Community understanding of malaria, and treatment-seeking .Community understanding of malaria, and

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Transcript of Community understanding of malaria, and treatment-seeking .Community understanding of malaria, and

  • Community understanding of malaria, and

    treatment-seeking behaviour, in a holoendemic area

    of southeastern Tanzania

    INAUGURALDISSERTATION

    zur

    Erlangung der Wrde einer Doktorin der Philosophie

    vorgelegt der

    Philosophisch-Naturwissenschaftlichen Fakultt der

    Universitt Basel

    von

    Susanne Hausmann Muela

    aus Neuchtel (NE)

    Basel, Juni 2000

  • Genehmigt von der Philosophisch-Naturwissenschaftlichen Fakultt

    auf Antrag von

    Herrn Professor Dr. Marcel Tanner, Herrn Professor Dr. Mitchell G. Weiss und

    Herrn PD Dr. Christoph F.R. Hatz

    Basel, den 6. Juni 2000

    Professor Dr. A. Zuberbhler

    Dekan

  • _______________________________

    To Johani, Flrli and Anne-Kthi

    _______________________________

  • Without our realizing it, medicine has carried us into the social sphere, there to meet up with

    the great problems of our time. Let us be well aware that we are not concerned here with the

    treatment of a patient by means of medicinal remedies and the adjustment of his home

    environment. No, we are dealing with the entire culture of a million and a half of our fellow

    citizens who have been physically and morally degraded.

    Rudolf Virchow, 1848

    (quoted by Nuland, 1988)

  • TABLE OF CONTENTS

    Acknowledgements............................................................................................................... iSummary.............................................................................................................................. vZusammenfassung.............................................................................................................. viiiGlossary.............................................................................................................................. xiiList of tables and figures................................................................................................... xiv

    PART I INTRODUCTION.................................................................................... 1

    Malaria: a top priority......................................................................................................... 2

    A brief history of malaria..................................................................................................... 5Early descriptions and treatmentsThe discovery of the host-vector-parasite triangleMalaria history and community knowledge

    Malaria: a biomedical perspective....................................................................................... 8Clinical presentation

    Severe and fatal malariaDiagnosisPrevention and treatment

    Preventive measuresChemotherapyParasite resistanceArtemisinin and drug combinations: Increasing the lifespan of antimalarialsVaccine development

    Malaria in highly endemic areas........................................................................................ 19Acquired immunityMalaria in children under five years of age

    ImmunoprotectionClinical patterns and transmission intensityClinical attacks and recurrences

    Efforts to control malaria................................................................................................... 23100 years of combatting malariaCurrent global malaria control strategyHealth Resources for All: resources to reach people, people to reach resources

    Lay perspectives and treatment-seeking for malaria in Africa: Literature review..........31Lay perspectives on malariaTreatment-seeking for malaria in the context of medical pluralismFactors for delay in attending prompt and adequate treatment for malaria

  • PART II GOALS AND OBJECTIVES............................................................. 39

    PART III STUDY SETTING AND METHODS............................................... 42

    Study setting........................................................................................................................ 43Malaria in the study areaMedical pluralism in IfakaraHealth information about malaria

    Methods.............................................................................................................................. 48

    PART IV COMMUNITY UNDERSTANDING AND TREATMENT-SEEKING FOR MALARIA................................................................ 52

    Outline of papers................................................................................................................ 53

    Paper 1 Medical syncretism with reference to malaria in a Tanzanian community................................................................................................... 57

    Paper 2 Illness naming and home treatment practices for malaria -an example from Tanzania.......................................................................... 81

    Paper 3 Fake malaria and hidden parasites - the ambiguity of malaria.................99

    Paper 4 Cost and affordability of traditional and government healthservices in Tanzania: policy implications of a paradox.............................122

    Paper 5 Women, seasons, and resource-seeking for treating childhoodfevers and malaria - case studies from an African community................138

    PART V GENERAL DISCUSSION AND CONCLUSION 157

    Malaria control and studies in treatment-seeking........................................................... 158

    From folk illnesses to medical syncretisms: rethinking the traditional -modern dichotomy............................................................................................................ 161

    Normal malariaDegedegeMalaria and witchcraft

  • Traditional treatments: a source of delay in obtaining adequate care?..........................165

    Traditional treatments and implications for interventions..............................................168Interventions targeted at the general publicInterventions targeted at traditional healers: implications for referral systems

    The tools are there, but where are the means?Economic obstacles for treatment-seeking....................................................................... 172

    Implications for future research....................................................................................... 174

    Recommendations for action............................................................................................ 176Community level: improve informationCommunity level: broader approachesTraditional healersHealth institutional level

    Conclusion......................................................................................................................... 182

    References.......................................................................................................................... 184

    Appendix........................................................................................................................... 206

    Curriculum Vitae.............................................................................................................. 230

  • Acknowledgements

    -i-

    Acknowledgements

    My most sincerest thanks are expressed to all members of the community of Lipangalala,

    its local leader Mr. Kassim Njohole, and all informants who collaborated in this study. Particular

    thanks go to the many mothers who interrupted their daily activities for talking and to me and

    my research team. Their hospitality, and the many hours spent together with them, made this

    work an outstanding experience which has deeply impressed me. Many thanks also to the

    traditional healers who shared their knowledge on traditional medicine with me and allowed me

    to observe and participate in their healing rituals. Kwa wote, ahsanteni sana!

    Very special thanks are addressed to my supervisors Prof. Marcel Tanner (Director of

    the Swiss Tropical Institute) and Prof. Mitchell Weiss (Head of Department of Public Health and

    Epidemiology of the Swiss Tropical Institute) for their support and the many fruitful discussions.

    Prof. Tanner animated me to shift from the hard sciences of biology to the soft sciences of

    medical anthropology. His advice and support to do the MSc course of Medical Anthropology

    at Brunel University changed not only my professional, but also my personal life (resulting in

    a joyous family with one child and another one expected). His stimulating discussions and

    inspiring comments throughout the thesis greatly encouraged me, both during the field stay and

    during the onerous writing up phase, and his continuous support motivated me to complete this

    work. Dir ganz herzlichen Dank.

    My most heartfelt thanks are directed to my husband Joan Muela Ribera who was

    without a doubt my greatest supporter, in all possible ways, during the entire thesis work. He

    accompanied me in the field where for short periods of time his endless thinking and reflecting

    was interrupted by concentrating on learning to ride a bicycle (which was only partly successful).

    He significantly shaped this work in stimulating discussions (and sometimes even more

    stimulating disputes) nearly 24 hours a day, and by enriching the work with anthropological

    perspectives. Even more important was his emotional support, also nearly 24 hours a day. Moltes

    gracies per tu.

  • Acknowledgements

    -ii-

    Many thanks are expressed to the research assistant Mr. Adiel K. Mushi, an enthusiastic

    sociologist from the Sociology Department of Dar-es-Salaam University, whose empathy with

    the community was outstanding, and the local translator and cultural broker Mr. Athumani

    Ngongowele, who organised sim