By Eva Krah
In this article, I use classical anthropological and sociological theory on exchange to explain the robustness of the cultural economy of healing in Northern Ghana. While many scholars have argued that health care in Africa should be understood through the lens of neoliberal marketization, ethnographic research among Mamprusi healers shows that practices of traditional healing are firmly embedded in a cultural system of exchange. Although confronted with an expanding monetary economy, the healers adhere to the local credo that ‘money spoils the medicine’. This alludes to an approach to healing characterized by a kind of reciprocity that reflects (post-)Maussian principles of gift exchange. Drawing on these principles, I propose to complement our understanding of exchange with the concept of ‘moral monies’. As peculiar monetary (counter)gifts, these serve as instruments to reconcile contemporary monetary needs with the sociocultural, moral, and historical institutions in which traditional health care is rooted.
Anthropological analyses of public health issues in Africa, in particular the work of scholars writing in the tradition of critical medical anthropology, often concern the impact of global neoliberal reforms on public health systems in the region. A clear example is the much-debated structural adjustment programs (SAPs), which began to be implemented in the 1980s by the World Bank and International Monetary Fund in thirty-seven countries across Africa to promote the market fundamentalism that constitutes the core of neoliberalism (Pfeifer and Chapman 2010). Apart from the wider impacts of SAPs on national economies, they have stirred rapid privatization and economic deregulation of public health systems. Anthropologists have been critical of these developments, often pointing to growing social inequalities that threaten the health and well-being of the world’s unprivileged (Castro and Singer 2004; Kim et al. 2000). Although the significant socioeconomic impact of SAPs is undeniable, most scholars appear to leapfrog into commentating – often lamenting – their local effects without sufficiently scrutinizing the process of transformation itself. For instance, van Dijk and Dekker (2010, 1) state that both biomedicine as well as ‘traditional’ healing in Africa have become ‘subject to monetization and commodification, in short, the “market”’.
But the idea that century-old systems of health care in Africa have simply fallen ‘victim’ to ‘the market’ doesn’t do justice to the complexity of local-global encounters in which, for instance, agentive powers are manifest. Rather than to draw public health transformations into a structure/agency discussion or a social inequality debate, I argue there is the need to re-emphasize and theorize ‘culture’ in the context of socioeconomic transformations. One way of doing this is through rethinking classical anthropological (and sociological) theories on exchange as they shed light on the sociocultural and moral dimensions of change. More specifically, by employing classical theory on the gift, and based on insights deriving from ethnographic fieldwork among the Mamprusi healers of Ghana’s West Mamprusi district, I aim in this article to explain the functioning of the apparently maladaptive sociocultural system of exchange that is characteristic of traditional healing in Northern Ghana. I argue that in particular the concept of the gift sheds light on the robustness of culture in the context of an expanding global neoliberal market.
It is estimated that 80 percent of all Ghanaians rely on traditional medicine for primary health care (UNDP 2007, 42). This can partially be explained by simply comparing the number of available physicians with the number of available traditional healers. In the country’s northern rural regions, the physician-to-population ratio is said to be 1:100,000 while the healer-patient ratio is estimated to be 1:200 (Hill et al. 2014; Tabi and Frimpong 2003). These statistics show the importance of traditional healers in serving the primary health needs of the majority of the population. Traditionally, healers have not charged patients for their services and they usually worked as farmers next to their (voluntary) healing activities. Contemporary population growth, however, and the consequential growing number of patients are putting a burden on the healer’s food security, because after treating forty fractures a day, as some popular healers do, there might be no time left to farm. At the same time, healers, like everyone else, are confronted with a growing need for cash in the context of the rapid monetization of everyday life. And the healers face an additional problem: whereas money typically increases everyone’s status, their professional authority is intrinsically bound to the absence of money. The ‘adoption’ of money in their branch is highly problematic because of a persistent local moral sentiment that ‘money spoils the medicine’, which implies that if the healers charged for their services, their medicines would become powerless. It is this friction – of healers struggling to live by an apparently essential moral code while confronted with ubiquitous sociocultural change – that forms the inspirational basis of this article. To allow for a thorough understanding, I explore how the belief that money corrupts curing relates to an economy of healing characterized by gift giving and reciprocity.
Notions of gift exchange and reciprocity have been central to anthropology since its very beginnings (for example, in early studies of the potlach and kula). The single most important contribution to the debate comes from the French sociologist Mauss in his Essai sur le don ( 2011).The central argument in this influential essay is that reciprocal (gift) exchange is constitutive of social relationships. In fact, Mauss argues gift exchange is the very foundation of human society. By comparing data collected by fieldworkers studying different ‘archaic’ societies, he argues that exchange systems around the world center on the obligation to give, to receive, and – most importantly – to reciprocate.
