a way of life that appears as "madness" to the Western world.In other words, what the West condemns as backward is appropriated and celebrated as an alternative cosmology.Gomo's narrator is a soldier participating in the war.This is interesting because we rarely think of soldiers as poets, let alone intellectuals.Soldiers are usually seen as machines of power who take orders without asking why.Gomo's soldier-narrator is different because he seems to understand why he is fighting.His frame of reference is seemingly Afrocentric for he propagates the view that Africans 'have been moved off terms culturally, psychologically, economically, and historically' (Asante 1) hence the need for psychological repositioning.

The first poem in the collection, "Tinyarei" ("Give us a break") celebrates the beauty of Africa which is embodied in Tinyarei, the narrator's fiancée.Tinyarei is a Shona word which is usually used to warn or rebuke someone in confrontational situations.It may also be translated as "give us due respect".In this poem, Tinyarei is a symbol of Mother Africa endowed with natural beauty and, as the narrator puts it, in colloquial streetwise language, she is 'the perfect thing' (4).The narrator's love for Tinyarei is "a fine madness" because it goes against the popular view that beauty and old age cannot go together.We normally associate beauty with the radiance of youth, but Tinyarei is an older woman "aged in beauty" (4).The juxtaposition of age and beauty may suggest that the narrator's love is quite deep and goes beyond the superficial erotic level of youth.The resilience of Tinyarei's beauty is also emphasised when the narrators says her beauty "hangs on even as age takes its toll / Lingering on like a summer sunset" (4).Summer is usually associated with joy and new life.Thus, Tinyarei's beauty resists the passing of time.She still has a seductive smile capable of "disarming" men.

˜˜˜˜˜

This poem interrogates two conflicting views about Africa and her relationship with the West.On one hand, there is a view that Tinyarei's beauty should be "scattered around or shared […] globalised if you like" (4).On the other, there is a view that Africa should take its own path and stop depending on foreign assistance for its own development.The use of the word "scattered" to refer to the manner in which some Westerners want Tinyarei's beauty to be consumed implies a reckless and unsustainable process.Perhaps this is an allusion to the manner in which Africa's resources have been plundered without accountability.The narrator equates this way of distributing Tinyarei's wealth to globalisation.From the narrator's point of view, globalisation is a euphemism for the systematic plunder of Africa's resources, a process of disempowering Tinyarei on the pretext that "there cannot be too much power over the hearts of men in any woman's hands" (4).To globalise is therefore to limit Tinyarei's (Africa's) bargain power.This is probably an allusion to the unfair and exploitative trade relations between developing and developed countries.Biney (130) intimates that "globalization is negative when it allows itself to be handmaiden to ruthless capitalism, increases the danger of warfare by remote control, deepens the divide between the haves and have-nots, and accelerates damage to our environment".

The soldier-narrator stands "at variance with" (5) globalization which he depicts as a smokescreen for perpetuating the exploitation of Africa.In fact, the name "Tinyarei" is also a stubborn rejection of Western interference in African affairs.Western countries are portrayed as deceptive suitors who believe that Tinyarei should not know her value because if she did, she would be difficult to woo.The narrator lampoons those who associate progress with "walking the streets of London and Paris, signing contracts that shackle [them] to European commerce" (5)."Walking the streets of London and Paris" conjures the image of a prostitute selling her body for money.The implication is that globalization and economic liberalization are part of the West's agenda to siphon Africa's resources.In the fourth stanza, the narrator becomes more overt when he points out that Europeans want to abuse Tinyarei, however there are some "surprisingly black too / who have argued that beauty so superlative is too good for an African" (4).The implication is that some Africans have internalised inferiority complexes and thus cannot appreciate the beauty of their own kind.The black men that the narrator refers to are perhaps those that Ngugi wa Thiong'o calls the "comprador bourgeoisie" who collude with international capital to perpetuate the exploitation of Africa.They accuse Tinyarei of "sitting on money" which implies that they want her to commercialise her body without thinking about sustainability.In fact the phrase "sitting on money" is literally an insult on women who fail to commercialise sex and earn a living from it.Some black people also want Tinyarei to "invest herself in European fashion magazines".Here, the notion of "investment" is portrayed as a promiscuous transaction whose only focus is money making.The "streets of London and Paris" symbolise European centres of commerce where Africa's ˜˜ resources are exchanged for a pittance.By signing such contracts, Tinyarei would "shackle herself to European commerce", implying that she would lose her freedom or the ability to exercise free will.

