Treating Diabetes in Cameroon: A Comparative Study in Medical Anthropology Paschal Kum Awah (MSc) NEWCASTLE UNIVERSITY LIBRARY ---------------- --- - -~ -.._-- -'-- •.. 204 26706 a --_._----._- -------. -------- Thesis submitted for the degree of Doctor of Philosophy, University of Newcastle upon Tyne. Research conducted in the School of Population and Health Sciences and School of Geography, Politics and Sociology October 2005 Abstract This thesis presents and analyses the findings of research into the management of diabetes in one urban and one rural district of Cameroon. The phenomenon of non­ communicable diseases like diabetes mellitus is becoming a recurrent problem in middle and low-income countries, notably in Sub-Sahara Africa. This ethnographic study, in the tradition of medical anthropology, involved over two years of fieldwork, and has been undertaken to shed more light on the paradoxes that underpin the interpretation and management of diabetes in Cameroon. Initially, I set out to study how diabetes was managed in clinical settings; but as the research developed my enquiries led out from the clinic to encompass first the perspectives of patients and their families, and in the end the perspectives of traditional healers also. It thus draws together four distinct sets of actors engaged in the process of treating diabetes mellitus: clinical staff, patients, their families, and traditional healers. In this research, I explored the ways in which Cameroonians negotiate a meaningful and manageable path between alternative therapeutic regimes. But as my analysis shows, behind different therapeutic approaches lie alternative presumptions about aetiology and efficacy, about behaviour and the body. In integrating the perspectives of the different actors identified above, the research highlights three major themes. The first concerns the concept of 'compliance', and the language of frustration voiced by clinic staff about patient reluctance to adhere to medication and advice. The second concerns 'aetiology' and the ultimately incompatible styles of reasoning and understanding advanced to explain the causes and consequences of diabetes, including its complications and its significance as chronic and incurable in a 11 cultural context where the notion of an incurable disease is still seen as unconvincing. The third concerns ideas of 'power', and the differing ways in which power is attributed or assumed, ranging from the apparent power of biomedical knowledge and clinic injunctions, to the assumed power of traditional explanatory frameworks, or the powers of divination of traditional healers, or the powers of witchcraft or ancestors in inducing diabetes. My thesis is unusual (a) in subject matter, (b) in its comparative scope, and (c) in being done by a Cameroonian ethnographer. While rural Bafut has been the site of several previous ethnographic studies, almost nothing has been done ethnographically in Yaounde. This thesis shows that, contrary to my initial working hypothesis, the similarities in outlook and behaviour between rural and urban settings are more striking than the differences. The universe of the clinic and biomedicine is not more effective and accepted in the city, as might have been anticipated, for in both settings traditional healing beliefs continue to hold a strong influence, creating the problems around 'compliance' mentioned above. iii Dedication I dedicate this thesis to my family: my mother (Futeh Kai Awah), my wife (Ana Nkouetcha Awah), my kids (KaIseuh, Awah Jr, Ikaititchia and Ngando), my brother (Awah Mbeh Azibou) and sisters (Mrs Rebecca Ihims, Mrs Ateh Evelyn, Ms Margaret Awah, Ms Magdalene Awah). IV Declaration I confirm that this is my own work and the use of all material from other sources has been fully and properly acknowledged. Paschal Kum A wah v Abbreviations AIDS: Acquired Immuned Deficiency Syndrome ANSA: Action on Non-communicable diseases in Sub-Sahara Africa. BP: Blood Pressure CHC: Catholic Health Centre CHU: Centre Hospitaliere Universitaire (University Hospital Centre) DFID: Department For International Development DH: District Hospital OM: Diabetes Mellitus DMO: District Medical Officer DO: Divisional Officer EBHC: Etoug Ebe Baptist Health Centre Ed: Editor Ed(s): Editor(s) ENHIP: Essential Non-communicable Diseases Health Intervention Project EPC: Eglise Presbyterienne Camerouniase EPCH: Eglise Presbyterienne du Cameroun, Hopital de Djoungolo Annexe de Biyem Assi FGD: Focus Group Discussions HIV: Human Immuno-deficiency Syndrome Hrs: Hours HT: Hypertension 101: In-depth interviews VI IEC: Information, Education and Communication KI: Key Informants MOH: Ministry of Health NCO: Non-communicable diseases NGO: Non-governmental organisation PHC: Presbyterian Health Centre