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Akogunetal.InternationalJournalforEquityinHealth2012,11:5 http://www.equityhealthj.com/content/11/1/5 RESEARCH Open Access Febrile illness experience among Nigerian nomads Oladele B Akogun1*, Minnakur A Gundiri2, Jacqueline A Badaki3†, Sani Y Njobdi2†, Adedoyin O Adesina1† and Olumide T Ogundahunsi4† Abstract Background: An understanding of the febrile illness experience of Nigerian nomadic Fulani is necessary for developing an appropriate strategy for extending malaria intervention services to them. An exploratory study of their malaria illness experience was carried out in Northern Nigeria preparatory to promoting malaria intervention among them. Methods: Ethnographic tools including interviews, group discussions, informal conversations and living-in-camp observations were used for collecting information on local knowledge, perceived cause, severity and health seeking behaviour of nomadic Fulani in their dry season camps at the Gongola-Benue valley in Northeastern Nigeria. Results: Nomadic Fulani regarded pabboje (a type of “fever” that is distinct from other fevers because it “comes today, goes tomorrow, returns the next”) as their commonest health problem. Pabboje is associated with early rains, ripening corn and brightly coloured flora. Pabboje is inherent in all nomadic Fulani for which treatment is therefore unnecessary despite its interference with performance of duty such as herding. Traditional medicines are used to reduce the severity, and rituals carried out to make it permanently inactive or to divert its recurrence. Although modern antimalaria may make the severity of subsequent pabboje episodes worse, nomads seek treatment in private health facilities against fevers that are persistent using antimalarial medicines. The consent of the household head was essential for a sick child to be treated outside the camp. The most important issues in health service utilization among nomads are the belief that fever is a Fulani illness that needs no cure until a particular period, preference for private medicine vendors and the avoidance of health facilities. Conclusions: Understanding nomadic Fulani beliefs about pabboje is useful for planning an acceptable community participatory fever management among them. Background campsareoftenignoredtotheextentthatlessthan3%of When compared to the urban populations, rural com- childrenbelow2yearsmaybenefitfromfullimmunization munities are poorly served by the health system, but in serviceinsomeareas[5]. comparison with nomads, the gap between nomads and Althoughdisproportionatelymoreexposedtoinfectious rural settled communities is even wider [1]. diseasessuchasmalaria,nomadsremainisolatedfromthe First, the formal health system appears ill-adapted for ongoing malariamanagementcampaigns[6,7].Account- extending services to constantly mobile communities of ing formorethan 10%ofAfrica’soveralldiseaseburden, nomads[2]andlocalauthoritiesoftendisregardtheexis- malariaisresponsibleforupto20%ofmaternaldeathsin tence of nomads with respect to health service delivery. health facilities in sub-Saharan Africa [8]. In Nigeria, Forexample,inSouthwesternNigeria,guinea wormcase malaria remains the most important cause of childhood detectionscouts“forgot”toincludevisitstonomadcamps morbidity and mortality. In 2000, malaria accounted for [3],andivermectindistributioninthecontrolofonchocer- 63.4%ofallreporteddiseases,with50%ofthepopulation ciasis,oftenmarginalizednomadicFulanisettlements[4]. havingatleastonemalariaepisodeleadingtobetween30 Locatedontheoutskirtofsettledcommunities, nomadic and50%inpatientadmissionsand50%outpatientvisitsto healthfacilities[9]. *Correspondence:[email protected] The typical Fulani household has a headman, his †Contributedequally wives, children and dependents [10]. About 15 house- 1CommonHeritageFoundation,No.1BishopStreet,Box5124,Yola,Nigeria hold units aggregate in an area to form a wuro (camp) Fulllistofauthorinformationisavailableattheendofthearticle ©2012Akogunetal;licenseeBioMedCentralLtd.ThisisanOpenAccessarticledistributedunderthetermsoftheCreativeCommons