Mauss was particularly fascinated by the question of which ‘spiritual mechanism’ obliges us to make a return gift for a gift received. Mauss argued that even when abandoned by the giver, the gift still is a part of him, retaining a magical hold over the recipient. This key characteristic of the (Maussian) gift is clearly manifest in the ethnographic explorations of the present study.
More specifically, it is of essential importance that healers giving patients the ‘gift of health’ – treatment with traditional medicine – retain a ‘magical hold’ over the patient, as this is crucial for facilitating successful treatment. The gift ’objects’ are imbued with the intrinsic and ineffable identities of their owners: the healer and his ancestors, who continue to play an active role in processes of healing and whose grace is a precondition for the medicine to work. In this light, Godelier’s (1999) concept of ‘sacred objects’ and Weiner’s (1992) paradox of ‘keeping-while-giving’ are useful to contemplate the complex nature of traditional medicine as a gift-object, characterized by an inalienable collective ownership that transcends the possibility of individual possession and henceforth forbids individuals from making a profit by selling it.
Whilst recognizing the rich and longstanding Africanist literature on money, exchange, and gifting, including Bohannan’s (1955) classic work on ‘spheres of exchange’ and its revisions by Guyer (2004), this article theoretically draws on insights from Melanesianist economic anthropology in particular, which, I argue in agreement with Guyer (1995, 88) has much to offer for the African ‘ethnographic and cultural-historical project’. It is my intention here to go beyond the contested gift-commodity dichotomy, as Peebles (2010, 226) encourages us to do, by shifting attention to processes of exchange in which culture and moral discourse need to be taken into account. For this endeavor, I find the foundational work of Mauss, drawing on ethnographic materials from Melanesianists, and Godelier (1999) enlightening because of the way they bring cultural analyses to the study of money and exchange.
Here I propose a crucial addition to our understanding of exchange by analyzing the construction of ‘moral monies’: special monetary gifts that allow healers to survive in today’s money-based economy while remaining loyal to local moral traditions. ‘Moral monies’ are thus tools to reconcile moral ancestral legacy with contemporary needs. Rather than indicating a health care system that has fallen ‘subject’ to the ‘market’, ‘moral monies’ are a warily and culturally appropriate way of dealing with global change without endangering the social, cultural, moral, and historical institutions in which traditional health care is carefully embedded.
Analyzing the robustness of local cultures of care is one way that classical theories of exchange can enrich the field of medical anthropology. More specifically, they increase our understanding of how culture mediates the transformations of medical systems – and people’s social and moral struggles that accompany them – in the current era of globalized neoliberalism.
Money spoils the medicine
Ever since Aristotle, money has acquired a dubious moral status in Western thinking. In the Bible, for example, we find St. Paul’s warning that ‘money is the root of all evil’. Parry and Bloch (1989, 9) convincingly argue that the problem is that ‘for us money signifies a sphere of “economic” relationships which are inherently impersonal, transitory, amoral and calculating’ (emphasis in the original). There is often no parallel of such thinking in other societies (see also Maurer 2006; Peebles 2010; van der Geest 1992, 1997), though many contemporary scholars still stubbornly apply this perspective to non-Western societies. The anthropologist Bierlich (2007, 156; see also 1999) has studied the relationship between health care and money among the Dagomba of Northern Ghana, a neighboring tribe of the Mamprusi, who similarly hold that ‘money corrupts curing’. While Bierlich ultimately concludes that ‘money spoils the medicine’ is an expression of male elders’ anxiety regarding the possible collapse of male authority through the commodification of health care, which women seem to take over (Bierlich 2007, 174–77), this gendered aspect was entirely absent in my research. Instead, I argue that there are other, more satisfactory explanations for the famous dogma.
If we take a close look at the answers that healers gave me when I asked them whythey do not charge for their services, we find a pattern of statements related to powers that are beyond the healer’s personal control, particularly with reference to their forefathers, such as: ‘My grandfather did not charge and my father too did not charge’, ‘That is not how the medicine started’, and ‘I didn’t [just] pick up the medicine on the way’.[note 1] The forefathers are the – continuing – source from which medicines derive their power. An individual’s use of medicines implies a moral relationship with the ancestors. This explains the humility that healers show when they talk about their medicines, saying ‘it is my (grand)father’s medicine’ instead of ‘it is my medicine’. And this denial of personal ownership is explicitly manifested during healing rituals. One day I observed Abdul Kaliq, a healer, calling to his forefathers and offering a fowl to appease and persuade them to let their medicine work.[note 2] Holding a living chicken in both hands, with closed eyes, and before his words became completely incomprehensible, speaking a secret language, I heard him say: ‘My children are here for you to help them, and they are asking you to help them, it is not me who is going to help them, it is you to give them whatever they want. If you are to accept [to help them] you will take this chicken. Come and collect [the chicken], come and collect, come and collect’. Seconds later, he laid down the chicken, now dead; to show me that his ancestors had come and consumed its blood, he cut the chicken’s throat with a knife, and, indeed, there was no blood left. His grandfathers had accepted to give us whatever we would ask for. When we came back the following week to collect the medicine, the healer again emphasized its true origin: ‘It is God who has given you this medicine, not me. It is my grandfather who has given you this medicine, not me. It is my father who has given you this medicine, not me’. The use of ‘God’ here seems to refer to a superior power who was there even before the first grandfather: the ultimate unknown owner of the medicine.