In this poem, the narrator uses vernacular to tape into public discourse.The line "kuti Unomupei?"( 5) is Shona for "What will you offer her".The expression is commonly used in an attempt to discredit poor men who may be interested in courting a beautiful woman.In this case, the narrator presumably lacks the financial stamina to take care of Tinyarei's needs.However, in spite of the alleged poverty, the narrator feels that he can still love Tinyarei because African women are not "beautiful invalids" who marry only for economic gain.The contrast between "beautiful" and "invalids" evokes the notion of Africa as a rich poor continent-rich in resources but poor in technical expertise.The narrator seems to advocate self-reliance as the way forward for Africa.Tinyarei does not need men to sustain her beauty, she can be "beautiful as she wants to be and yet not be shared or sustained by men" (5).The narrator refuses to give in to external pressure, and insists that "the madness of falling in love with her should owe no explanation to anyone … / not even a group of white journalists from a European fashion magazine".The use of the ellipsis in this quote suggests that the narrator is actually reserving his words; he could have said more to ward off his detractors.

In a Nkrumahist fashion, the narrator thus condemns those Africans who see "partnership" with Western powers as the only way to develop the continent.In a preface to Moving the Centre, Ngugi underscores the need for cultures to interact and borrow from each other.However, he cautions that "while there is need for cultures to reach out to one another and borrow from one another, this has to be on the basis of equality and mutual respect"."Conditions of external domination and control, as much as those of internal domination and oppression, do not create the necessary climate for the cultural health of any society" (xvi).Colonialism displaced Africans through cultural domination.Therefore, there is need for cultural reorientation, of changing our perceptual lenses so that we can see the world from a diversity of centres.This is in fact the "madness" implied in Gomo's title-the ability to appreciate other worldviews that have been suppressed by colonial epistemology.The narrator's madness is "very fine and enjoyable" (8) because it is home grown, it "owes no explanation to anyone" (5).The implication is that Africans ought to be psychologically located in Africa and not measure themselves against Western standards.Being a Zimbabwean writer, Gomo was probably influenced by the official discourse of the Mugabe regime, which has over the years been trumpeting the victim trope based on Africa's colonial history.

For the narrator, the war in the DRC is between Western powers, who finance the rebels, and those defending the sovereignty of the country.On this note, Oliver Nyambi (3), accuses Gomo of representing "the neo-colonial siege" in an essentialist way.The soldier-narrator claims to be resisting neo-colonialism and thus categorises ˜˜ his opponents as puppets of the West, 'it felt nice to defy the judgment of a world that has styled all life to the whims of barbarians' (8).The use of the word 'barbarians' to refer to Europeans reverses stereotypes and restores (at least discursively) African dignity denigrated by years of colonial barbarism.Europeans are barbarians because they use hi-tech military equipment to kill innocent civilians in Africa.

Towards the end of the poem, it becomes clear that the narrator is not only fighting a political war but also a cultural one.He is proud to declare his African names and defy attempts by colonial schools to destroy African culture, "it felt spitefully nice to be all the names the British priest had refused in Sunday school" (8).The notion of madness is in fact subjective and fluid.It is in fact a construct used to denigrate and discredit the other, yet it can also be celebrated as an alternative worldview.We are told that when the narrator left the Christian church "the priest thought [he] was mad" (8).The narrator embraces the term "madness" as a counter-discourse; the way négritude poets affirmed stereotypes as a way of resisting cultural imperialism.

