1

1 All pictures are the authors own and permission

for the usage was obtained from all informants.

Left: Akosi; right: Bubu and Owowusu

Social Anthropology Dissertation March 2013

Michaela Hubmann Student Number: 1017555

The Politics of Blame and Self-Blame

Stroke in the Ashanti Region of Ghana:

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Abstract

This dissertation investigates the lived post-stroke experience in Ghanian Akan

society. It shows that Akan matrilineal values of reciprocity, respect and

deservedness influence both the provision of care and the experience of care.

Investigating the lived experience and illness narratives of afflicted persons and

their care providers is of utmost importance when trying to make sense of

people’s health seeking and care provision behaviour. Only by developing an

emic perspective are the hidden inequalities of care provision within families

highlighted. Such inequalities are influenced by wider structural factors (e.g.

poverty or minimal access to health care) which occur in Akan society and in

Ghana at large.

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Table of Contents

Abstract ......................................................................................................... 1

Acknowledgement ......................................................................................... 4

Chapter 1: Introduction and Background ........................................................ 5

1.1. Introduction ........................................................................................................... 5

1.2. General background: Ghana .................................................................................. 7

1.2.1. The Akan and Asante ...................................................................................... 8

1.2.2. Stroke in Ghana .............................................................................................. 9

Chapter 2: Literature Review ........................................................................ 12

2.1. Studies on stroke in sub-Saharan Africa and Ghana ........................................... 12

2.2. Epidemiological approaches in anthropological perspective .............................. 13

2.3. Anthropological approaches ................................................................................ 15

Chapter 3: Fieldwork, Fieldsites and Methodology ........................................ 20

3.1. Fieldwork in Offinso, Ashanti Region, Ghana ...................................................... 20

3.2. Fieldsite I: Hospital .............................................................................................. 21

3.2.1. Physiotherapy Department .......................................................................... 21

3.3. Methodology ....................................................................................................... 23

3.4. Fieldsite II: Community ........................................................................................ 25

Chapter 4: The syncretisation of different health systems in Ghana ............... 27

4.1 The archaic concept of ‘pluralism’ ........................................................................ 27

4.2. Medical systems in historical context.................................................................. 28

4.3. Preference for choosing herbal treatment .......................................................... 29

4.4. Negative perceptions of herbal treatment .......................................................... 32

4.5. Herbal treatments to ‘go modern’ ...................................................................... 33

4.6. Conclusion ........................................................................................................... 35

Chapter 5: The aetiology of stroke and politics of blame and self-blame ........ 36

5.1. Unhealthy Diets ................................................................................................... 36

5.2. Poor lifestyle practices: Alcoholism ..................................................................... 38

5.3. Witchcraft causation............................................................................................ 40

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5.4. Self-Blame ............................................................................................................ 41

5.5. Conclusion ........................................................................................................... 42

Chapter 6: Experiences of Care and Care Provision ........................................ 44

6.1. The role of the family in care giving .................................................................... 44

6.2. Case study I: Camie .............................................................................................. 45

6.3. Case study II: Akosi .............................................................................................. 48

6.4. Conclusion ........................................................................................................... 55

Chapter 7: Conclusion ................................................................................... 57

Bibliography ................................................................................................. 60

Appendices ................................................................................................... 66

Total Word Count: 14,730

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Acknowledgement

This dissertation would not have been possible without the help of Father Joah,

who was responsible of approving my research in the hospital, and whose natal

family welcomed me into their Offinso home.

In Ghana, my grateful thanks are extended to the members of the

physiotherapy department who provided a warm working and research

environment, and to my research assistant Justice, for liaising with stroke

patients in the community.

I am profoundly grateful to my informants, for their co-operation. For the

purpose of confidentiality, all names have been changed.

I would like to thank Melissa Parker for her invaluable support and guidance

throughout the process of writing this dissertation.

Finally, I wish to thank Nicole for her support and encouragement throughout

my study.

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Chapter 1: Introduction and Background

1.1. Introduction

This dissertation investigates how matrilineal values of reciprocity, respect and

deservedness influences the lived post-stroke experience of the Akan in the

Ashanti region in Ghana. These values determine the level of care provided to

the sick individual whilst at the same time influencing the care giving

experience. The dissertation further analyses my informant’s understandings

and explanations of the aetiology of their affliction, as such views are influenced

by wider socio-political and cultural factors. State-led health education

programmes additionally influence such aetiologies, as primary focus is on the

individual’s lifestyle choices, their health seeking behaviour and the

establishment of risk factors and risk behaviours. This, in turn, fosters a politics

of blame and self-blame, whereby informants either blamed themselves for

becoming sick, or they were accused by others of having led an unhealthy and

‘risky’ lifestyle.

Stroke for my informants was a disruptive event, whereby the sudden

malfunctioning of their body interrupted all aspects of their daily life and those

of their families. Stroke survivors were particularly troubled by the loss of their

personal independence and their role as income generator. This, in turn, caused

familial and emotional consequences. To accelerate recovery a syncretic

approach to health care was employed: The use of contemporary medicine for

treating acute and serious symptoms was coupled with the use of local healers

in order to address the spiritual aspect of their affliction.

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My informants’ illness experience was characterised by inequalities

accessing adequate care and health facilities, as well as by structural factors

such poverty and social inequality. This dissertation therefore highlights the

lived post-stroke experience in order to understand health seeking and care

giving behaviour.

Chapter 1 provides basic demographic information about Ghana, Akan

matrilineal values, and stroke. Chapter 2 places this dissertation in the wider

literature of non-communicable diseases and stroke, focusing on

epidemiological and anthropological approaches. Chapter 3 provides an

introduction to the fieldsites and a discussion of the research methods utilised.

Chapter 4 focuses on the pluralistic health care system found throughout

Ghana, and the treatment preferences of patients and their families. Chapter 5

discusses my informants’ understanding of the aetiology of their stroke, with an

explanation of the most frequently attributed factors. Chapter 6 analyses how

in Akan society matrilineal values such as reciprocity and respect play a

fundamental role in the provision or withdrawal of care.

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Figure 1: Ghana and its neighbouring countries2 Figure 2: Ghana and its

districts

Figure 3: Ashanti Region, with Offinso

1.2. General background: Ghana

Ghana is located on the south-central coast of Africa, sharing boarders with

Togo, Burkina Faso and Cote d’Ivoire (Figure 1 & 2). Before Europeans first set

foot on the shores of Ghana in 1470, its history was derived primarily from oral

2All maps accessed on worldatlas.com:

(http://www.worldatlas.com/webimage/countrys/africa/gh.htm [Accessed on 02/02/2013].

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tradition. The Portuguese arrived in the region in 1472, followed by the Dutch,

Danish, French, and British. The British took over the coastal region in 1821,

followed by the appropriation of the Ashanti region in 1902. In 1957, Ghana

became independent3 (Horton 2001).

1.2.1. The Akan and Asante

Ethnically, Ghana is divided into ethnic groups speaking more than 50 languages

and dialects. English is the official language and the main language used in state

education. The largest ethnic group are the Akan, who consist of many sub-

groups including the Asante (which my informants belonged to), Fanti, and the

Bono. Although the groups are classified as Twi- (which the majority of my

informants spoke) or Fanti- speakers, their matrilineal social system is the same.

That is, every individual belongs to the mother’s clan, successions are

matrilineal, and marriage is exogamous. Sociality is an important aspect for this

dissertation, as these values influence the experiences of sick people and care

providers (Stoeltje 1997; Crentsil 2007). The Asante occupy the Ashanti Region

(Figure 3), which, according to the Population and Housing Census (PHC) (2010),

was the most populous region in Ghana in 20104. The basic economic activity in

the Ashanti region is farming, with yams, cocoyam, oil palm, and plantain as the

main crops.

3Ghana was the first African nation to gain independence.

4For statistical data on Ghana please refer to Appendix A.1.

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1.2.2. Stroke in Ghana

In common with other developing nations, Ghana’s health system is under-

funded and under-resourced. The situation is further intensified by the

increasing burden of infectious (so called ‘communicable’), and chronic (‘non-

communicable’) diseases (de-Graft Aikins et al 2012). Stroke is a non-

communicable disease (NCD) and is the second-leading cause of death amongst

adults worldwide; whereby 87 per cent of stroke deaths occur in middle- and

low-income countries (Agyemang 2012). Furthermore, stroke is reported to be a

major contributor to disability and reduced quality of life (ibid). There are two

known forms of stroke: ischemic and the hemorrhagic stroke5, with the former

accounting for 90 per cent of all stroke cases. The location and the extent of

affected brain tissue determines the physical impairment after the stroke.

However, most stroke patients are left with either paralysis or weakness on one

side of the body, speech-impairment and incontinence (NHS n.d.). The in-

hospital, post-acute care and subsequent rehabilitation management of stroke

are crucial for its treatment. This, however, seems to be a difficult task for

developing countries, as the majority of patients do not have access to life-

saving investigations, which, if they exist, are only available in major cities

(Kengne et al 2006). Furthermore, such investigations are often not covered by

national health systems. Despite the Ghanaian National Health Insurance

(NHIS)6, which aims to provide access to basic health services to the whole

population, many Ghanaians’ cannot afford the annual fee, let alone expensive

5 For more information on the medical definitions of stroke refer to Appendix A.2.

6 For more information on the NHIS refer to Appendix B.

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drugs or treatments. Although rehabilitation management, such as

physiotherapy (PT), is covered by the NHIS, most Ghanaians (including health

professionals) are not aware of this service, (especially in rural areas). This was

also confirmed by one of my informants, Bubu7

When I started here at St Patrick’s hospital, it was difficult, as not

many were aware of the discipline [PT], not even the doctors. Only

hospitals in big cities have PT departments. Even now patients are

suspicious – they rather want to have drugs.

This reflects the findings of the 2010 Ghana’s Health Service Report (GHSR): a

mere 68 physiotherapists were employed throughout Ghana in 2008. The

majority of physiotherapists (30) were employed in the Accra region, in

comparison to only eleven in the Ashanti region. The entire northern region

with a total population of 4,227.665 has only 5 physiotherapists (GHSR 2010,

PHC 2010)8. These findings suggest that the majority of Ghanaians have

inadequate access to post-stroke rehabilitation management. However, it is not

only the Ghanaian health care system that is affected by the social and

economic costs of long-term care for stroke survivors - long-term care also

threatens patients’ households’ livelihoods as care providers are required to

spend substantial periods of time away from work. Lemogoum (2005) suggests

improving the provision of home-based rehabilitation, in order to minimise

disabling conditions and to promote the re-establishment of productivity of an

7 For my informants demographic information’s please refer to Appendix C.

8 For more information on the North-South dichotomy and statistics please refer to Appendix

A.1.

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affected individual. However, considering the scarcity of physiotherapists and

the lack of knowledge about stroke rehabilitation, this is a rather unrealistic

proposal.

The following literature overview contextualises my research into the wider

field of related literature.

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Chapter 2: Literature Review

This chapter provides an overview of the epidemiological and anthropological

literature on stroke and non-communicable diseases (NCDs). A brief outline of

such studies in Ghana and SSA is provided and an anthropological discussion of

the epidemiological approach and its shortfalls is presented. Finally,

anthropological studies in sub-Saharan Africa (SSA) with their focus on the

Explanatory Models (EM) approach of stroke are examined. Taking into account

the reviewed literature, I suggest that when studying the lived experience of

stroke sufferers, more attention should be devoted towards anthropological

approaches of illness narratives, interpretive phenomenology, and biographical

disruption. Furthermore, this literature review revealed the non-existent nature

of anthropological research on stroke in Ghana.

2.1. Studies on stroke in sub-Saharan Africa and Ghana

It is reported that NCDs are an emerging problem in developing countries

including countries in SSA. In their extended literature review on the burden of

stroke in SSA, Kengne & Anderson (2006) argue that current epidemiological

studies are mainly hospital based. The data suggests an increased rate of

stroke, affecting people at much younger ages in SSA than in developed

countries. Lemogoum (2005) further argues that in order to tackle the increased

burden of stroke in SSA, the treatment of high blood pressure (hypertension)

has to be optimised. Cappuccio et al (2004) studied the prevalence of

hypertension in the Ashanti region in Ghana, where 1013 men and 628 women

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were interviewed. The results confirmed the urgent need for preventive

strategies on hypertension control in Ghana. Agyemang et al’s (2012) study

stresses that stroke constitutes a significant cause of morbidity and mortality in

Ghana and an implementation of population-based health education

programmes is suggested. The above mentioned studies are focusing on the

improvement of individuals’ risk factors and risk behaviours without taking the

lived experience of stroke sufferers into account. To my knowledge, no

anthropological research on stroke has been conducted in Ghana.

