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Lutte contre le trachome en Afrique subsaharienne

 | 
Anne-Marie Moulin
, 
Jeanne Orfila
, 
Doulaye Sacko
, 
et al.

Part One. Synopsis and recommendations. English Version

The experience of the populations

Texte intégral

POPULAR CONCEPTIONS OF TRACHOMA: THE CONJONCTIVITIS/TRICHIASIS LINK

1Jugu te maa la, bana de ye jugu ye” (Mankind has no enemy, disease alone is the enemy).

2Modern medicine establishes a link of cause and effect between reinfection of the child with C. trachomatis and trichiasis in the adult. With endemic disease like trachoma, the difficulty is to make the disease socially visible. An epidemic of the cholera type is easily grasped by all those working socially, even if there is no coincidence between their respective conceptions of the etiology or even of the symptoms. Populations generally do not see the link between benign and temporary eye infection, and the serious sight problems several decades later. Moreover, during childhood, eye infections are eclipsed by diseases that can be fatal: diarrhea, lung diseases or other infectious diseases.

3One of the first difficulties faced in combating trachoma is thus to confront the concerns of public health doctors, targeting a specific disease, with those of the populations, infinitely more global.

4The knowledge that anthropologists have of the environment can help to design programs taking into account the way in which the populations see “cleanliness and dirtiness“, and the transmission of disease.

5Biomedicine generally distinguishes three ways of transmitting diseases. They can be hereditary (of genetic origin), contagious from person to person, or transmitted by the environment (including by insects). In West Africa, the populations do not distinguish these three factors. However, we find these three components in varying proportion in their conception of the “passage” of diseases.

6The observation that a disease is frequent among certain siblings leads, for example, to evoke “hereditary” or regular transmission within the family. Certain families, even certain villages, would be thus predisposed to develop the disease. When a member of the group is free from trichiasis in certain villages, he may be considered by the others as not being a worthy descendant of his ancestors.

7Certain diseases are recognized as transmitted by contact between people. Contagion may also be attributed to the sharing of utensils, such as the stick for applying kohl (antimony) on the eyelid.

8Certain environments are considered favorable to eye infections because of miasmas or forces emerging from them (marshes, sacred forests, etc).

9The eye, the concentrate of the human being, is sensitive to the images that it receives. Eye diseases can be attributed to the frequentation of evil places, soils with suspect smells, impregnated with urine or excrement, frightening places such as the edges of marshes or deep in the bush. They may also be linked to having witnessed a forbidden scene (similar to the “primitive scene” of psychoanalysts) of violence or sexuality.

10The peculiar nature of the eye, its association with the function of communication, explain why contagion may be linked to the danger of crossing glances. The “evil eye” is a cultural syndrome encountered in many civilizations, particularly around the Mediterranean and in West Africa. The beautiful child is thus exposed to the “evil eye“, particularly in a polygamic context with rivalry between co-wives. Hence, the old custom of concealing the baby from inquisitive eyes and not washing it at birth, which is supposed to be a protection like a carapace.

11Anthropologists note the present hybridization between “tradition” and “modernity” in conceptions and practices. This is seen in the variety of “ways to health” and the therapeutic methods available from nursing staff, “witchdoctors”, western health systems, and many intermediate steps.

Conceptions of trachoma in the cultures of West African countries

12The little research devoted to the anthropology of eye infections shows that West African populations pay great attention to eye disorders that are irritating (itching, burning, gritty feeling, visual troubles) and easy to observe lesions. They consider as abnormal in the eyes any redness, secretion and suppurations, swelling. The nyèdimi, eye ache (from nyè, eye, and dimi ache, pain) overall denotes many eye disorders, in Bambara language. Nyèdimi dialan (from nyè, eye, dimi, ache and dialan, dry), corresponds to “xerosis” (dry eye) of Western medicine.

13The populations are aware that eye troubles, whatever they are, if they are not looked after, can damage sight. They underline all the extreme fragility of the eye, a very precious organ because deprivation of sight represents a heavy drawback for the individual preventing him from providing for his needs and those of his family.

Infantile conjunctivitis, a minor illness

14The frequent eye infections of the child, usually not serious, are associated with key moments in growth such as the growth of the first teeth, a period of particular fragility.