AttributionLicense(http://creativecommons.org/licenses/by/2.0),whichpermitsunrestricteduse,distribution,andreproductionin anymedium,providedtheoriginalworkisproperlycited. Akogunetal.InternationalJournalforEquityinHealth2012,11:5 Page2of10 http://www.equityhealthj.com/content/11/1/5 and many wuro constitute a gure. Nomadic Fulani oftenconsistsofseveralgroupsofconcentrictentsinhab- dependence on herbal remedy and private medical out- itedbyanomadiccommunity.Severalsuchcommunities lets in health seeking is well documented. may be located in a particular place within 5 kilometers Despite currentGovernmenteffortsto reduce thedis- ofeachotherunderaclanleader[10].Theclanisasub- ease burden through distribution and promotion of group within the larger Fulani tribe that claim descent insecticide treated nets (ITN) usage, simple diagnostic from a common ancestor or share a perceived kinship. tools, behaviour change communication, appropriate TheclanoftentakesnamesoftownssuchasJahun,Kiri, chemotherapy, intermittent preventive treatment and Bodewatodenoteitsoriginorthatofitsfoundingances- community management of febrile illnesses, access to tor.Thesharingofthestipulatedcommonancestryisthe theseservicesremainachallengetothe nomads.Oneof symboloftheclan’sunity.Themigratoryroutesareclan the major health issues in Africa is how beliefs about based and the group passes through the symbol of the health and illness are used in health care delivery since clan (suchasKiriforthe KiriFulaniclan)duringa cycle the concept of illness is informed by cultural identity ofmigration.Itisnotuncommontofindwithinthesame [11]. For example the Fulani express the sense of differ- clan, another set of groups that attempt to distinguish ence between them and other groups through the man- themselves from the other group members as a subclan ner in which they acknowledge illness. Being Fulani basedonanagnateofthesamesymbolicprogenitor[10]. meansperseverance,strengthofcharacter,disciplineand Members of the same clan usually camp in a particular providingleadershipoverothers.Thelackofunderstand- areaoccupyingsometimesabout3kilometersradius,and ing of their cultural experiences with malaria is a hin- sharethesameroutesandmovementtiming. drance to integrating them into the malaria control Three main nomadic Fulani clans use the Benue- programme.Yetifnotaddressed,nomadswillremainan Gongolavalley fortheirdry season stopover.Atthepeak epidemiologically significant group when the disease is ofthedryseasons,forty-eightcamps(estimatedpopulation eventuallyreducedtoalevelbelowpublichealthimpor- of12,000) dotted theentirearea accordingtotheirclans. tance amongsettledpopulations.Astudyonthemalaria The Kiri undergo a migration within a radius of 30-100 illness experiences of nomadic Fulani communities that kilometers and have a sedentary phase of old people, the camp in the valleys of rivers Benue and Gongola of Jahunmigrateoveralongerdistancebutusethevalleyon Northeastern Nigeria during the dry season was con- anannual basis whiletheBororo(Bodyelclan) arecross- ductedpriortodevelopmentofanappropriateinterven- bordernomadstravellingover800kmandonlyreturning tionprogramme. tothevalleyonceineverythreeyears.Mostofthecamps had moved in and out of the valley in the past 15 to Methods 20years.MembersoftheKiriclanclaimthatasfarasthey The study wascarried out betweenNovember 2003 and could recall their great grandfathers had camped in the April2004.Amixedapproachcombiningtraditionalbio- valleyaswell. logicaltechniqueswithethnographicmethodswasused. While the Kiri and the Jahun may spend up to 5 Informal conversations, unstructured interviews, group months in the valley the Bororo hardly spend 3 months discussion, andliving-in-camptechniqueswere used for before moving on. Camps of particular clans arrive and collecting information from nomads about their febrile leave the valley at different times thus providing oppor- illnessexperiences.These werethencomplimentedwith tunity for collecting data from different members of the householdandmalariaprevalencesurveys. same clan throughout the dry season (November to May). A typical