Fragile Futures: Ambiguities of Care in Burkina Faso

Fragile Futures

Series: Epistemologies of Healing

General Editors: David Parkin and Elisabeth Hsu: both are at ISCA, Oxford

This series publishes monographs and edited volumes on indigenous (so-called traditional) medical knowledge and practice, alternative and complementary medicine, and ethnobiological studies that relate to health and illness. The emphasis of the series is on the way indigneous epistemologies inform healing, against a background of comparison with other practices, and in recognition of the fluidity between them.

Recent volumes:

Volume 22

Fragile Futures: Ambiguities of Care in Burkina Faso

Helle Samuelsen

Volume 21

Breathing Hearts: Sufism, Healing, and Anti-Muslim Racism in Germany

Nasima Selim

Volume 20

Chinese Medicine in East Africa: An Intimacy with Strangers

Elisabeth Hsu

Volume 19

Configuring Contagion: In Biosocial Epidemics

Edited by Lotte Meinert and Jens Seeberg

Volume 18

Fierce Medicines, Fragile Socialities: Grounding Global HIV Treatment in Tanzania

Dominik Mattes

Volume 17

Capturing Quicksilver: The Position, Power, and Plasticity of Chinese Medicine in Singapore

Arielle A. Smith

Volume 16

Ritual Retellings: Luangan Performances for Healing as Emergent in Practice

Isabell Herrmans

Volume 15

Healing Roots: Anthropology in Life and Medicine

Julie Laplante

Volume 14

Asymmetrical Conversations: Contestations, Circumventions, and the Blurring of Therapeutic Boundaries

Edited by Harish Naraindas, Johannes Quack and William S. Sax

Volume 13

The Body in Balance: Humoral Medicines in Practice

Edited by Peregrine Horden and Elisabeth Hsu

For a full volume listing, please see the series page on our website: https://www.berghahnbooks.com/series/epistemologies-of-healing

Fragile Futures

Ambiguities of Care in Burkina Faso

Helle Samuelsen

First published in 2024 by

Berghahn Books

www.berghahnbooks.com

© 2024 Helle Samuelsen

All rights reserved. Except for the quotation of short passages for the purposes of criticism and review, no part of this book may be reproduced in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system now known or to be invented, without written permission of the publisher.