15“If the child has started teething, his eyes redden, his body becomes hot, and he has eye infection. This is the kolobo nyèdimi. When the eye pains tire him, the child may also let the disease escape through the belly, he vomits and has diarrhea”.

The conjunctivitis/trichiasis link is generally badly accepted

16Trichiasis, with the telltale sign of in-turned eyelashes rubbing the cornea, is well known. Many terms describe it in the various languages: in Bambara language, a b’i nyè sogosogo means the “eyelashes prick the eyes”, nyèsibo literally means “eye or eyelashes coming out“, nyé si karilèn and nyèsisara refer to the “broken eyelashes” and the “dead eyelashes”.

17In most West African societies, locally-made tweezers (kènkèn in Bambara language), for pulling out the eyelashes, are part of the “outfit” of old people. These implicate trichiasis as one of the many diseases of ageing, and dreaded as such. Nevertheless, the populations do not establish a link between the conjunctivitis of childhood and the disease of adulthood or even of old age.

18However, the perception of this link varies according to ethnic or social contexts. Thus the Dogons record that “a child who has eyes poorly looked after develops an eye infection in old age”. Current anthropological researches comparing hygiene practices among the Fulani and Dogon, for example, will have a double impact:

  • they allow us to better understand the mechanism of disparities of prevalence between ethnic groups,
  • in the preparation of hygiene messages, they will take into account the intimate knowledge that the populations have of risks in their environment.

Conclusions and recommendations

19In implementing a public health strategy, it is of vital importance for the populations to follow the measures suggested, and understand them. The frustrating consequences of insufficient consideration of the conceptions of the populations are now well known. This is why combating trachoma first of all implies understanding the real expectations and demands of the populations, and find adequate resources so that those working in the society acquire the medical knowledge useful to them.

20Trichiasis tends to being accepted fatalistically. If trachoma control in recent years has not given the expected results, it is because some of the difficulty lies in mutual lack of understanding between health worker and patient, even the impression of the populations that their real problems are not taken into account.

CAN TRADITIONAL PRACTITIONERS PLAY A ROLE IN CHANGE OF BEHAVIOR, ESPECIALLY BETWEEN MOTHER AND CHILD?

21Do bè do don, do to don. Do tè do don, do bo don” (one person knows something that the other does not…). Proverb in the Bambara language

22For a long time, western medicine has fought local healers, comparing them with illegal charlatans. The Alma Ata conference in 1978 marked a turnaround to the rehabilitation of healers, now called traditional practitioners in this era of primary health care. The term intends to pay respect to their long experience and availability. Traditional practitioners culturally used to listening, even to sympathizing, are from now on seen as a valuable relay, within reach of the most modest budgets. From there, has grown the idea to improve their training and integrate them in the networks dispensing simple and effective treatment. Moreover, they embody a real inheritance thanks to their knowledge of natural substances, which, in addition to their symbolic value, could constitute a valuable reservoir of molecules for the ongoing search for new medicines against emergent and re-emergent diseases.

23Since then, attitudes to traditional practitioners have been highly variable. Depending on the country, traditional practitioners are regarded as an unrivalled, even effective, resource or as the eternal obstacle to rational and scientific procedures. In this latter case, it is difficult to train professionals towards whom a real mistrust remains. Furthermore, traditional practitioners are largely in competition with the official system.

  • 1 Jaffré Y., Olivier De Sardan J.-P. (eds), 2002 – Rapport sur les dysfonctionnements des systèmes d (...)

24Also, the portrait of the traditional practitioner has changed. Particularly in the cities, there are many hybrid characters combining popular practices with modern treatment, as is well illustrated by the case of AIDS. Some healers have their patients monitored in laboratories to check the “T4” number, (index of resistance to the HIV virus) and prepare therapeutic protocols that they try to promote. Finally, disappointment generated by an “inhospitable” medicine1 has led many patients to return to traditional methods.

25Without questioning the principle of collaboration, the WHO in recent years has shown more caution than in the past.

26In Mali, where there are many types of «informal» health workers, 80 % of the rural populations turn to these practices. Today, the Malian ministry of health officially recognizes the traditional practitioners as a link in the treatment system. Mali has created a department of traditional medicine within the national institute for research into public health (INRSP), issued regulations concerning the exercise of traditional medicine, registered medicines known as «improved traditional medicines» on the list of essential medicines and founded the Malian federation of associations of traditional therapists and herbalists. About fifty associations of traditional therapists are active in Mali including the Malian association for the promotion of traditional ophthalmologists (AMPOT).