RAP: Rapid Assessment Procedure SSA: Sub-Sahara Africa WHO: World Health Organisation vii Table of contents Page Title Abstract ii Dedication iv Declaration v Abbreviations VI Table of contents viii List of Figures XII List of Maps xiv Note on orthography xv Acknowledgement xv Chapter I - Introduction 1.1 Introduction 2 1.2 Aims, objectives, purpose and research questions 4 1.3 The problem of diabetes in Cameroon 9 1.4 Summary of main arguments 11 1.5 Outline of the thesis 15 Chapter II - Background to Two Fieldwork Settings 20 2.1 Introduction 21 2.2 The two study settings: an introduction 23 2.2 Biyem-Assi 25 2.2. J Historical background 28 2.2.2 Current administrative and political structures 30 2.2.3 Earning and spending: work, markets and consumption 33 2.2.4 Urban-rural links and family structures 35 2.3 Bafut. 37 2.3.1 Historical background to the Bafot kingdom 40 2.3.2 The political and administrative structure of modern Rafot 43 2.3.3 Earning and spending: work, markets and consumption 46 2.3.4 The ritual calendar in Bafut 48 2.3.5 Urban-rural links andfamily structures 57 VIII Chapter III - Methodology 61 3.1 Introduction 62 3.2 Access and data gathering 64 3.3 Data sources and data types 72 74 3.3.1 Observation 3.3.2 Conversations and interviews 74 3.3.3 Focus group discussions (FGD) 75 3.3.4 Transcription and analysis 79 3.3.5 Language offieldwork 81 52 3.4 Social interaction 3.5 Comparison between doing fieldwork in Yaounde and Bafut 85 3.6 Insider and outsider - home anthropologist 89 89 3.6.1 Doing anthropology at home 3.6.2 The strange scientist-doctor 92 93 3.7 Local power relations in this ethnography 3.8 Concluding discussion on fieldwork 95 Chapter IV - Chapter IV - Literature Review 101 4.1 Introduction 102 4.2 Epidemiology of diabetes in sub-Saharan Africa 104 4.3 Medical sociology and anthropology in West and Central Africa 112 4.4 Ethnography of Cameroon 119 4.4.1 Historical Overview 120 4.4.2 Yaounde 123 4.4.3 The Grassfield and Bafot 124 IX 4.5 Concluding note on literature review 130 Chapter V - Case study 131 5.1 Taa Samuel Ntumngia, his status in Bafut, my connection to him 132 5.2 Setting up of Diabetes Association 134 5.3 His illness and death 135 5.4 The funeral, Takumbeng and the Fon 138 5.5 Themes 141 5.6 Conclusion 143 Chapter VI - Clinic perspectives on treating diabetic patients 145 6.1 Introduction 146 6.2 Treating diabetes: clinical settings and procedures 148 6.3 Staff-patient relationships 158 6.4 Issue of compliance and non-compliance 169 6.5 Conclusion 175 Chapter VII - 'If they were not there, we would have died'. Patient 177 and family perspectives of diabetes 7.1 Introduction 178 7.2 Popular understandings of diabetes 179 7.3 Adapting to life with diabetes 195 7.4 What does 'compliance' mean? Dealing with competing regimes of 209 treatment 7.5 Conclusion 216 Chapter VIII - The perspective of traditional healers 218 8.1 Introduction 219 8.2 Who are the 'traditional healers'? 221 8.3 How traditional healers explain diabetes 229 8.4 Healing practice: carrying conviction for patients 243 8.5 Relationship between traditional healers and clinic staff 245 8.6 Traditional authority and the reproduction of knowledge about diabetes 248 8.7 Conclusion 254 x Chapter 9 - Conclusion 256 Bibliography 266 Glossary 285 Appendices 288 xi List of Figures Page Chapter II - Background to Two Fieldwork Settings Figure 1: The protective robe lay across the road to protect the entrance to the 50 Bafut Palace Figure 2: Two pillars where a ram is slaughtered and buried as sacrifice to Bafut 52 ancestors Figure 3: The Bukum (Ngang - Ngangs) going to a waterfall to perform rituals 53 Figure 4: Fon of Bafut presiding over the traditional annual dance [Abin-a-Nfor] 54 Figure 5: Achum [the lodge of ancestors of Bafut] 55 Chapter III - Methodology Figure 6: Muntoh [Prince] 68 Figure 7: Progress in fieldwork 69 Figure 8: Children of the Presbyterian Church Manji dance towards my home to 87 present a trophy to me Chapter VI - Clinic perspectives on treating diabetic patients Figure 9: A nurse consulting a diabetes patient at Biyem-Assi 146 Figure 10: Health talk session at a Diabetes Clinic in Biyem-Assi 146 Figure 11: Nurse in a clinic at Bafut waiting for patients 147 Figure 12: Medical doctor consulting a diabetes patient in his office at Bafut, 147 while I look on Chapter VII - 'If they were not there, we would have died'. Patient andfamily perspectives ofdiabetes Figure 13: Dancing at Nsani during a death celebration in Bafut 196 Figure 14: Women in Yaounde displaying during a death celebration 196 Figure 15: Matthew and Florence in Bafut 196 Figure 16: Ambition shares a litre of palm wine with me 196 xii Chapter VIII - The perspective oftraditional healers Figure 17: Dr Tumasang (Bafut) performing