The narrator keeps on alluding to Boende, a village in the DRC, a symbol of African space, and a vantage point from which he reflects on the machinations of the colonial enterprise, 'looking at it all paBoende, it felt so awfully nice I could have enjoyed refusing his suggestion again and again and again" (8).Boende gives the narrator a bird's eye view of the hypocrisy of Western discourses.Looking at the whole situation from Boende, which is also symbolic of a site of struggle, the narrator begins to realise that European traditions are also pagan because Father Dion's name was from Dionysus "the pagan Greek god of wine and fertility" (9).Apparently, this god was a drunkard who "always moved with a good supply of beers" (9).

The narrator celebrates African names because they are social statements.His own name "Muchineripi" is a "slap" because it embodies the spirit of resistance to cultural colonialism.African names reflect events and experiences unique to the African space.A name is therefore a memorial.The narrator's grandfather is called Takawira, which can be translated as "We fell" to capture the brutal experience of defeat and dispossession which came with the colonial experience.The name 'Takawira' also evokes memories of the liberation struggle.Leopold Takawira is the legendary hero of Zimbabwe's liberation history.The narrator is thus a reincarnation of the revolutionary spirit of the anti-colonial struggle.Human beings are constituted by their experiences; therefore what makes the narrator an African is not just the name but the "circumstances [he has] been born into / circumstances that [are] part of [him]" (99).These names situate the narrator within a specific culture and history and act as signposts of particular experiences.The constant reference to Mbuya ne Nehanda and Mukwati (spirit mediums of Zimbabwe's first Chimurenga) implies that the current war is inspired by the same spirit mediums that inspired the war of liberation.

In the poem "Kufa Kunesu Machewe" ("Death is with us for real") the narrator celebrates the way Zimbabwean soldiers in the DRC war used music as an antidote to heal loneliness.Mbira music is portrayed as a medium for transmitting history and culture.The musical melody is "a wistful one […] a migration of sound from the darkest recesses of the race psych […] tentatively descending the broken hills of African experience into the valley of neocolonial conflict below" (101).The soldiernarrator prefers to listen to the music because listening "gives one time to savour the music without the distraction of involvement" (100).The use of the word "savour" suggests that music is like food for the soul; it takes the narrator into a tranquil state of relaxation.The two mbira players in the poem (the "man on transit" and the "tall commando") are metaphorically engaged in a musical battle which dramatizes neocolonial conflict in Africa.The "transit man" takes the lead tune while the "tall commando" follows with a rumbling, domineering bass.The tune of the music is "a wistful one" because it conjures up memories of the past "the broken hills of African experience" and "the valley of neocolonial conflict".The notion of "broken hills" as an image of the African experience implies that the African past is not perfect.On the other hand, representing the neocolonial dispensation as a "valley" creates the impression that neocolonialism is the Achilles' heel of Africa's development.In the musical drama, the tall commando stalks the transit man "with evil intentions" (101), the way European colonizers stalked Africa in order to colonize, "waiting for an opportune moment to pounce" (101).The bass tune rumbles "all over the tentative lead tune like a bully" (101).This is reminiscent of the way former colonial powers continue to make decisions for Africa without consulting her.In the neoliberal order, the battle between the lead tune and the bass tune resembles that between neo-imperial powers and developing countries.The former are bullies who seek to impose their will on the vulnerable lead tune.To make matters worse, when the latter reports the bully to the international world, nothing is done: the international world [is] ruled by the bully and the most it can do for fear of victimization [is] to simply say what [is] being done [is] wrong" (101).