Traditional practitioners, the relay between populations and modern health workers as regards hygiene?

27Generally, in Africa, cleanliness is above all a woman’s job involved in personal washing and body care, preparing food, cleaning the house and yard.

28Thus, where diseases due to lack of hygiene are concerned, it is particularly the traditional midwives who potentially have a great role to play and could transmit the hygiene message. In the rural environment, they are responsible for three quarters of childbirths. In the past, several reforms were planned to give them a role, elsewhere played by the “visitor” or “welfare worker”. The results in the past were unequal, through lack of training and financial incentive. Nevertheless, eye care can be part of the midwife’s work in a limited but real way. The medical bag of the “retrained traditional midwife” today includes tetracycline ointment for preventing neonatal conjunctivitis.

Conclusions and recommendations

29Traditional practitioners are very frequently consulted by patients about eye infections. It is advisable to be extremely careful because many popular practices are harmful, like instillations of untested substances, possible sources of ocular superinfection.

30The use of traditional practitioners to transmit relevant information is thus far from being the automatic thing to do. First, they are not in a tradition of “information”. They work close to their patient, with whom they are “on the same wavelength” from the outset. Their possible integration in IEC programs would make them play a role that they have never held until now in society. Moreover, there exists unquestionable competition between doctors and traditional practitioners; and the latter may tend to protect their knowledge, which is also their livelihood. Only dialogue will make it possible to identify possible convergences between traditional practices and health messages. The difficulty lies in setting up a climate of partnership between professions that have a long history of mutual distrust.

31Traditional midwives could more easily play a role. For this, they should acquire concepts of general hygiene regarding the cleanliness of underwear and linen in contact with babies, knowledge of the ways trachoma is transmitted and the action to be taken confronted with a manifest eye infection.

32Finally, recognition of the role and social utility of traditional practitioners should not result in economizing on a lucid thought on the dissatisfaction of patients regarding the treatment given in the dispensaries or hospitals, insufficient reception, lack of availability and attention of the personnel, and the shortage of drugs and equipment. Above all, this recognition should not make us forget that, for example, reduction in maternal mortality passes through a decrease in non-medicalized childbirth. It is important for possible work with healers and neo-traditionalists not to be in contradiction with other health programs.

THE IMPACT OF TRADITIONAL SUBSTANCES ON THE EVOLUTION OF TRACHOMA

33In the search for effective products, the African continent has a particularly rich flora to explore with modern means. In this context, traditional practitioners would appear to know how to use substances that may lead to important, even potentially remunerative, discoveries, on condition obviously that international regulations be fairer than in the past and protect their rights.

34Eye infections, including trachoma, are the subject of many “recipes” with a very precise way of administration and indication.

Natural substances used in traditional medicine in Mali

  • 2 The work of Father Malgras, in 1992, lists 160 trees and shrubs used in the Sikasso region. As reg (...)

35The first Malian (ex-Sudanese) collection of medicinal recipes was prepared by Domenica Traore in 1920. Since then, several illustrated works2 present the plants and describe their uses, with precise details on their geographical origins and their content of active ingredients according to the period and the collection area.

36In Mali, the department of traditional medicine (DTM), which comes under the ministry of health, manages the policy of developing the traditional medicine resources. The DTM has been a partner center of the WHO for traditional medicine since 1980. Since 1983, improved traditional medicines (ITM) are an interesting attempt to validate the use of medicines resulting from the traditional pharmacopoeia, without embarking on the complete procedure leading to the marketing of products of the large pharmaceutical firms. The simplified procedure aims at confirming pharmacological activity, evaluating the toxicity threshold, quantifying proportions and quality control.

37These medicines are not only of economic interest (their price being lower than that of equivalent specialist products), they form a bridge between traditional and official medicine. Seven of them today appear in the list of Malian essential medicines and the national therapeutic pharmacopoeia. In theory, they are available in all pharmacy dispensaries and medical units. None concerns trachoma.

