Abstract
Since 1972, inpatients at the Fann Psychiatric Clinic have been required to have a family member or close friend—an accompagnant—stay with them for the duration of their hospitalization. In recent years, however, the role of the accompagnant has seen a dramatic transformation. This article considers the emergence of a new kind of accompagnant at Fann: the for-hire accompagnant mercenaire, who is unrelated to the patient and not employed by the clinic. Against the backdrop of Senegal’s neoliberal turn and in light of the growing prominence of the biomedical approach at Fann, the author shows how the idealized accompagnant model of family caretaking has given way to this new form of commodified care. At the same time, however, the author argues that accompagnants mercenaires regularly draw upon and establish new sets of moral codes, obligations, debts, and expectations in their day-to-day interactions with patients, family members, and staff alike. By way of a careful ethnographic examination of the evolution of the accompagnant role at Fann, this article brings into focus a complex and multidimensional picture of the shifting economies—moral and political, as well as therapeutic—within the present-day clinic.
This is a preview of subscription content, log in via an institution to check access.
Similar content being viewed by others
Notes
The CNHU, or Centre National Hospitalier Universitaire de Fann, is a large teaching hospital connected to the University of Dakar. It is comprised of a number of specialized medical facilities, including the Fann Psychiatric Clinic (Service de Psychiatrie–Clinique Moussa Diop).
Though the word ‘accompagnant’ may be translated into English as companion, attendant, or escort, I have left the original French word untranslated for the purposes of this paper. According to Gbikpi and Auguin (1978), the term ‘accompagnant’ was chosen quite deliberately at Fann as the result of careful discussion and consideration. The word signaled a more active investment in the therapeutics and caretaking of the patient than the word ‘accompagnateur,’ which seemed to suggest a less engaged role (1978, p. 7). My decision to keep the original word reflects the intentionality of this choice.
The relationship between neoliberalism and biomedicine (including biomedical psychiatry) has been a variously construed. Along with sharing the basic core concepts of the atomistic and autonomous self, both neoliberalism and biomedicine idealize of individual responsibility, rational choice or action, and productivity. In terms of how one might affect the other, some scholars have highlighted the ways in which neoliberal policies and reforms shape research trajectories, thus fostering and favoring the production of certain kinds of knowledge while limiting others (e.g., Valdiya 2010). Others have argued that the rise of biopsychiatry “help[s] to create the social and cultural milieu favoured by neoliberal policies” (Moncrieff 2008, p. 235) and more pointedly, that biomedicine and its accompanying technologies have been used as a tool of neoliberal expansion (Lock and Nguyen 2010).
As a sociocultural anthropologist by training, my ethnographic research at Fann has consisted of participant observation (alongside doctors, nurses, social workers, medical students, care providers, patients, and family members), structured and unstructured interviews, and historical/archival research.
Named after the Wolof word meaning “village meeting or gathering,” pënc meetings were designed “in the image of the traditional African village” (Dia 1976, p. 373) and served to affirm the ideal of collective African life within the clinic. Though described by many as a unique and distinctly Senegalese addition to the clinical setting, pënc were in some ways similar to radical Italian psychiatrist Franco Basaglia’s “town meetings,” which became a regular part of the psychiatric hospital in Gorizia, Italy at about the same time (Scheper-Hughes and Lovell 1987).
Sall was mentored by former president Wade and played a major role in his government, acting as Prime Minister from 2004–2007 and then directing Wade’s successful reelection campaign in 2007. He also stood as President of the Senegalese National Assembly from 2007–2008. In 2009, however, amidst allegations of corruption and foul play on both sides, Sall broke with the Wade’s Senegalese Democratic Party (Parti Démocratique Sénégalais or PDS) to form his own party, the Alliance for the Republic-Yakaar (Alliance pour la république-Yakaar or APR).
The waxing of the biomedical model has been noted in the North America, Europe, and throughout the world (Lakoff 2005, Luhrmann 2000, Petryna, Lakoff and Kleinman 2006). As Fann has embraced a biomedically oriented approach and the clinic has relied more heavily on pharmaceuticals, however, the high cost and short supply of medications has never ceased to present problems for both patients and doctors alike.
References
Bartoli, Daniel 1968 Aménagement de l’Environnement des Malades Mentaux à Dakar. Etudes Médicales: 18–25.