I argue that it is precisely because the first owner of the medicine is unknown, that today’s healers cannot charge. Informants explained that their forefathers also did not charge and argued they must have had good reasons for it, for instance because they also did not know the original, mystical source of knowledge. Adam, a healer from a particular remote village who was specialized in children’s diseases, explained:
My medicine, I cannot give it to someone else. Because it is from our great-grandfathers. Because it is an animal. … And that is why before the fire festival we slaughter a fowl and sacrifice it to the grandfathers to ask their continuing assistance in our healing activities. Then the next morning, turtles will come to our house. … They will come to the compound here, every year. And that means the medicine is still working. We cannot charge because we don’t know who gave the medicine to our ancestors. Maybe it was an Arezene [demon]who gave it to them. Or maybe it was the river. We don’t know. That’s why.
Godelier’s (1999) re-examination of the gift helps to shed light on the Mamprusi healers’ reluctance to charge patients for their medicine. Drawing on ethnographic data from the Baruya tribe from New Guinea, Godelier contemplates certain sacred objects that must not be given (or sold) but rather kept. The most powerful and secret of these objects is the kwaimatnie. It is powerless however without the secret spell and the sacred name that were passed on together with the kwaimatnie by the ancestors. Originally itwas given to their ancestors by Sun, Moon, or spirits. The Baruya believe that other clans do not have a kwaimatnie because they were not worthy of having one. Hence, concludes Godelier (1999, 120), it is not hard to understand why these objects, as well as the secret knowledge that goes with them, are inalienable possessions that theoretically are withheld from any kind of exchange: ‘They are inalienable because they constitute an essential part of each clan’s identity’ (emphasis in the original). I want to make a similar argument about the Mamprusi. Just as the Baruya invoke the Sun, Moon, or spirits, the Mamprusi refer to God, Arezene, demons, or a river as having given the first medicines to their forefathers.This heritage, passed on from father to son for generations, is indeed an essential part of a healer’s family identity.
I want to take this line of argumentation one step further, because in the case of the Mamprusi, it cannot be said that the medicines are so sacred that they cannot be given away, since healers do treat patients by distributing herbal concoctions. Godelier’s interpretation of sacred objects is inspired by Weiner’s work (1992) on inalienable possession. In fact, both contributions echo Mauss ( 2011, 43), who already touched upon the subject. Weiner (1992, 6) draws on fieldwork on the Trobriand islands, testing Malinowski’s earlier theories on gift exchange, and theorizes the paradox of ‘keeping-while-giving’: possessions are ‘imbued with the intrinsic and ineffable identities of their owners’ and thus are not easy to give. Ideally, these inalienable possessions are kept by their owners from one generation to the next within the closed context of family, just as Mauss ( 2011, 42) described: ‘sacra which the family parts with, if at all, only with reluctance’. Godelier (1999) also notes this paradox when he explains how his Baruya informants are obliged not only to keep these sacred objects but also to share their beneficial effects with others. Without alienating the object, the source of their powers, they alienate the beneficial effects. This obligation to share beneficial effects sounds familiar with respect to the context of my own field. What is alienated is not the object in their possession; this remains immovable within the clan, connected to the ancestors and Sun. What is detached from the object – what is alienable, givable, even exchangeable – is not its powers but their effects (Godelier 1999, 121–22). This is the true enigma of the gift: it can be given and at the same time be kept. What is given is the alienable right of usage, what is kept is the inalienable ownership,which should be understood as an intertemporal ancestral legacy.
If, as I argue, Mamprusi medicines are alienable and therefore suitable for (gift) exchange with regard to the right to use them and receive their beneficial effects, while being at the same time inalienable with regards to their ownership, why would moneyspoil the medicine? In his Philosophy of Money,Simmel ( 2011, 360) argues that the power of money to bridge distances enables the owner and his possessions to exist so far apart that each of them may follow their own precepts to a greater extent than when the owner and his possessions still stood in a mutual relationship. This is, exactly, the problem of money – standing at ‘the heart of all that is “alienable”’ also for Godelier (1999, 204) – it irreversibly spoils the historical inheritance of ownership, which is the inalienable essence of the power-to-heal, by distancing it from its original owners, interrupting and consequently destroying the generational relationship through which the secrets of medicine have been passed on for thousands of years.