2.2. Epidemiological approaches in anthropological perspective

Epidemiology studies patterns, causes and effects of health and disease

conditions in defined populations. As such, epidemiology identifies risk factors

and risk behaviours in order to establish preventive medicines and public health

campaigns, thus targeting risk behaviour in a given population (Pool & Geissler

2005). The underlying hypothesis is that there is a rational basis for an

individual’s decision making. Indeed, current epidemiological studies on stroke

and NCDs are promoting an ‘aggressive’ risk factor control-strategy. Such risk

factors include limited health care facilities throughout SSA; poor detection,

treatment and control of high blood pressure9; unhealthy diet; alcohol and

tobacco abuse; and physical inactivity (e.g. Cappuccio et al 2004; Lemogoum

2005; Kegne & Anderson 2006; Agyemand et al 2012).

These studies indicate that NCDs are ‘lifestyle diseases’ that can be

tackled by changing people’s behaviour. This implies, however, that “people can 9 High blood pressure is a major predictor of stoke as nearly 70% of all stroke cases in Ghana are

caused by high blood pressure (Agyemang 2012).

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choose how to live and stay healthy through proper self-discipline” (Whyte

2012: 65). For epidemiologists, confronting the context of risk,10 in which stroke

and other NCDs are prevalent, is central to the success of public health

campaigns locally as well as globally. Conversely, anthropological studies

suggest that such risk factors are also an outcome of structural violence and

that ultimately a change of ‘life conditions’ is necessary, as opposed to a change

of ‘lifestyles’ (Pool & Geissler 2005; Whyte 2012). Farmer’s (1992) famous study

on structural violence in Haiti is a good example of how inequalities in Haitian

society are responsible for conditions which foster vulnerability to HIV

infections. Furthermore, such inequalities deprive those infected of necessary

care, appropriate living conditions and drugs that could prevent early death

(ibid)11.

According to my informants, structural violence takes on many forms

in Ghana: e.g. poverty, unequal access to health care and the production of

toxic foods through contemporary agricultural practices. Setel (2003) suggests

that:

A more anthropological or social epidemiological concept of risk, would

encompass structural and social vulnerabilities, as well as biological and

behavioural ones…[A]nthropologists would draw a wide circle around

the notion of ‘risk’ and ‘risk factors.’ In particular, they would explore

10

Lemogoum (2005) summarises risk as follows: “[R]educing the stroke burden will require the increased awareness on the preventable nature of stroke, educate populations and health professionals on the modifiable risk factors, on healthy lifestyles and early warning symptoms… [The implementation of] population-based surveillance [is equally important]” (ibid: 97). 11

The World Health Organisation (WHO) 2010 report has emphasised the importance of such structural factors. However, the same report also stresses the health education on diet and physical activity in order to change people’s life style (WHO 2011).

` 15

how the rise of NCD risk reflects the changing social and economic

position of certain groups and individuals relative to other members of

society. In this model of risk, structural, environmental, and individual

forces would all receive consideration in the design of NCD intervention

and policy (Setel 2003: 151).

In Africa, as elsewhere, confronting the context of risk in which stroke and NCDs

occur, as well as incorporating the emic perspective of the social and cultural

basis of health, healing, and health-seeking behaviour, will be central to the

success of future international public health policies.

2.3. Anthropological approaches

Anthropological research exploring stroke experience in developing countries

has largely focused on Explanatory Model(s) (EM[s]) and health seeking

behaviour (Hundt et al 2004; Mshana et al 2006). The EM of illness was

developed by Arthur Kleinman in order to distinguish between disease and

illness, and to bridge the gap between clinical knowledge and constructions of

clinical reality (Kleinman et al 1978: 251). EMs are used to explain how people

view their illness in terms of causation, personal impact and the effectiveness of

treatment. Such EMs are always embedded within a given culture and social

structure of a particular place and time (Kleinman 1978).

Hundt et al (2004), for example, investigated the lay conceptualisation of

stroke-like symptoms and health-seeking behaviour in South Africa. Individuals

considered stroke-like symptoms as a combination of physical and social

conditions. Mshana et al (2007), furthermore, used EMs to explore the

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causation beliefs of stroke in rural and urban Tanzania, and how Tanzanians

make sense of and respond to their illness. In both studies attention was paid to

treatment decision-making. A recent study (de-Graft Aikins 2012) exploring the

lay representation of chronic diseases in Ghana concluded that individuals draw

on a broad range of sources when forming opinions on the cause of their

illnesses. The most frequently mentioned factors are biomedical and local

medical encounters, mass media, rumours and experiences of people living with

the same condition (de-Graft Aikins 2012).

What these studies have in common is that they focus on the individual

and their understanding of illness. Such studies lose sight of wider social

relations beyond the individual’s perspective. Additionally, the social conditions

of medical knowledge production (e.g. how mass media and health education

programmes influences the individuals EMs) are often perceived as secondary

(Pool & Geissler 2005). Lynch & Medin (2006) further criticise the EM

framework for ignoring the ways social relations shape and distribute illness and

how power relationships between groups (i.e. the family) can shape the

experience of sickness. Indeed, throughout this dissertation it becomes clear

how intra-household relations shaped my informants’ illness experiences, for

instance denying care or access to health care.

Instead of focusing on EMs, I follow Pool & Geissler’s (2005) argument to

focus on Illness Narratives:

Illness narratives are a way of exploring the patients experience of

illness [e.g. how a patient comes to term with disability after stroke;

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the lived experience; blame; self-blame] and the wider cultural

models [e.g. matrilineal decent and cultural understanding of

reciprocity] that underlie or give form to that experience (Pool &

Geissler 62).

Hence, illness narratives are tales of a sick person’s lived experience. In turn, the

lived experience is “influenced by globalisation, urbanisation and local economic

development which alter conditions of day-to-day life of individuals and their

society” (Setel 2003: 151). The ‘lived experience’ or phenomenological approach

is, therefore, of particular interest to this dissertation, as my informants stroke

experience did not end with its onset.

Interpretive phenomenology focuses on human consciousness and on

the sick person’s subjective experience of their surrounding world. Therefore,

through the individuals’ narratives, the meanings behind their experiences can

be uncovered (Desjarlais & Throop 2011). Such narratives, therefore, are always

situated in the social, political and cultural contexts. This phenomenological

framework has subsequently helped anthropologists to better understand

“what it means to be human, to have a body, to suffer and to heal, and to live

amongst others” (Desjarlais & Throop 2011: 87). Thus, the combination of both

ethnography and interpretative phenomenology is an appropriate framework to

understand people’s lived experience. However, two more theoretical

approaches have to be considered when investigating the lived experience of a

sick person: the ‘disruptive life’ and the ‘biographical’ approach.

Stroke as a ‘disruptive’ event is widely discussed in western-based

literature (Becker 1993; Faircloth et al. 2004). That is, an individual’s former

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self-identity is disrupted by the loss of physical and mental ability through

impairment (ibid). Michael Bury’s (1982) concept of biographical disruption is a

useful framework to analyse this loss. According to Bury (1982), stages of

chronic illness are: disruption, a discontinuance of an on-going life, and a critical

situation. The sudden onset of chronic illness throws people’s daily lives into

chaos. Illness begins to dominate their lives, and taken-for-granted assumptions

about the world are thrown into question. Attention is given on bodily states

and how the ill person reconsiders their biography and self-concept, ultimately

resulting in a mobilisation of resources to respond to the disruption (Faircloth et

al 2004).

The disruptive nature of stroke and its subsequent impairments has a

negative impact upon household livelihoods, as income is lost for care providers

staying at home with the afflicted person. This was acknowledged in Crentsil's

(2007) study of HIV-positive individuals and in Van der Geest’s (2002, 2009)

work on care of the elderly Akan in Ghana. In both studies, the focus was on the

lived experience of the carer, the family and the sick person; and how wider

cultural values shape an individual’s illness experience.

All of these studies focus on pluralistic health care systems which are

widely found throughout the developing world. According to Pool & Geissler

(2005), medical pluralism describes “the existence, within one medical system,

or one society, of different medical traditions” (ibid: 39). However, medical

pluralism has been criticised for drawing the line too neatly between different

health systems. In Ghana different medical traditions co-exist next to each

other, and are often intermingled and used together. New modern herbal clinics

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are managed like western hospitals, and herbalists may undergo basic

biomedical training and conversely, scientifically-trained biomedical healers -

called herbatologists - may make use of ‘local’ practices without perceiving it as

a paradox. In such clinics both systems are uniquely combined in what can be

termed a ‘single syncretic health care alternative’ (Tsey 1997). In other words,

medical systems are syncretised, which is “the unifying and merging [of]

different or opposing schools of thought” (Pool & Geissler 2005: 40). It is

therefore important to understand both, the pluralistic health care systems, as

well as the actual (everyday) practice of such systems. Further, it is important to

acknowledge that modernisation, globalisation and other social forces influence

a given health care system.

In summary, the studies on stroke and NCDs have primarily been

informed by either the epidemiological approaches to risk behaviour, or

anthropological investigations of EMs. However, as I have demonstrated, the

focus on illness narratives, the lived experience, interpretive phenomenology,

and biographical disruption of a sick person are of equal importance. The

triangulation of all these theoretical frameworks may contribute to an effective

policy for stroke and NCDs, which constitute an increasing burden both in

Ghana12 and throughout the globe.

12

Stroke is the fourth leading hospital in-patient cause of death in Ghana (Agyemang et al 2012).

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Chapter 3: Fieldwork, Fieldsites and Methodology

3.1. Fieldwork in Offinso, Ashanti Region, Ghana

It was the ‘in-between’ season13 when I arrived in New Offinso14, which is

located 15 miles from Kumasi, the capital of the Ashanti region. Offinso is the

capital of the Offinso South Municipal district15.

During my six-week stay I lived with Father Joah’s natal family. They

were a typical matrilineal family in which the eldest female was the head16.

Twelve family members lived in the house, and during my stay I established

good relationships with each of them, having the closest relationships with the

three granddaughters: Aroha, Abah and Fai. My family and I quickly settled into

a daily routine17, providing me with the stability of a home, in which I could

concentrate on my work (e.g. writing-up of field notes). Staying with a local

family had another key advantage: whilst doing daily chores, such as cooking,

washing clothes, or during and after dinner, I could talk with them in a relaxed

atmosphere. This provided valuable insights into contemporary Ghanaian

affairs, its history, its tradition, together with my host family’s everyday lives. At

dinnertime we often watched TV which displayed many advertisements of new

and modern herbal clinics.

13

For more information on Ghana’s seasons please refer to Appendix A.1. 14

The correct name is New Offinso, but my informants called their city Offinso. I will refer to Offinso throughout this dissertation. 15

For statistical information please refer to Appendix A.1. 16

See Appendix A.3.: lineage of family 17

For more information on the daily routine please refer to Appendix A.4.

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3.2. Fieldsite I: Hospital

The primary fieldsite of this study was St. Patricks Hospital, a Catholic mission

hospital serving a community of approximately 100,000 people in a 60+ km

area. Researchers, especially when not medically trained, often have difficulties

gaining access to hospital settings. They may encounter resistance from

physicians and nurses, who might refuse access to patients’ medical histories

and entrance to operating theatres (Pope 2005). Fortunately, I did not

encounter any of these difficulties, as one of my main gatekeepers in the

hospital was Father Joah - a board member of the hospital. As a key figure in the

hospital he was responsible for approving my research and enabling

unrestricted access to the hospital. Initially I spent three days on the maternity,

outpatient and children’s wards. However these wards did not provide a fruitful

research environment as they were too busy for staff to have sufficient time to

introduce me to patients, translate conversations, or explain patients’ medical

histories.

