healthmedicinet

Local definitions of uncomplicated malaria

The term ‘malaria’ was considered to be a ‘toubab’ (meaning ‘white man’) word – referring to the biomedical doctors’ expression – for
a sickness locally referred to as Kadjeh, Sainaabo, Fula Kajeo or Susula Kurango in Mandinka, Jontinooje or Kajeje in Fula, Samama Ntong Yea in Soninke (Serahule), and Sibirru in Wolof. Respondents unanimously described malaria as the disease that occurs during
the rainy season, the period “when the maize ripens” and “the period when people are
busy working on the farm” (October-December).

The term ‘malaria’ was described as an illness with a combination of some of the following
symptoms: fever, the person feels cold even though their body is hot, severe headache,
continuous vomiting of yellowish or greenish colour (“the colour of maize” or “leaves”),
lack of appetite, fatigue, and inability to work. At times additional signs were mentioned
such as “yellow eyes” and “the urine turning red”. Middle-aged or elderly individuals
would use ‘malaria’ for any condition of tiredness, fever and vomiting in combination
with any other of the above-mentioned symptoms, with no mention of diagnostic tests.
Conversely, among younger people, many stated that only a rapid diagnostic test (RDT)
test could confirm whether the sickness was actually malaria.

Although many people equated malaria to their local ‘translations’, sometimes these
were perceived to be different diseases to malaria, but with similar symptoms (Table 1). For example, in certain North Bank study sites (Upper River Region) study participants
frequently reported that malaria was a very serious disease caused by mosquitoes but
could be easily treated at the health centre, whereas Jontinooje/Kajeje (malaria in Fula) was a very common disease of unknown cause.

Table 1. Quotes illustrating perceptions of different disease categories

Perceived aetiology of malaria

General cosmology

According to local Gambian cosmology, sickness is considered to be caused by either:
i) an agent or micro-organism inside the body that is detectable by biomedicine (such
diseases are called kura? keso in Mandinka); or, ii) by supernatural forces, originating “outside the body”, that
are undetectable through biomedical diagnosis (called ming kesa sande). Examples of these are “foul wind” (fonyo jawo) and illnesses caused by Jinne spirits or witchcraft. This classification directly affects consequent treatment-seeking
itineraries. In addition, several perceived causes may co-exist or inter-relate and
require a combination of treatments.

Uncomplicated malaria

Uncomplicated malaria is categorized as kura? keso. When participants were asked what the cause of malaria was, almost all responded
that mosquitoes were involved in the sickness. However, mosquitoes were not believed
to be the only cause of malaria. Further singular causalities were: i) climate-related
factors such as the cold (“the cold coming from the ground when you don’t wear shoes”;
“when the cold wind blows and you are sleeping outside”); ii) infection, as in direct
contact with other infected people (i.e., sharing a calabash with someone who has
malaria, sleeping next to someone who has malaria, transmission from animals); iii)
hygiene (dirty hands before eating food); iv) certain foods such as sour milk, sorrel
(hibiscus) that is not cooked properly, oily food, “jumbo” food flavouring; and, v)
malnutrition. Those who did not think that malaria was the same as local illness categories
(e.g. Jontinooje, Kajeje) said that they did not know what the cause of the disease was (Table 1).

Severe malaria

For symptoms suggesting severe malaria, such as convulsions, fainting, disorientation,
and confusion, the illness was often attributed to the affliction of supernatural
entities or factors “outside the body” (ming kesa sande), such as Jinne or witches.

