Ghana

In 1973 I did fieldwork in Ghana about sexual relationships and birth control. One of the most worrisome findings was that young unmarried students lacked access to reliable contraceptives. In their attempt to prevent a pregnancy that would threaten to place their entire future in jeopardy, some resorted to dangerous abortion methods that could damage their health, make them infertile for the rest of their lives, or even kill them. Others used harmless and ineffective methods and had their babies too early. Most of these girls never returned to school and indeed saw their futures collapse before them.

The irony of the situation was that the official planning organizations did supply reliable contraceptives to married couples who were largely uninterested in using contraception. It was primarily the young and unmarried who were interested, but were denied access on the basis of formal traditional and Christian rules of morality. My attempt to bring these disconcerting findings to the attention of those who had the power to change the situation was limited to writing a series of six articles about the situation for the popular Ghanaian weekly The Sunday Mirror. It produced only one reaction, from the director of the National Family Planning Programme (NFPP), indicating – rather implicitly – that his organization did allow unmarried youngsters access to its services. His statement did not alter the fact that young people continued to avoid the NFPP because they felt they could not go there. Three decades later, little had changed; youngsters still relied almost exclusively on the informal trade in contraceptives and abortifacients.

Cameroon

In 1980 I carried out research in Cameroon on the use and distribution of modern pharmaceuticals in hospitals, health centres, pharmacies, and informal drugstores and market booths. It proved to be another delicate – and policy-relevant – topic. The outcome of the research showed that public health care institutions suffered from serious shortages of medicines. Health care in the public domain was officially free, but because of the lack of drugs, ‘free care’ had become an absurdity. People stopped visiting health institutions that had run out of medicines, or were forced to go and buy medicines outside the hospital, which resulted in them paying even more than those who sought health care in private institutions. For the people, medicines were the main reason for visiting a doctor or public health nurse. A doctor without medicines was useless, a contradiction in terms. Two main causes of the shortage of medicines were: (1) the bureaucratic sluggishness and corruption of those responsible for ordering and supplying the medicines; and (2) theft and misappropriation of the medicines that had been delivered.

One of the Cameroon authorities’ main concerns was about the potential for political resistance among the urban population, particularly among those in the army and police force. It is no coincidence, then, that the quality of health care for these groups was conspicuously higher than for the rural population. The fact that 50% of the health budget went to the central administration and the two central hospitals in Yaoundé and Douala, and that only 7% was spent on rural health care, speaks for itself. shortage or lack of medicines was particularly disastrous in rural areas. The further the distance of a hospital or health centre from the city (from where the medicines were distributed), the longer the line of delivery and, therefore, the fewer medicines arrived at their destination. The most remote health centre I visited received just over half of the medicines it should have received. A centre in a rural town of about 5000 inhabitants received 87%, the hospital in the divisional capital an estimated 90 to 100%, and the central hospitals of Yaoundé and Douala even more than 100%.

I added practical suggestions to my conclusions and managed to send a 200-page (too thick?) report in French to about one hundred institutions, organizations (including the Ministry of Health), and individuals within a few months of the end of my research. One of the suggestions was that it would be better to make people pay a reasonable price for medicines and actually supply them than to pretend to give them free medication while in fact giving them nothing.

My recommendations did not fall on fertile ground, to put it mildly. The Ministry of Health took offence to my harsh criticism and said they would never turn the hands of the clock back, meaning: they would not give up the right of the public to access free medicine. I realized – too late – that my approach had not been tactful and had antagonized the authorities. The title of my report, for example, was already irritating before they even started reading it: La pathologie de services medicaux [the pathology of medical services]. My personal love of provocation and literary style, such as paradoxes, worked counterproductively and failed to entice the policy-makers.

They took revenge. When I asked their permission two years later to conduct a short follow-up research, they responded that there was no need for it and refused to let me in. This happened in 1983, in the pre-digital era. The letter with this message arrived three days before my planned departure. My flight had been booked. I decided to travel anyway and lied to the ‘surprised’ officials upon my arrival that I had not received the letter. After long ‘discussions’ they grudgingly handed me an autorisation for three months, if I remember correctly. I did not attempt to send them follow-up policy recommendations.

Reflection

Looking back on my anthropological career, I must confess that I have been almost entirely incapable of carrying out research that inspired policy-makers, in spite of the fact that I always intended to render my research useful. I was attracted by hot and pressing issues that excluded certain categories of citizens from the rights and benefits they were entitled to enjoy, at least in my view. Social and political exclusion by authoritarian regimes logically drove me to the side of the oppressed. I saw my research as an investigative project, similar to investigative journalism. The anthropological method of lengthy periods of participant observation seemed an effective way to delve more deeply into the experience of discrimination and exclusion and analyse the ‘real’ causes of it. Teo Ballvé (2020: 238) argues that

… violent economic situations in specific spaces can be productively studied through a hybrid style of research that combines techniques of investigative journalism with the conceptual and methodological commitments of ethnographic inquiry. ‘Investigative ethnography’ … can help provide finer-grained accounts of violent economies.

Obviously, research among marginalized categories such as child soldiers, sex workers, ‘illegal’ immigrants, refugees, and psychiatric patients (Schlegel & Hewlett 2011, Anan 2009) cannot be carried out in cooperation with those who cause their marginalization. Similarly, investigating the practices of violent entrepreneurs, human traffickers, criminals, political elites, corrupt politicians, religious fanatics (etc.) can in most cases only be done by covering up the objectives of the research, as well as the intentions, even the identity, of the fieldworker (cf. Harrell-Bond 1976, Falcone 2010).

