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Doi:10.1016/j.trstmh.2005.08.003

Transactions of the Royal Society of Tropical Medicine and Hygiene (2006) 100, 515—520
a v a i l a b l e a t w w w . s c i e n c e d i r e c t . c o m j o u r n a l h o m e p a g e : w w w . e l s e v i e r h e a l t h . c o m / j o u r n a l s / t r s t Malaria treatment in remote areas of Mali:
use of modern and traditional medicines,
patient outcome

Drissa Diallo , Bertrand Graz , Jacques Falquet , Abdel Kader Traor´
Sergio Giani , Pakuy Pierre Mounkoro , Adama Berth´
Massambou Sacko , Chiaka Diakit´
a D´epartement de M´edecine Traditionnelle (DMT), Bamako, Malib Antenna Technologies, Geneva, Switzerlandc Centre National de la Lutte Contre la Maladie (CNAM), Bamako, Malid Aide au D´eveloppement des M´edecines traditionnelles (AIDEMET), Bamako, Malie Direction de la Pharmacie et du M´edicament, Bamako, Malif Direction Nationale de la Sant´e: Programme National de Lutte contre le Paludisme, Bamako, Mali Received 5 April 2005 ; received in revised form 17 August 2005; accepted 17 August 2005Available online 17 October 2005 KEYWORDS
Use of official health services often remains low despite great efforts to improve quality of care. Are informal treatments responsible for keeping a number of patients away from standard care, and if so, why? Through a questionnaire survey with proportional cluster samples, we studied the case histories of 952 children in Bandiagara and Sikasso areas of Mali. Most children with reported uncomplicated malaria were first treated at home (87%) with modern medicines alone (40%), a mixture of modern and traditional treatments (33%), or traditional treatment alone (27%). For severe episodes (224 cases), a traditional treatment alone was used in 50% of the cases. Clinical recovery after uncomplicated malaria was above 98% with anytype of treatment. For presumed severe malaria, the global mortality rate was 17%; it was notcorrelated with the type of treatment used (traditional or modern, at home or elsewhere). Inthe study areas, informal treatments divert a high proportion of patients away from officialhealth services. Patients’ experience that outcome after standard therapeutic itineraries isnot better than after alternative care may help to explain low use of official health services.
We need to study whether some traditional treatments available in remote villages should beconsidered real, recommendable first aid.
2005 Royal Society of Tropical Medicine and Hygiene. Published by Elsevier Ltd. All rightsreserved.
∗ Corresponding author. Present address: c/o le Chˆateau, Galland, 1374 Corcelles-sur-Chavornay, Switzerland.
E-mail address: bertrand.graz@chuv.ch (B. Graz).
0035-9203/$ — see front matter 2005 Royal Society of Tropical Medicine and Hygiene. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.trstmh.2005.08.003 1. Introduction
away from the nearest city and hospital of Bandiagara. The In Mali, attendance at community health centres often vast majority of inhabitants are farmers. In Kendi´ remains poor despite great efforts to improve quality of is a community health centre and there is also a tradi- care. Several explanations have been proposed: patients’ tional healers’ association. The health area of Finkolo AC lack of resources, long distances from home to the nearest is situated in Sikasso region, 40 km away from the region’s health centre, poor health services management ( capital, Sikasso, on the road to Burkina Faso. In Finkolo This situation seems common in Africa, and has there is a community health centre. In the area there are been related to the fact that modern medicines often remain many traditional healers, who are not organized in an asso- problematic in remote areas: even when apparently avail- ciation. Agriculture is the main economic activity in this able, they are often unaffordable, misused or even coun- 2.4. Population
From discussions with community representatives, we suspected that another reason could partly explain low A questionnaire was administered in households at the end attendance in community health centres: self-medication of the rainy season (high transmission period). As it is usually and traditional medicines might keep patients away from impossible to have just one person answering a question- official health services. We were able to test this hypothesis naire in a village, every interview was set up as a mini-focus through a case study: an enquiry about therapeutic prac- group (with the mother, and a few family members) about tices for children with presumed malaria, uncomplicated or one particular patient (age 0—16 years) and disease episode with a recall period of 2 weeks for an uncomplicated episodeand 6 months for severe malaria. Proportional cluster sam- 2. Methods
ples were drawn according to the population census andcontinuous civil records of the areas (Sample size was decided on the basis of the expected preva- 2.1. Study design
lence of malaria in the area, in order to find at least 600uncomplicated malaria cases.
