A staggering 33, 000 AIDS deaths occurred in Ghana in 1999 alone (GAC 2003); in 2003, another 30, 000 deaths from the disease were recorded. The estimated number of people aged zero to 49 years living with the disease in 2003 was around 560, 000. The specifics about HIV/AIDS as a big threat in Akan society and in Ghana generally reveal a grim picture. The most vulnerable group is the 15 to 49 age category with a prevalence rate of 7.0 per cent; moreover, this group also forms the bulk of Ghana’s labour force.
As in other sub-Sahara African societies (Webb 1997), in Akan-land and in Ghana the disease afflicts mostly the youth, the future leaders. In recent years, a drop in Ghana’s prevalence rate (from 3. 6 per cent in 2003 to 3.1 per cent in 2005) was quite encouraging but the reality is that new infections are recorded daily in the country. It is feared that there may be more than the current 550, 000 cases in a population of around twenty million.48 Not all infected people report to the hospitals for testing although many regional and major district hospitals have HIV-testing and screening facilities.
Ever since HIV/AIDS burst onto the public health scene in the mid 1980s, the effects of the disease in Africa have been overwhelming (Bosompra 2001). Poverty, migration, the need to feed the household or family, and attitudes to fertility consistently raised important questions in early research on AIDS in Africa. About the mid 1990s, ‘African sexuality’, as Douglas Webb (1997: 29) puts it, began to dominate the cultural variables because of the heterosexual mode in the spread of the disease in Africa. Many have read racist undertones into this and other aspects of such inquiries; a particular construction of the disease in Africa has been created (ibid).
HIV/AIDS is constructed through various cultural practices and categories among the Akan. Like any experience of illness in the society it almost always expresses broader abstractions and relate closely to many other cultural categories. In the cultural epidemiology of HIV/AIDS, social processes usually categorise patients as not of moral worth. The disease is associated with ‘negative’ sex relations—multiple partners or lax sexual behaviour, unprotected sex, as well as premarital and extramarital sex in Akan society.49 There is more to it than meets the eye; therefore, this chapter goes beyond ordinary descriptive accounts of HIV/AIDS. I show the conscious cultural models involving the practical factors for risks and
48 Figures are according to United Nations estimates. Internet source: http://www.un.org/
49 Akan society frowns on premarital and extramarital sex despite the commonality (cf.
Bleek 1976), although it is less so today than it used to be (even as recently as in the early 1970s when I was a teenager).
insecurity associated with HIV infection and such less conscious cultural categories as witchcraft, conceptualised to operate mostly in the lineage group. There is another aspect to issues about the matrilineage. An HIV/AIDS illness and many of the factors leading to infection (directly or indirectly) may reflect the holistic and encompassing nature of the matrilineage; it also shows its contradictions. These themes are visible in the everyday lives and lineage organisation of the Akan.
Grace B’s burden and infection
Grace B, 27, was burdened as a major breadwinner in the family at quite an early age. She was still a teenager when her father abandoned her mother for another woman. The father had moved to another town outside the Kwawu area; there he had married the woman he had had a relationship with long ago, leaving Grace’s mother to care for their five children alone. As the first child, Grace was expected to help when she completed the junior secondary school at about 18 years. This meant that it was not possible to further her education even if she had wanted to; she was forced to work and help her mother in the upbringing of her other siblings. As a farmer, her mother had been struggling to care for the children. Life in the village was so unbearable. Grace had been forced to live with a distant relative at Nkawkaw in her early part of schooling. Soon she left for Koforidua, some twenty kilometres south east, where she lived with one of her mother’s friends to complete school. At Koforidua, Grace sold vegetables for the woman and through that her education was financed. After her schooling, Grace was expected to be on her own. She decided to live in Koforidua and continue with trading, using the money her guardian had given to ‘see her off’ for living with her.
Grace traded in petty items like candies and biscuits. She did not earn much from her sales, nevertheless, she had to support her other kin members back in the village. Her status as a positioned individual, a contributor for the family’s upkeep was significant. Her support for the upbringing of others expresses the matrilineage’s encompassing nature and individual members’ chance to help and be helped for the good of the family, which is usually paramount. For instance, a household survey in this study showed that 24 out of 96 migrants (or 25 percent) who were traders or wage earners at Nkawkaw gave monthly or occasional financial support to kin members back in the village. Only 14 percent (14.6 percent) did not remit to other kin members. The bulk of the respondents (58, or 54.1 percent) did not give any answer on remittances in the survey questionnaire, which does not mean
they do not remit to kin members back home. Rather, it may be linked to an Akan value—the obligation to help other kin members is seen as a virtue and to mention it could be taken as bragging about it, which is usually frowned on.
Supporting others indicates the pulls of matrilineal descent on the individual and the burden to be of help to other kin members. Having left school and with an opportunity to earn money from petty trading (even if her earnings are minimal), Grace was seen as better off than someone who is still in school or with no means to trade. Anything from her was eagerly anticipated. Grace, then a beautiful woman of about 22 years, started a relationship with a ‘rich businessman’; it was also obvious that she ‘roamed around’ men and did not stay at one place, as the Akan say. After some time Grace started to feel ill every now and then. She returned to the village to complain to her mother and went to the Holy Family Catholic Hospital at Nkawkaw, where she was tested as being HIV positive in January 2003.