As we will see in the next section, the ‘passing on’ of medical knowledge usually causes no confusion since it is taught from father to son and is sometimes seen as passing ‘through the bloodline’. At first, I was surprised to find healers who initiated non-kin into the sacred sphere of medicine-exchange. But I later observed that, in these situations, the inalienability of medicine remains nonetheless intact, undetached from its original owners, since the apprentice can be said to be ‘adopted’ by the healer and initiated into the family lineage.
Ancestors and apprentices: Transmitting the gift of medicine
In The Elementary Structures of Kinship Levi-Strauss ( 1969)famously sees the exchange of women as the most elementary form of exchange. He argues that a woman is the ‘ultimate gift’ and that the circulation of women as property is at the foundation of kinship systems. I argue that for the Mamprusi of Northern Ghana, medicine comes close to being the ‘ultimate gift’. With ‘medicine’, here, I refer to knowledge on how to treat. There are however, interesting parallels in Mamprusi thinking about medicine apprenticeship and matrimonial circuits, and exploring these parallels helps to shed light on the contemporary tensions of monetization in these spheres. This is illustrated, for instance, by a parable told by the elderly chief, and healer, of the village of Zangum Rana. During a meeting for traditional healers, he compared ‘the ultimate gift’ of medicine with the ‘ultimate gift’ of a marriageable woman:
Before, if you wanted to marry a girl, you would not go to her directly, but you would just go and greet and talk to the head of the family. You would do this for some time, everyday greeting the father. After some time the father will ask you why you are always greeting him like that and you will say: ‘Oh, nothing’. He will feel uncomfortable because he is now also getting shy and he also wants to give you something [back]. And when he comes to know that you are not married he will think that ‘Ah, this man is looking for a wife’. Then one day the father would call all [his] family members together and tell him that you are always greeting him so friendly, that he doesn’t have anything else to give to you so that he decided to give his daughter [to you]. But nowadays, people just meet and marry on the way. But healing is like marriage in the olden days … just respectfully greet the healer every day and if he needs herbs, you can find them for him. Then maybe one day, he will also teach you how to heal.
The chief continued: ‘But nowadays, sometimes, eh, you will just stand [next to a healer] and say: “oh, take this money” and you will give him five cedi [approx. $US1] and after giving the five cedi you just get up and say: “I want you to show me how to treat”. Well, that’s why in medicine there is no respect again’.
In the chief’s account, wives and medicines seem to fall in the same category of special things that should not be bought with money. All of this may be reminiscent of classical Africanist literature on exchange but there are important differences. Bohannan’s (1955) seminal work on the spheres of exchange among the Tiv of Nigeria, for instance, exposes a differentiation between the distribution of goods via the ‘market’ and through ‘gifts’. Regarding the first, Bohannan (1955, 64) presents various categories of interchangeable commodities that are implicitly hierarchically ranked on the basis of ‘moral values’, the highest being marriageable women. Bohannon explains that Tiv elders are most concerned about the impacts of monetization on this highest exchange category; women ought to be exchanged for items with an equivalent exchange value, usually other women, and not foodstuffs, cattle, or brass rods, for example. Crucially, the Tiv exchange of women is explicitly differentiated from gifting. This is in contrast with Mamprusi – and indeed Levi-Straussian – perspectives on the distribution of women and medicine, which are always accompanied by the idea of receiving a countergift. Indeed, the way the chief juxtaposes marriage ‘in the olden days’ with medicine apprenticeship reveals the preference for a kind of ceremonial ‘payment’ consisting of long-term respect in the form of greetings. To ‘meet and marry on the way’ is seen as culturally inferior to the long-term process of ‘courtship’ in which the groom-to-be pays his most humble respect to the father and his fiancé’s male family members.
Offering a direct monetary ‘countergift’, so that someone will ‘show you how to treat’, is painful evidence that the person is profoundly confused about appropriate exchange behavior in this context. Paying for medicine would first of all imply an illicit and inappropriate shift from medicine-as-gift to medicine-as-exchange, which signals, from the perspective of the healers, the end of respect. More importantly, as explained earlier, giving money for medicine or selling medicine would alienate the medicine from its intergenerational channel of sacred ownership, consequently spoiling its curing power. While healers usually teach the secrets of their profession to their own children, it is also possible for an unrelated novice to be initiated, but this requires a long-term commitment by serving the healer for years. Qualified healers will tell their novices that they also ‘did not [just] pick up the medicine along the way’ and that one should ‘suffer small’ before getting something back of real value. In this process of deferred reciprocity, the apprentice is slowly ‘adopted’ into the healer’s lineage, which allows his communication with the healer’s forefathers.