Library of Congress Cataloging-in-Publication Data

A C.I.P. cataloging record is available from the Library of Congress

Library of Congress Cataloging in Publication Control Number: 2023053382

British Library Cataloguing in Publication Data

A catalogue record for this book is available from the British Library

ISBN 978-1-80539-197-5 hardback

ISBN 978-1-80539-259-0 epub

ISBN 978-1-80539-213-2 web pdf

https://doi.org/10.3167/9781805391975

Contents

List of Illustrations

Acknowledgments

Abbreviations

Introduction

Part I. Family, Care, and Everyday Life

1. A Family Narrative

2. Ambiguities of Child Care

3. Migration as Care Work

Part II. Technologies of Care

4. Technologies and Cosmologies

5. Treatment Seeking and the Work of Hope

Part III. Care of the Public

6. The Availability Logic

7. Moments of State Presence

Conclusion

References

Index

Illustrations

Figures

0.1. Polling Station in a rural area, Burkina Faso (© Helle Samuelsen 2023).

0.2. Municipal office in a rural area, Burkina Faso (© Helle Samuelsen 2023).

1.1. Rural household, Burkina Faso (© Helle Samuelsen 2023).

1.2. Harvest of red sorghum, Burkina Faso (© Helle Samuelsen 2023).

2.1. Mother and baby in front of a dispensary, Burkina Faso (© Helle Samuelsen 2023).

2.2. Kitchen in a rural household, Burkina Faso (© Helle Samuelsen 2023).

3.1. Loaded van, Burkina Faso (© Helle Samuelsen 2023)

3.2. Female tailor, rural Burkina Faso (© Helle Samuelsen 2023).

4.1. Marabout in front of his house, Burkina Faso (© Helle Samuelsen 2023).

4.2. Rural dispensary, Burkina Faso (© Helle Samuelsen 2023).

5.1. Medicines on display at the market, Burkina Faso (© Helle Samuelsen 2023).

5.2. Examination room at a rural dispensary, Burkina Faso (© Helle Samuelsen 2023).

6.1. Admission room, rural dispensary, Burkina Faso (© Helle Samuelsen 2023).

6.2. Malaria medicine, Burkina Faso (© Helle Samuelsen 2023).

7.1. Empty market during lockdown, Burkina Faso (© Landry Bambara 2023).

7.2. Daily COVID-19 announcement, Ministry of Health, Burkina Faso.

8.1. Abre de palabre (discussion tree), rural Burkina Faso (© Helle Samuelsen 2023).

Table

6.1. Diagnoses of patients at CSPS Tenga and CSPS Keru (prepared by Helle Samuelsen based on monthly reports from dispensaries).

Acknowledgments

This book has been a long journey, and many people have contributed to its completion. First, I want to thank the citizens of Keru, Bangri, and Tenga for their hospitality, support, guidance, and engagement during my fieldwork and my many visits over more than two decades. I am thankful for the many hours they devoted to helping me understand the complexity of their everyday lives and health care practices. My warmest thanks go to Thomas, Beatrice, and their seven children, who welcomed me to their house and shared their experiences and knowledge. It has been such a rich personal experience for me and my family to follow the Bancé family, seeing the children grow up, exchanging family news, and keeping in contact, even though my visits to Burkina Faso have been restricted over the last several years because of the escalating security problems in the country. I owe my deepest gratitude to this fantastic family, including the late Jean, who guided me through the herbal landscape and introduced me to the many vernacular healers living in the area. Special thanks to the Samadin, members of the royal court of the Mossi king of the area, the delegués of the villages, and in particular the chief of Keru for giving me permission to conduct my studies in their region. I also want to thank the regional and district directors of health for taking time to talk with me and for providing me with local health data.

Furthermore, I want to thank my research assistants, Fatmata, Emmanuel, and Landry, who at different periods helped me in the field and translated between French, Bissa, and Mooré. Their dedication and commitment to the research process and fieldwork were extremely important.

I wish to thank my many research colleagues in Burkina Faso, among them Dr. Lea Paré Toé at the Institut de Recherche en Sciences de Santé (IRSS) and Professor Gabin Korbeogo, director of Groupe de Recherche sur les Initiatives Locales (GRIL) and now director of research and head of the graduate school at the Faculty of Social Sciences at Université Joseph Ki-Zerbo in Ouagadougou. It has been a huge inspiration to jointly develop new project ideas and share project responsibilities with both. Thanks also to Professor Maxime Drabo, Research Director at IRSS and former director of Centre National de Recherche Scientifique (CNRS) in Burkina Faso, who generously shared his medical knowledge with us for the Emerging Epidemics project. I thank Dr. David Ilboudo, Dr. Yacouba Cissao, and Dr. Issa Sombié for their enthusiasm and hard work as PhD fellows in the Fragile Futures: Rural Life in Times of Conflict project. My gratitude also goes to Dr. Hamidou Sanou, Dr. Cheick Omar Diallo, and Huguette Tyenou, PhD fellow, for their flexible adjustments to fieldwork conditions during the COVID-19 pandemic and for their contributions to the Emerging Epidemics: Improving Preparedness in Burkina Faso project. I have benefited tremendously from their insights and knowledge about the functioning of the public health care system. The Danish embassy in Ouagadougou has always welcomed my visits, and the various ambassadors have shown a genuine interest in our research findings. Special thanks to Birgitte Markussen and Ulla NæsbyTawiah, both of whom served as Danish ambassadors to Burkina Faso.

I thank Professor Jean-Bernard Ouedraogo, Laboratoire d’Anthropologie des Institutions et des Organisations Sociales (LAIOS), IIAC, CNRS-EHESS for his invitation to be affiliated as a guest researcher in Paris for two periods in 2017 and 2022, as well as for his interest in discussing research findings and brainstorming new ideas. Thanks also to the Fondation Danoise, and particularly Marianne Bak Papiau, for accommodating me during research stays in Paris and to the board of Ludvig Preetzmann-Aggerholm og Hustrus Stiftelse for granting me a one-month writing retreat in Rue de la Perle.