nomadic Fulani household unit consists Study population of a set of concentric tents (built with reed, millet or The nomadic Fulanicampcommunitiesofinterestwere corn stalks) in a semi-circle overlooking where animals concentratedattheconfluenceofriversBenueandGon- are tethered. It is composed of a man, his sons, younger golainNortheasternNigeria(Latitude9°13’Nand9°46’N brothers, first cousins and other dependents. A house- and Longitude 11°30’E and 12°10’E) spreading out over hold is a unit of economic activity headed by a jom five Local Government Areas (LGAs). An extensive wuro, or household head. The basic settlement of the SavannaSugarfarmprojectirrigationschemesituatedin Fulani is the wuro (camp) that is composed of 12-20 the area provides abundant vegetation all year round. household units and headed by a Jauro or bulama. Each Withanopenvegetationofshrubsandherbaceousplants wuro is part of a cluster of several other wuro in an area muchfavouredbyanimals,theareaservesasamajordry belonging to the same clan. A collection of wuro is seasonstop-postfornomadsintheirnorth-southmigra- called the gure over which the eldest among brothers is tory cycle. The camp is a settlement where the nomads the Ardo or clan leader. The Ardo wields the greatest maketemporaryshelter.Thecampvariesinsizedepend- influence in nomad leadership hierarchy. The Ardo has ing on the number of households inhabiting it. A camp responsibility for coordinating movements, mediating Akogunetal.InternationalJournalforEquityinHealth2012,11:5 Page3of10 http://www.equityhealthj.com/content/11/1/5 disputes within the clan, negotiating with settled local intendeddurationintheircurrentlocationandwillingness community leaders or ordering a combat. The Savanna to participate in a study on febrile illness. The team Sugar Irrigation farm project encouraged a set of camp returned to the Ardo at least three more times to offer sites with semi-permanent tents where in recent times specificfollowuphealthandveterinaryserviceswhilecon- the elderly nomadic Kiri Fulani and their children tinuing informal conversations, gaining visibility and remain while the youth herd the animals within a radius acceptance and developing useful contact for the subse- of 50 and 100 kilometers. The elderly Kiri now combine quentstage.Serviceswerelimitedtothosewithinthepro- mediatory and negotiation roles with trading in livestock fessionalcompetenceoftheCommunityHealthExtension at the local markets which may give rise to the sedentar- worker and the Veterinary Assistant in the team and ization of the next generation. They do not cultivate includediarrhealandfevermanagementandofferofrefer- crops at the moment. The Kiri keep goats and sheep in ral support. The Ardo was encouraged to invite other addition to cattle while the Jahun and Bororo keep only eldersoftheclan(particularlytheJauro,thecampleaders) cattle. tothemeetings.Thisprovidedadditionalopportunityfor Anorganizationwithpreviousexperienceworkingwith informal conversations with other elders of the clan and nomads was consulted to learn how the nomads may be for documenting their knowledge and febrile illness approachedand their participationinthe research nego- experience. The conversations sought information on tiated.Alocalguidewithexperiencecarryingoutveterin- knowledge oflocal terminology, vocabularies and usages ary services among the nomads and with whom the aboutfebrileillnessesandmalaria.Specificinformationon nomads had developed some trust was assigned to the febrile illness recognition and classification, response to teamforthepurposeofintroducingandguidingtheteam perceivedcasesofsevereillnessaswellashowthehealth through the social and cultural norms of the nomadic systemservedthemwasalsosought.Thelocalguide’srole Fulani. diminishedwitheverysubsequentvisitandfinallystopped TheSarkinsanuorSarkinFulani(aninformalposition whensufficientrapporthaddevelopedbetweenthe Ardo foraFulanielderwhoservesasaliasonfornomadsatthe andtheteam.Theprovisionofbasichealthandveterinary local government office or at the traditional court of the services during the study was very helpful in