2023-06-22 18:57:38
In Benin, the cardiovascular illnesses have become, in recent decades, an important public health problem, both in urban and rural areas.
In rural areas, unequal access to care, social distance with so-called “modern” medicine, the prevalence of self-medication and the use of so-called “traditional” medicine are at the heart of the lives of patients and their families. .
In Tanvè, a small village in southern Benin, an epidemiological cohort study, the Tanve Health Study (TAHES), documented between 2015 and 2021, through a series of annual surveys, the state of cardiovascular health of the population. Along with this epidemiological study, pioneer in Africaet rich in public health lessonswe conducted a complementary ethnographic survey between 2019 and 2021.
Through a series of case studies, we were able to highlight the way in which different registers of interpretation of the disease and plural care logics cohabit locally. We have also shown how the absence of a protection and social assistance policy in this area ultimately places the daily care of the sick on the families, and in particular on the women.
Families coping with illness
In the absence of state support, the size and availability of families are indeed crucial. A large household, children who remained in the village with more or less regular income, and the presence of daughters and daughters-in-law in particular are thus determining elements in the therapeutic trajectories of those who have been hit by a “crisis”. , as they say locally. But obviously not all families have such resources.
In April 2018, Honorine – the first names have been changed – stumbled on the threshold of her house. She has never walked alone since then. That day, her husband called neighbors to help him carry his wife inside. But she was not taken to a health center.
One of her legs swelled up, and Honorine was put to bed. Her husband then went to consult soothsayers. These affirmed that the fall and the swelling had been caused by sorcerers, prescribed ceremonies to be performed to defend once morest it, and made protective talismans. A son-in-law recommended an ointment, bought in a pharmacy, and recruited a masseuse in the village to come and massage his mother-in-law’s leg until the swelling subsided. It was only regarding ten months later, during the annual survey of the TAHES project, that the medical diagnosis of stroke was made.
In the following months, the two daughters of the couple present in the village took turns with their parents, providing the toilet, maintenance, laundry and part of the meals. This situation has gradually put their own households under pressure. In the spring of 2019, the son-in-law who had procured the ointment and masseuse for his stepmother a year earlier suggested that the half-blind mother may have been reckless in trying to move around anyway. his home, and might have some responsibility for what had happened to him… He also openly feared that a worsening of his mother-in-law’s condition would lead to an even greater mobilization of his wife by his side, depriving her own home from her domestic work.
The Tanvè health center in 2022. The village health centers are frontline centers. More serious cases are referred to the nearest area hospital, regarding ten kilometers away, but the anticipation of the cost of hospital treatment discourages many households. : Tonaï Guedou, Supplied by the author
The meanings given to the disease can thus closely intersect with more general lines of tension, such as that which traditionally opposes in these circles a husband and his parents-in-law around the domestic obligations of women. Honorine finally died in April 2020.
The sense of evil
Here as elsewhere, the question of the meaning of evil is rarely innocent. The part that a medical diagnosis can hold is variable. It cohabits here, even enters into competition, with other ways of interpreting the disease.
It is not uncommon for the interpretation to be given to a “crisis” to be discussed, if not disputed. On the one hand, diagnoses in medical terms are well known in the village as in the city. On the other hand, however, the sudden nature of a hypertensive crisis or a cardiovascular accident and, in the absence of regular medical follow-up, the virtual invisibility of the underlying problem upstream, lend themselves readily to suspicions of occult aggression, or of transgression by the patient of a customary prohibition.
The summoning of the witchcraft There is nothing incompatible here with the recognition of medical causes, and is part of other representations of evil, which locally distinguish between “simple” illnesses and “shadow” illnesses. Thus, a hypertensive crisis or a cerebrovascular accident may have been “provoked”, as they say in the local French, like any other disease. The sorcerer or the sorcerer may well have acted through an illness known to the medical world. The medical discourse does not necessarily exhaust the quest for the meaning of evil.
The diviner and healer Yakpechou, from Tanvè, now deceased, photographed here in 2009 with some of his vodoun deities. The reputation of this man then extended well beyond his village, and people came to see him from afar to seek a solution to their problems and to make sense of evil. Today one of his sons has succeeded him in his office. Photo: Geoffrey Fritsch. Provided by the author
The “crisis” of a person occupying a jealous position, or involved in a family or neighborhood conflict, thus has a good chance of being interpreted in terms of occult aggression. A diagnosis made in medical terms can then be articulated with another layer of meanings linking the event to the social tensions in which the individual was caught.
“As close as possible” support
The anticipation of the cost of medical care also often weighs a certain weight in the face of the occurrence of a crisis: will we have the means to meet the prescriptions that will be presented by the medical profession? The question runs through many heads when faced with such a situation.
The choice of self-medication, as in the case of Honorine mentioned above, can thus be partially motivated by economic reasons. As well as the transfer of a sick person to an evangelical or prophetic church, where one will pray with conviction for his healing without expecting immediate financial compensation. Faced with the uncertainty of the meaning to be given to evil, it is better to put all the chances on your side.
When Mathieu had a stroke in October 2019, his children immediately took him to the village health center. He stayed there for five days, without his condition improving. The local health worker suggests a transfer, which is inevitably expensive, to the departmental hospital centre. But, at the same time, voices are raised in the family circle, to suggest that the disease probably has occult causes. Mathieu is indeed the head of a lineage community, a coveted position, and his illness is said to have been “caused” by a jealous cousin.
He was then moved to a prophetic church in Abomey, the neighboring town, whose leader is known for the divine healings he sometimes obtains. Mathieu is massaged there with decoctions of plants, which he is also given to drink, for two weeks. His condition did not improve, and his children then took him home. In the months that followed, they continued to administer potions from the “traditional” pharmacopoeia and occasionally brought in a masseur at home, when they managed to pay for the sessions. It was her youngest son, still single, who took care of her toilet and helped her on a daily basis, and her only daughter residing in the village who paid for her meals. Mathieu finally died in July 2022.
In a social world strongly marked by a therapeutic pluralism and an pervasive economic precariousnessthe care compromises negotiated in the hours, days and weeks following a “crisis” often place great emphasis on theself-medicationadvice taken from members of the entourage, and recourse to carers who are socially (and family) close – women then find themselves particularly solicited.
In such configurations, recourse to health centres, where the cost of care is apprehended, does not necessarily seem unavoidable. And the forms of treatment regularly combine medicines from pharmacies and the black market, and products from the traditional pharmacopoeia, typically in the form of decoctions of plants, ointments or powders produced by the diviners and healers of the area.
Lives under tension
Since 2019, and in line with the priorities of the Global Health Agendathe Beninese government has prepared the establishment of a universal health coverage minimum, which must become a central part of the program ofInsurance for the Strengthening of Human Capital (ARCH) launched by the current government. Allowing free coverage for the poorest of a basket of basic care, this highly desirable development has gradually been extended to the entire national territory until it is fully covered at the beginning of 2023. Cardio health -vascular is unfortunately not concerned at this stage.
The ricochet effects of cardiovascular diseases are particularly important on those around the sick. Relatives – and especially women – are often immobilized at their side, which reduces their income and their financial autonomy. This observation might in the future constitute an argument in favor of extending medical aid for the cardiovascular health of Beninese.
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