Over the years, I have learned a lot from conversations with a number of other Scandinavian colleagues and experts on West Africa, including Sten Hagberg, Jesper Bjarnesen, Jonina Einarsdottir, Stine Loft Rasmussen, and Heidi Bojsen.

My first research project in Burkina Faso was funded by the Danish Bilharziasis Laboratory. I also received financial support from the Council for Development Research under Danida as well as the Carlsberg Foundation, which also included two terms as by-fellow at Churchill College, University of Cambridge, UK. Two large collaborative projects—Fragile Futures: Rural Lives in Times of Conflict and Emerging Epidemics: Improving Preparedness in Burkina Faso—were both supported by grants from the Ministry of Foreign Affairs of Denmark. I want to thank the various members of the research councils and the Danish Fellowship Centre for their support and trust in our research ideas.

I am grateful to colleagues in the Health and Life Condition research group in the Department of Anthropology, University of Copenhagen, for creating a constructive and supportive academic environment. Special thanks to Professor Susan Reynolds Whyte, who knows what it means to care for students and colleagues and who continues to inspire. Thanks also to Hanne Overgaard Mogensen, Ayo Wahlberg, and Tine Gammeltoft for providing constructive feedback on my writing. To Lise Rosendal Østergaard and Pia Juul Bjertrup, my deepest thanks for their enthusiastic engagements and hard work as PhD fellows on the Fragile Futures and Emerging Epidemic projects, respectively. I have enjoyed their collaboration, friendship, and companionship in the field.

I would like to thank Britt Pinkowski Tersbøl at the Section of Global Health, University of Copenhagen, for her collegiality and friendship and for her continuous invitations to participate in projects and activities at the Global Health section. My deepest gratitude to Ib Bygbjerg, an academic and personal lighthouse, whose originality and intellectual capacity is outstanding. Thanks to Karin Schiøler and Dan Meyrowitsch for their constructive contributions as PhD supervisors in the Emerging Epidemic project.

I owe many thanks to Elisabeth Hsu and David Parkin, editors of the book series Epistemologies of Healing and to the two reviewers for their encouraging and constructive comments and suggestions, as well as to Tom Bonnington and Anthony Mason at Berghahn and to Jeremy Rehwaldt who helped with the English editing.

Last but not least, I would like to thank my family, particularly Bjarne, Anna, and Frederik, for their companionship, support, patience, and care and for continually reminding me what really matters and why.

Abbreviations

ACT: Artemisinin-based combination therapy

AIDS: Acquired Immune Deficiency Syndrome

AIS: Agent Iténerant de Santé/local health care worker

AQIM: Al Qaeda in Magreb

BAC: Baccalaureate

BCG: Bacille Calmette-Guerin vaccine

BEPC: Brevet d’études du premier cycle

CEP: Certificat d’étude primaire

CDP: Congrès pour la Démocratie et le Progrès

CDR: Comités de Défense de la Révolution/Committees for the Defense of the Revolution

CENI: Comission Électorale Nationale Indépendante

CFA: The West African CFA Franc

CNIB: Carte Nationale d’Identité Burkinabe

COVID-19: Coronavirus disease 2019

CSPS: Centre de Santé et de Promotion Sociale/dispensary

DANIDA: Denmark’s development cooperation

DHS: Demographic Health Survey

DPT: Diphtheria, tetanus and pertussis vaccine

EPI: Expanded Program of Immunization

GAVI: The Vaccine Alliance

GDP: Gross Domestic Product

HIV: Human Immunodeficiency Virus

ICD: International Statistical Classification of Diseases and Related Health Problems or International Classification of Diseases