trust- localchief)wascontactedandalistofArdowascompiled building. andappointmentsmade to visit.Every contactteam visit With the assistance of the Ardo, camps were selected hadatleast3researchteammemberscomprisingculture from each of the community of camps. Clan representa- specialist, facilitator, and a note-taker, one of whom is tion and duration in the valley were important consid- either a veterinary or health personnel. Diaries and field erations in camp selection. The Ardo facilitated entry to notes were used for documenting information and the camps and introduced the team and the objective of impressions. the study to the Jauro. Team training Formal interviews and discussions Membersoftheresearchteamhadpreviousexperiencein Information from the informal contacts and conversa- communityinteractiveresearchandwerefluentinHausa tions with clan elders was used for developing in-depth and/orFulfulde, thelanguageoftheFulani. The research interview and group discussion guides. Group discus- teamreceivedanorientationonFulaniculture.Sincetape sions were held with women (young, mothers, grand- recordingwasnotusedattheonsettoavoidsuspicionand mothers), herders (young males) and children. In-depth misunderstandingthatarelikelytooccurduringthefirst interviews were held with camp leaders, local specialists meeting,teammembersweretrainedonnotetakingtech- (such as traditional healers). Specific questions on clini- niques.Inordertoensurequality,fieldnoteswerejointly cal signs, causality, meanings and perceived incidence reviewed by all the team members that were present rates were asked. duringparticularinteraction. Muchoftheinteractionwaseitheratdawnorlateinthe evening in order to synchronize with their daily routine. Contact and Informal conversations with clan leaders The nomadicFulanifollowaveryfirmroutinethatcom- During the first visit to the Ardo, the local guide intro- mencedatabout4hours(GMT+1)andendedatabout21 ducedtheteamandinitiatedinformalconversationsabout hours(GMT+1)whentheanimalshadbeentetheredand thehealthoftheiranimalsandtheirfamily.Conversations thedailyschedulecompleted.Informantswereselectedto werethendirectedtofebrileillnesses,accesstoinsecticide representrelevantdiversityineachcommunity(age,gen- treatednetsandantimalariamedicinesbeforetheobjective der,locationandclass).Inordertoavoidinterviewfatigue ofthevisitwasintroduced.Inorder to ascertainthatthe specific but few questions were asked about experience studiedpopulationwouldbearoundlongenoughtocom- with febrile illness to the exclusion of other aspects that plete the study, inquiries were made about the clan’s wasdiscussedwithotherinformants. Akogunetal.InternationalJournalforEquityinHealth2012,11:5 Page4of10 http://www.equityhealthj.com/content/11/1/5 The data from the camps were used for developing ICTDiagnostics,SouthAfrica.ParaHitfisanimmunodiag- household survey questionnaires that were administered nostic test that provides in vitro qualitative test for the to four members (male and female parent of under-five detectionofP.falciparum(Pf)-specificHistidineRichPro- child,unmarriedherders)ofthehouseholdwhereformal teinII[12,13].Rapiddiagnostictestkitsareusefulforthe interviews were not held. This allowed the collection of promptmalariadiagnosisincommunitysurveys[14].The information from this category of people whose experi- currentstudyispreliminarytoaninvestigationonmalaria ences would not otherwise be represented in the study, managementamongchildrenundertheageoffiveyears andtocheckforconsistencyandgeneralizabilityofinfor- sincetheyareespeciallyvulnerable. mation from the other sources. The data were thenana- The quantitative approach was used to assess malaria lyzedandthederivedinformationusedfordevelopingan prevalenceinchildrenandculturalepidemiologicalindica- observationandinformalconversationguides. tors:frequencyofself-reportedexperienceofvariousdis- eases in order to estimate the perception of disease Live-in experience burdenandagreementoncausation.Qualitativeapproach Inordertounderstandthecontextwithinwhichinforma- assessed the domains of knowledge, causation, severity, tion was obtained, three