My restricted time-frame of six weeks, created immense pressure to

collect and produce good and ‘rich’ ethnographic data. Therefore, following

advice from my host family, I decided to observe the Physiotherapy Department

which proved more successful for my research.

3.2.1. Physiotherapy Department (PTD)

The PTD is a small ward at St. Patricks Hospital. It is located along a dark

corridor opposite the men’s ward. The PTD consisted of an exercise room which

was equipped with one therapy bed, one ‘bicycle’, one ‘standing’ machine,

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crutches and other equipment which were stored at the back of the room.

There was also a separate therapy room with one therapy bed, one massage

bed, one infrared machine and a desk and two chairs for patients to be assessed

or treated. Patients needed to register at a desk first, which was located at the

back of the corridor. Two benches were lined along this corridor, where patients

waited for their treatments.

The PTD comprised three permanent members of staff, and one

volunteer18. The department saw patients with a wide range of symptoms: most

commonly people with fractures, lumbago, osteo-arthritis, cervical palsy and

stroke patients. The PTD was generally busy, but this increased during so-called

‘stroke-days’. As discussed in the previous section, stroke is common in Ghana

and due to this demand, the PTD held these ‘stroke-days’ every Tuesday and

Thursday, from 8am until noon. However, patients were not always able to

attend due to a shortage of money. Nevertheless these stroke-days were still

busy, sometimes with more than twenty patients.

Patients were first required to report to Manu at the registration desk.

They then waited until some were called into the therapy room, where hot-

packs and massages were administered. Other patients were taken into the

exercise room where active or passive exercises were performed. In the

exercise room patients could exchange their experiences and thus establish

some sort of support group. It was here where the PTs were most engaged with

the patients, spending time listening to the patients’ worries and providing

personal advice and support. This was unusual in a hospital-setting, in which

18

For further information on the PTD and for pictures please refer to Appendix A.5.

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power-relations and inequalities between doctors/nurses and patients were

regularly played out within the different wards. Bubu explained:

I know about the way nurses and doctors treat patients on the

ward, this is partly due to the unwillingness to become too

emotionally attached to the patient. Here [PTD] we think that we

need to treat the patient as equal. Only then they will cooperate

with us, which is very important for a successful therapy.

All PTs were very engaged, encouraging and, most importantly, they gave the

patient a positive environment. Bubu and Manu, especially, joked with patients;

hence there was constant laughter and a light-hearted mood.

3.3. Methodology

I travelled to Ghana with the aim of recording every interview on my voice

recorder, but I discovered that this interrupted the interactions with my

informants. Therefore, I collected most data by taking fieldnotes with pen and

paper.

After two weeks of observing the daily routines in the PTD and talking to

PTs and patients I decided to focus on stroke patients. I observed treatments,

and at the same time interviewed patients and their accompanying

family/friends. My colleagues functioned as both a valuable source of

information and as interpreters. The PTD seemed to be a somewhat ‘natural’

setting for my informants, due to the longevity of their rehabilitation. Such

long-term treatment allowed my informants to get to know other patients and

` 24

their PTs, as they met and talked during the stroke-days. This also contributed

to the establishment of a natural setting, which in turn was favourable for me

as a researcher: individual patients did not feel exposed by my presence, which

created a sense of ease for the informants under observation (O’Reilly 2009).

Interviews with PTs and patients were informal and unstructured at

first; whilst I used semi-structured interviews at a later stage, to build upon the

previous ones. According to Fetterman (2009), informal interviews are casual

conversations with specific but implicit research agendas. They provide an

opportunity to discover what people think and how one person’s perceptions

differ from others. Such comparisons help to identify shared values in the

community - that is, values that inform behaviour.

The above mentioned establishment of a natural setting was further

fostered by the participatory aspect of my research. Van der Geest et al (2004)

have suggested three possibilities for the researcher to become a ‘native’

within a hospital environment: joining the staff, being a patient, or a visitor. As

a former professional massage therapist, I actively participated in the day to

day running of the PTD (e.g. administering massage to patients). This helped to

establish a good rapport with my informants, and also to define my role within

the team.

Despite the above mentioned positive aspects of my research, I also

encountered problems and limitations. The language barrier was the most

difficult one to overcome. My inability to communicate in Twi (the local

language in Offinso) meant that I was dependent on translators, such as my

` 25

colleagues and English-speaking relatives of the patients. However, given the

fact that English is the official language of Ghana, many of my informants were

sufficiently fluent. Nevertheless, as the PT was a busy department, it was

sometimes not possible to rely upon my colleagues for translating. At such

times I was restricted to the role of an observer, which according to Lawson

(2001) can also be an advantage. Non-verbal communication - e.g. how people

move through space and how they occupy it; facial expressions; body language

- can give the observer vital information of patients physical and mental states

(Lawson 2001).

After three weeks of working in the PTD, a pattern of pro-biomedical

and anti-herbal healers came to the fore: my colleagues were in favour of the

former, whereas many of my informants reported to make use of herbal

treatments. Therefore, the urge to acquire an understanding of how stroke is

affecting people and their social environment in the neighbouring community

emerged.

3.4. Fieldsite II: Community

One day when I was observing the treatment of PT-patients, Justice - who later

became my research assistant - came in with two young children and their

parents. Whilst the children were assessed and treated by Fedu and Bubu, I

talked with Justice. He runs a charity in the neighbouring community, serving

mentally and physically impaired children. As he lived in the community his

entire life, he knew stroke patients and agreed to help me gain access to them.

From that day onwards Justice and I met up regularly in order to interview

` 26

‘community’ informants. As time passed, we expanded our terrain by visiting

my ‘hospital’ informants in their villages, and thus in the natural settings of

their family homes19.

In the community, I made use of informal and unstructured interviews,

followed by semi-structured interviews, with handwritten fieldnotes as the

primary mode of note-taking. In this setting the language barrier was an even

greater limitation, as I solely relied on Justice as an interpreter. Although Justice

had previous research assistant experience20 and good knowledge of English,

during the first interviews he tended to summarise informants’ answers rather

than translating word-by-word. According to O’Reilly (2009), even the best

translation runs the risk of losing subtle nuances and context. After addressing

my concerns, Justice’s interpretation style improved, yet I started to re-read my

notes to him in order to verify, and if necessary, to amend the information.

Using an interpreter might have contributed to loss of data, but at the same

time it opened unique opportunities for me, e.g. the access to sick people in

their family homes.

Conducting ethnographic research in the PTD and in the community has given

me valuable insights in the post-stroke lived experience of my informants.

These lived-experiences are the focus in the chapters to come. The next chapter

deals with the diverse health systems which were available to my informants.

19

For these visits Justice’s uncle lend his car to us. I paid for the petrol and our food. In turn, Justice invested his time, and also showed me the surrounding area. It was not long before Justice and I became good friends, and I partly owe my research-success to him and his support. 20

Physiotherapy students from Europe were studying disability in Offinso.

` 27

Chapter 4: The syncretisation of different health systems in Ghana

This chapter discusses the different treatment options available to the Akan and

to Ghanaians in general. It begins by discussing concepts of medical pluralism,

and by situating Ghana’s medical systems in historical context. Next, attention is

drawn towards the co-existence of the diverse medical systems present in

contemporary Ghana. Consideration is given to herbal treatment options and its

syncretisation with biomedicine and how some of my informants prefer herbal

treatment whilst others have a negative perception of it. Attention is paid

towards the modernisation of the herbal sector, how modern herbal clinics

operate and how stroke patients are excluded or discriminated against in the

health care system.

4.1. The archaic concept of ‘pluralism’

Medical systems are described by anthropologists as cultural entities, in which a

community’s ideas and practices related to illness and health come to the fore

(Pool & Geissler 2005). In Ghana different medical systems co-exist and

anthropologists use the concept of ‘pluralism’ to analyse such sectors (Tsey

1997). Pluralism however, has been criticised for being too static, and ignoring

the fact that such medical systems - including the biomedical one - are

constantly shaped, reconstructed and renewed by socio-political, economic and

historical forces (Pool & Geissler 2005). For instance, biomedicine in non-

Western societies undergoes an indigenisation process, whereby biomedical

` 28

knowledge and practices are adapted to local environments and influenced by

local culture21. Furthermore, medical traditions are often intermingled and used

together. In other words, medical systems are syncretised, which is “the

unifying and merging [of] different or opposing schools of thought” (ibid: 40).

Therefore, I use the concept of syncretisation to explain the health seeking

behaviour of my informants. Furthermore, instead of using the term

‘traditional’ (which is often used to refer to static, closed systems) I employ the

term ‘local’ in order to describe non-biomedical health systems.

4.2. Medical systems in historical context

In the past, the Akan and Ghanaians in general have sought health advice from,

amongst others, herbalists, cult healers, fetish priests and church leaders. It has

been reported that the use of herbalists was the most sought after treatment

option until colonial rule (Tsey 1997; Darko 2009). Herbalists were understood

to have contact with the spiritual world, where the ancestors of the ill were

contacted and if necessary calmed. Illness was therefore regarded to be both

physical and spiritual, and could only be cured by being treated holistically

(Darko 2009). Throughout colonial rule in Ghana western-led medical services

were established, equipped with the newest technologies and medicines of the

time. In order to promote colonial ‘modernity’ local health systems were often

suppressed, local healers accused of being ‘witchdoctors’, depicted as

‘backward’ and portrayed to be the ‘enemy of colonial modernity’ (Pool &

Geissler 2005: 103). After Ghanaian independence importance was given to the

21

The case study of Edjala, an herbalist, illustrates this point further (Appendix D).

` 29

rediscovery of ‘heritage’, including the revival of local medicine. This revival,

however, was greatly influenced by the biomedical model, and professional

bodies of local healers and western-style herbal clinics were established (ibid).

In 1975 the government established the Scientific Research into Plant

Medicine (CSRPM), in order to “regulate, investigate, and coordinate the

activities of herbal practitioners so as to avoid the dangerous and wasteful use

of plants” (Darko 2009: 42). Only in 2003, however, did the Ghanaian

government legally recognise herbal practitioners as a body that offered

healthcare to its population (ibid). The Ghanaian administration, like many

other African and Asian governments, aims to incorporate local herbal medicine

into the formal healthcare sector. Another consequence of modernisation is the

rise of the so-called herbatologists who are scientifically trained medical

practitioners, who work in ‘hygienic’ and ‘sterile’ western-style clinics, and who

use herbal medicine to treat illnesses.

4.3. Preference for choosing herbal treatment

Most of my informants exhibited a distrust of being treated in hospital.

Nevertheless, the hospital was often the first starting point for treatment of

serious and life-threatening conditions. Because of my informants wariness of

hospitals and biomedicine at large, herbal treatment options were a recurring

theme. Thus, herbal healers22 are an important alternative to biomedicine and

may possibly be the preferred method of treatment for many Ghanaians today.

In addition to general distrust, other factors determining whether my 22

For more information on spiritual and non-spiritual herbal healers please refer to Appendix D.1.

` 30

informants chose the biomedical route were accessibility to a hospital, the

seriousness of the symptoms and financial matters.

This preference for herbal treatment is partly due to the local understanding

of illness, which is based on spirituality (i.e. the relationship between a supreme

being, ancestors, lesser gods, deities and man) (Speck, cited in Darko 2009).

Whilst contemporary medicine denies spiritual causes of illness, most local

healers employ spiritual treatment. Many of my informants combined both

systems: the former to treat serious symptoms, and the latter to employ

spiritual healing in order to accelerate recovery. They frequently reported that

friends, family members, neighbours and church members advised them to go

to the herbalist. Alibama, for instance, was considering going to the herbalist

following his release from the hospital based on such advice.

Some herbalists, especially older ones, are inexpensive or may just ask for

appreciation if the patient gets better. Bubu and Manu agreed:

In the past the herbalist had only one herbal medicine for a specific

illness and they did not charge much, if anything. There are new

herbalists who produce one medicine very cheaply which they then sell

very expensive for all illnesses. This also happens in those modern

herbal clinics. People normally do not go back to those healers and

clinics.