ICP: Infirmier-chef de poste/ head nurse at dispensary

INSD: Institut National de la Statistique et de la Démographie

IOM: International Organization for Migration

IPT: Intermittent preventive treatment

IRSS: Institut de Recherche en Sciences de la Santé

ISGS: Islamic State of the Greater Sahara

ITN: Insecticide-treated mosquito nets

IRS: Indoor residual spraying

MPP: Mouvement du Peuple pour le Progrès

NGO: Non-governmental organization

OCP: Onchocerciasis Control Program

OECD: Organization for Economic Co-operation and Development

OPT: Opportunistic presumptive treatment

PCR: Polymerase chain reaction

RDT: Rapid diagnostic test

REN-LAC: Le Réseau national de Lutte anti-corruption/The national anti-corruption network

UNICEF: United Nations Children’s Fund

UNDP: United Nations Development Program

USAID: United States International Development

WHO: World Health Organization

Introduction

A Sudden Death

Every time I visit the village of Keru in southeastern Burkina Faso, I pass by Thomas’s compound to say hello and hear the latest news from Thomas, Beatrice, and their seven children.¹ I first met them in 1996 when they all lived together in a compound just next to the marketplace. At that time, Thomas and Beatrice had five children, of whom Michel and Caroline were the youngest. Later, Beatrice gave birth to two more girls, Janine and Claudine. While I was doing fieldwork in November 2016, Caroline told me about her baby’s sudden death. The sad story demonstrates how important, complex, and fragile social relationships and family bonds are in rural Burkina Faso, and it elucidates how present the spiritual world is in local care practices and in interpretations of tragedy.

After spending the morning at the district hospital interviewing the chief medical officer, my research assistant Landry and I drove to the village in the afternoon, hoping to arrange a couple of interviews for the following day. Landry was a young university student who grew up in a Bissa village not far from Keru and who spoke both Bissa and Mooré, the two main local languages spoken in this district. He was a very diligent fieldworker with a lot of empathy. We stopped as usual at Thomas and Beatrice’s compound. Thomas was not at home, but his eldest son, Pascal, welcomed us into the inner courtyard to sit on the household’s only two chairs. The chairs were placed in the middle of the courtyard under a small tree that provided a bit of shade against the strong sun. The customers of Beatrice’s cabaret (millet beer bar), which she ran every third day year-round, found shade for themselves on a few wooden benches under a thatched shelter. The cabaret was located close to the entrance of the compound, near the fireplace where the dolo (home-brewed millet beer) was produced. On days when the cabaret was closed, we sometimes sat and talked there, but usually we were invited to the inner courtyard, which provided a little more privacy, although the two areas were divided only by a low mud wall.

As customs prescribe, we were first served a calabash of fresh water. It was a busy time of the year as the last harvest was being secured. Often, people with land work collectively in the fields all day, helping each other finish the harvest. This day, many women were working in their fields together, and other women were busy in their small vegetable gardens located outside of the village, where a nearby well provided water. Many women grew tomatoes to sell on market days when buyers from Togo or the nearby provincial town passed by. After drinking a calabash of fresh water, we were, as usual, offered a calabash of dolo, and Caroline sat down to talk to us. It is not unusual for married daughters to occasionally stay for a few days at their paternal compound to assist with specific tasks or participate in religious or family ceremonies. However, Thomas had told me a few days earlier that Caroline had lost her small child, who died suddenly one Sunday morning. According to Thomas, the child had not been ill prior to his death, he just died.

Caroline was a twenty-four-year-old woman who had completed six years of education at the local school. At the age of about nineteen, she married a much older man who lived in a nearby village with his elderly mother. After the marriage, Caroline moved to live with her husband and her mother-in-law, following the patrilocal traditions in Burkina Faso. She gave birth to a girl in 2012, and three years later she gave birth to her second child, a boy, delivering him alone at home with only a little help from her mother-in-law, despite living close to a rural dispensary.

