Research Director,
French National Centre for Scientific Research (CNRS)

“Interactions between populations, health workers and health programmes for prevention of malaria: teachings of an analysis « from below »”.

Un texte publié dans, Fostering innovation for global health. Global Forum Update on Research for Health Volume 5, pp, 76-679. Global Forum for Health Research. United Kingdom : Pro Brook Publishing Ltd., 2008, 192 pp.

One of the most accurate ways of qualitatively  evaluating a health situation consists of analysing it  from the point of view of diverse social groups who are  supposed to benefit from the development programmes  and who also physically feel the difficulties of their situation  each day.

Of course, one must beware of succumbing to a “populist”  approach or confusing the “actors oriented” position with a  naive approval of what could be considered as “traditional” or  unanimously shared homogeneous “communitarian” opinions. Populations everywhere are pluralist and always  manifest economic inequalities, contradictory cultural options  and political conflicts [1]. To put it simply, nothing is ever  “communitary” or “traditional” : everything is always  “political” and “historical”.

Besides, if various “laymen” behaviours are socially  explicable, this cannot mean that they are coherent and  commonplace from the health angle. Having reasons for  acting in a certain way cannot be synonymous to right action,  and a good number of causes of infantile and maternal  mortality find their explanation in harmful popular  behaviours. But once these precautions are taken, the  approach “from below” is indispensable because it permits  the shift from “global” to “local” and allows the study in situ  of how big strategies conceived by international institutions  come to install themselves in the ordinary course of lives and  in social practices that impact on health.

These ordinary dimensions of daily life are often ignored by  research or development programmes. And if the technical  goals of “projects” benefit from a lot of attention, these social  dimensions are evoked only very erratically under the  term “context”. The error here is obvious, since this term in  fact designates a set of essential variables: how one eats, lives, sleeps or washes… in short, the “context” that we have  not yet taken the time to study is simply “all that is social”,  and that nevertheless determines and explains the essentials  of the actors’ behaviours.

Methodologically, this qualitative approach “from below” corresponds to several theoretical models that emphasize the  links between “sociological reasoning” and its socio-historical  environment [2]. It is sufficient here to mention “thick  description” that aims at describing and analysing the links  between actions and the meanings given to them by their  authors [3] or micro-history that identifies invisible structures  according to which the actors’ experiences are articulated [4].

Concretely, in the framework of the application of health  programmes, this position enables two vital processes. It first  permits the comparison of words used by “developers” and  the realities they are supposed to designate. In short, it  permits us to know if the notions used to define health  strategies have a “real” reference or if they are mere “paper  words” designating only the rhetorical universe of “projects”  and “seminars” [5]. Consequently, this position permits us to  analyse the applicability of theoretically conceived health  measures in real situations – more precisely, in their “contexts”.

Proposals and difficulties of malaria
prevention programmes

Let us briefly recapitulate the situation. Globally, various  preventive strategies for limiting the morbid effects of malaria  – besides vaccine research – have three objectives that imply  broad fields of activities, with unfortunately as many specific  difficulties [6].

(1) To begin with, establishing an early diagnosis can  permit a rapid and satisfactory management of the disease  and the necessary observation of the treatment. However,  forms of resistance to antimalarial measures that have been  observed give the impression that the treatment is not always  appropriate to the complaint as would be desired.

Questions of quality of health offer and mutual  understanding between populations and health personnel are  essential here.

The exchange of health information always implies a  translation of the doctor’s technical medical vocabulary into  the laymen’s representations of the illness. This difference  between reference systems explains the great number of  difficulties of mutual understanding between health teams  and populations. This is accentuated by the fact that in a  number of countries, the scientific language used (most often  English or French) is different from the language ordinarily  employed by people to express themselves. In this case,  when local languages do not possess a true scientific lexicon  and medical terms, the health dialogue requires multiple  interpretations and adaptations of the terms used. Health  dialogue can then be described as a confrontation between  two semantic systems bringing about different classifications  of the pathologies.

Several “distortions” will then result. Some diseases like  malaria, distinguished by the medical discourse, can be  conceived by populations as constituting a single morbid unit  (“diseases of fever”) and hence interpreted wrongly as  benign. Reciprocally, several clinical signals defining a single  medical syndrome can be distinguished by populations as  many different illnesses.

Lack of scientific analysis of these laymen interpretations  of the disease and its treatments have made confusions  between health teams and populations more of a norm than  an exception. Yet, populations can only adhere to the  prevention of what they can label and understand. Very  broadly, these constant divergences prevent the  establishment of a true health dialogue and encourage  populations to have recourse to popular remedies or  “informal chemists” [7] – economically more costly than  judicious medical treatments, but culturally closer to  the populations.

To put it plainly, following the treatment and resistance to  new molecules is largely a matter of communication and  quality of the health offer.

(2) Preventive measures must then be planned and  implemented particularly for “risk” groups, such as pregnant  women. Bednets and insecticide-treated curtains used for  some years seem to constitute an effective means. However,  they are still little used in Africa outside “pilot” programmes.  This is simply because “bed manners” defined according to  kinship, the status of the child or ill-adapted architecture,  gradually deconstruct and dilute the theoretical coherence of  health “messages”.

Thus, preventive proposals are remodelled by the ordinary  course of things: bednets are torn during children’s games,  intense heat prevents people from sleeping under the net,  sexual intimacy leads to children being kept at a distance,  mosquitoes breed in beds with boards, the status of elders  reserves bednets for seniors.

These ordinary norms and daily actions construct  references for a way of living. This is why impregnated  bednets are used in the frame of restricted programmes –  when “the project” plays the role of a reminder for the new  norms proposed. But their effectiveness diminishes when  new actions imposed by this innovation are eroded or  demolished by the routines of daily behaviours.