This work was a collaborative programme between theDepartment of Traditional Medicine (National Institute of 2.5. Data collection
Research in Public Health, Mali) and Antenna Technolo-gies (Geneva, Switzerland). A population-based retrospec- As this study was, to our knowledge, the first of its kind (i.e.
tive survey, with questionnaires, was conducted in two rural with this attention to outcome and disease severity), we had districts in southern and eastern Mali. Field research was to construct and validate an original questionnaire. Several complemented by laboratory screening of the local treat- drafts were revised by malaria researchers, public health ments correlated with the best clinical outcome.
specialists, pharmacists, anthropologists, local health work-ers, malaria patients and parents. Then the questionnaire 2.2. Definition of malaria
was pre-tested in 34 houses, with similar ethnic composi-tion, adjacent to the study areas. Data were collected in Two perspectives were used and compared: popular knowl- edge, which is the basis for therapeutic decisions at thevillage level, and community health centre clinical defini- 2.6. Data analyses
tions. It was already known that in Mali popular knowledgedistinguishes between uncomplicated and severe malaria Data were analysed with EpiInfo 6 software (CDC, Atlanta, The clinical definition of malaria was based GA, USA), with ␹2 and Fisher’s exact tests for discrete vari- on national malaria policy; in community health centres, ables, and Kruskall-Wallis test for means.
where laboratory tests are not available, any fever is con-sidered to be malaria unless there is another obvious cause 2.7. Laboratory analyses
and any fever with coma or convulsion during the rainy sea-son or soon after is treated as severe malaria. Recent studies Samples of plants with the best clinical outcomes, deter- tend to increase reliance on clinical definitions of malaria, mined by analysis of correlation between outcome and in showing that Plasmodium falciparum parasitaemia is not well correlated with actual disease (some patients have Sikasso region. The plant parts used locally (e.g. stems and low parasitaemia and severe symptoms; others have high leaves) were extracted with water and organic solvents parasitaemia with no clinical disease) except for very high (dichloromethane, methanol and ethanol) at the Depart- ment of Traditional Medicine in Bamako. Extracts were freeze-dried and used for biological tests.
The extracts were tested for their IC50 (concentration 2.3. Study sites
inhibiting 50% of parasite growth) on cultured chloroquine-resistant P. falciparum (strain K1, stage IEF, Swiss Tropical The study areas were chosen in view of their relative iso- Institute, Basel, Switzerland). In these tests, the control was lation (long distances to the modern health centre). The Malaria in Mali: use of traditional medicines 2.8. Ethical aspects
The study was accepted by the Malian ethical committee.
It was conducted in retrospect because we were also inter-ested in severe malaria and its actual local treatments.
3. Results
Information to the local people and respect of traditionaletiquette resulted in a good acceptance of the survey: fromthe 483 households in the Bandiagara region and 469 house-holds in the Sikasso region, nobody refused to answer thequestionnaire, so the global response rate was 100%; somequestions, however, were not answered by 100% of respon-dents, as will be mentioned below.
Unless otherwise mentioned, results presented here are derived from pooled records from both regions (Finkolo andKendi´ e areas). Similarities in sample sizes and results justify Local designations of uncomplicated and severe malaria were in fairly close agreement with definitions based on clin-ical criteria and used in local dispensaries and health centres(86% agreement in Bandiagara, 98% in Sikasso region), thelatter being used for correlation analyses below.
ern medicine, see below) as first treatment was the rule foruncomplicated malaria (87% of 719 cases), with increasedrecourse to traditional healers and modern health centreswhen a second treatment was sought. For severe malaria(224 cases with a first treatment, 84 with a second), 55%started with self-medication, while visits to traditional heal-ers were relatively frequent (32 vs. 4% for an uncomplicatedepisode, P < 0.001). Modern health centres tended to receive Health services used for first treatment (1st Rx) more demands for severe episodes (13 vs. 9% for an uncom- and second treatment (2nd Rx) in cases of (A) uncomplicated In the case of uncomplicated malaria, more than 60% of the patients received treatment at the first symptoms. For lowed by oral administration as soon as possible; fumigation severe malaria, only 24% were treated before convulsions or and inhalation were often reported in case of severe malaria (35%) as a way of giving treatment to a comatose or convuls- that exclusive use of traditional medicine ing child, as well as massage with a plant-based ointment as first treatment was more common in severe malaria.