While seated in the shade under the small tree, I asked Caroline if she would tell me about the tragedy. Although ten months had passed since the death of her child, I was a bit worried and uncomfortable asking her to talk about it, but to my relief she promptly agreed. I remember Caroline, or Caro² as she was called by her family, from her early childhood during my initial fieldwork in Keru in 1996. At that time, she was a lively, self-confident girl with lots of energy. I often saw her playing with her younger brother Michel. As she entered adolescence, she became a shy and hard-working young woman, doing farm work and assisting with Beatrice’s millet beer production. During her adult years, I had not talked much with her; she always kept to herself, staying inside, I surmised, because she had suffered a serious corneal infection and strong sunlight caused her pain. However, on this occasion, it was as if she really wanted to tell her story. I sensed a great sadness but also a kind of vacillation. It was clear that she felt locked into a situation: she could not continue living with her husband, yet moving back with her parents did not seem to be a viable solution either. She wanted me to understand her situation, and perhaps she hoped that I would be able to help her. She sat on a small stool just in front of us. To my surprise she started to disclose her story in French—I had never before heard her speak much in French. But this time, she spoke French during most of the heartbreaking interview, only switching to Mooré in the last part of the conversation. Her statements, which revealed how complex family relations can be, were very clear:

Helle: Last year you gave birth at home and the baby was fine. How did your boy die?

Caro: He just died like that. He was not ill before he died. He just died.

Helle: He just died? He had not been ill before he died?

Caro: No, he was not ill before he died. It was a Sunday, he died. I woke up Sunday morning and went to church with him.

Helle: Did you go to church in this village or in the village where you live?

Caro: Yes, at that village, at Bangri. At the prayers there, I breastfed him. He was not dead then. It was after the prayers. I placed the child on my back, and we went home. It was when coming home that I saw that the child had died. He had simply died, just like that.

According to Caro, the cause of the child’s death was related to a conflict with her husband and mother-in-law, an active woman, probably in her mid-eighties, whom I had met a couple of times. Caro explained:

Caro: The problem is that my husband is Muslim, and I am Christian. He has told me that if I take the child to the church, the child will die. His mother, my mother-in-law, has also forbidden me to go to church with the child, saying that in that case, he will die. My husband says that it is his child, and that the child is therefore Muslim, and that it is not my child. I have replied that it is also my child. I have said to my husband that the child belongs to both of us. The mother of my husband has talked with things. I don’t know how to explain this. My mother-in-law has performed some sacrifices to the ancestors in order for the child to die. She has told me that if I go to church with the child, he will die. She has sacrificed the child to the ancestors of her natal village. My mother-in-law has told me that she does not agree with me to convert the child to Christianity, as she is herself Muslim. But my mother-in-law is herself Christian, as she has done the catechist, and she is baptized. That day, both of us went to church. When my mother-in-law went [to her village] to do the sacrifice, she told me that my child would die on my back.

Caro was clearly worried about the conflict with her husband and her in-laws, and she was afraid that the mother-in-law would also bewitch her four-year-old daughter. I will unfold the story of the sudden death of Caro’s son in more detail in chapter 2, as it illustrates the importance of the spiritual world in interpretations of a child’s sudden death in this part of Burkina Faso and highlights that caring for a small child and caring for family relations are sometimes at odds.

Aim of the Book

The aim of this book is to illustrate how rural citizens of Burkina Faso encounter and live with a fragile state and an elusive public health care system. At a time when medical anthropologists focus, to a large extent, on biomedicine, with clinics or hospitals serving as the main field sites (Hannig 2017; Livingston 2012; McKay 2017; Scherz 2018; Street 2014; Strong 2020; Wendland 2010), this book follows Dorothy Hodgson’s recommendation to engage in research with long-marginalized rural peoples. Hodgson argues that perspectives and experiences ‘from the margins’ offer key theoretical and political insights into this complicated place we call ‘Africa’ by challenging grand narratives of modernization, of ‘Africa rising,’ of supposedly ‘universal’ ideas of progress and justice (Hodgson 2017: 38). The chronically precarious political and social situations of countries like Burkina Faso raise a number of questions: How do rural citizens perceive and relate to an absent-present state? How do they balance the insecurities and uncertainties of everyday life with the search for new opportunities to improve their lives as well as the lives of their relatives? How do rural citizens exercise hope and agency in the quest for health care? How do they relate to and imagine the state? Fragile Futures is based on more than twenty years of engagement with Burkina Faso and, in particular, on my engagement with the Bancé family. Their story discloses the hardships, ambiguities, hopes, and ambitions of populations in low-income rural societies. Each of the chapters includes narratives from members of the family.