Financial concerns were an additional factor for the preference of herbal

medicine. Despite the NHIS, many of my informants were so poor that they

` 31

could not afford the annual fee23 and therefore could not pay for expensive

drugs or treatments. When people are faced with expensive healthcare they

have to be resourceful. Alfred, for instance, took advice from relatives who

argued: “if you have that [herbal] medicine, why do you need to go to the

hospital?” Margaret confirmed that patients improvise to gain access to

expensive biomedical drugs:

People who work or are very poor do not have time to go to the

hospital as that would mean loss of income for them. People with

‘same symptoms’ give them their drugs.

Faith and confidence in the abilities, methods and tools of local herbal healers

were for many of my informant’s reason enough to choose this treatment.

Herbalists are “accepted without question and his or her success [is] greatly

appreciated and applauded and his and her failures [is] understood and

condoned as acts of God” (Anfom, 1986, cited in Darko 2009: 23).

Comfort’s brother had unlimited faith in the herbalist and took her to one

after she was discharged from hospital. At that time she could not talk and

could not raise her concerns about the herbalist. The herbalist treated her with

herbal ointments and knife-cuts into the skin, in which he rubbed the herbs.

Fedu once told me that knife-cuts cause the muscles to contract and blood

circulation to slow down, which may worsen the condition. However, the

herbalist, and consequently Comfort’s brother, interpreted the contraction to

23

The annual insurance fee starts from four cedis (GBP 1,37) for the very poor and young children, whereas the highest fee accumulates at seventy cedis (GBP 24,00) for the very rich. For more information on the NHIS please refer to Appendix B.

` 32

be a ‘good’ reaction to the therapy. Yet, once Comfort regained speech she

stated her preference for physiotherapy.

Those informants who employed a syncretised approach sought out

herbal treatment in order to treat ‘small’ or ‘normal’ symptoms and sicknesses,

e.g. fever, stomach pain and headache. Manu confirmed this:

I am not against herbal treatment per se. ‘Small’ symptoms are

successfully treated with herbs. When a sickness goes ‘deeper into the

body’ one needs to go to the hospital.

Both health systems - herbal and biomedical - are used successively, as most of

my informants employed a syncretised form of treatment following hospital

discharge in hope of a quick recovery. This hope was fuelled by the belief that

western medicine may be effective in dealing with naturally caused illnesses,

but only local herbal healers can treat illnesses involving spiritual agents.

4.4. Negative perceptions of herbal treatment

Not all of my informants had a positive attitude towards local herbalists. Some

had seen their relatives die or had never seen someone recover when being

treated solely by an herbalist. The most common argument, however, was that

only ‘uneducated’, rural people go to the herbalist. Bubu explained:

This is due to the influence of [our] old traditions: the herbalists were

there before doctors came, hence rural and uneducated people believe

more in it. Educated as well as illiterate prefer herbal treatment, but when

` 33

an educated person chose herbal treatment he/she is looked down by

his/her peers, as one should only make use of biomedical treatment and

not being backward and go to the herbalist.

This illustrates the way in which the state was successful in producing

‘biomedical citizens’, but does not explain why herbal treatment is still popular

amongst the educated middle class. The analysis of the ‘go modern’ approach

from herbalists, especially the large herbal clinics, might offer an explanation.

4.5. Herbal treatments to ‘go modern’

In contemporary Ghana large, modern herbal clinics are built nationwide and

promoted through aggressive advertisement via mass media. TV adverts depict

such clinics as mirror-images of biomedical ones. These herbal clinics have the

same advanced laboratory equipment, the newest tools for analysing and taking

blood, x-ray machines, computed tomography equipment, and fully equipped

physiotherapy units. The Centre of Scientific Research into Herbal Medicine is

one such clinic, where patients can choose between herbal and biomedical

treatment. The centre is located next door to the Tetteh Quarshie Memorial

Hospital24 and patients are referred back and forth, depending on their financial

capabilities (Tsey 1998).

Some of my informants had similar experiences of syncretised

treatment. For example, Rose went to an herbalist clinic where on arrival she

was given an attendance card. After waiting for some time she was called into

the consulting room where the doctor examined Rose by touching her hand. He

24

Both institutions are located less than an hour’s drive east of Accra, the capital of Ghana.

` 34

then wrote out a prescription and Rose collected the pre-packed medication

from the clinic’s pharmacy. In Rose’s case, there was no consultation fee as the

charge is included in the medicine, for which she paid an inexpensive six25 cedis.

She explained the cheap price as follows:

I think they do not charge a consultation fee as the clinic needs to

advertise their business. This clinic is fairly new. They earn money

when a patient needs more medicine. This will then pay for the

herbalist and the clinic.

What becomes apparent from Rose’s statement is that the structure of the

clinic was much like a western hospital. According to Stoner (1986), herbalists

might have had a basic biomedical training and conversely, scientifically-trained

biomedical healers may make use of local practices without experiencing a

paradox. In such clinics both systems are uniquely combined in what can be

termed a ‘single syncretic health care alternative’ (ibid).

Much of the symbolic content of the biomedical treatment system, i.e.

attendance card or pre-packed medicines, has been exported directly to the

herbal clinic. These herbal clinics are thus a ‘modern’ health-care resource,

exhibiting elements of both local and biomedical systems of illness diagnosis

and treatment (Tsey 1997). Plants are tested in laboratories and later

industrially produced and exchanged within capitalist markets. Hence modern

herbal medicines become commodities, detached from the producers of the

medicines and lose what was once so important for herbal treatment - the

25

Six cedis are GBP 1,95; conversion rate of 13/01/2013.

` 35

interpersonal, social relationship between the healer and the patient. As with all

commodities, mass produced herbal remedies are becoming increasingly more

expensive (due to the high cost of testing). This, in turn, will undermine the ease

of access which is often associated with local medicine (ibid). Consequently, this

could reinforce a two-tier society with problems of access to herbal health

systems similar to those experienced with Western-style treatments (Pool &

Geissler 2005; Tsey 1998).

4.6. Conclusion

There is a pluralistic health care system in Ghana, and fieldwork among the

Akan revealed that it is used in a syncretised way. For my informants, the

interpersonal relationship between healer and patient was regarded as playing

a part in the healing process, as only through the healer can the ‘spirits’ heal.

Yet, with new forms of herbal clinics - which are on the increase especially in

urban areas in Ghana - the interpersonal relationship between healer and

patient is lost. Such clinics resemble their western counterpart in

administration, mass-treatment and mass-production of herbal medicines. The

cost of herbal products rises, due to investment in modern laboratories and

equipment for mass production. This may undermine access to local medicine,

and reinforce a two-tier society and access to health systems. Moreover, the

spiritual aspect of local healing is lost in such clinics, as herbatologists are

scientifically-trained, medical practitioners. In the following chapter, another

element of my informants’ lived experience of stroke is discussed: questions of

blame and deservedness, which plays an important role in the provision of care.

` 36

Chapter 5: The aetiology of stroke and politics of blame and self-blame

This chapter analysis my informants understanding of the aetiology of their

illness, whereby unhealthy diet, poor lifestyle practices (e.g. alcoholism), and

witchcraft were the factors frequently cited to have caused their affliction. This

understanding was fostered by Ghana’s health education programme. As a

result, some informants either blamed themselves for becoming sick, or were

accused by others to have led an unhealthy or ‘risky’ lifestyle, and thus

‘deserved’ to be ill. Others made sense of their illness by attributing their

‘undeserved’ illness to the malice of another person. In all cases, however,

stroke and its disabling symptoms invoked self-blame, as none of my informants

were able to contribute to the household livelihood.

5.1. Unhealthy Diets

My informants reported that there were two aspects to their diet and food

practices which impacted on their stroke. The first aspect related to self-

practice: e.g. what my informants ate in their everyday life, in particular the

consumption of high fat and starchy foods. The second aspect related to

practises by others, for instance the production of toxic foods through

contemporary agricultural practices. Rose’s husband illustrates this point26:

26

All interviews were conducted in Twi. Justice translated what was said into English.

` 37

[Rose] got it [the stroke] from the food (aduane). The food we eat

now is no good because of the chemicals. We are using the

chemical to make tomatoes grow better.

In Ghana health education is publicised via TV and radio, and such programmes

are focused on promoting a healthy lifestyle through healthy food intake (Tsey

1997). This was also confirmed by Mr Opoua:

I once listened to a programme on the radio, where they talked

about veins and blood flow and that the body is not used to fat and

fatty food. The fat can cause blockage of blood and this is the reason

why stroke (ndwodwoe3)27 occurs. At another time there was a

programme on blood groups. For blood group ‘A’ yam is supposed to

be not good. Also we should use palm oil, as it is good oil. No fatty

meat should one eat, and the chicken should be left on the fire to

reduce the fat. Okra28 is also not good for stroke patients; I am not

eating Okra anymore.

Radio programmes in Ghana argue that fatty and oily foods are the cause of all

sorts of problems, from stomach pain to cardiovascular diseases, and a low-fat,

more nutritious and varied diet is promoted. However, the reality is that the

local food in Ghana, called Fufu29, is still widely eaten by the poor, elderly and

rural population. Fufu is considered unhealthy by health officials, as it is rich in

carbohydrates, and therefore ‘too fat’ and ‘heavy’. The older generation, as

well as the poor and rural population, are reluctant to change their diet, partly

27

According to Justice the Twi word for stroke, ndwodwoe3, can be translated as paralysis. For more information on the local aetiology please refer to Appendix E. 28

For an explanation of Twi terms please refer to the Glossary in Appendix C.2. 29

(ibid).

` 38

because they are not used to anything but Fufu. This was affirmed by my host

family’s father: “I would miss it, even when I just have one other meal, it would

not feel right. Fufu is the food we [elderly] are used to, and we love our Fufu”.

Poverty is another factor why Ghanaians are holding on to this local meal as

they cannot afford a more nutritious, more varied or healthier diet.

Through the media, therefore, the sick person is made responsible for

their condition due to failure to adhere to a healthy diet. Moreover, Mr Opua’s

statement indicates that he is now actively attempting to improve or rectify his

situation by adhering to a healthier diet, thus becoming a ‘biological citizen’

(Rose and Novas 2005). However, such a model fails to address the fact that

there are much broader socio-political (e.g. the production of toxic foods

through contemporary agricultural practices) and structural factors (e.g.

poverty) involved in an individual’s health behaviour. These practices may play

a central role in influencing and constraining health behaviour and creating

vulnerability (Pool & Geissler 2005).

5.2. Poor lifestyle practices: Alcoholism

My informants attributed unhealthy lifestyle practices, such as unhealthy diet,

drinking and smoking, to be the cause of their affliction30. Two of my

informants31 were decade-long alcohol abusers and through their and others’

accounts, I could experience how Akosi and Oseja Yaw not only blamed

themselves, but were stigmatised and disadvantaged within the intra-

30

In Ghana there is a general culture of social drinking which is promoted by a powerful alcohol production industry with aggressive advertising campaigns (Luginaah 2008). 31

Akosi and Oseja Yaw.

` 39

household care provision. Furthermore, the access to essential medical

treatment was often denied to them (see next chapter).

Akpeteshie is the cheap, preferred alcoholic drink of poor Ghanaians.

Akpeteshie is distilled from fermented palm wine or sugar cane juice and the

alcohol strength is estimated between 40% and 50% volume. Drinks are called

‘kill me quick’, ‘take me and fly’ and ‘let me kill the bastard’ (Luginaah 2008).

Those names are an indication of a wider societal problem: it takes the drinker

away from the problems of their daily lives, but may also lead to violent

behaviour.

In Akosi’s case, alcoholism forced him to be separated from his wife and

children. Their former landlord evicted him and his family from their compound

due to the ongoing violence which occurred between Akosi and his wife. Since

then they were living separately: Akosi with his family, while his wife Roberta

and their children live in a small compound in another part of Offinso. Justice

knows the family well:

In the past Akosi hit and abused his wife and he didn’t treat his

family well either. Now that Akosi is sick, the family does not treat

him well too. Same, same…. If stroke patient has a good relationship

with family, this pays back as they will be good caretakers. Stroke is

a punishment for drinking.

It becomes apparent that Akosi’s stroke was perceived to be a consequence of

his excessive drinking, interpreted by his family to be risky and unsafe health

behaviour and as an intentional ‘wrong-doing’ (Finerman & Bennett 1995).