I have thus demonstrated that gift exchange is the only acceptable form in Mamprusi medicine apprenticeships. And, if we look at what is actually exchanged, we see that more is actually keptthan given. True ownership, as over commodities, is never given. That’s why the healers are eager to tell their patients that ‘it is my father’s medicine, not mine’. Perhaps we could argue that, in this case, there are more than just two parties involved in giving. The (living) master is not the only – and perhaps not even the most important – one, deciding to whom to ‘give it’ and ‘to whom not to give it’. As Abdul Kaliq’s healing ritual with the chicken shows, the deceased forefathers actively engage in exchange relations, receiving chicken blood and other offers and ‘adopting’ new students in return. We can understand this as a true triadic exchange, with the ancestors being the third and overarching party. This also explains why non-kin student-healers need to spend so much time with the healer; they are busy proving their commitment and trustworthiness to the master’s forefathers, who will ultimately decide whether to ‘adopt’ him into their lineage.
The ultimate ‘non-gift’, so to say, is the inalienable ownership over medicine, which remains with the collectivity of the ancestors; the ultimate gift is the alienable right to usethe medicine. As mentioned earlier, Godelier points to another alienable aspect of sacred objects, which is their beneficial effects. We will find these in the next section which explores the ‘gift of health’: the treatment of patients with traditional medicine.
The gift of health
Generally, patients who consult traditional healers are expected to ‘beg for medicine’, as it is locally phrased. The patient, often accompanied by family members, needs to go to the healer’s house to greet him and to ask for a favor. In Northern Ghana, ‘greeting and asking for favors’ is theway of ‘getting things done’, also outside the sphere of traditional healing (Bierlich 2007, 132). Usually, this combination of greeting and requesting was accompanied by a first small gift of kola (betel nut), which is a token of appreciation and respect. If the healer knows he can help the patient, he will tell them to ‘go and come [back]’ with at least one fowl. In the meantime, he will collect the herbs he needs for the medicine. When the patient comes back, the healer will first call the names of his ancestors and ask them for their assistance. The fowl, as an offering, will be wounded or killed (or its limbs will be broken in the case of bone setting) so that its blood will mix with the herbs. Hence, the fowl is not a gift from the patient to the healer, even though the latter usually distributes the meat among his (grand)children. Rather, it is a gift to the forefathers, who are fed with the animal’s blood. The obligation to give gifts to the gods or ancestors was noted by Mauss ( 2011, 13), who wrote that ‘they in fact are the real owners of the world’s wealth’. The ‘owner’, that is the herbalist in our case, can ‘buy’ from the spirits the right to do certain things with ‘their’ property. Godelier (1999, 180) elaborates on this idea, which he calls ‘Mauss’ famous fourth obligation’. And indeed a true obligation it is, because a failure to fulfill one’s part of the exchange may lead to the ancestors taking revenge on your family, inflicting sickness on someone else. This shows us how gifts – like an innocent chicken’s blood to feed one’s ancestors – may be voluntary, disinterested, and spontaneous in theory, but are, in fact, obligatory and interested, with a high price to pay when they are not voluntarily given.
The obligation of voluntary gifting reveals a crucial paradox, pointed out by Pyyhtinen (2014): for the gift to work, it cannot ‘behave’ as a gift. The (nonacademic) conceptual essence of gifts is that they are ‘free’, unconditional, and disinterested; but in its empirical reality, the gift’s reciprocity rule, captured well by the Latin phrase ‘do ut des’, is centered on three obligations: to give, to receive, and to reciprocate. That the gift is always transmitted with a ‘burden attached’ was argued already by Mauss, and has caused some scholars to conclude that the gift is therefore nothing but a deceit, an illusion (see, for example, Blau 1964). Bourdieu (1997, 231) however, takes the gift’s ‘dual truth’seriously, arguing that the subjective truth is that the gift is free and irreversible, and the objective truth of the gift is that it must be reciprocated.
Hence the gift cannot be what it in reality is (obligated reciprocity). And it is conceptually what it empirically cannot be (unconditional/free). Now what is it in the object given that obliges the receiver to make a return gift? Mauss ( 2011, 9) explained this rule of reciprocation with the indigenous Maori concept of hau, the spirit of the object given that ‘wants to return to the place of its birth’. Without adopting the concept of hau in this study, Mauss’s central argument is nonetheless of crucial importance: to receive something is to receive part of someone’s spiritual essence. It retains a magical hold over the recipient: ‘Even when abandoned by the giver, [the gift] still forms a part of him’ (Mauss  2011, 9). Indeed, as Parry (1986, 464) rephrased the enigma: the gift itself seems ‘animated with the spirit of its original homeland and donor, to which it strives to return’. It is in this light that we can understand the need for patients to pay a countergift to the healer, who then is obliged to return, as it were, the gift to its ‘original homeland’.