(3) Finally, from an administrative point of view, the  multiplicity and “verticalization” of programmes makes  their harmonization difficult. It often leads to confusion  among populations and provokes iatrogenic effects  like the constant transfer of health personnel towards more  “profitable” programmes.

An economy of “projects” is in evidence everywhere  (bonus, daily allowance, transport) along with a  misappropriation of health personnel towards public health  that is considered more advantageous [8].

Thanks to various health education campaigns, there has  been a real improvement of knowledge about the role of the  mosquito in particular and the advantage of bednets. But this  new knowledge does not “automatically” lead to new practices. Unfortunately, it must be admitted that little  change has been noted in the presence of malaria in the  zones of highest transmission. This is particularly so in Africa  where the appearance of new resistances and new “urban”  forms of the disease has been noted [9].

New trails?

Naturally, programmes once begun must be continued and  attempts made to diffuse these health proposals that are  really new body practices [10]. But, if one agrees with what has  been affirmed here, three other broader paths that can only  be briefly mentioned here must also be considered.

(1) A political ecology: between public and private spaces: constructing a healthy city

Several dimensions are interlinked and must therefore be  treated together. The rapid growth of urban population [11], the  transformation of malaria features, the great social  inequalities as well as the common presence of other  pathologies (dengue, chikungunya, schistosomiasis,  trachoma, etc.) give a global dimension to parasitical and  infectious risks in new urban spaces.

In other words, although the rural world cannot be  abandoned, a large number of new health questions are  linked to the specificities of contemporary mégapoles [12]  where 72% of the population of Africa lives in  unsanitary conditions [13].

In short, it is obvious that no progress in malaria  prevention will occur without conducting a solid reflection  involving urbanists, architects, doctors and specialists in  social sciences on the various ways of constructing “healthy  cities” rather than “pathogeneous complexes”. Several fields  need to be examined here.

Public spaces must be analysed and their general  management improved [14] [15] [16] [17]. It is necessary to understand  the various ways in which public policies and occupation  of “lived spaces” are articulated depending on  the territories [18] [19] [20]. Once again, to put it simply: it is  ridiculous to ask the poor and destitute to protect themselves  when open drains run across the cities.

Simultaneously, in private spaces, more adapted  architectures could be developed. Indeed, the diffusion of  architectural models – use of tin and cement – particularly  unsuited to the extreme heat of tropical climates, besides  being an ecological absurdity, renders the regular use of  bednets illusory.

As was the case for tuberculosis or all water-borne  diseases, the struggle against malaria is thus linked to a policy of habitat. Although this cannot be detailed here, two  essential points must be mentioned that encourage  populations to take care of their environment.

First of all, access to property must be developed. This  alone can guarantee the time required for planning and  impart a desire to improve one’s environment.

History also teaches us that transformations of space owe  more to aesthetic reasons than to health guidelines.  Therefore, new norms combining beauty and function must  be diffused [21] [22].

Globally, these multiple dimensions, mainly economic,  sanitary and urban, must orient a real reflection on the  political ecology of the disease [23].

(2) University and continuing education concerned with  contexts of healing practices

More specifically, the dialogue between health personnel and  populations must be improved. But if this dimension is  recognized as essential in the texts, practically no teaching –  initial training – dealing with the complex links between  languages and popular behaviours versus sanitary proposals  is proposed in faculties of medicine or paramedical schools.

Ehnolinguistic works on the body and on disease [24] [25]  should be used – not as a “curiosity” or a social “plus” – but  in order to initiate a real reflection on conditions of future  healing practices in a specific environment. Let us put this  even more simply: is good medical advice if not understood  or applicable by patients “good advice”?

The most common practices refute the precepts taught,  thus reducing teaching to a purely rhetorical exercise. For  example, practically no hospital in sub-Saharan Africa uses  bednets despite recommending their use. If requirement  levels shouldn’t be lowered, nonetheless concrete questions  must be raised about the suitability of “basic material” for  local conditions of practice (linguistic uses, specific forms of  organization of work, etc.).

(3) Intitate better coordination of development policies and  help clinicians remain at their posts

The following three observations counteract the  “verticalization” of health programmes and would thwart  iatrogenic effects of health development projects.

First of all, it is culturally of little relevance to treat  “nuisances felt” requiring similar “defensive barriers”  (malaria, dengue, chikungunya) separately.

Next, work on the causes of parasitic infections would  permit action on common initial causes largely linked to  water and hygiene.

Finally, clinicians could be helped to remain in their  departments rather than encouraged to join different, more or  less temporary, specific programmes of “public health”.

The struggle against malaria depends largely on how aid  and development policies are conducted. A better  coordination of programmes, the pooling of means,  enhancing actions and grants of research subsidies granted to  practitioners who despite their low salaries and difficulties  continue to work with sick people, would be an essential aid.

To conclude, at different levels all authorities interact with  various health programmes. Consequently, helping local  authorities comes down largely to thinking about ways of  promoting an offer of quality health.

Yannick Jaffré worked as an anthropologist in West Africa for  20 years. He collaborated with public health teams, conducted  many anthropological research projects focused on health priority  and taught in many African and French medical faculties.

He is now Research Director at the French National Centre for  Scientific Research (CNRS – UMR 6578) and responsible for  PhD teaching in health anthropology in SHADYC (Sociology,  History and Anthropology of Cultural Dynamics) in a French social  sciences high school (EHESS). Yannick Jaffré has written many  books and articles about disease in West Africa and the  relationships between health-care providers and users.