` 40

Furthermore, this accountability for his abusive drinking behaviour limited his

deservedness for appropriate care, since his “sickness and sick role status serve

as indices that patients [were] irresponsible [in the past]” (Finerman & Bennett

1995: 2). I discuss care, respect, reciprocity and deservedness in more depth in

the next chapter.

5.3. Witchcraft causation

Many of my informants made sense of their illness with reference to witchcraft.

As Evans-Pritchard (1937) points out in his famous monograph on collapsing

granaries in Zandeland, witchcraft can provide explanations of seemingly

random coincidences which afflict people at different times and places.

Additionally, witchcraft can provide a framework for moral agency (ibid). For

my informants, witchcraft was a synonym for their undeserved misfortune

(stroke), where the malice of another person was deemed to be the source of

their suffering. My informant, Owowusu, articulated this in the following way:

I think that my village people believed that I am suffering from a

‘different disease’. I also think that my extended family members

tried to kill me by using Muju [witchcraft]. They wanted to gain

access to my land. Everyone could do it when ‘bad motives’ are

there.

Through Owowusu’s statement it becomes apparent that the origin of his

misfortune is social: another person is blamed to have caused the stroke. This

was confirmed in a recent study on lay causation of chronic diseases in Ghana.

` 41

It is argued that witchcraft and sorcery can occur in four ways: due to

unprovoked envy or jealousy; as a result of past and on-going family conflicts;

as form of disciplinary action and as revenge for moral misbehaviour (de-Graft

Aikins et al 2012; see also Tsey 1997). The sick person can therefore be seen as

victim (Owowusu), or as culprit (i.e. through alcohol abuse in Akosi’s case), and

thus, to be deserving or undeserving of care and affection.

5.4. Self-Blame

My informants reacted to their diagnosis with feelings of shock, self-blame,

anger or depression. The feeling of becoming emotionally, economically and

socially dependent on relatives put pressure upon my informants, and often

contributed to intra-household tensions. This situation was aggravated if the

sick person had been a contributor or the sole income provider for the family

(Dilger 2008). Individuals in Akan society are expected to contribute to the

families’ household in various ways: financially, with their labour, and by

looking after one another in times of hardship (Crentsil 2007). Due to the

disabling symptoms of stroke most of my informants perceived themselves to

be a burden for the family. Owowusu, for instance, was proud of his past

achievements in launching a large and successful cocoa, palm tree and orange

plantation, and was especially troubled by the fact that he needed to “beg for

money” from his sons after his stroke.

A growing body of literature suggests that people who suffer from a

disabling or chronic illness have experienced loss of income with its

accompanied hardship through poverty. This literature implies that under such

` 42

constrained circumstances self-blame becomes most prevalent as it is often not

possible to maintain the living standards of the family (Crentsil 2007; Dilger

2008). Rose’s case study demonstrates this in a dramatic way.

Rose was thirty-five when she suffered a stroke. Before the onset of her

affliction she was tilling her family’s field and was the main care provider for her

eight children. Her husband was away for long periods of time as he worked as a

seasonal carpenter. The family lived fairly well on the husband’s income and the

harvests from their farm. However, since Rose suffered the stroke she was not

able to work on the fields, and her husband was unable to pursue his

profession. He obtained local work only occasionally, which put the family

under immense financial and emotional pressure. Due to the loss of income,

their elder children had to drop out of school and work on the fields in order to

meet their basic food requirements. Rose and her husband were hoping for a

quick recovery, so that they were able to take out a micro-loan to establish a

small business for Rose (a small market store to sell clothes and sandals). This

would then enable her husband to take up his seasonal work again, which in

turn would enable the children to continue with their education. This example

demonstrates how loss of income, poverty, and the accompanied dependency

on others, are all contributors to invoke self-blame in a sick person.

5.5. Conclusion

This chapter has drawn upon my informants’ understandings of the aetiology of

their affliction. Many attributed unhealthy diet (e.g. fatty food) to their illness

` 43

and blamed themselves for being responsible for their affliction. Conversely, my

informants also employed ‘the politics of blame’ where they either blamed

someone (i.e. a jealous family member), or something (i.e. witchcraft) to have

caused their affliction. Peoples’ explanations of the cause of their illness form

an important aspect of their illness narratives and such narratives have to be

analysed within the context of a whole set of socio-cultural and individual

idiosyncrasies.

My informants understanding of their affliction was further fostered by

Ghana’s health education programmes. Such programmes often rely on

assumptions similar to those employed in the Health Belief Model (HBM) of risk

behaviour, which according to Pool & Geissler (2005) focuses on the individual.

The underlying hypothesis is that there is a rational basis for an individual’s

decision making, thus health is “knowable, mutable, improvable, eminently

manipulable” (Rose and Novas 2005: 442), by, for instance, leading a healthy

lifestyle.

Lastly, I introduced the reader to the fact that if a sick person displayed

abusive behaviour towards his family before the onset of his/her stroke, this

behaviour was reciprocated in times of their sickness by limiting ones

deservedness for appropriate care. This will be discussed in more detail in the

following chapter.

` 44

Chapter 6: The Experience of Care and Care Provision

Due to the lack of a comprehensive social security system, the family continues

to be the dominant source of care for the elderly and chronically sick in Ghana.

This chapter draws upon two case studies: Camie, a fifty-eight year old female

whose husband and female relatives were amongst the most engaged in caring,

and Akosi, a sixty-six year old male whose family provided the minimum of care.

These two case studies illustrate the way in which reciprocity and respect

influence both, the provision and withdrawal of care for the sick in Akan society.

The level of care delivered by the family is often a consequence of the patient’s

behaviour towards the family and children before the onset of the affliction. If

the sick did not respect the family it will be evident in phases of illness and

dependence. To quote a Ghanaian proverb: Panyin fεre ne mma a, na ne mma

suro no, it means: If the elder respects his children, the children will fear

(respect) the elder (van der Geest 2002: 26).

6.1. The role of the family in care giving

Akan families are traditionally organised in extended family clans of three or

four generations, descended in a direct line of female members. This includes

parents, grandparents, brothers, sisters, children, cousins, and in-laws (Apt

1993). The extended family also functions as a social security system, as

members are required to assist each other in times of crisis. During periods of

sickness, the all-encompassing nature of Akan matrilineage becomes most

visible, as caring for the sick means trying to ‘restore’ them to health (Crentsil

` 45

2007). Furthermore, providing care contributes to the way people make sense

of health and illness in general. The role of relatives as carers extends to the

hospital setting, where they provide informal care for the sick on the ward

(Crentsil 2007). I have often seen patients being accompanied by their relatives

when attending the ‘stroke-days’ on the physiotherapy ward. Relatives either

waited patiently on a bench in the hospital corridor, or they actively

participated in the therapy process. Conversely, van der Geest (2002) argues

that the social and cultural bases of care are undergoing profound changes32 in

Ghana and through these changes, care providers are under immense pressure

to provide for the sick and the family. Through the care process, care providers

are required to spend time away from work and this may lead to intra-

household tensions, often resulting in the denial of the patients’ illness (Crentsil

2007).

During my fieldwork I encountered both sides of care: the positive,

where family members were eager to care for the sick and took pride in it; and

the negative, where the sick family member was neglected and left to their own

devices.

6.2. Case study I: Camie

Camie, aged fifty-eight and obese, was brought into the PTD in a wheelchair by

her brother and several female members of her family. Her brother, an

orthopaedic surgeon, came from Germany in order to assist his sister during the

32

For more information please refer to Appendix F.

` 46

first weeks after her acute stroke33. He managed to organise the best possible

treatment, including CT scans34 of the brain, which was provided in Komfo

Anokye Teaching Hospital35, located in Kumasi. Furthermore he organised post-

rehabilitation, where it was agreed that Bubu would attend her at home for the

first two weeks. Camie did not show any improvement during this time, hence

Fedu, the head of department, decided to pay her a visit in order to get an idea

of the situation.

I accompanied Fedu and noticed six female family members in the room

with Camie. One of her sisters (68) was sleeping in the same room, and was the

primary carer. Camie was lying on a mattress on the floor and appeared

withdrawn. During the day most of the family members were at work or on the

fields, and in the evening the family was busy feeding and bathing her. There

was no time to perform exercises with the patient. This, however, was a vicious

circle: due to the lack of mobilisation, Camie was in constant pain which

prevented her from having restful sleep during the night. It was thus agreed

that the family should bring Camie to at least one stroke-day per week. In

addition to the lack of exercises, the family also made use of herbal treatments

in the hope of a faster recovery. This might also be the reason why the family

was initially reluctant to perform exercises with Camie.

The next day, which was a stroke-day in the PTD, Camie arrived in a

wheelchair pushed by her husband, accompanied by three female family

33

The first weeks after a stroke are the most important (because most effective) ones in terms of providing rehabilitation. 34

For explanation of medical diagnostic tools please refer to Appendix G. 35

Komfo Anokye Teaching Hospital is the main referral hospital in the Ashanti, Brong Ahafo, Northern, Upper East and Upper West Regions.

` 47

members. This was remarkable, as other patients were normally escorted by

only one or two family members, if any. Bubu and Fedu actively including

Camie’s family members in the therapy process and all of them were

participating enthusiastically.

In the following two weeks Camie’s family regularly brought her to the

stroke-days, resulting in Camie going from being depressed and withdrawn to

being an alert, happy, responsive and actively participating patient. This was

partly due to regular attendance at the stroke-days in the PTD, but mainly made

possible through the excellent care the family provided. After three weeks, the

physiotherapists decided that Camie was well enough to start with active

exercise, i.e. standing and walking with the walker.

This case study demonstrates the all-encompassing nature of Camie’s

matrilineage, as caring became an indirect self-fulfilment for the family members

(van der Geest 2002). Care for Camie had an emotional meaning, as it expressed

concern, dedication and attachment, and brought the family closer together

(ibid). This dedication and concern was displayed in the appearance of Camie.

Cleanliness is an important value in Akan culture and to be dressed in clean and

neat clothes is a sign of respect towards the sick (ibid). Furthermore, good care

can impact positively upon the well-being of the sick person, as it provides them

with a sense of self-worth, dignity and belonging (Crentsil 2007). By following

the instructions and explanations of the physiotherapists, resulting in small but

visible improvements, Camie’s family was able to make sense of her illness

(Darko 2009). Moreover, the caring nature of the family members and Camie’s

husband indicates that her family considered her as a valuable family member

` 48

and wife before the stroke occurred, and therefore was deserving the good care

provided.

6.3. Case study II: Akosi

My research included stroke patients from the community. The first stroke

sufferer we visited was Akosi, a 66 year-old former revenue collector. It was

widely acknowledged amongst his community that Akosi suffered from alcohol

addiction, resulting in abusive behaviour towards his wife and children and

refusal to support his extended family.

Akosi’s family lived in an impoverished neighbourhood, with no running

water and only one public toilet facility for hundreds of families. The compound

was small and Akosi’s room was separated on the outer part of the main house.

This was the first sign of neglect: traditionally the architecture of the houses

(i.e. a compound surrounded by rooms) allows communal living which takes

place outside the rooms of the compound (van der Geest 2002). When we

stood outside Akosi’s room, Justice pointed to the door bolted with a lock: “this

is what I meant that such [chronically ill/disabled] people are locked away”.

When we entered the room the first I noticed was the smell. One of the

accompanying symptoms of stroke is incontinence of faeces and urine, and

patients are required to wear diapers (Lemogoum et al. 2005). The smelly, dark

and stuffy room indicated that Akosi’s diapers had not been changed since the

previous evening, and that the room was not aired often. The interior consisted

of Akosi’s decrepit bed; a rug opposite the bed, which belonged to James (the

older brother), and a wheelchair, folded neatly on the other wall. Additionally

` 49

there were several household items and suitcases stored in the room, making it

more akin to a storage room rather than a bedroom.

On our first visit, Akosi was lying on one side and turned away from the

door. It was obvious that he was stationary in the same position throughout the

night. Due to this immobility, it seemed as if Akosi was in constant agony. He

looked malnourished and much older for his sixty-six years. When I first saw

Akosi, my first impression was that the family provided only minimal care.

