Gamett, Kevin Economic Influence on Pediatric Health Care in a Medically Pluralistic Society: An Ethnographic Study among the Asante people of Ghana Faculty Mentors: Randy Val Johnson, William Carl Olsen There are many factors that influence decisions regarding medical care, including financial, situational, and ideological issues. Families may choose to avoid modern health care facilities because of the costs associated with hospital stays, treatment regimes, transportation, and lost time. Long waiting times, disrespectful treatment from doctors and nurses, and family obligations are also qualitative issues that contribute to the eschewing of modern medicine. Other families choose to go to hospitals and health clinics because they believe that medicines are the ultimate source of healing, following the western paradigms set by principles of physiology, anatomy, chemistry, and internal medicine. In questions of pediatric health care decisions, this modern paradigm is commonly accepted. The common pediatric illnesses were malaria, anemia, pneumonia, gastrointestinal infection, typhoid fever, and worms. Most children are immunized by the district health programs, but some children were brought in from outlying settlements with tetanus, pertussis, and hepatitis. Typhoid fever was the most severe, requiring the strongest antibiotic (rifampin), a longer hospital stay, and occasional surgery from internal complications. Malaria and anemia were ubiquitous; every child that came in received some form of quinine to treat malaria and folic acid/vitamin supplements for anemia. Blood transfusions were common; the AIDS issue was rarely brought up in the children’s ward because most children with AIDS die early. The hospitals were, overall, quite clean and well-kept, despite the financial difficulties enshrouding the administration of the Mampong District Hospital. In an interview with Dr. Amanfo, the chief hospital administrator, he revealed the deeper concerns at their hospital, including non-collections, logistics, water storage shortages, transportation costs to Kumasi for serious illnesses, and lack of qualified doctors. The doctor shortage is the most startling and severe problem with most doctors remaining abroad where they will earn twenty times their Ghanaian salaries. The government cannot afford to pay the doctors more, and the doctors usually do not open up private practices because of culture and poverty levels of patients. Each doctor in Ghana is paired up against 30,000 patients, an impossible task; this shortage may account for, at least partially, the prevalence of alternative medicine. The feasibility of a government health insurance has been researched in the Asanti area, and many hope to implement it after the next national elections. The average annual income of an Asanti in the Sekyere West District is 3 million cedis, an equivalent of $300. The average Ghanaian family spends 60,000 cedis on health care annually; most of that money is spent on hospital visits for their children. At the Mampong District Hospital, fees for outpatient care were within the reach of average parents, equaling the amount of a daily salary. However, if the child is admitted, the daily fees for bedding, laundry, consumables (syringes, gauze, catheters, etc.), food, and drug regimes often surpass the family’s ability to pay. The Ministry of Health covers the costs of tuberculosis, buruli ulcer, and HIV. Other chronic illnesses or surgeries are not covered; the prices escalate rapidly into a significant portion of the parents’ annual salary. A patient with hepatitis was released from the hospital against the orders of Dr. Limonta, the pediatrician, because the family was unwilling to continue to pay for a child who had only a 50-50 chance of living. I also saw a boy whose parents had the ability to pay ask for a release against the doctor’s orders because of their preference for traditional medicine. Many members of the Asanti tribe frequent spiritual healers. These okomfo are purported to possess special powers to see to the true causes of the afflictions. Their expertise is not limited to physical illnesses, but also includes misfortunes and spiritual interactions. In effect, a doctor can tell you what is happening inside of your body; a traditional healer will tell you why you are afflicted. Observations with the traditional healers were varied and instructional. Gyasi, the healer of Penteng, which is a small village located to the north of Mampong, told of his instruction in the art of herbal medicine. He said that when he was in his final year of attending a school of accounting in a larger city, he felt that the abosom (minor gods) were calling upon him. Mmoetia, mystical three-foot creatures with feet attached in an opposite orientation, took him into the forest near his home in Penteng and showed him how to make herbal concoctions out of the plants, barks, and fruits. Gyasi claims that children are only rarely affected by witched and other evil-intending persons, but they can be cursed with sickness for parental faults, including jealousy and violations of taboos. Another traditional healer in Krobo introduced a 10-year old girl as a witch; her parents had brought her to him because of his reputation for being one of the best healers in the vicinity able to combat witchcraft. The diagnosis of witchcraft follows a different stream of logic, tying all of the family events and interactions into causal relationships. After consulting with the abosom to find the correct diagnosis, treatment is assigned that directly corresponds to the ailment. Not all sickness is ‘sunsum yare’, i.e. spiritual illness; many illnesses, especially those encountered in childhood, are natural diseases. For these ailments, traditional healers may prescribe herbal remedies or a visit to the nearby hospital. It is important to remember that although their views include both spiritual and physical causality for diseases, their understanding of the world around them is valid and their decisions logically follow this holistic paradigm. With this cultural understanding and remembering the financial situation these parents face, it is easier to understand why they may choose to combat their child’s illness with traditional medicine, Western medicine, or a combination of both.
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