Naiti residents’ expectations about the quality of treatment also influence how families engage with local health systems. A majority of respondents believed that good treatment, traditional or biomedical, ought to induce diarrhoea and/or vomiting, because they assumed severe fever to result from a clogging of the gut. Therefore, good medicine needed to contain purgative properties or intestinal side effects (see also Carruth, 2014). In a focus group discussion, one elderly woman told me that:
The paracetamols do not clean your gut, so you have to drink fresh milk regularly to clean up and get the fever out of your system. That’s why us herders, we do not like going to hospital regularly. It is because the Western medicine is not good for your gut, it clogs you up.124
122 Interview, Naiti, 16 May 2017. 123 Ibid.
Some respondents openly discredited the services at the local dispensary, which they believed were not good because the doctor “only talks to you and does not use machines to check your pain”,125 even though they simultaneously used this service, and they would buy drugs from an unlicensed seller who obviously did not have diagnostic tests or training. This desire for better healthcare and diagnostics points to broader issues regarding the inherent limitations in Tanzania’s healthcare system, explained in Chapter One. This is not unique to Naiti or indeed to Tanzania but is apparent across sub-Saharan Africa. For example, Carruth (2014) found that Somalis in the agro-pastoral Somali region of eastern Ethiopia also harboured anxieties about the poor quality of healthcare in rural health posts. She interviewed a patient who explained:
We do not trust those pills [from the recently opened health post] … we do not have any idea about where medicines are from. When they [a medical aid organisation] left we have a big problem about malaria or a severe cough, if you have those diseases you cannot just go to the clinic here… they do not have a laboratory, so now we have a big problem. (Carruth, 2014: 411)
In Naiti, pharmaceutical drugs are easily accessed through the village kiosk or in nearby markets such as Makuyuni. Participants preferred buying these medicines rather than going to the village clinicbecause the facility did not have enough medicines to give out to patients, and the medicine that was available at the clinic was more expensive than from the kiosk. I caught up with one patient who was buying medicine at the local kiosk and she explained that:
I can easily buy medicine from the kiosk instead of going to the doctor because they make you wait for a long time, and then in the end they sell you the same medicine that you get cheaper at the kiosk.126
Patients and their care-givers oscillate between herbal and pharmaceutical treatment regimes, sometimes within a single illness episode. The clinician suggested that lay health providers misled patients about their symptoms, which delayed effective treatment. But as Marsland (2017) argues, biomedical practitioners who criticise lay healing techniques, like Naiti’s clinician, may fail to see how their own practices are situated within the local cultural framework. They contribute to shaping and are shaped by patients’ awareness
125 Interview, Naiti, 14 July 2017.
126 Interview with male patient, 6 June 2017. He believed that he had pneumonia and bought antibiotics to treat it.
and perceptions of inadequate official provision for, and support of, health facilities. Among Naiti’s residents, although febrile illness is more common in the wet season, when the water pools in rocks and other spaces close to olmareis, and bushes grow thick outside homesteads and herds graze close to homes, none of the participants linked local illness categories of “malaria” to mosquito bites. Self-treatment of severe illnesses, including those perceived to be malaria, was widespread, often using a mixture of traditional and modern pharmaceuticals, as has been found to be the case in other sub-Saharan African settings (see Jephcott, 2013; Beiersmann et al., 2007). Kunda et al.’s (2007) study of febrile patients with brucellosis in northern Tanzania found that patients delayed going to hospital, with a median delay of 90 days and with 20 per cent of cases presenting to hospitals more than a year after the onset of symptoms. As shown above, the reasons for this are complex, relating partly to how illness is classified, partly to financial and infrastructural resources, and partly to social and cultural processes of diagnoses. It can be deduced, from the interpretation and classification of febrile illness in Naiti, that seeking treatment for “severe” febrile cases manifesting as homa kali are more common among younger males (see Table 5.1). In Chapter Five, I showed the demographic characteristics of patients who presented at the health facility in Naiti suffering from homa kali. Over half were under the age of fifteen and were predominantly male. The main reason for these demographics, as I mentioned before, is that families are keen to take these young boys to the clinic because of their role in herding and wanting them to recover quickly so that they can continue their herding chores. Another possible reason for their presentation at formal health facilities could be school attendance, as these boys sometimes attend school (and herd outside schooling hours), where they may learn about their health and access to health services (see also Kunda et al., 2007).