However, with every visit36 it became apparent that this case was far more

complicated than I had first anticipated. In order to make sense of and analyse

Akosi’s suffering and neglect, it is important to acknowledge the different views

of the people involved in this case: the patient himself, his estranged wife and

the different family members. In doing so, I employ the explanatory model37

approach, which reveals how people make sense of illness, as well as their

experiences of living with it and caring for a sick person. Rather than using this

model to understand different explanations of Akosi’s illness, I aim to

demonstrate how intra-household power relationships were played out and

how they affected Akosi’s care.

Akosi and Roberta

When Justice and I first visited Akosi, he complained of being neglected by his

family and expressed his wish for more attention from the family. The reason

for the neglect was, in Akosi’s opinion, his lack of financial resources: “No

36

I visited Akosi three times in total. I also had the chance to interview Akosi’s wife away from the family, in her workplace. In addition I conducted interviews with various family members, his brother James for instance, during Akosi’s physiotherapy treatment. 37

For further information on the EM please refer to Appendix H.

` 50

money means no food, no care and no time for me. This is the reason why I am

left alone”. This was also confirmed by Roberta, Akosi’s wife:

They [the family] rather let him lie in his own excrements and wait for

me to come. I am the only one who is cleaning him up, who changes his

diapers and who turns him.

Both blamed Edward (the senior brother) for the situation, as “he only cares

about money”. Two of Akosi’s sisters live abroad, one in the US and the other in

Europe. Both have sent money for Akosi’s care, however, neither Roberta nor

Akosi have received any of that money. To my question on whether Akosi feels

that herbal treatment has helped him, he answered:

At first yes, but ever since I come for exercises [to the PTD] I do not

like herbal treatment anymore. I can feel immediate improvement

through exercises, which the family also acknowledges.

Because of her low status as a ‘married in’, Roberta is not included in decision-

making processes (e.g. the choice of treatment). According to Roberta it was

Edward’s sole decision to employ an herbalist. Roberta also believes that the

senior brother is possessed by witchcraft:

How else could he [Edward] develop such a negative attitude towards

my husband? A friend of mine asked Edward about Akosi’s health: ‘We

want him to die’ was Edward’s answer. When I confront other family

` 51

members they are rather annoyed with Edward, and they disagree on

how he treats Akosi.

The EM’s of Akosi and Roberta demonstrate that both perceive themselves as

victims of Edward’s dominance and decision-making. Edward is further criticised

and blamed for destroying the harmony of the family as he is divorced and his

children do not want contact with him.

James

James, Akosi’s brother, aged sixty-nine, accompanied Akosi to every

physiotherapy session. This offered me the chance to interview James by

himself. He disagreed with Edward's handling of the situation with Akosi:

I am not happy with Edward’s decisions. In the last three months,

Akosi was just lying in bed. No exercises. I am not happy with the

herbal treatment, but what can I do? I have to agree.

James attributed the worsening of Akosi’s condition to the herbal treatment,

which in James’s eyes is/was ineffective. James also blamed Akosi directly for

not co-operating with the family: “He does not do anything, not even wash

himself”. It seems that James did not know, or refused to acknowledge that

Akosi’s ‘disobedience’ was due to his ill health and not due to his unwillingness

to help. In James’ EM it is clear that Edward’s decisions were culpable for the

worsening of Akosi’s condition.

` 52

Edward

Edward is the eldest son in Akosi’s natal family and hence the head of the

family. He is also the main decision-maker when it comes to Akosi’s treatment.

When Justice and I visited Akosi for a second time, Edward was also present.

Akosi was made ‘presentable’, i.e. he was bathed and wore fresh diapers. After

introducing ourselves, I wanted to know why Akosi was so thin. Edward gave a

curious answer:

Because he is always lying in bed and cannot move, his muscles are

atrophied. Akosi is eating plenty of food. In the morning we feed him

porridge, in the afternoon rice with stew or beans, and evening fufu or

banku [a cooked maize meal] with soup.

When we inquired about the money that the sisters had sent from abroad,

Edward argued that the money was used for paying the herbalist’s bills. For a

three-month treatment the herbalist apparently charges 300 cedis38 - where

170 cedis have to be paid up front.

Edward told us that he did not know that exercise would be good for

Akosi. Later, however, he mentioned that the Komfo Anokye Teaching

Hospital39 had referred Akosi for rehabilitation treatment back at St. Patrick’s

Hospital. Hence, Edward knew about the available PTD, and according to

Edward, the family was planning to bring him to the PTD, if after three months

of herbal treatment, Akosi’s condition had not improved. Here we can see that

38

300 cedis are GBP 98, and 170 cedis are GBP 56; conversion rate from 14/01/13. 39

Akosi was first admitted to St Patricks Hospital, but as his condition was severe, he was referred to Komfo Anokye Teaching Hospital.

` 53

Edward has a completely different explanation of Akosi’s deteriorating

condition, which is Akosi’s physical immobility.

Situating Akosi’s case study into a theoretical framework

Akosi’s case study demonstrates how the willingness to care for a sick person is

dependent on that person’s behaviour towards their family prior to the onset of

the sickness (van der Geest 2002). As Akosi was an alcohol addict in the past, he

could not contribute productively towards his natal family, nor was he able to

support his wife and children. This was reciprocated by his family by way of

withdrawing basic care and denying food in his time of need. Akosi rightly

identified his lack of financial resources to be one of the reasons why his family

is neglecting him. Individuals in Akan society are expected to contribute to the

family’s household and look after one another in times of hardship (Crentsil

2007). Akosi’s stroke was a cause of economic hardship (e.g. cost of medicines

and therapy) for his family, and his disease produced constant conflict in the

family. Dilger’s study suggest that:

Acts of care and support are situated in the specific relations

between social persons that define themselves not primarily as

‘caregiver’ and ‘patient’, but first and foremost through their

relationships as siblings, parent, child and so forth (2008: 108).

In Akosi’s case, the family treated him the same way he had treated them

before he suffered the stroke and, according to Roberta, the responsibility of

` 54

care was shifted to her. Akosi’s case also demonstrates how power relations are

played out within the family. Pool and Geissler (2005) argue that:

Power, according to Foucault, is no commodity or attribute of status,

but a strategic relationship. Power is inherent within a relationship,

but dominance - manifested and felt imbalances and inequalities in

that strategic relationship – varies (2005: 68).

The dominance of the senior brother, Edward, was perceived differently by the

various family members. For instance, Roberta felt his dominance was due to

her low status of being “only married in”.

It has been reported that caring for a chronic sick person over a longer

period of time can lead to the discrediting of the ill person and frustration and

hostility towards them. Furthermore, through the fatigue of caring duties, the

‘sick-role’ might be denied to the chronic sick (Crentsil 2007). This was reflected

in James’s complaint about Akosi’s disobedience of washing himself.

Lastly, Akosi’s case study might also demonstrate that caring for the sick is a

private domain, and it also draws upon the unwillingness to spend money on a

sick person. Van der Geest (2009) points out that:

Funerals are public events but sickbed and death occur in the seclusion

of the house. Medical care is expensive and the outcome is uncertain, so

the willingness to spend money on a sick person who is going to die

anyway is limited” (2009:268).

This was also confirmed by Bubu:

` 55

[The] family is rather interested in a funeral then in treatment. If a

family member suffers a stroke, the family thinks that the illness cannot

be cured. The patient should die as soon as possible so that they can

‘earn’ money at the funeral, as the mourners need to ‘pay’ their respect.

Sometimes family members give patient a poisoned drink so that he/she

dies faster.

Bubu’s statement in turn corresponds with van der Geest (2009), who further

argues that:

Money spent on a funeral, however, is much more certain to be

effective and bear fruit. Death, indeed, is eclipsed by the funeral, in

many ways (2009:268).

6.4. Conclusion

Care in Akan society is a complex endeavour and matrilineage emerges as the

central unit in the care process of a sick person. Ideally, the family should

function as a social security system, as its members are required to assist each

other in times of crisis. The all-encompassing nature of matrilineage comes to

the fore in times of crises, as through care-giving people make sense of illness.

Reciprocity and respect are important values in Akan society and even more so

in times of sickness and hardship. Yet, the social and cultural basis of care is

undergoing profound changes particularly in Akan society but generally across

Ghana. The shift from the extended to a more nuclear family, and the migration

of the younger generation into cities are two major changes of note.

` 56

The two case studies also demonstrate how illness is constructed in

Akan society. Stroke, which renders someone immobile and dependent,

disrupts the coherence of the meaning of everyday life. Good health is

associated with an individual’s ability to perform duties and roles. Illness is

therefore perceived as a disturbance in the health balance, as it reduces the

productivity of an individual. As both informants were completely dependent

upon the family, they could not participate in the reciprocal character of the

support networks, e.g. contributing to the family’s income. In turn, this led to

considerable intra-household tensions with a resulting breakdown of the key

social support networks of the matrilineal kin. Some people even regard a dead

person as better than a chronically sick person, as funerals generate income.

In summary, how a sick person is cared for depends on how that sick

person behaved towards the family before the onset of his/her sickness. Being

cared for is not an automatic right, but a notion that requires considerable

investment.

` 57

Chapter 7: Conclusion

This dissertation has demonstrated that stroke, with its accompanying physical

impairment, disrupted the lives of my informants and their families. Stroke

often had a negative impact upon the livelihood of my informants’ households,

since the care process prevented care providers from pursuing income

generating activities. Unique manifestations of Akan matrilineal values of

reciprocity, respect and sense of deservedness influence the provision of care,

and thus impact the individual’s experience of illness. Illness experiences and

narratives, therefore, are never produced within a socio-cultural vacuum, but

are always situated in the wider social, political and cultural contexts of a given

society.

For my informants, these matrilineal values not only determined the

type and amount of care they received, but these values were also influential on

other aspects of their lives. For instance, decisions concerning possible

treatment, if any, were often made without the patient’s consent. This can be

related back to the reciprocal character of Akan society - whether a patient

‘deserves’ treatment or not was dependent on how they behaved towards the

family before the onset of the affliction. Moreover, the choice of treatment was

influenced by accessibility, costs and other factors, which may or may not

exclude certain groups from a particular form of treatment.

The experience of care and care giving, however, is always influenced by

much wider political, economic and structural factors and restrictions. State-run

health education programmes, for instance, with their focus on the individual’s

` 58

life style choices, are blame-oriented as “the disease [and the] onset and

outcome [of that disease] are directly ascribed to the afflicted themselves”

(Finerman & Bennett 1995:1). Such programmes, therefore, instil anxiety and

fear: in the case of my informants, fear about a future living with the disabilities

of stroke, the fear of not being able to pay for their children’s education, and

the fear of becoming dependent on their family in a society where individuals

are expected to contribute to the family’s household.

Risk factors as advertised by health education programmes might be an

outcome of structural factors. Due to poverty, for instance, my informants’

often had no other choice than to consume unhealthy, fatty and nutritionally

deficient diets. Poverty and poverty-related stress (e.g. depression and anxiety)

often had physical and psychological implications for my informants, including

the adoption of addictive behaviours. Considerable alcohol consumption as a

‘risk factor’ in Ghana, therefore, might be rooted in poverty.

Furthermore, my informants’ illness experience was characterised by

inequalities accessing adequate care and health facilities. As Ghana’s health

system is underfunded and underdeveloped it lacks basic and sophisticated

medical equipment and technologies, necessary for stroke diagnosis or

treatment and rehabilitation (especially in rural areas). As demonstrated earlier,

the in-hospital, post-acute care and subsequent rehabilitation management of

stroke are crucial for the treatment of stroke. However, such medical care is

often not covered by the NHIS and the majority of Ghanaians do not have

adequate access to post-stroke rehabilitation management. Structural factors

such as poverty and social inequality, therefore, greatly impacted on my

` 59

informants’ illness experience. Ultimately a change of ‘life conditions’ is

necessary, as opposed to a change of ‘styles’ in order to tackle the increasing

burden of stroke not only in Ghana but elsewhere in developing and developed

countries (Finerman & Bennett 1995).