Jinne are non-human spirit creatures that are believed to inhabit the world alongside humans.
All questioned participants believed in them and, because they are mentioned in the
Holy Koran, their existence is indisputable for local Muslims. Jinne are said to be invisible to humans under ‘normal’ circumstances and do no harm although
some ‘bad’ Jinne can afflict human beings, causing aggressive behaviour, ‘madness’ and mental illness,
sickness or death by ‘attacking’ a person through ‘wind’ or in ‘unsafe’ places in
the bush. Jinne are commonly believed to dwell in trees in the bush and attack specifically vulnerable
people, e.g., pregnant women walking through their territory. However, a Jinne may attack anywhere and no place is completely safe. Most of the symptoms described
match the clinical presentation of severe malaria or other serious diseases, such
as meningitis or septicaemia (Table 2). Mentally unstable or developmentally disabled individuals (including children)
are believed to be possessed by Jinne. Their state of mind is said to depend on the Jinne’s moods and the extent to which the marabout’s treatment is driving the force of the
Jinne out of the body. Marabouts are well-respected religious figures across West Africa
who specialise in Islamic and non-islamic spiritual matters such as prayers, healing,
clairvoyance and other rituals around life and death.

Table 2. Quotes illustrating perceived symptoms ofJinneattacks

Witchcraft is another malaria-related aetiology. Whereas Jinne are non-human creatures, buwaa or sukuñaabe are humans that metaphorically ‘eat’ other human beings. In English, Gambians mostly
call them ‘witches’. The buwaa possess a quality that makes them addicted to spiritually consuming other human beings
– ‘sucking out’ their life force until the victims get very sick and die. A Wolof
marabout explained this process the following way: “You know if you put the insect
in a small container with a groundnut, it will suck away all the liquid contained
in the seed. That is the same way that the witches operate”. Witches are said to “like
to get involved” when someone has malaria and “finish off” the sick person. The symptoms
someone experiences when attacked by a witch tend to be mainly described as rib pain
(Table 3). Most respondents, however, say they do not know how witches operate and how they
eat people. An experienced marabout explained that “witches have two different kinds
of eyes, the eyes of darkness and the eyes of day light – just like a normal human
being. When you place an opaque bottle here and put something inside, the witch will
see through and know what it contains. Before it attacks a person, it will see all
the organs that are in the human body […] that is the reason why if you are with a
person who is suspected of being a witch, don’t allow the person to be at your back,
instead ask the person to stay in front and then follow him so that it will not see
through you.”

Table 3. Quotes illustrating perceived symptoms of witchcraft (Buwaa) attack

The above-mentioned supernatural entities are said to cause ming kesa sande sicknesses, and are believed to commonly afflict individuals through “foul wind”
(fonyo jawo in Mandinka and heendu bonndu in Fula). Gambians speak of foul wind in an unspecific way when it is unknown what
kind of creature (Jinne or witch or other) is believed to have caused sickness (e.g., malaria).

The diagnosis and treatment of uncomplicated malaria

Different diagnostic methods of detecting malaria and, consequently, perceptions of
who is capable of effectively doing so, co-exist. Participants who thought that an
individual had malaria as soon as they had symptoms of tiredness, severe headaches
and vomiting, believed that the best treatment was biomedical and it would be necessary
to attend a health facility. Some individuals, particularly the older ones (65–90
years of age), would consume natural treatments prepared from tree bark as soon as
they felt “malaria was coming on”. However, they still felt that biomedical treatment
was more effective as it got rid of the symptoms “within three days”. Those advocating
RDTs as the only reliable diagnostic method also believed in biomedical treatment.

Biomedical diagnosis and treatment

Health facilities were perceived to effectively diagnose and treat illnesses that
were understood to be caused by small infectious organisms in the body (kura? keso illnesses). If a person was thought to have ‘malaria’ a visit at the health facility
was thought to be required for diagnosis and treatment.

Traditional treatment

‘Herbal treatment’ or ‘trees’ (le??e ?alee?e, garab) were often consumed as first emergency treatment for sicknesses involving vomiting,
nausea, diarrhoea, stomach pain, until funds had been raised to take the sick person
to the health centre. The middle-aged (35–65 years of age) and older generations (65–90
years of age) were used to consuming natural treatments for weakness and tiredness.
It was common to put the leaves of some trees or bushes in the bathwater to refresh
the body when suffering from tiredness. In all households there were individuals who
could point out where in the neighbourhood their source of healing trees or bushes
were positioned. The advantage of using herbal treatment or ‘trees’ was that it was
free and readily available at all times without having to consult a doctor or marabout.
However, younger respondents (15–35 years of age) stated they did not like the taste
of these trees and preferred to attend a health facility or buy paracetamol. Almost
all respondents said that they stopped consuming herbal treatments as soon as they
had been prescribed biomedical treatments.