These boys are also more exposed to livestock and thick bushes, where they graze the stock (explained in Chapter Four). As the boys herd full-time, they are constantly interacting with animals. They also consume uncooked milk direct from the cows (and goats) during grazing hours. It is therefore possible that they come into frequent contact with sick animals, resulting in infections that cause “severe fever” and which prompt them to seek medical help (see Crump et al., 2013).
Lastly, homa mpya, “new/unusual fever”, is the syndrome about which little was known in the study area. This illness did not exist in the historical body of illness experiences
and the assumption therefore was that homa mpya was not “indigenous” to Naiti, whereas the other two categories of illness (“ordinary” and “severe”) were. This perhaps explains why many patients who spoke about homa mpya sought treatment through formal health services. Despite this clear interest in seeking health treatment, when fever was deemed either serious enough or novel enough to require expert intervention, health-seeking was non-linear and complex, involving an interplay of social, infrastructural, economic and power dynamics. This complexity is important to bring out as it furthers understanding of why a focus on technical solutions for health problems may be insufficient to reduce the burden of zoonotic disease in agro-pastoralist societies.
6.7 Conclusion
Zoonotic control measures emphasise changing lay habits, such as careful preparation of food for consumption and limited interaction with impaired animals, as ways to reduce transmission of diseases, without considering the complexities and negotiating processes involved in health-seeking. As this chapter shows, biomedical approaches would have limited impact in places like Naiti where illness is experienced collectively and socially. People’s health beliefs influence how symptoms are perceived based on the physical (symptom categories), personal (patient profile), historical (experience of previous illness) and social (socio-cultural) contexts within which illness occurs. Some people may choose to live with rather than seek to ameliorate symptoms if they or others in their social network believe that the symptoms do not constitute a serious health problem warranting medical attention. But where symptoms are believed to be serious and a cause for concern, response and actions are influenced by the immediate material conditions that the patient and his or her family find themselves in. Lay referral networks may put pressure on a patient to seek remedies (based on perception and interpretation of the illness) and help with mobilising resources for the patient, to seek professional treatment, or even share past illness experiences upon which treatment can be based. Decisions to approach family and friends or engage in self-treatment or visit a clinic are influenced by inter- and intra-household relationships and interests. Whether people treat themselves or consult family, friends or medical services is complicated further by other factors such as support for health-seeking, ability to secure financial resources, and access to, availability of and quality of healthcare.
many factors, including the type of illness and perceptions about its severity, who it affects within the household, access to what therapies and for whom, and the perceived quality of the service, as well as financial and infrastructural constraints and familial or household dynamics.
In Naiti, in some instances, residents may choose traditional healers and untrained village allopathic “doktas” above formally trained practitioners or government health facilities. In other cases, and upon consultation with lay referral groups comprising family and kin, they may decide that a particularly severe or new type of illness warrants professional and costly treatment. In all instances, gender and household power dynamics, social relationships, and the availability of income cause delays in and complicate decisions about healthcare options. Neither route necessarily offers a clear-cut trajectory back to health or a dependable means of dealing with zoonotic disease.
In conclusion, zoonotic disease interventions centring on the individual rather than the collective are unlikely to work (Strang and Mixer, 2015; Biehl and Petryna, 2013; Good, 1994). It is crucial to explore and understand how household and intra-household relationships impact care-seeking and health outcomes in places like Naiti. As illness is collectively experienced, treatment is defined by these processes. Appreciating these factors can lead to improvements in the design of health interventions, which could result in greater uptake by targeted populations.