Exclusive use of traditional medicine was also the most fre- The trend was towards less modern treatment with more quent second treatment, whatever the type of malaria. The remoteness, which was statistically significant in the case traditional medicines used were mainly medicinal plants of severe malaria in the Sikasso region: among those liv- (91%), otherwise incantations and prayers (4%), or others ing more than 15 km away from the PHC centre (63% of the (3%). Patients with uncomplicated malaria that were treated sample) more than half (54%) started with traditional treat- with medicinal plants took them orally and as a bath in 95% ment only, compared with 33% among those living closer of the cases (fumigation 4%, others 1%). For severe malaria (P = 0.04). Modern treatment was more often sought when a treated with plants, 59% of patients had baths, usually fol- motor vehicle was available in the household (alone or with Number and percentage of patients receiving each type of treatment 1st Rx: first treatment; 2nd Rx: second treatment.
4. Discussion
Progress of patients after different treatments The objective of this study was to examine how and why use of home- or village-based treatments may keep patientsaway from official health services. For this, we studied ther- apeutic practices and subsequent patient progress in pre- sumed malaria episodes in remote areas.
Self-medication (modern drugs or traditional medicine) was the most frequent type of first treatment sought, even for suspected severe malaria. For severe malaria, traditional medicine was the only treatment used in half the cases.
After uncomplicated malaria, total recovery was above 98% with any type of treatment. For severe malaria, the global mortality rate was 17% and did not significantly differ with the type of treatment used. Some local products were sys- tematically associated with good clinical outcome and found to have medium to high in-vitro antiplasmodial activity.
Severity in itself was not a reason for seeking modern health care: only 24% of patients with severe malaria chosemodern medicine as their first option, whereas 41% of thosewith uncomplicated malaria did so. One reason for this couldbe that severe malaria is more often related to supernatu- traditional treatment, all cases: 73 vs. 66%, P = 0.02) and ral events (Another explanation could be the when the mother had studied in the ‘madrasa’ or Koranic perceived effectiveness of traditional medicine for severe school (85% sought modern treatment, vs. 67% among those malaria and experience of high case-fatality rate in the hos- who had no schooling, P = 0.004). No relation was found between the type of treatment used and the father’s profes- The trend was towards fewer fatalities after traditional sion and level of education, nor the number of other children treatment (11%) than after modern treatment (26%). One at home. Prices of treatment (in francs CFA: 1000 CFA ≈ £1 explanation might be that some of those considered as or D 0.8) were related to type of malaria (uncompli- suffering from severe malaria in our sample actually had cated episode mean price = 504 FCFA; severe [whatever the another less fatal illness (the same applies to the 2% of type of treatment used] = 1340 FCFA; P = 0.03) and type fatalities observed after presumed uncomplicated malaria: of treatment (first treatment traditional mean price = 200 it might have been another disease). Uncomplicated malaria FCFA; modern [whatever the type of malaria] = 830 FCFA; might have become severe, although in this case the patient should have been registered only once, as a severe case.
As shown in total recovery after uncomplicated Another possible explanation is a certain degree of effec- malaria was above 98% for any treatment. In the case of tiveness of some local, traditional treatments. Even if they severe malaria, the global death rate was 17%. Patient are less effective than modern drugs in absolute terms, they progress did not statistically differ with different types of could improve the prognosis of malaria patients because of treatment. For data missing on progress (2.2% of uncompli- the shorter time lag between onset of the malaria episode cated cases, 3.6% of severe cases, P = 0.2) types and places and treatment. In other words, greater effectiveness of of treatment were similar to the ones found in the total care offered in modern health centres might be offset by sample, as well as socio-demographic data. Sequelae were the fact that patients arrive there after a long journey in reported in 5% of severe cases and 0.5% of uncomplicated a more critical state. Such a hypothesis could be tested with a non-experimental design, for ethical reasons None of the local treatments was correlated with poor patient progress, but some were systematically associated with clinical cure. Some of these were already known to be chloroquine-resistant P. falciparum were not necessarily active against P. falciparum. Six plants with activities not described as such in the literature. Spondias mombin L.