Like all such patients, she became the hospital’s outpatient and reported for the counselling sessions organised every other Thursday.
The hospital also organises visits to interact with the HIV/AIDS patients in their homes and to check on their medication. It was during one of those visits on a bright Wednesday afternoon in April 2003 that Grace told what she termed as her “whole sad story” to the team of hospital personnel.50 Grace had cohabited with the rich businessman but separated from him because “he was a womaniser”. It was not long after the separation that she was diagnosed as being HIV-positive. She never told the man about her status, although he still pressures her to come back. Grace, however, assured the hospital team that because of the counselling she had decided not to go into relationships with men any more. She had come back to settle fully in the small village of a few huts and about fifty inhabitants, and was not expecting the men to visit her there. It was a remote village, Grace mused, but it was the place where she had lived as a child until she started schooling initially at Nkawkaw and later at Koforidua. Like among Haitians, as found by Paul Farmer (1992), there was the pattern of people having left the village to the urban area where they got infected and came back to live in the village. Radstake (1997) records a similar pattern in Ashanti.
50 I accompanied the team on their rounds to a number of villages and towns that day. It was a tiring day, which started with some problems in getting a vehicle and other logistics for the journey. Someone whispered that sometimes the team has to run around for a vehicle, fuel and the signing out of other logistics; it is just cumbersome and it “shows the highly bureaucratic way of doing office work in Ghana”. She, however, observed that it is worse in government hospitals.
When we met Grace B in her home at the village where she was currently living, she did not look ill. She was exuberant, full of smiles and grateful that we had visited. Behind those smiles, however, the patient was to reveal her ‘real’ post-diagnosis worries to us. She was almost always confronted with financial difficulties. It is, however, not the financial problems that concerned Grace. She was bitter about her mother’s attitude towards her. In the open space of the compound, however, she could not tell us anything about it; she invited us into her own room, quite far away from her mother, her younger brother, and sister. Hardly had we sat down in her room, when Grace started to pour her heart out. She first assured the visiting team that everything was fine with her health and she still had some of the medicines she had collected during the counselling session the previous Thursday. Grace’s greatest problem was that she had had no peace in the home ever since she revealed her status to her mother some weeks back.
Grace was disappointed with her mother’s attitude towards her: “Ever since I told her that I had been tested as HIV positive, she insults me at will.
One day, she even cursed me for my lifestyle that resulted in my infection,”
Grace revealed. She said her mother even went further to tell her brother and sister about her status. “She told them that I got it because of the kind of lifestyle that I had led. But I haven’t done it for my own sake alone.” With tears in her eyes, Grace further poured her emotions out: “You all [meaning her mother and Grace’s siblings] have benefited. I had to look for money and some property to make life easier for us. This compound and the few houses we have been able to build have all been through my efforts,” she pointed out as she tried to force back the tears in her eyes. Grace said her mother insults her at the least chance. She was convinced her mother had revealed her status to her younger brother and sister on purpose. Grace was bitter that her mother had not been sympathetic, considering her efforts and help in the family until her infection.
Her mother’s castigation and the contempt from some of her siblings aside, Grace was faced with another problem. She revealed that to us thus:
“When I didn’t know my status, not many men proposed to me. Now that I have been tested as HIV-positive, surprisingly many potential suitors are emerging and proposing immediate marriage. I have been saying no, even though I know they must be unaware of my status. But my mother comes in here too.” Her mother has been insulting her for the negative answers to the men. “My mother has been trying to put pressure on me to agree and marry a certain rich man. The man is so rich, and my mother thinks I could go ahead and marry him without telling him about my status.” Her mother’s prodding had confused Grace and she wanted advice from the health team.
As expected, the health personnel advised her to ignore what they viewed as her mother’s unfortunate behaviour and advice. Grace now loathes her own mother, whom she calls an evil person.
The family still lived together in the same remote village near Nkawkaw. For her living, Grace works on the farm she used to keep when she schooled at Nkawkaw. As a migrant without her lineage group in the Kwawu area, she grows cocoa on someone else’s land. As the usual practice for migrant farmers in Akan-land, she goes into ‘ebusa’ terms. The inclusive nature of the group sees migrant and tenant farmers as ‘outsiders’ who have no direct access to lands unless they go into the traditional ‘abusa’ system whereby the land owner receives one-third of the produce. She also has a vegetable farm specifically for the household’s consumption. Grace faces many other challenges. The undulating dirt-road from her village to the main junction on the Accra-Kumasi highway, an apology of an outlet for vehicular use, makes drivers plying the route charge quite high fares.
Lorries and taxis are not regular and sometimes Grace has to walk the more than 10 kilometres from her village to the main junction. She gets so tired that on the next counselling day if she is not able to find a vehicle, she abandons the trip to the hospital altogether. Even when she can get a vehicle to transport her, the fare of five thousand cedis (about sixty five US cents in 2003) is unbearable to her. But she is determined to face life boldly in her predicament.