The attempt to analyse this research in relation to the wider literature

on stroke in Ghana has proven difficult: though epidemiological literature is

available, the opposite is true for anthropological studies and publications. This

might be due to the fact that non-communicable diseases in Ghana, including

stroke, have not gained prominence in anthropological research as the primary

focus has been on infectious and parasitic diseases, such as HIV/AIDS, malaria

and neglected tropical diseases. Thus, the need for future anthropological

research on stroke in Ghana is prevalent, and a triangulation of diverse

disciplines would help the establishment of a well-formed body of knowledge

on morbidity and mortality rates, the individuals’ aetiology of their affliction,

their health care seeking behaviour, and the lived-experience of stroke sufferers

and their care givers. This triangulation might provide useful information for

the implementation of future health care programmes on stroke and other

NCDs, not only in Ghana and SSA but also throughout the globe.

In summary, this dissertation has highlighted the importance of

investigating the lived experience of stroke sufferers in the Ashanti region of

Ghana in order to understand health seeking and care giving behaviour.

` 60

Bibliography

Agyemang, C, Attah-Adjepong, G., Owusu-Dabo, E., de-Graft Aikins, A., Addo, J.,

Edusei, AK., Nkum, B.C., Ogedegbe, G. (2012). Stroke in the Ashanti Region

of Ghana. Ghana Medical Journal. 46(2): 12–17.

Apt, N. A. (1993). Care of the elderly in Ghana: An emerging issue. Journal of

Cross-Cultural Gerontology. 8(4): 301–312.

Becker, G. (1993). Continuity after a stroke: implications of life course disruption

in old age. The Gerontologist. 31(2): 631–9.

Bury, M. (1982). Chronic illness as biographical disruption. Sociology of Health

and Illness. 4(2): 167–82.

Cappuccio F.P., Micah F.B., Emmett, L., Kerry S.M., Antwi, S., Martin-Peprah, R.,

(2004). Prevalence, detection, management, and control of hypertension in

Ashanti, West Africa. Hypertension. 43(5): 1017–22.

Crentsil, P. (2007). Death, Ancestors, and HIV / AIDS among the Akan of Ghana.

PhD Thesis. University of Helsinki.

Darko, I. N. (2009). Ghanaian Indigenous Health Practices: The use of herbs.

Master Thesis. University of Toronto.

de-Graft Aikins, A., Anum, A., Agyemang, C., Addo, J. and Ogedegbe, O et al.

(2012). Lay Representations of Chronic Diseases in Ghana. Ghana Medical

Journal. 46(2): 59–68.

` 61

Desjarlais, R. & Throop, J. C. (2011). Phenomenological Approaches in

Anthropology. Annual Review of Anthropology. 40(1): 87–102.

Dilger, H. (2008). “We Are All to Die” Kinship, Belonging, and the Morality of

HIV/AIDS-Related Illnesses and Deaths in Rural Tanzania. Anthropological

Quarterly. 81(1): 207–232.

Evans-Pritchard, E. E. (1937). Witchcraft, Oracles and Magic amongst the

Azande. Oxford: Oxford University Press.

Faircloth, C., Boylstein, C., Rittman, M., Young, M. E., Gubrium, J. (2004). Sudden

illness and biographical flow in narratives of stroke recovery. Sociology of

Health & Illness. 26(2): 242–261.

Farmer, P. (1992). AIDS and Accusation: Haiti and the Geography of Blame.

Berkeley: University of California Press.

Fettermann, D. M. (1998). (eds.). Ethnography: Step by Step. SAGE Publications,

Inc.: California.

Finerman, R. and Bennett, L. A. (1995). Guilt Blame and Shame: Responsibility in

Health and Sickness. Soc. Sci. Med. 40(1): 1–3.

Ghana Statistical Service. (2012). 2010 Population and Housing Census:

Summary Report of Final Results. Accra: Sakoa Press Limited.

Ghana Health Service. (2010). The Health Sector in Ghana: Facts and Figures.

` 62

Horton, R. (2001). Ghana: defining the African challenge. Lancet. 358(9299):

2141–2149.

Hundt, G., Stuttaford, M., Ngoma, B. (2004). The Social Diagnostics of Stroke-

Like Symptoms: Healers, Doctors and Prophets in Agincourt, Limpopo

Province, South Africa. Journal of Biosocial Science. 36(4): 433–443.

Kengne, A. P. and Anderson, C. (2006). The neglected burden of stroke in Sub-

Saharan Africa. International Journal of Stroke. 1(4): 180–190.

Kleinman, A. M., Eisenberg, L., Good, B. (1978). Culture, Illness, and Care. Annals

of International Medicine. 88(2): 251–258.

Lawson, B. (2001). The Language of Space. Oxford: Reed Educational and

Professional Publishing Ltd.

Lemogoum, D., Degaute, J-P., Pascal Bovet, P. (2005). Stroke prevention,

treatment, and rehabilitation in sub-saharan Africa. American Journal of

Preventive Medicine. 29(5 Suppl 1): 95–101.

Luginaah, I. (2008). Local gin (Akpeteshie) and HIV/AIDS in the Upper West

Region of Ghana: the need for preventive health policy. Health & Place.

14(4): 806–816.

Lynch, E. & Medin, D. (2006). Explanatory models of illness: a study of within-

culture variation. Cognitive psychology. 53(4): 285–309.

` 63

Mshana, G., Plummer, M.L., Wamoyi, J., Shigongo, Z.S., Ross, D.A., Wight, D.

(2006). “She was bewitched and caught an illness similar to AIDS”: AIDS

and sexually transmitted infection causation beliefs in rural northern

Tanzania. Culture, health & sexuality. 8(1): 45–58.

National Health Insurance Scheme. (2010). Annual Report. Accra: National

Health Insurance Authority.

O’Reilly, K. (2009). Key concepts in Ethnography. SAGE Publications Ltd.:

London.

Pool, R. & Geissler, W. (2005). Medical Anthropology: Understanding Public

Health. London: London School of Hygiene and Tropical Medicine.

Pope, C. (2005). Conducting ethnography in medical settings. Medical Education

39(12): 1180-1187.

Rose, N & Novas, C. (2005). 'Biological citizenship', in Stephen J. Collier & Aihwa

Ong (eds.) Global assemblages: Technology, politics, and ethics as

anthropological problems. Malden, Mass. ; Oxford: Blackwell Publishing.

Setel, P. W. (2003). Non-Communicable Diseeases, Political Economy, and

Culture in Africa: Anthropological Applications of an Emerging Pandemic.

Ethnicity & Disease. 13(2): 2–167.

Stoeltje, B. J. (1997). Asante Queen Mothers: A Study in Female Authority.

Annals of the New York Academy of Sciences. 810(1): 41–71.

` 64

Stoner, B. P. (1986). Understanding Medical Systems: Traditional, Modern and

Syncretic Health Care Alternatives. Medical Anthropology Quarterly. 17(2):

44–48.

Tsey, K. (1997). Traditional Medicine in Contemporary Ghana: A Public Policy

Analysis. Social Science & Medicine. 45(7): 1065–1074.

Tsikata, D. and Seini, W. (2004). Identities, Inequalities and Conflicts in Ghana.

Working Paper. CRISE: Centre of Research and Inequality, Human Security

and Ethnicity. Oxford University: 3–50.

Van der Geest, S. (2002). ‘I want to go!’ How Older People in Ghana look

forward to death. Ageing and Society. 22(1): 7-28.

Van der Geest, S. and Finkler, K. (2004). Hospital ethnography: Introduction.

Social Science and Medicine 59(10): 1995-2001.

Van der Geest, S. (2009). 'End of Life Care in Ghana and the Netherlands: Good

Death, Bad Death and Euthanasia', in Christine Oppong et al. (eds.) Care of

the seriously sick and dying: perspectives of Ghana. Bergen, Norway: BRIC.

Ventevogel, P. (1996). Whiteman’s Things. Amsterdam: Het Spinhuis.

World Health Organisation (WHO). (2011). Global Status Report on non-

communicable diseases 2010. Geneva: World Health Organization

Whyte, S. R. (2012). Chronicity and control: framing “noncommunicable

diseases ” in Africa. Anthropology & Medicine. 19(1): 37–41.

` 65

Websites:

Government of Ghana. (2013). Ashanti: Introduction. Available at:

http://www.ghana.gov.gh/index.php/about-ghana/regions/ashanti

[24/01/2013].

NHS UK. (n.d.). CT scans: Introduction. Available at:

http://www.nhs.uk/conditions/ct-scan/pages/introduction.aspx [22/01/2013].

NHS UK. (n.d.). Stroke. Available at:

http://www.nhs.uk/Conditions/Stroke/Pages/Intro-duction.aspx [22/01/2013]

World-map. (n.d.). Ghana. Available at:

http://www.worldatlas.com/webimage/countrys/africa/gh.htm [02/02/2013].

` 66

Appendices

Appendix A A.1. General information and statistics on Ghana The Offinso muncipal is one of 2740 districts in the Ashanti region and according

to the 2010 household census, the population in this district comprised of 76,

89541 inhabitants. Offinso , the district capital has a population of approximately

30,000.

In 2010 the estimated population of Ghana was 24,658,823. The Ashanti region

as the most populated region accounted for a total population of 4,780,380,

compared to 4,010,054 in the Greater Accra region (Accra is the capital of

Ghana) (Population and Housing Census Report 2010). Greater Accra is the

smallest but most developed region (especially in terms of health care facilities)

in Ghana. For example: 466 Health facilities (including hospitals and health

centres) are found in Greater Accra, compared to 548 in the Ashanti region.

In West Africa, widening inequalities between a more developed south coastal

area and an underdeveloped periphery in the Sahelian north has been reported.

In Ghana the root of the North-South dichotomy can be traced back to colonial

dependency. The internal production of goods and services had a dual

structure: a dynamic modern export sector (Southern Ghana) and a backward

and underdeveloped subsistence sector (Northern Ghana, including Upper East,

40

For further information refer to the official governmental website of Ghana: (http://www.ghana.gov.gh/index.php/about-ghana/regions/ashanti [accessed on 24/01/2013]). 41

Population and Housing Census 2010.

` 67

Upper West and Northern region) that also served as a labour reserve for the

modern sector. Northern underdevelopment therefore stood, and still stands, in

stark contrast to the relative development of the South. Recent studies in

Ghana revealed that most of the poor (70 percent, with earnings of less than

GBP 298) and the extreme poor (59 percent, with earnings of less than GBP 231)

were to be found in the rural savannah (North), while less poverty was found in

the rural forest (South) – where 38 percent were poor and 21 percent extremely

poor (Tsikata & Seini 2004).

The ‘in-between’ season occurs between the two rainy seasons. The Ashanti

region experiences its first and major rainy season in March until July, the

second and minor one starting from September to November. December to

February is dry, hot, and dusty.

A.2. Medical definitions of stroke

Ischemic stroke occurs when a blood clot occurs as a result of an obstruction

within a blood vessel supplying blood to the brain. Hemorrhagic stroke is more

aggressive: it occurs when a blood vessel on the brain’s surface ruptures and

blood streams in either the space between brain and skull, or the brain’s

surrounding tissue. This then causes pressure on the brain. In most cases, this

form of stroke is fatal and people die within minutes. Hypertension is the most

common cause for hemorrhagic stroke (NHS n.d.).

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A.3. Lineage of family

A.4. Daily routine in Offinso

I was getting up in the morning at around 7am; having breakfast (usually

porridge) in Aroha’s kitchen; going to work (between 8-9am) by taxi for 1 Cedi

(GBP 0,33) per person each way; having lunch around 1pm with Fai, who at that

time, completed a two-month internship for the administration at the hospital. I

usually finished the working-day between 5 and 6pm. On Saturdays my family

either just relaxed at home, or travelled to Kumasi for shopping. On Sundays it

was time to go to church, followed by a visit of the Sunday market in town, and

later to wash our cloths by hand. However, we did not adhere to this routine

(especially for the church services) too strictly: it dependent very much on the

weather and on our mood.

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A.5. Further information on the Physiotherapy Department Permanent staff members included: Physiotherapist Fedu42,, physiotherapy

assistants Bubu and Manu, and the volunteer Alian. Fedu was the head of the

department, as he held a degree in physiotherapy, and thus was regarded to be

the best trained personnel in this department. Bubu obtained a diploma from

the physiotherapy assistant college. He gained experience in other PTDs, before

joining St. Patricks Hospital two years prior. Manu was the newest member of

staff, joining the department recently. As he came fresh out of college, this was

his first work experience. Alian was a trained physician assistant, but planned to

retrain as a physiotherapist assistant.