38In Mali, there is a legislative and statutory framework for the practice of traditional medicine in private surgeries, opening and operating herbalist’s stores and production units for improved traditional medicines.

Medicines useful to explore?

39Many substances are currently used in the treatment of eye infections. The ways of administering ocular remedies include instillation, fumigation and eye baths.

40The disease targeted is primarily conjunctivitis. Trachoma probably appears in a considerable part of the disorders treated. The symptoms concerned in order of importance are nyèdimi (ocular pain), nyèjaladimi (ocular dryness) and bugun (blurred vision).

41The use of mineral substances such as the dyes for leathers, derivatives of copper and antimony, arsenic, oxides of zinc and iron, goes back to ancient times. In the Maghreb and among the Malian Touaregs, antimony (kohl) was used in particular for eye infections. However, none of this treatment has been the subject of clinical trials in the modern sense.

42The powders are supposed to be active both chemically and mechanically to dry the eye, scrape or extirpate the granulations. Powders based on goat excrement recall the importance of substances of animal origin in all the pharmacopeias. The eye baths utilize a whole range of plants. Shells play the same role as eyeshades, which were widely used in Europe in the twentieth century. In the Dogon region, the shell is filled with decoctions or various organic liquids such as tears, vaginal liquid, mother’s milk.

43Research undertaken between 1968 and 1996 on a score of plants has revealed properties such as antiseptic, bactericide, virucide, fungicide and pesticide, and plants with healing, anti-inflammatory and local analgesic properties, in keeping with the presence of alkaloids, flavonoids, saponins, tannins and terpenic compounds. In the field of ophthalmology, the effects concern the contraction of pupil (alkaloids), improvement in retinal and/or chloroidal circulation (flavonoids), regeneration of the pigment of the retina, rhodopsin (flavonoids), fungicides, anticandidiasis and antiviral activity (saponins), antiseptic effect (terpenes), softening and antipruritic substances (tannins), and the anti-inflammatory effect (sterols).

44The revealing of active ingredients in the plants makes it possible to suppose a cause and effect link between the pharmacological activity of the natural substances and the use of plants by traditional practitioners. Chemical, pharmacological and clinical research must be more thorough if we want to go further. To date, no plant has proved its effectiveness in treating eye infections caused by C. trachomatis.

But firstly, there must be no harm!

45An investigation carried out in Malawi suggests that 26 % of blindness in a school for blind children would be due to the use of traditional medicines. According to research published over the last twenty years into the causes and prevalence of blindness in Africa, many traditional medicines, particularly those instilled directly into the eyes, aggravate eye infections and retard treatment of injuries and serious illnesses of the eye. Some of the scars observed could be due to traditional practices.

Conclusions and recommendations

46There is no traditional substance that has demonstrated its effectiveness in treating trachoma. It is urgent to banish the instillation of mineral or traditionally- prepared vegetable products that are dangerous for the eye.

47Having firmly stated this, we can reasonably assume that there are indeed traditional substances active against eye infections and in particular trachoma. Nevertheless, their large-scale use is not possible as long as there has been no research into their harmlessness and effectiveness compared with currently available medicines. It will then remain to organize research following usual scientific methods (clinical trials); then to produce drugs in industrial quantities in a suitable pharmaceutical form.

48For products that comply with the criteria of non-toxicity and effectiveness, it is desirable to ensure their traceability, to allow the establishment of intellectual property in the event of confirmed effectiveness, in the spirit of the Rio Convention of 1992, which is designed to ensure that communities receive a just remuneration for their traditional knowledge.

Notes

1 Jaffré Y., Olivier De Sardan J.-P. (eds), 2002 – Rapport sur les dysfonctionnements des systèmes de soins, enquêtes sur l’accès aux soins dans cinq capitales d’Afrique de l’Ouest. Marseille, Unicef-Coopération française, 289 p.

2 The work of Father Malgras, in 1992, lists 160 trees and shrubs used in the Sikasso region. As regards ophthalmology, 73 species from 28 botanical families, giving rise to 101 recipes of decoctions, macerations or simple boiling.
The thesis of Haoua Keita, for the district of Bamako, listed 60 recipes for treating eye infections, from 57 vegetable species distributed between 36 botanical families, a product of animal origin (honey) and one of mineral origin (cowry).

© IRD Éditions, 2006

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