In cases when malaria was not perceived to be the same as the local folk illnesses
(i.e. Kajeje or Jontinooje, often translated as ‘malaria’), respondents would not rush to the health centre
for diagnosis or treatment. They would only go if they thought that they were suffering
from something more serious (e.g., malaria) or if the symptoms were getting more severe.
They reported almost exclusively drinking tea made of the leaves of trees (particularly
eem tree and everdie) when suffering from Jontinooje/Kajeje (Table 1).

Access and affordability of biomedical treatment

An important reason for delay in treatment is related to the lack of financial resources
to travel to a health facility. Household heads in charge of financial resources were
reported to not make money for treatment available when a person was perceived to
suffer from a ‘mild’ ailment that may go away without treatment. It was not until
a person was perceived to be moderately to severely sick, i.e., if the patient was
bed-ridden and no longer able to work, that resources for transport to the health
centre or hospital were made available or borrowed. Respondents reported to rely on
herbal treatment as a first remedy for malaria while looking for the means to take
the sick person to the health centre.

The diagnosis of severe malaria

If a sick person was suffering from severe malaria involving hallucinations and unpredictable
behaviour, respondents agreed that these symptoms could be caused by supernatural
entities (witchcraft or Jinne) or foul wind and, therefore, it was important to consult a marabout for diagnosis
(Tables 2, 3 and 4). The marabouts’ methods of diagnosis are based on divination practices using either
the Islamic practice “listahar” or “black magic”. Both Islamic and “black magic” diagnoses are referred to non-specifically
as timgal in Fula and jeebero in Mandinka, which is interpreted as “to check yourself out” or ‘diagnosis’. In general people believe that most sicknesses or misfortunes are due to spiritual
blockages. Individuals suffering from fever and hallucinations are thus believed to
be suffering from a spiritual blockage inflicted by a Jinne or a witch or the evil deeds (black magic) of another person. If the individual is
seriously sick, it is crucial to identify what exactly has caused the blockage before
the person can recover. The correct treatment depends on the correct diagnosis by
a marabout. This means that a person suffering from severe malaria may not consult
a biomedical health practitioner because he/she believes that a spiritual blockage
inflicted by a Jinne or witchcraft is causing the sickness – a case for a marabout.

Table 4. Quotes illustrating perceived optimal treatments for malaria

The Islamic listahar is the most conventional method to diagnose blockages that does not involve black
forces. The marabout recites some prayers at night that inspire a dream in which God
lets the marabout know the cause of the disease and what remedies can cure the person.
Only a marabout with good knowledge of the Koran can use this method. Although this
is the most conventional method there are many other traditional non-Islamic forms
of divination to diagnose (timgal/jeebero) ‘blockages’, such as marking lines on a piece of paper or in the sand to diagnose
witchcraft. It is also common to throw cowrie shells, do palm-readings, use a calabash
filled with clean water and throw eight short sticks into the water while reciting
incantations and talking to the consulting person about their problems based on the
movement of the sticks in the water. None of the marabout respondents ever physically
examined their patients.

Spiritual treatment for severe malaria

The treatment given depends on the marabout’s family traditions and common practices.
Some marabouts use herbs from the bush while others just tell their patient what charities
they have to give. Once the marabout knows which Koranic verses will help the person
through the performance of listahar, he writes those verses on a blackboard or a piece of paper. If the verses are written
on a blackboard, the marabout wipes them off with a cloth and instructs the sick person
to put the cloth in a bottle of water with perfume. If the verses are written on a
piece of paper it is dissolved in the bottle with perfume. The person is instructed
to wash their body with such water twice a day for a recommended period of time. The
washing is believed to apply the needed Koranic verses onto the body and remove the
‘blockages’ that are making the person sick (e.g., the Jinne possessing the body or the soul-eater spiritually devouring the flesh). It is also
common to sew the piece of paper with the Koranic verses into a leather amulet to
be worn at all times.