Countergifts from patients to healers were usually done only after recovery, ‘when you [patient] are also happy’. This resonates with classical principles of gift exchange as put forward, for example, by Bourdieu (1977, 5), who claims that for the countergift to not be an insult, it should be both deferred and different. In fact, it is the ‘temporal structure’ of gift exchange, meaning the time elapsed between gift and countergift, that allows for the ‘individual and collective self-deception’ about the objective truth of the gift (Bourdieu 1997, 231–32; see also Andaya 2009).
The countergift in our case behaved in a way that did not annul the idea of the gift. It was given days or weeks after receiving the gift of health, and consisted of ‘everything you want to give [the healer] after you are now better’, as one of my informants put it. These post-treatment donations could be anything: (more) kola, more chickens, other animals, human labor for the healer’s farm. Receiving small amounts of cash, afterwards, was strictly distinguished from charging money: ‘I don’t charge. Even if they wake me up in the night [to treat them]. By daybreak, if they give me one or two cedi I will take it. … If they want to give us anything afterwards, we will take it’.
These donations were said to depend on what someone could afford. Even if people were too poor to offer fifty pesoas ($US.50), the healers argued they appreciated the time that someone took to visit and greet them again, and to confirm that their family member had recovered. This was expressed by chief Nasir al Din: ‘When the child recovers and the sickness goes away, they will bring him or her to show me that he is now ok, or your wife is now ok. [They will say:] ‘I just bring them for you to see them, but I don’t have anything to give to you’, and I appreciate it. I don’t have to force people to pay’.
Healers indeed convincingly argued that they were pleased when patients came back to greet them and to show them that ‘they are now ok’, even if they have nothing to give (back). I do not want to argue this is not true. Observations, however, granted me additional insight into the contested boundaries between morally accepted and reasonable exchange, which turned out to be more complex than (socially accepted) answers from interviews would suggest. I witnessed, for example, former patients returning to greet Abdul Kaliq, who lived close to me. These ‘old’ patients, however, were largely outnumbered by the new patients and fortune-seekers who would come to my house – walking or riding their bicycles or motorbikes, clothes covered in white dust – to ask the way to ‘the powerful medicine-owner’. Spending many days at Kaliq’s compound, I noticed that most of the old patients who came back to greet him were not giving him anything. The healer was always friendly and respectful, giving extra medical advice or some additional herbs, and never showing disappointment with not receiving any material gift. As soon as the patient had left, even before his bike fully disappeared in a cloud of dust, one of Kaliq’s wives would immediately approach him, ‘begging’ for small money, to see if he had received any cash because she had run out of maize or yams and wanted to cook for her children. At these moments there was definitely disappointment, and sometimes frustration, and Kaliq would look at me, uttering ‘You see?’ or ‘That’s how we suffer’.
Such ‘parasitic’ (see Pyyhtinen 2014) clients endanger the healers’ economic survival, because if they were not given animals, clothes, or other material necessities, they also did not have money to buy them. Asking for – not charging – ‘moral monies’ thus serves as a functional and meaningful solution for the healers.
‘This is kola’: The creation of moral monies
Confronted with ubiquitous economic change, though loyal to local moral traditions, the healers struggled to meet opposing expectations, bridging their forefathers’ moral inheritance with their children’s material requests, juxtaposing the community-service nature of their profession with individual and family needs. In this friction there was a lot of experimentation; boundaries were shifted, moral principles were renegotiated, and moral monies were invented to navigate a changing socioeconomic context. For the sake of clarity let me here define moral monies asa means of exchange that convert money’s immoral associations (of selling) into morally accepted interpretations (of gifting). Money has two immoral associations concerned with selling: 1) it implies individual ownership, including the right to sell one’s possessions and 2) it implies that one’s interests are commercial, or at least profit-oriented. Now what made these associations particularly immoral in this context (and not in others) was that they conflicted with the inalienable nature of the ownership of traditional medicine, which transcends individual ownership and belongs to the ancestral lineage. Individual commercial aspirations further problematized matters because practices of healing are supposed to be beneficial to the group as a whole, with healers only being guardians of sacred knowledge obliged to distribute their beneficial effects. To understand how moral monies are capable of transforming money’s immoral associations, leaving its exchange value unchanged and even enriched with moral value, I will give some concrete examples.
A classic one is kola, that is, money used in continuation of what used to be/supposed to be kola. Kola is betel nut that especially old men like to chew. As mentioned earlier, it is a culturally and morally accepted gift, a token of respect that is exchanged when people of lower social status greet and ask favors from those with a higher (authoritative) status. An ethnographer of Mamprusi, Drucker-Brown (1995), argues kola is valued because it stimulates sociability and symbolizes ideals of amity and trust that should exist between donor and recipient. Revealing further connections in the spheres of exchange of women and medicine, Drucker-Brown also explores how kola is, in fact, also a traditional gift through which women are courted and marriages are established.