Ambiguities of Care

Throughout this book, I use the term ambiguities of care to frame understandings of care, illness, and treatment seeking. Ambiguity refers to the quality of being open to more than one interpretation (Oxford English Dictionary 2008), and it is this openness that I find particularly interesting. Sickness itself is an ambiguous state, and one central task of caring is the management of this ambiguity (Holden and Littlewood 2015: 170). Families experience ambiguities of care when a child falls sick and decisions have to be made about how best to intervene. Each new step of the therapeutic pathway is impelled by uncertainty, but also incites hope for healing and restoration of everyday life. The decision about whom to consult in case of sickness is ambiguous. It is, I argue, not so much a choice between different epistemologies, but a pragmatic choice of time and cost and a choice about how best to confirm and nurture good relations with human as well as non-human beings. The symptomatology of a disease such as malaria is itself ambiguous, and getting a negative result from a rapid diagnostic test for malaria at the rural dispensary and then receiving a prescription for malaria medicine from the same nurse is also an ambiguous experience. As I elaborate later, this seemingly illogical praxis relates to the fact that Burkina Faso has a strong focus on the fight against malaria, and the diagnostic repertoire of the nurses at the dispensaries is limited.

Taking ambiguities of care as an analytical framework for exploring different forms of care relationships, I wish to illustrate, in line with China Scherz’s study from Kampala (Scherz 2018), that if we want to understand the diversity of human practice and experience within the domain of health, we need a renewed focus on treatment seeking in medical anthropology that includes both vernacular healing by local experts and self-treatment at home. In this book, I argue that families, and in particular mothers of small children, spend an enormous amount of time on care work. Taking care of family members is both about managing actual cases of sickness in the most appropriate (and economically sound) ways and about maintaining and nurturing various social relationships to humans and non-human beings. My core contention is that citizens of Keru actively and intelligently address the ambiguities of sickness and care and explore potentials and openings in their determination to maintain and secure a decent future for themselves and their families.

Fragility refers to being easily broken or damaged, being delicate and vulnerable. At the social level, fragility is related to other concepts such as uncertainty, insecurity, contingency, and vulnerability. While these concepts are interrelated, it might be useful to distinguish between them in order to see how they relate to and complement each other. In her epilogue to Dealing with Uncertainty in Contemporary African Lives, edited by Liv Haram and Bawa Yamba (Haram and Yamba 2009), Susan Reynolds Whyte defines uncertainty, insecurity, and contingency, and she briefly discusses how these concepts feed into and are often entangled with each other (Whyte 2009: 213–15). Uncertainty, she says, may be thought of as a state of mind and minding. It pertains to our situated concerns and refers to a lack of absolute knowledge: inability to predict the outcome of events or to establish facts about phenomena and connections with assurance (Whyte 2009: 213). Uncertainty is a way of thinking about the future, and it creates worries and fears. In Whyte’s definition, insecurity denotes a social condition where there is a lack of protection from dangers, weakness in the social arrangements that provide some kind of safety net when adversity strikes (Whyte 2009: 214). Having little room to maneuver may generate uncertainty. Contingency is related to the two abovementioned concepts but refers more specifically to an existential situation. To be contingent "is to be dependent on, or affected by, something else that cannot be fully foreseen or controlled" (Whyte 2009: 214). Contingency is about the unexpected, the events that may arise suddenly and affect one’s plans for the future. All three concepts relate to the present and the future: uncertainty refers to a state of mind, insecurity to a social situation, and contingency to an existential situation. However, they all take their point of departure from an existing situation entailing negative consequences for the future.

According to Whyte, dealing with uncertainty is not so much about trying to make things certain as about trying to create more security. While insecurity and contingency are very closely related, contingency emphasizes dependency and interrelatedness. Vulnerability, which is also about dependency, is closely related to contingency but denotes a social situation. The concept of vulnerability is used by social welfare institutions and aid agencies to categorize people—such as orphans or malnourished children—with extra needs or entitlements due to their exposure to particular risks (Whyte 2009: 215). My use of fragility as a concept relates closely to the notion of contingency, as it also accentuates interdependence.