"C'est le palu qui me fatigue" : une étude en l'anthropologie de la santé sur les conceptions et les pratiques locales face au paludisme à Abidjan, Côte d'Ivoire

Malaria is the most frequent reason for consultations in Côte d'Ivoire's health centres. In the year 2004, 57% of all medical cases were attributed to malaria. The resulting social and economic burden for the local population is considerable.
This medical anthropology thesis aims to better understand what malaria means for the inhabitants of the city of Abidjan and how they deal with it. More specifically, the thesis pursues the following objectives: (1) to examine the experiences, meanings and practices in everyday life of adults concerned with the illness, (2) to compare the distribution of these topics in an urben squatter settlement and a middle-class area, (3) to study what meanings and practices constitute for an episode and (4) how they have changed over time.
The study is located in Abidjan, the economic capital of Côte d'Ivoire, and more precisely in the municipality of Yopougon. The rapid urbanisation of the area began in the 1970s, and today Yopougon is home to already over one million inhabitants. The development of the urban infrastructure could not keep up with these fast population changes. In the context of the research project NCCR North-South, this study was carried out in a squatter settlement, a quartier précaire, and a neighbouring middle-class area.
The study combines classical anthropological methods and methods of cultural epidemiology. The ethnographic data were collected between 2003 and 2005 during a total of 13 months of field work. Ethnography included interviews, formal and informal discussions, literature review and participant observation. A semi-structured interview catalog (EMIC interview) based on cultural epidemiology was developed and used in interviews with 160 adults. In each area, 80 men and women were randomly selected, all of whom had experienced a self-diagnosed malaria episode within the last fortnight.
The results illustrate that the biomedical term for malaria found its way into the local illness terminology. The abbreviation "palu" for the French term "paludisme" (malaria) is frequently used in everyday interaction. However, a more thorough analysis shows that even when the same word is used in the professional and the local context, the meanings only corerspond to a certain degree. There is an overlap between the biomedical and the local classification. The local use of the term essentially covers a much wider range of meanings. experiences and treatment options than the original biomedical term. Fever as a symptom does not have an outstanding position, but represents only one of numerous signs.
The concept of malaria was appropriated in a process during which an expansion of its meanings took place. The theoretical framework of appropriation, understood as an active process of interaction that makes something one's own, is most useful to trace this developent and its results. For this urban population, the causes of palu are not limited to the parasite transferred by the mosquito, but they refer in particular to people's living conditions. Bad housing conditions shaped by environmental risks due to an insufficient infrastructure or difficult working conditions are experienced as causes of the illness episode. Furthermore, food that does not correspond to the local ideals can lead to palu. The people affected by palu express thus through palu a malaise that is due to a general vulnerability anchored in this urban field. In a more abstract sense, palu becomes an embodied metaphor for the adversities that people experience in their everyday life.
During the process of appropriation, not only the meanings but also the possible treatment options were expanded. The health system for Abidjan offers a great diversity of treatment options ranging from university hospitals to Chinese drug sellers offering their produts at the roadside. For the treatment of palu, pharmaceuticals from official as well as illegal pharmacies and local herbal medicines are the most commonly used products. Self-treatment plays thereby an important role. Local herbs and pharmaceuticals were used by 63% and 52% of the study participants respectively in order to fight their episode. Health services were visited mainly in combination with self-treatment. However, the study illustrates that overall only 28% and 42% received appropriate malaria treatment within 24 and 48 hours, respectively, of the onset of symptoms. Additionally, results show that inhabitants from the poor area had significantly less access to timely and appropriate malaria treatment compated to inhabitants of the middle-class area. Although spatial proximity to high-quality treatment exists in the urban context, access to it is not ensured. On the one hand, this can be blamed on factors, which concern the quality of care. The sold drugs do not correspond to the current treatment guideline and many private facilities are not equipped with the qualified personnel and material to diagnose and treat malaria appropriately. Above all, the moment of interaction between private health providers and their clients is not taken advantage of by the providers to advise the customers regarding adequate treatment.
On the other hand, the study shows how social context and cultural concepts of illness may be considered in explaining timely and appropriate treatment for malaria. The expansion of the malaria concept and its relative treatment possibilities through appropriation incorporate the risk of over- and mistreatment. The complex interaction of these different factors therefore affects access to a successful cure.
The restults illustrate that the improvement of access to effective malaria treatment must make it easier for patients to select the appropriate treatment from the broad urben offer. On the one hand improvements of the quality of the care are necessary. Training of health staff and, in addition, a clear marking of appropriate medicines is central. The introduction of the new ACT-antimalarials should be limited to products that are clearly identifiable as recommended therapy. This improvement will allow making an informed choice for home management. The introduction of new drugs must be accompanied by close monitoring of information, education and communication campaigns. Thus, the appropriation process of these products is to be controlled in order to be able to limit an extension of their meanings as much as possible.
On the other hand, multi-layered interventions are necessary to reduce the general vulnerability of city dwellers with regards to palu. Improved work and housing conditions as well as a reduction of the urban environmental risks are indispensable.