households with at least three perceived burden and pattern of treatment seeking under-five children andthatare willing tohost the team response to illness. Quantitative data were entered into were selected from each clan for a 7-day live-in-camp EPI INFO (version 3.3.2) and analyzed with IBM SPSS experience.Typicalfamilydecision-makingprocesseswith Statisticsversion18whilequalitativedatawereprocessed respecttocare-giving,healthandillnessbehaviorsuchas withAtlasTi. gender roles, extended family influence and age were documentedintheprocess.Attentionwasgiventofamily Results care, recognition of febrile illnesses, home remedies ShrubsandherbaceousplantscharacterizetheBenueriver (orthodox or traditional), health service usage, nursing valleyattractingnomadstothelimitedgrazingareasparti- care and recuperation. The 3-member team comprised a cularly during the dry season. Although 28 camps were health and veterinary assistant led by a facilitator (teams counted during the study, the team was informed that A,B,C).Theteammemberssharedthesametentbuiltby therewereprobably160campsatdifferentlocationswith the women and interacted within limits of the culture. a total estimated population of about 10,000 nomads at Each member of the team selected a particular skill to thetime.TheinitialrealizationwasthatthetermBororo, acquire during the live-in experience. For example the which non-Fulani people erroneously use to describe all woman member spent much of the time with the eldest Fulaninomadsonlyapplytoaparticularclan.Thosewho womaninthecampbutinteractedwithotherwomenpar- didnotbelongtotheclanfeltoffendedwhenerroneously ticipatingintheireverydaytasks(learningtomilkthecow, referred to as Bororo. The research team talked to more prepareyoghurtormilletmeal).Similarly,amalemember than 72 nomads during the qualitative data collection oftheteamspent muchofthetimewiththeherdersand while 97 respondents participated in the survey. More participated in herding and tendering the animals. The males participated in the survey (60.8%) than females thirdmembersharedthetimewiththeeldersoftheclan (39.2%). The malaria survey involved 691 under-five andwheredecorumpermitted,accompaniedtheArdoin children. someofthemissionstothelocalcommunityandmarkets, The test kit detected only Plasmodium falciparum and to resolve misdemeanors at the local court. These parasite antigen in blood. Infection was similar in both offered opportunity for obtaining information on their male (37.0%) and female (36.6%) but not between age- migrationandfever management practices.Thearrange- groups (Table 1). mentalsoallowedtheresearcherstobeasunobtrusiveas Infection was lowest among children that were less muchaspossible.Notesweremadebyeachteammember than 12 months but highest among two and four-year at intervals. Every evening the team shared information olds. Clan was not an important factor in infection with andcomparedobservations.Theeveningdiscussionsalso malaria parasite provided opportunity for identifying issues that required furtherunderstanding. Clans, camps and lifestyle Altogether 72 individuals participated in either informal Malaria prevalence survey conversations,group discussions orinthe key informant A subteam (D) carried out a malaria prevalence survey interviews.Thewomenandchildrensleepinsidethetents amongunder-five yearoldcampmembersusingarapid whilethemensleepoutside, unprotected frommosquito diagnostic test kit, ParaHit f developed by Program for bites. The Bororo children (5-12 years) sleep among the Appropriate Technology (PATH) and manufactured by animals to “prevent mosquito bites”. Irrespective of the Akogunetal.InternationalJournalforEquityinHealth2012,11:5 Page5of10 http://www.equityhealthj.com/content/11/1/5 Table 1Prevalence ofmalaria infection amongunder-5 children No.Examined %Infected Significance Age(years) ≤1 237 27.4 P<0.05,Chisqr:18.6,Significant 2 151 45.5 3 131 34.1 4 172 45.1 Sex Male 349 37.0 P>0.05,Chisqr:0.013,NotSignificant Female 342 36.6 clancampmembers’dutiesandinteractionsaresegregated couldposeamajorobstacletoobtaininginformationon by age and sex (elderly, married male, unmarried