After the first week in the PTD I started to realise that there was a power-

struggle going on between Fedu and Bubu. I had the impression that Fedu tried

to embarrass Bubu in front of the patients. Furthermore it was Bubu who did

the majority of treatments. Fedu was mainly in the therapy room, sitting behind

his desk and doing work on his computer. At first I thought that it was because

of me, as he might have felt obliged to explain as much as possible. As time

progressed I began to feel the tension within the PTD and at times I was very

uncomfortable with Fedu’s treatment of Bubu. But when I spent the majority of

my time with patients and hence with Bubu, Fedu’s behaviour towards Bubu

deteriorated. After three weeks in the PTD, Fedu needed to attend an advanced

training in Accra which would last three weeks. This allowed me to discuss my

42

Informed consent was obtained from all informants. However, due to the size of the department, it was clear that even though I change the names, the characters will be still recognisable. I informed my respondents of this, but none raised any concerns about the identification problems.

` 70

impressions with Bubu, who told me that he felt bullied and treated badly by

Fedu. It was Bubu who established the PTD at St Patricks and not Fedu, and

Bubu, Manu and Alian confirmed that Fedu is not very helpful for the

department. In Fedu’s absence, the mood of the department changed

drastically: the three remaining staff members clearly relaxed and thus opened

up to me. This was also the time in which I was allowed to become an active

member of the team, and helped with administering therapies to patients. As a

former professional massage therapist, I greatly enjoyed this time.

` 71

Pictures of the Physiotherapy Department

Corridor and waiting area for patients

Treatment Room

` 72

Exercise Room

` 73

Appendix B: National Health Insurance Scheme (NHIS)

Since independence in 1957, the Ghanaian government has committed itself to

a welfare system that includes a ‘free health care for all’ policy. Between 1957

and 1966, Ghanaians could seek medical attention for free. In 1982, user fees

were introduced in government run facilities to supplement limited health

financing resources. This led to a dramatic decline in health care utilisation. In

1997, with the help of donor funding, voluntary Mutual Health Organisations

(MHOs) were introduced to certain districts throughout the country, which in

2002 consisted of around 159 MHOs, with 67 Ghanian districts involved. In

2003, Ghana introduced the National Health Insurance Scheme (NHIS), which

aimed to cover the entire population with affordable access to basic health

services within five years. The membership of NHIS is open to all persons

resident in Ghana by subscription. Exempt from the fees are: children under

eighteen years; the elderly aged seventy and above; the poor and, since 2008,

free ante-natal and post-natal care to all pregnant women. At present the NHIS

benefits package covers 95% of the most common disease conditions in Ghana,

and includes outpatient and inpatient care, delivery care, diagnostic tests,

generic (cheap) medicine, emergency care and rehabilitations care. The insured

has to go to his/her district hospital to receive treatment (NHIS Report 2010).

In comparison to other African countries, Ghana is certainly a role model

in terms of public health system. However, as with all great policy intentions,

the NHIS has major flaws, which on the ground affect the poor the most.

According to my informants the annual insurance fee starts from four cedis

(GBP 1,37) for the very poor and young children, and goes up to forty cedis (GBP

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13,74). According to the NHIS Report the highest fee accumulated at seventy

cedis (GBP 24,00) for the very rich. I was somewhat surprised to read in the

same report that children under the age of eighteen and the poor should be

exempt from the insurance. My informants had to pay for their young children,

no matter how old they were. Justice pays the insurance for every child in his

charity. There are of course advantages with this system, such as the out and

inpatient care and the free ante- and post-natal care. However only basic

treatment is covered, e.g. a cast for a broken bone is not covered by the NHIS.

Conversely, rehabilitation after the removal of the cast is covered. The current

NHIS policy, therefore, is creating the same inequality as in the year 1982. Many

of the poor cannot afford the annual fees for themselves and their family, hence

they turn to local healers.

When I first heard about the NHIS it reminded me of the NHS here in the

UK and this was confirmed by Fedu:

The policy makers wanted to install the same medical system as in

UK, where every patient is treated in his/her own district and is

seldom referred to another hospital. In Ghana this does not work as

people attend hospitals in districts where their relatives live. These

hospitals then refer them back to their original district hospital. But

by then it is often too late.

In Fedu’s opinion, more applied medical personnel need to get into policy

making and politics in order to improve healthcare.

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Appendix C: Demographic information of my informants

Informants

Name Age Profession

Akosi 66 Revenue collector

Alfred 53 Teacher

Alibama 48 Taxi driver

Comfort 38 Farmer

Camie 58 Farmer

Edjala 75 Herbalist

Justice 27 Research Assistant/Owner of a charity for disabled children

Margaret 50 Teacher

Opoua 69 Farmer

Oseja Yaw 48 Farmer

Owowusu 83 Farmer

Rose 35 Farmer

Physiotherapists

Name Age Profession

Fedu 28 Physiotherapist/Head of Department

Bubu 26 Physiotherapist Assistant

Manu 21 Physiotherapist Assistant

Alian 22 Volunteer

Family

Name Status in family

Father Joah Grandson of family eldest

Aroha Great granddaughter of family eldest

Abah Great granddaughter of family eldest

Fai Great granddaughter of family eldest

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C.1. Glossary of Twi terms

Twi term English word / explanation

Aduane Food

Akpeteshie Cheap alcoholic drink

Banku A cooked maize meal

Fufu

Fufu is made by boiling starchy vegetables like cassava, yams or plantains, which are then pounded into a dough-like consistency. It is eaten with an accompanying soup, e.g. peanut, palm nut or groundnut soup, which is often made with different kinds of meat or fish.

Mogya Blood

Muju Witchcraft

Ndwodwoe3 Paralysis (in connection to stroke)

Okra Okra is a plant that produces an edible pod that is eaten as a vegetable

Yafunu Belly

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Appendix D: Case Study: Edjala - a local herbalist

The left picture shows Edjala, pointing to roots which she used for treatment of ‘weak veins’. Note that the roots in the left pictures look like veins. The picture on the right displays the cooking of herbs, which Edjala used to make teas and ointments.

I was introduced to Edjala, a seventy-five year-old, female local herbalist by my

research assistant. Edjala learned her profession from her father when she was

a child. He introduced her to herbs and roots, and taught her how to prepare

remedies suitable for certain illnesses and injuries. Even today, long after the

death of her father, she prays to him through an object her father once gave to

her. According to Edjala, this object helps her, to “open her eyes to new drugs

and to possible diseases.”

On several fireplaces, herbs were cooking and her home was crammed

with utensils, benches, and sacks of dried herbs, which were scattered around

the compound. Edjala is a non-spiritual healer who bases her knowledge on the

actual herbs and their efficacy. However, by praying to her late father she also

incorporates a spiritual nature.

The first I noticed when I visited Edjala’s compound were the many

people (young females) who were having a white powder spread over their

body. At first I thought they were her children, but I learned that they were

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patients, staying with her in her compound or in her ‘hospital’ not far from the

compound. Accommodation in this hospital is free - however, food and care

have to be provided by the patients’ relatives. In the past, Edjala did not charge

anything for the treatment. Her patients simply showed their appreciation after

they recovered. Nowadays, with increased living expenses to cover, she is

forced to charge one-hundred cedis.

Cause of stroke

Edjala’s believes that stroke is a vein disease. If the vein is not strong enough,

the blood flow is blocked, hence a stroke occurs. The lesser the blood flow, the

thinner the vein will become. If a person is thin and has no blood, Edjala advises

the patient to go to the hospital in order to “make blood and veins stronger”

(through blood transfusions). If the patient has no “hospital disease”, the doctor

will send him/her back to her. Different diseases are transmitted by air and they

enter the person’s body through the skin. If a person wakes up paralysed in the

morning it is caused by the air.

According to Edjala, diet is another factor for causing stroke, as today’s

food does not contain enough energy due to the added chemicals. The food is

also too fatty and oily. This notion was also repeated by many of my informants.

She further argued that “white people are stronger then black people. White

people can take better care of themselves and they have a better diet”. People

also believe in witchcraft, although they cannot see witches. Edjala explained:

“A person’s jealousy can also cause stroke, as when someone thinks about

someone in a jealous way the other person will be possessed by witchcraft.”

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Witchcraft can be interpreted to have not only a spiritual but also a social origin

(Evans-Pritchard 1937; Tsey 1997; de-Graft Aikins et al 2012).

Edjala has ‘indigenised’ biomedical knowledge and is using it for her

advantage (Pool & Geissler 2005). Equally, contaminated and fatty food,

witchcraft and her claim that white people are stronger then black people,

points to structural violence which occurs in the daily lives of the Ghanaians,

especially the poor. Such structural violence incorporates unequal access to

healthcare, education, employment and, due to poverty, lack of access to

nutritious food (Darko 2009, Pool & Geissler 2005, Tsey 1998, Stoner 1986).

Another interesting fact which we can see through Edjalas case study is

that she refers patients who have ‘no blood’ to the hospital. In turn, hospital

doctors refer them back to her when they cannot help the patient with

conventional treatments. A syncretised form of health care takes place as both

systems co-exist and complement each other.

D.1. Explanations of the profession of herbal healers

In Ghana, there are spiritual and non-spiritual herbal healers, and several routes

of training can lead to this trade. The first is through informal learning from a

close family member. A second method is through a three-year apprenticeship,

and the third route is through ‘spiritual calling’. The former two base their

knowledge on herbs and their efficacy. Spirituality (for explanations of

spirituality please refer to the next section) is a very important, though

secondary component. These herbalists usually also provide some sort of

accommodation for their patients. The last group of herbalists have a strong link

` 80

to the spiritual world, and herbal treatment serves as a mere means of driving

away evil spirits, destroying the supernatural powers responsible for any illness,

or involving the help of good spirits. Local priests/priestesses, cult healers, fetish

priests and pastors are part of this group (Tsey 1997; Darko 2009).

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Appendix E: Further information on the local aetiology of stroke

The blockage of blood therefore might suggest either an upcoming paralysis,

which is an actual symptom of stroke or a weakening of the veins, which Edjala

the herbalist also suggested. Another important fact to note is that in the Akan

conceptualisation of disease, the belly (yafunu) is often regarded to be the

center from where diseases originate. The belly in turn is connected with the

blood (mogya). Often, therefore, disease aetiology is explained in terms of

‘blood that has changed’ or ‘something is in the belly’ (Ventevogel 1996: 16).

Appendix F: Changes in the socio and cultural foundations of care

Van der Geest (2002) writes about the care of the elderly, which is also

important for this dissertation as many of my informants were elderly. Van der

Geest (2002) identifies four major developments in care giving: The first, he

argues, comes from the shift from lineage and extended family to the nuclear

family. Families began to exclude non-nuclear relatives, so that extended family

members were denied access to their income, possessions and heritage. At the

same time however, the new established nuclear-families were keen to

maintain some sort of ties to their matrilineage. For example, at funerals, it is

considered prestigious to summon as many family members as possible. The

second development affecting care-giving is the continuous migration of the

younger generation into cities and therefore they are not able to provide

immediate care. What they can provide, however, is care from the distance by

sending money and food contribution back home, which is the third

development. The fourth development is the shift from the appreciation of the

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knowledge and wisdom of the elderly, which is based on long life experience, to

a knowledge based on school education and general changes in society (van der

Geest 2002).

Appendix G

A CT scan is a computerised tomography scan. It uses X-rays and a computer to

create detailed images of the inside of your body. The images produced by a CT

scan are called tomograms and are more detailed than standard X-rays. A CT

scan can produce images of structures inside the body including the internal

organs, blood vessels, bones and tumours (NHS n.d.).

Appendix H

The explanatory model of illness was developed by Arthur Kleinman in 1978. He

developed these models and related questionnaires in an attempt to distinguish

between disease and illness, and to bridge the gap between clinical knowledge

and constructions of clinical reality. Questions for informants included: What do

you think has caused your problems? Why do you think it started when it did?

(Kleinman 1978: 251). Explanatory models (EM[s]) are often used to explain

how people view their illness in terms of how it happens, what causes it, how it

affects them, and what will make them feel better. It is a method used in both

clinical settings and qualitative research as a way to obtain individual

explanations about a particular phenomenon