mentioned in the scientific literature were investigated in (Anacardiaceae) is a medium-sized tree bearing edible fruits (‘hog plums’), common in both South America and tropi-cal Africa. The bark and leaves are traditionally used fordisinfections (e.g. abscesses, caries, conjunctivitis). Anti- 3.1. In-vitro studies
herpetic tannins have been isolated and characterized fromthis plant. Opilia celtidifolia (Guill. et Perr.) (Opiliaceae) Crude extracts of the selected plants were obtained and is either a small tree or a creeper reaching 8—10 m and tested in the laboratory: all were found to have medium restricted to tropical West Africa. The roots and leaves to high antiplasmodial activity in chloroquine-resistant are used to treat fever, influenza and intestinal worms.
P. falciparum cultures. Four crude extracts displayed a Rare modern studies on this plant demonstrated its high medium inhibitory concentration (IC50) smaller than 5 ␮l/ml: content in saponins and tannins. Argemone mexicana L.
Spondias mombin, Opilia celtidifolia, Securinega virosa, (Mexican poppy or prickly poppy) is a robust herbaceous annual, a member of the poppy family (Papaveraceae) Malaria in Mali: use of traditional medicines course of this study, of patients waking immediately after yellow flowers are characteristic of the Papaveraceae, as an inhalation, may be an indication of product effect not is its abundant bright yellow latex. Typical chemical con- solely related to the parasite cycle. To determine physio- stituents are benzophenanthridine alkaloids (among them logic activities would require specific research (for example berberine, protopine and sanguinarine). Securinega virosa with animal models or healthy volunteers).
(Roxb. ex Willd.) (Euphorbiaceae) is a 2—3 m shrub commonin West Africa, but also in Australia and Asia. It has numer- 5. Conclusions
ous traditional uses, and its roots are frequently describedas soporific and analgesic, although its leaves are considered In the areas studied, self-medication and traditional a stimulant and an aphrodisiac. This plant has been studied medicines for malaria divert a high proportion of patients away from modern health centres, especially for severe Limitations of this study include the uncertainty created episodes. For the latter, case-fatality rates tend to be by the controversial definition of malaria in areas where lower after traditional home- or village-based treatments, diagnosis and therapeutic decisions must be performed with- although without any statistically significant difference. This out laboratory facilities. The fact that the diagnosis of suggests that distance, poor quality service, or economic malaria, both severe and uncomplicated, is not by necessity barriers are not the only reasons why attendance to health confirmed greatly weakens the conclusions made. Defini- centres is poor, but also perceived effectiveness of alterna- tions of malaria by traditional practitioners probably result tive care. Rather than ignoring or suppressing this situation, in over-diagnosis: in a study by Willcox et al. (unpublished) a pragmatic approach could be to study the potential effec- of 245 patients diagnosed with ‘soumaya’ (considered equiv- tiveness of some home-care and whether local or regional alent to uncomplicated malaria) by a traditional practitioner synergies between different health systems could improve in south Mali, 30 had no plasmodia in their blood and 118 had only a low parasitaemia (<2000 parasites/␮l), thus notreaching commonly used criteria of malaria. Observation of Conflicts of interest statement
actual therapeutic itineraries along categories of ‘first’ and The authors have no conflicts of interest concerning the work ‘second’ treatments is very schematic and probably elicits only part of the very complex process of health-care-seekingbehaviours. Data may be incomplete and biased, because Acknowledgements
they are based on memories of the past 6 months. Miss-ing data on progress was probably due to the interviewer, Thanks to the populations and authorities of Bandiagara and because it is unlikely that parents forgot the outcome of Sikasso Regions for their warm welcome and active partic- their child’s disease. For dramatic events the recall errors are probably small, but for details they can be important.
For severe malaria, recommendations are to bring the and Malian doctoral students and surveyors for help in data sick child to the health centre as fast as possible. However, collection; Reto Brun and his team from the Swiss Tropical travel is often difficult, especially during the rainy season, Institute for in-vitro tests; Bernard Burnand for constructive and health professionals attribute many of their treatment comments on the study results; and Merlin Willcox for sug- failures to delayed access to modern treatment in the case gestions on an earlier version of this paper. This study was of severe malaria, as well as delayed or inappropriate treat- supported by The Swiss Cooperation Agency.
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