Mbira music does not only provide entertainment and relaxation to the mind, but also functions as a repository of important moments in history.In this poem, Mbira music retraces the African experience and celebrates African heroes and heroines.Neocolonial conflict is the "African Armageddon" (101)-the biblical war of the end of the world-because it is not likely to end any time soon.The bass strand and the tentative lead tune symbolize the imperialist, on one hand, and the anticolonial freedom fighter, on the other.Just as the bass tune wants to silence the lead tune, colonialism aims to obliterate African knowledge systems.However, the lead tune remains resilient like "a lone guerrilla drawing strength from solitude" to keep fighting for freedom.Mbira music connects the narrator to his roots, particularly his ancestors.Mbira also enables the narrator to "revisit the past and appreciate its values from an elevated view" (102), to reflect on and relieve memories from the past "the good music transcended my mind into memory lane / a solitary lane one walks all alone even when in the company of others" (102).The music speaks to the narrator 's soul and guides him to a place of self-introspection.

Playing Mbira music is also a way of communicating and fellowshipping with the dead "a plea to the spirits of the land" (102).The narrator portrays the world of the ancestors as a peaceful world free from the hustle and bustle of modernity.As he is taken down memory lane by the mystic powers of Mbira music, the narrator recalls a woman "possessed by an ancient spirit of the land" ( 103) "enjoying a moment of respite in the modern world" (103).Thus, the narrator mocks those who have forsaken their traditional ways and calls them, derogatorily mhuka dzakarasika ("cursed or lost animals").While we often think of possession as a traditional practice, the narrator points out that Western culture also has spirits and those who follow it get possessed too "by the rouged deities of Western cultures and the meaninglessness of their socalled sophistication" (103).The woman possessed by the spirit of the land "dance [s] to life" to imply that the true personality of African people is found in their culture.The song that the woman sings, Kufa kunesu machewe acknowledges the role of ancestors in the lives of the living.The woman cannot die without the approval of her ancestors Kunoda vadzimu kufa kwangu ("my death requires ancestral authority") (103).As the Mbira plays, the narrator travels back into precolonial Africa where Africans had complete sovereignty over their own land "And Chief Nyandoro was being inaugurated / And armed traditional men were dancing around Tinyarei" (103).In traditional Shona culture, knowledge is passed on from generation to generation by word of mouth, and according to the narrator's grandmother the "armed traditional men dancing around Tinyarei "are mediums of the heroes of the First Chimurenga" (103).

One can thus argue that A Fine Madness is a daring attempt to re-affirm African values in a world where Western values have been embraced as the ideal.The poem "The light of Western civilization'"debunks the myth of Europe's so-called civilizing mission which destroyed African knowledge systems.Colonial education celebrates Western heroes, "the legendary white explorers who discovered an Africa that was dark and chaotic" and the "light of Western civilization, democracy and Christianity" (39) while denigrating African heroes and cosmologies respectively.Colonial/neocolonial schools impart knowledge which is "catastrophically irrelevant" (38) to the African context.Although the narrator studied geography at high school, what he learnt did not prepare him for the "punishing heat" of the equatorial region.Ironically, Africans who fail such useless syllabi are classified as illiterate.

We read about famous white men of the cloth who facilitated dispossession and forced labour of poor African people And we read about custodians of modern democracy and the rule of law who formed minority apartheid governments that denied African people the right to vote and chart their own destiny (39).

Here, the narrator exposes the contradictions of Western thought.Missionaries were supposed to bring salvation to the lost but they ended up facilitating the dispossession and enslavement of African peoples.Europeans claimed to be custodians of democracy but they also created undemocratic regimes such as apartheid in South Africa.European scholars may not be valuable to Africans because their ideas were used to justify colonialism.