Biehl, João and Adriana Petryna, eds. 2013 When People Come First: Critical Studies in Global Health. Princeton: Princeton University Press.
Brown, Tamara Mose. 2012 Who’s the Boss? The Political Economy of Unpaid Care Work and Food Sharing in Brooklyn, USA. Feminist Economics 18(3):124.
Collomb, Henri 1965 Assistance Psychiatrique en Afrique (Expérience Sénégalaise). Psychopathologie Africaine 1(1):11–84.
Collomb, Henri 1967 Methodological Problems in Cross-Cultural Research. International Journal of Psychiatry 3:17–19.
Collomb, Henri 1967b Les Problèmes Psychiatriques en Afrique Noire. La Gazette Médicale de France 3(3):1723–1732.
Collomb, Henri 1975 Histoire de la Psychiatrie en Afrique Noire Francophone. African Journal of Psychiatry 2:87–115.
Cruikshank, Barbara 1999 The Will to Empower. Ithaca: Cornell University Press.
Dembele, Demba Moussa 2005 The International Monetary Fund and World Bank in Africa: A “Disastrous” Record. International Journal of Health Services 35(2):389–398.
Dia, Alhousseynou 1976 Une Communauté Thérapeutique: Le Pinth de Fann. African Journal of Psychiatry 2(1):147–151.
Diop, Momar-Coumba 2004 Gouverner le Sénégal: Entre Ajustement Structurel et Développement Durable. Paris: Karthala.
Diop, Babacar and Maurice Dores 1976 L’Admission d’un Accompagnant du Malade à l’Hôpital Psychiatrique. Perspectives Psychiatriques 59(5):359–368.
Easterly, William 2005 What did Structural Adjustment Adjust?: The Association of Policies and Growth with Repeated IMF and World Bank Adjustment Loans. Journal of Development Economics 76(1):1–22.
Edelman, Marc 2005 Bringing the Moral Economy back in … to the Study of 21st-Century Transnational Peasant Movements. American Anthropologist 107(3):331–345.
Farmer, Paul, Arthur Kleinman, Jim Kim, and Matthew Basilico, eds. 2013 Reimagining Global Health: An Introduction. Berkeley: University of California Press.
Foley, Ellen 2008 Neoliberal Reform And Health Dilemmas: Illness, Social Hierarchy, and Therapeutic Decision-Making in Senegal. Medical Anthropology Quarterly 22(3):257–273.
Foley, Ellen 2010 Your Pocket is What Cures You: The Politics of Health in Senegal. New Brunswick: Rutgers University Press.
Gbikpi, Paul and Roselyne Auguin 1978 Evaluation d´une Pratique Institutionnelle à Fann, l´Admission d´un Accompagnant du Malade à l´Hôpital. Psychopathologie Africaine 14(1):5–68.
Glenn, Evelyn N. 2010 Forced to Care: Coercion and Caregiving in America. Cambridge, MA: Harvard University Press.
Griffith, David 2009 The Moral Economy of Tobacco. American Anthropologist 111(4): 432–442.
Griffith, David, Manuel Valdéz Pizzini, and Carlos Garcia Quijano 2007 Entangled Communities: Socioeconomic Profiles of Fishers in Puerto Rico. Miami: NOAA Southeast Fisheries Science Center.
Harvey, David 2005 A Brief History of Neoliberalism. Oxford: Oxford University Press.
Kelly, Valerie, Thomas Reardon, Bocar Diagana, and Amadou Abdoulaye Fall 1995 Impacts of Devaluation on Senegalese Households: Policy Implications. Food Policy 20(4):299–313.
Lakoff, Andrew 2005 Pharmaceutical Reason: Knowledge and Value in Global Psychiatry. Cambridge: Cambridge University Press.
Lock, Margaret and Vinh-Kim Nguyen 2010 An Anthropology of Biomedicine. Oxford: Wiley-Blackwell.
Luhrmann, Tanya M. 2000 Of Two Minds: The Growing Disorder in American Psychiatry. New York: Vintage Books.
Melly, Caroline M. 2011 Titanic Tales of Missing Men: Reconfigurations of National Identity and Gendered Presence in Dakar, Senegal. American Ethnologist 38(2): 361–376.