What I observed happening was healers asking for kola, but receiving actual money, usually coins of 1 cedi or 2 cedi. When I asked Mohammed if he charges when he treats patients, he told me: ‘No, I only ask for some kola for the children who are getting the herbs for me’. Since kola is a gift for old men (and women) and not for children, I was very confused by this answer until he continued: ‘That means money. It is small money but not really charging. It is two cedi or three cedi and it means you give the person kola. That’s how we use it’. Bierlich (2007, 161) found similar equivalencies among the Dagomba of Northern Ghana. He argues that money ‘achieved’ the status of kola, and was, therefore, not opposed to local practices of giving kola: ‘When representing kola or when offered with the expectation of receiving a counter-gift, money does not have any morally negative significance’ (Bierlich 2007, 161). To represent money as kola, shifting it to the morally accepted sphere of reciprocal exchange, was as ‘simple’ as giving it another name: calling money by the thing it replaces. This was sometimes done when referring to other material gifts. Mohammed explained that he very much appreciated the gift of a goat. ‘But’, he said, ‘if you don’t have money to buy a goat, you can turn the goat into money and give me half a goat’. An observation of a similar practice is made by Bloch (1989, 166) who researched the morality of money in Madagascar, where money gifts at weddings or funerals are usually called by the thing they replace, ‘even if what is replaced is quite specific and charged with meaning’. The essence, I argue, is that moral monies are given with the expectation of receiving a countergift, not a countercommodity. Among the Mamprusi, patients paid with moral monies to receive the gift of health.
In a second functioning of moral monies, the escape of certain (morally charged) terminology is even more present. Some healers convincingly told me that they ‘don’t charge’ but at the same time I saw them asking for substantial amounts of money, albeit with a different terminology. Adam for example said: ‘I don’t charge, but for a lady I collect 8.40. If it is a boy or a man I collect 6.60. And then a chicken in addition’. Now with such precise amounts we have definitely left the sphere of donations. As I explained earlier, the problem was the idea of charging, with its link to the immorality of profiting, not the exchange of monies as such. In this light, healers’ claims become more understandable, as when they claimed the right to take care of their families with the money patients give them, as Josue explained: ‘The money depends on the sickness. Sometimes [I ask for] 100 Ghana cedi, sometimes 40 Ghana cedi or 20. … My medicine, I use it to take care of my family; we use it for food’. This money, used ‘to take care of the family’, does not fit the neoclassical economic axiom of maximizing profits and was therefore morally acceptable because it remained in the sphere of reciprocal and gift-exchange, transacting health for (money to buy) food.
Jacob, the secretary and general contact person of the traditional healers’ association in Walewale, was almost daily confronted with healers’ financial problems, as they sometimes lost money when they had to buy equipment or spend money on petrol to collect far-away herbs. He tried to persuade them to make the patient pay at least for those costs, which would not be ‘charging’ in the strict sense of the word. He perfectly addressed everyone’s profound fear when he said: ‘I am sure the ancestors won’t make a problem out of this’, and continued:
I am telling them [the healers] that if they just count what they need, if they are going to the next village to collect the herbs, ‘how much petrol am I going to buy for the motorbike, my lunch that I am going to take before going there, when I come back how many sachets of pure water am I going to need when I come home’. And you tell the person [patient] that ‘this is the amount I am going to use’, but they [the healers] say that the fellow [patient] will go out telling that ‘he is now selling his medicine’. But I say that, ‘no, when your ancestors know that that is the money you spent for bringing the herbs, I think they won’t spoil the medicine’.
According to Jacob, this moral money, which only covers the healer’s expenses but does not generate profit, will not spoil the medicine because the ancestors will understand that it is used to facilitate treatment. Some of his colleagues were still too afraid to ask even for these moral monies, but Fusseini, for example, shared Jacob’s conviction: ‘I don’t charge. But what is due to the medicine, I let you pay it. If it is a fowl, you pay for that, if it is four cedi, five cedi, I will tell you that. But I don’t charge’. Similarly, this had become the new policy of Rashid, a traditional birth attendant: ‘But I do ask, sometimes, when it is in the night, after [the patient has] given birth I have to cut the navel cord. So now we have set a law that when you come to deliver, [it is] five cedi. That five cedi I use to buy [the] battery for the lamp and I use it to buy [the] blade to cut’.
Arguing against a gift-commodity opposition, Parry and Bloch (1989, 24) emphasize the coexistence of two separate though interrelated transactional orders: those transactions concerned with the reproduction of the long-term social or cosmic order and those short-term transactions concerned with the arena of individual competition. My analysis of moral monies supports Parry and Bloch’s (1989; see also Maurer 2006; Peebles 2010) rejection of a rigid gift-commodity dichotomy, because moral monies, as mechanisms that convert the morally inappropriate cycle of money exchange into the morally accepted sphere of gifting, ultimately reunite money and the gift in the logic of exchange. Specifically, moral monies reunite the logic of money exchange – generating alienable all-purpose money (cash) that the healers can spend everywhere – with the enigma of gift exchange and its simultaneous expectation of reciprocity and subjective perception of something freely given.