The HIV/AIDS illness disorder
Before I left the field in mid March 2004, Grace looked quite ill and weak.
She could not do much as a farmer. HIV/AIDS has become a major illness disorder, which also expresses how illness is constructed in Akan society.
Any physical disorder that weakens the body or that renders someone immobile disrupts the coherence of meaning in everyday life. In folk medical discourses, illness is a disturbance in the health balance because it blocks one’s chances to be productive. The Akan view a good balance in health as an individual’s ability to perform duties and roles; illness is thus a problem for cultural categories. To better understand illness as a disorder in Akan conceptions is to consider the etymology of its local (Twi) name.
Illness is yadeε (usually, yareε)—from yaw (pain) and adeε (thing), making it a thing of pain (cf. Ventevogel 1996).
Various physical symptoms such as bodily pain, discomfort, weakness, psychological disturbance—anything that prevents the individual from pursuing his or her everyday activities (or which seriously minimises
the pursuit of them)—all indicate illness. Because AIDS always leaves patients’ bodies weak and emaciated, which prevents them from working, its status as an illness should then become obvious in Akan conceptions. In biomedical terms HIV (human immunodeficiency virus) is the infection caused by a virus that attacks and destroys the human immune system. It shows no symptoms of illness on the affected individual in the early stages of infection. It is explained that generally people infected with HIV may take as long as ten years before they develop AIDS (Acquired Immune Deficiency Syndrome) as the full-blown disease when opportunistic infections can easily set in (Webb 1997). Obviously, because of the long period it takes for an HIV-infected person to show signs of illness, known as the latency period, in Ghana the disease is simply called AIDS without any reference to HIV. AIDS has no Akan word. Instead, it is described in the idiom of gonorrhoea (babaso); it is referred to as babaso wiremfoכ (enigmatic gonorrhoea).
Douglas Webb (ibid) explains in his discussion of HIV and AIDS in southern Africa that the retrovirus that causes AIDS and has been known since 1986 enters the blood stream through contaminated blood, seminal and vaginal fluids. Once in the individual’s blood stream, the virus targets the CD4-T lymphocyte cells, a vital component of the immune system that fight against diseases in the individual’s body (ibid: 3). Webb makes a pertinent correlation between two contrasting environments and the span of time from initial infection to eventual death. According to him, the environment in many traditional societies has high levels of pathogens (which cause disease). This makes the process of immune deficiency in such societies considerably shorter than the average ten years after which HIV develops into AIDS in advanced societies.
Webb asserts that there is an average of six years between the time when HIV develops into AIDS in many sub-Saharan African societies and two years between full blown AIDS and death; eventual death usually results from the combined impact of opportunistic infections. The most common infections—tuberculosis (TB), diarrhoea, vomiting, and herpes zoster— combine with various oral and skin lesions such as candidiasis (ibid: 4). The picture in Akan society subscribes to almost all of Webb’s claims. All the AIDS patients I saw also suffered other ailments. Feverish conditions, diarrhoea and loss of appetite, TB, skin rashes, pains and weakness in the legs characterised the problems and suffering associated with the affliction.
Two major strains of HIV are identified in Ghana— 1 and HIV-2— which fits the pattern in most African societies. HIV-1, found in many
other parts of the world, is more prevalent in Ghana and accounts for a bigger percentage of infections. HIV-2, mostly confined to West Africa, takes up the rest of the infection in Ghana. There can, however, be a double infection of both strains.51
The experience of HIV/AIDS in Akan society is foremost a disorder for the individual; it is also a social disorder because it affects other kin members. Medical anthropology often recognises that illness indicates both a biological and social disorder, which also conveys psychological and emotional feelings. As Rene Devisch has pointed out in his study of rites to heal infertility among the Yaka, illness first concerns the subjectively and culturally informed experience of the ailing person. It also concerns the way it is given shape and interpreted in terms of the meaning and core values of the culture (1993: 30). The illness becomes social in character when the sick person, kin members and co-residents of the community acknowledge the disorder.52 Among the Yaka, the ailing person and his or her ‘therapy managing group’ interpret the specific way in which the individual’s state of health or style of behaviour deviates from the norm. They then “mark out or stigmatize the deviation with regard to the interests of the group” and to what extent the individual’s illness threatens them (ibid: 161). Similar ideas pertain in Akan society.
The social definition given to the HIV/AIDS affliction—that is, both as an individual biological disturbance and a social disorder—is important in Akan illness construction. Grace was being cared for by other kin members because they acknowledged that she was weak. Her illness is consciously or unconsciously marked out as one that cannot allow her to work and be able to support others as she used to do. She must now be
The social definition given to the HIV/AIDS affliction—that is, both as an individual biological disturbance and a social disorder—is important in Akan illness construction. Grace was being cared for by other kin members because they acknowledged that she was weak. Her illness is consciously or unconsciously marked out as one that cannot allow her to work and be able to support others as she used to do. She must now be