Mol, Annemarie, Ingunn Moser, and Jeanette Pols, eds. 2010 Care in Practice: On Tinkering in Clinics, Homes and Farms. Bielefeld: Verlag.
Moncrieff, Joanna 2008 Neoliberalism and Biopsychiatry: A Marriage of Convenience. In Liberatory Psychiatry: Philosophy, Politics and Mental Health. Carl I. Cohen and Sami Timimi, eds. pp. 235–255. Cambridge: Cambridge University Press.
Muehlebach, Andrea 2012 The Moral Neoliberal: Welfare and Citizenship in Italy. Chicago: University of Chicago Press.
Näre, Lena 2011 The Moral Economy of Domestic and Care Labour: Migrant Workers in Naples, Italy. Sociology 45(3):396–412.
Nguyen, Vinh-Kim 2005 Antiretroviral Globalism, Biopolitics, and Therapeutic Citizenship. In Global Assemblages: Technology, Politics and Ethics as Anthropological Problems. Aihwa Ong and Stephen Collier, eds. pp. 124–144. Malden: Blackwell.
Nguyen, Vinh-Kim 2010 The Republic of Therapy: Triage and Sovereignty in West Africa’s Time of AIDS. Durham: Duke University Press.
Paerregaard, Karsten 2012 Commodifying Intimacy: Women, Work, and Care in Peruvian Migration. The Journal of Latin American and Caribbean Anthropology 17(3):493–511.
Petryna, Adriana, Andrew Lakoff, and Arthur Kleinman, eds. 2006 Global Pharmaceuticals: Ethics, Markets, Practices. Durham: Duke University Press.
Pfeiffer, James and Rachel Chapman 2010 Anthropological Perspectives on Structural Adjustment and Public Health. Annual Review of Anthropology 39:149–165.
Prince, Ruth 2012 HIV and the Moral Economy of Survival in an East African City. Medical Anthropology Quarterly 26(4):534–556.
Rose, Nikolas 1990 Governing the Soul: The Shaping of the Private Self. London: Routledge.
Rowden, Rick 2009 The Deadly Ideas of Neoliberalism: How the IMF has Undermined Public Health and the Fight Against AIDS. London: Zed Books.
Scheper-Hughes, Nancy and Anne Lovell, eds. 1987 Psychiatry Inside Out: Selected Writings of Franco Basaglia. New York: Columbia University Press.
Scott, James C. 1976 The Moral Economy of the Peasant: Rebellion and Subsistence in Southeast Asia. New Haven: Yale University Press.
Stacey, Clare L. 2011 The Caring Self: The Work Experiences of Home Care Aides. Ithaca: Cornell University Press.
Striffler, Steve 2001 In the Shadow of State and Capital. Durham: Duke University Press.
Thompson, E.P. 1971 The Moral Economy of the English Crowd in the 18th Century. Past and Present 50:76–136.
Valdiya, Shailaja 2010 Neoliberal Reform and Biomedical Research in India: Globalization, Industrial Change, and Science. Ph.D. dissertation, Science and Technology Studies Department, Rensselaer Polytechnic Institute.
Acknowledgments
This research was funded by a Fulbright-Hays DDRA Fellowship Award and a Columbia University Travel Grant. A Zeising Award from Sarah Lawrence College allowed me to revisit Fann in 2013. I am grateful to Amira Mittermaier, Kristen Drybread, and Jenny Sime for their helpful suggestions on earlier drafts of this manuscript. I also thank the anonymous reviewers of Culture, Medicine and Psychiatry for their constructive feedback and support. Finally, my deepest gratitude goes out to Fara, Coumba, and so many others at Fann who have generously shared their stories with me over the years.
Author information
Authors and Affiliations
Corresponding author
Additional information
I use pseudonyms throughout the paper to respect the privacy and confidentiality of all of my interlocutors at Fann, including patients, family members, doctors, staff members, and accompagnants.
Rights and permissions
About this article
Cite this article
Kilroy-Marac, K. Of Shifting Economies and Making Ends Meet: The Changing Role of the Accompagnant at the Fann Psychiatric Clinic in Dakar, Senegal. Cult Med Psychiatry 38, 427–447 (2014). https://doi.org/10.1007/s11013-014-9386-7
Published:
Issue Date:
DOI: https://doi.org/10.1007/s11013-014-9386-7