In their volume, Parry and Bloch (1989) take a next step by illustrating the process of ‘decontaminating’ money derived from the short-term exchange sphere so that it becomes morally positive and ultimately serves the reproduction of the long-term cycle. Such procedures to convert money from one sphere to the other are often expressed in an alimentary idiom and include for instance the ‘drinking’ of cash in Fiji, the ‘cooking’ of money in Langkawi, and the ‘digesting’ of pilgrims’ gifts to the Brahmans of Benares. In the case of Mamprusi medicine however, such conversions are not necessary, as money in itself is not morally condemnable for the Mamprusi and it does not come from a dubious source (in contrast to ‘bitter money’, cf. Shipton 1989). Hence there is no actual morally equivocal money, only immoral associations, which are already purified through the discourse of moral monies. The only thing that is needed, and hence done by the healers, is to undo money from any linkage to the buying and selling of individual possessions – an impossibility considering the ownership of medicines – and the making of (illicit) profit (at the expense of others).
What remain are moral monies, which serve a dual purpose besides facilitating symbolic decontamination. In addition to restoring and reproducing the long-term transactional sphere of exchange concerned with the social and cosmic order of the ancestral lineage, they also are very welcome guests who bring and keep the food on the healers’ tables, hence facilitating the sustainable continuation of century-old practices of traditional healing in contemporary Ghana.
Ethnographic research among the Mamprusi of Northern Ghana shows that although confronted with an expanding monetary economy, traditional healers continue to live by the local credo that ‘money spoils the medicine’. This statement refers to a system of healing in which exchange between healers and patients as well as between healers and novices is regulated along the social and moral lines of a gift economy. This reality seems to challenge common explanations of recent neoliberal transformations in health care systems in Africa. Clearly, traditional healing in Northern Ghana has not fallen ‘subject’ to the marketization of care and commodification of medicine. Nor can one explain the situation as straightforward local resistance to global change. Rather than a field of commercial opportunity and pragmatic action or a theatre of global powers, traditional health care in Ghana is a sociocultural phenomenon, a system that comes with conventions and convictions that concern knowledge and care, and its inherent transactions. Global forces do not just eradicate local forms, and classical concepts that serve to explain cultural forms still prove valuable, including to explain the persistence of – apparently maladaptive – actions and beliefs. In this light, contemplating classical anthropological and sociological theory on exchange can prove useful for analyzing the sociocultural and moral dynamics of the transformation of health care systems in the context of global neoliberal change. In this case, I used the classical concept of the gift to explore contemporary medical economic practices. To enhance our understanding of exchange, in particular the complex negotiations of its morality in the current era of globalized neoliberalism, I propose the concept of ‘moral monies’. As special kinds of monetary (counter)gifts, these serve as instruments to reunite contemporary monetary needs with the sociocultural, moral, and historical roots of a cultural economy of healing.
The concept of the gift is still highly useful to explore and explain the nature of social interaction, for Ghana’s healing economy and beyond. If we acknowledge that care is social as well as medical, then we need to understand how these social interactions, and inherent exchange, are locally understood and organized. While this kind of understanding seems most urgent for countries in the global South, there may be an increasing importance in the West as well, where neoliberal thinking has also penetrated health care. In the Netherlands, for instance, the government has recently promoted a system of informal social care called ‘mantelzorg’, encompassing unpaid care for the elderly, chronically ill, or disabled by relatives/family members. The most typical cases of mantelzorg concern the care for elderly people by their children. Although mantelzorg is traditionally unpaid, the Dutch government decided in 2015 to grant family caretakers a very small stipend called the mantelzorg-compliment, of 200 euro per year, as a token of appreciation. In the end, the government, ultimately concerned with cutting budgets, is encouraging its citizens to take the opportunity to ‘give something back’ to their parents, making it basically a ‘deferred and different’ countergift of care.
I want to express my deepest respect and gratitude to the healers of the West Mamprusi district, who trusted a white stranger with some of the secrets of their knowledge. The chance to share in the richness of their wisdom is a gift for life. In particular I would like to thank Nabla Yussif, who made everything possible. And to Sister Alhassan Latifa, with whom I shared all my adventures: our memories are worth a million.
I also want to thank UNICEF Ghana, in particular dr. Luigi Peter Ragno, and ACDEP Ghana for facilitating this research.
I want to sincerely thank dr. J. G. de Kruijf from Utrecht University for his continued and selfless support, for overseeing fieldwork and for editing a first version of the manuscript.
Finally, I would like to thank two anonymous reviewers who showed themselves deeply engaged with the arguments being made. Their insightful comments and suggestions have improved the manuscript.
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