We read of Shakespearean works informed by an Elizabethan view of a God-created cosmos in which order was imposed on chaos just as they had done on Africa and history was not a blind chain of events but providential sequence governed by Western rule of law that sanctioned their dominance as destiny and sought to instil a sense of futility in would-be African revolutionaries (39)

The narrator feels that Western thought is not relevant to Africa because the same was used to support the plunder of African resources through colonialism.Eurocentric education only serves to divide Africans because those who acquire it became alienated from their people.This education system "breeds individualism that advances[s] the capitalist cause" (39).The narrator seems to echo the official discourse of the Mugabe regime when he insists that "no lessons about tolerance can be learnt from invading imperialists who beheaded African people for resisting dispossession and forced labour" (40).He advocates that those who participated in the anti-colonial struggle must take the central role in the writing of African history, especially "the guerrilla who was where it all happened" (41).Although the guerrilla's narrative may prevent distortion of African history, as the narrator assumes, it may also promote official narratives that are subjective and one-sided.However, the point that the narrator is making is that Africans ought to be agents of their own history: "I thought that African history should actually be designed and not left to providence and chance" (42).

The notion of designing African history speaks about agency, the ability to reject European distortions and promote Afrocentrism.While the narrator rightfully emphasises the need for social justice in the aftermath of colonial dispossession, he is, however, rather extremist to advocate a "Mosaic justice that should not allow invading land grabbers to hold onto even a square millimetre of stolen land" (43).

The poem "The wasp is corrupt" further interrogates the double standards of the West.The latter claim to be custodians of democracy and the rule of law yet they support violence and war in Africa.The relationship between the wasp and the caterpillar metaphorically represents that between Africa and Europe.The wasp (Europe) kills the caterpillar (Africa) to "nourish her own descendants" (59).The "subversive venom" that the wasp injects into the caterpillar is probably colonial education which paralyzes and enslaves African minds.In the wasp's plans, "violence would have to be used on the caterpillar's life […] as violence was used to enslave the African to nourish the children of white people" (60).The narrator asks, "What corruption could be worse than imperialist oppressors subverting and arming African children to commit fratricide and trash their own sovereignty and heritage" (61).The narrator sees war as a conduit through which the West gains access to Africa's vast mineral resources.Africa is the "fat caterpillar" (61) "transformed into the theatre of fights for geostrategic influences or a safe haven for outside opportunists who, in complicity with some greedy African leaders, operate their cynical pursuit of private interests" (Schittecatte 64).

In the preface to Gomo's anthology, Chirere notes that A Fine Madness is "a weapon of war and no weapon of war in the hands of a combatant is neutral".Indeed, the narrator has taken a radical stance to expose the West's continued involvement in the destabilisation of the African continent.Some scholars such as Ngugi wa Thiong'o caution that "Gomo's vision might come across as pedantry with the tendency to see history in terms of a monolithic whiteness against an equally monolithic blackness […] Essentially, "by subsuming class divisions in Africa under the struggle between two colour monoliths, Gomo denies himself a perspective that might better explain the emergence of postcolonial dictatorships and their actual relationship to the Western corporate bourgeoisie" (2).Although Ngugi has a point in highlighting the essentialist dimension of Gomo's narrative, not every struggle in Africa is a class struggle.Achille Mbembe, for example, characterizes Africa's wars as "wars of rapine pitting one set of predators against others" (88).

Conclusion

In conclusion, the article has argued that A Fine Madness is a political weapon aimed at exposing the hypocrisy and double standards of Euro-American policies on Africa.Along the lines of Nkrumahist Pan-Africanism the narrator debunks Western prescriptions for Africa's development.The West cannot provide a solution to Africa's problems because of its vested interests in Africa's resources.While the narrator seems to have a sound grasp of the relationship of exploitation between Africa and the West, he tends to take an essentialist position that projects the continent as entirely beleaguered by terrorist groups, rebels and opposition parties sponsored by western powers to destabilize African "democracies that threaten to overwhelm white minority influence" (Nyambi 3) He also leans heavily against the anti-imperialist rhetoric, overlooking excesses of some African regimes that purport to be victims of Western interference.However, as Chirere has pointed out, Gomo's narrative "is a weapon of war and no weapon of war in the hands of a combatant is neutral".A Fine Madness is not outstanding for its originality, but for its ability to articulate poetically an African perspective and issues that have affected the African continent since the days of ˜˜

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