The conditions in which I worked in Ghana and Cameroon may have been less dramatic, but the presence of political and moral authorities who suppressed the freedom and well-being of those I was trying to help by making them aware of the root causes of their problems was undeniable. The Ghanaian NFPP director responded politely that his organization was open to helping school-going teenagers, but the facts showed the opposite to be true. In all of their posters and communications, the NFPP portrayed happy Ghanaian families with two or three children; ‘happy’ because they had planned their family. I never saw the NFPP reaching out to distressed and desperate schoolgirls who had risked their lives to hide and get rid of a pregnancy. These youngsters were not planning their families but trying to prevent the shame and lifelong losses that would be the outcome of their unwanted pregnancies. The irony of the moral condemnation that prevented the NFPP from directing its attention to those who were in real need of so-called ‘family planning’ was that the older generation had once gone through similar worries when they were young. Moreover, some of them were still involved in secret extramarital affairs and were likely providing their girlfriends with the necessary contraceptive means from the NFPP (cf. Glover 2014).

My research in Cameroon took place in a society that was more in the grip of injustice meted out by pharmaceutical companies and corrupt policy-makers. At the time of my research (the seventies and eighties of the previous century), a flood of publications appeared that described the infamous practices of pharmaceutical multinationals in the so-called developing world (e.g. Gish & Feller 1979, Melrose 1982, Silverman et al. 1982, Medawar 1984). The main criticism was that the pharmaceutical industry was conducting a purely commercial policy behind a facade of curing and relieving pain. Profit-making was facilitated by the weak position of consumers in the third world. The Cameroon Ministry of Health did not succeed in purchasing sufficient medicines because it spent too much of its budget on expensive, non-essential drugs. The WHO Essential Drugs Plan was largely ignored and cheap generic medicines were often not available in public health facilities. This irrational policy of drug purchasing was, among other things, due to the mainly French industry’s ability to manipulate the Ministry of Health’s policy, which served the interests of individual policy-makers and urban elites at the expense of the rural population.

The Ministry of Health’s displeasure with my research findings and recommendations was not surprising. I had behaved as a spy, a secret invader, looking for hidden machinations that accounted for the ‘pathology’ of the country’s health care system. My colleague Corlien Varkevisser taught me that applied anthropological research should from the beginning involve policy-makers, health workers, and anyone who has direct interests in its outcome (Varkevisser 2010). The beginning of much research can already predict that the outcome will not lead to any practical action, if none of the interested parties were involved in the decisions and preparations that led to the research. My own experiences confirm this. Any research that is designed for action should from the outset be conceived and planned with – or rather by – those directly affected by the outcome.

Likewise, the end of much research is an alienating experience for the parties involved. Even if they became ‘owners’ when the project started, they may still experience acute dis-ownership when the researcher returns to his academic environment and – sometimes many years later – reappears with a fully completed text in which they never had a say. Preceding assurances of shared ownership turn out to have been fake, mere strategies to serve the interests of the researcher. Thus also their willingness to accept and act upon the conclusions will melt as snow in the tropical sun.

Would it have been possible to create and maintain such a feeling of shared ownership in the Cameroon case? I suspect that I would not even have been able to get permission for the research if I had been completely open about my intentions. ‘Embedded’ research in this context would have been a self-defeating trajectory. My movements were watched. I often had to present my autorisation before a visit or an interview, and once I was picked up by two policemen who took me to the police office to interrogate me.

My freedom of movement in Ghana was very different. I never needed to apply for an official permission and I entered the town through the backdoor, as it were. To quote the Dutch poet Gerrit Achterberg, I had reached the houses from behind [Ik had] de huizen achterom bereikt]. But in both countries, I avoided the local authorities. I disliked meeting and interviewing the elite and stuck to the ‘ordinary’ inhabitants; unlike some of my colleagues, who presented themselves to chiefs and other notables with bottles of Dutch-made jenever. My approach may have spared me the worries about combining conflicting positions that plagued Barbara Harrell-Bond (1976) after her fieldwork, but it also prevented me from involving the elite in my explorations in their community.

But there is still something else. In 1971, a Dutch sociologist, Enno Hommes, wrote a brief comment on intercultural research cooperation, in which he suggested that a critical attitude in research may be more feasible for expatriates than for researchers from the country itself. In India, he wrote, most critical evaluation studies were written by foreigners, because their outsider position made it possible for them to be more independent (p. 63). This may have been true in the case of India, but I am convinced that my foreign identity in Cameroon made my critique extra irritating, if not insulting.

Lessons for at home

These and other experiences made me realize that research in my own country would have had better chances of being relevant and helpful for policy-makers. Journalists in the Netherlands are almost per definition investigative. They consider it their task to signalize abuse, mismanagement, corruption, malversation, injustice, and other wrongs and to publish their findings in the daily press. When the scandal is ‘big enough’, the television will take it up, followed by members of parliament. The responsible minister will have to listen to the journalists’ grievances and promise to take action. Academic dissertations that touch on distressing issues will be quoted and translated by journalists into clear, understandable language, which may also lead to public debates involving the responsible authorities. Without glorifying our democracy unduly, it is clear that the political system in my country makes it possible for citizens to speak up and criticize the government and lower political bodies without fear of punishment. Journalists play a crucial role in this process.

Good journalism, based on careful research and solid sources and written in an accessible style, could serve as an example for applied anthropology. The objective of brokering information and understanding between parties has more chance of being achieved by clear, short, and attractive reportage. Anthropologists would do well to learn these skills from journalists, or to work with them to spread the news about critical issues in society and how to improve social inclusion. This is possible here, at home.

Acknowledgement

Obviously, this essay draws on various earlier publications, in particular Whyte et al. 2002 and Van der Geest 2010.