male, health among nomads using the live-in approach. How- marriedfemale,unmarriedfemale)andin-lawscouldnot ever thisiscompensatedbya rapidbuilt-upof trustand socially mingle. Responsibilities and duties are well rapportandenrichmentofthequalityofinformationcol- defined.Womentakecareoffood,children,andthetents lected during lay conversations and discussions while in whiletheyoungherdtheanimals.Theeldersserveasliai- thecamp. sontootherclansandtothelocalcommunitypopulation. Very few childhood fevers were managed in the camp They gather news about pasture, potential conflict and duringthelive-inperiod.Ontwooccasionsthehousehold patternsoflocalpoliticsthatmayaffectthem.Amongthe headbroughtantibioticspurchasedfromthelocalmarket BororoandtheKiri,herderswouldspendaboutonehour forthetreatmentofdiarrheaina7-yearold.Althoughwe studyinginArabicattheendoftheday’swork. weretoldthatthiswasacommonpractice,theparticular AmongtheJahunandtheKiri,younggirls(7-11years) actionwasasaresultofourpresenceotherwisewenoted participate in herding. The elders and women patronize thatattemptsweremadetoexhaustotherhomeremedies the nearest markets while the young tend the animals. beforepurchasingmodernmedicinesfromlocalmedicine Onlytheveryyoungandinfirmareleftinthecampduring vendors.Theteamwitnessedfourcasesofchildhoodfever theday.Informationgatheringandcommunicationisvery managementwhilethehealthteammemberwaswiththe criticaltothenomadiclifestyle.TheArdospendsasignifi- herdersand couldnot returnto camp for the night. The cant proportionofthe time inthe courtof the sedentar- observations were corroborated with information from ized local community chief or in the market scooping conversations and discussions. The household head on information that could be useful for the safety of camp receiving information about a member of the household membersandanimals.Acampcouldrelocatewithinafew being ill will assess the severity. The opinions of other minutesofadecisiontodoso.TheArdoisresponsiblefor men and in some cases suggestions of the old women the decision to relocate. The use of mobile handheld weretakentoaccount.Oftenthehouseholdheadwillnot phonesisverycommonamongthenomadsforenhancing make knownhisdecision but would leavethe camponly communication between the herders and the Ardo. The toreturnlaterinthedaywithmedicinesforthetreatment team (A, B) witnessed the relocation of five camps com- of the ill person. In exceptional cases the individual may prisingthousandsofheadsofcattletoapositionofabout be takentoa healthfacility but the team didnotwitness 25 kilometers upstream within an hour to avoid a local this. The team had an opportunity to observe a boka crisiswhichturnedouttobearuse. (medicine man) manage a non-malaria ailment. The The Bororo youth (both male and female) plait and womenseemedtohaveagreaterinfluenceonthedecision adorntheirhairand clotheswithbrightlycolouredorna- of the household head than acknowledged. They often ments.Aradio(withwhichtheyarelinkedtotheoutside influencethehouseholdheadbythemannerinwhichthe world) is an indispensable part of dressing as they herd ailmentisdescribed.Inordertoinfluence the household animalsin the fields.The Jahun arewitty, inquisitive but head’s decision they often give examples of those with extremelywaryofoutsiders. similar illness in some other place and how or where it Camp live-in observations posed some challenge as wasmanaged.Althoughthedecision-makeroftenignored wordswentroundthattheteamwasinterestedinhealth. thewomentheeventual actionseemedto havetheinflu- At the onset many ailments were brought to the team. enceoftheolderwomenwhoservedasnurseandadmin- However the splitting of the team helped reduce the istermedicinestochildrenandotherwomen. number as it became known that they would only meet It was much easier to observe the herders than activ- thehealthpersonnelmemberoftheteaminthenightor itiesinthe camp. The presence ofa guest hadvery little early in the morning. The provision of basic health care effect on their activities. The herders easily developed Akogunetal.InternationalJournalforEquityinHealth2012,11:5 Page6of10 http://www.equityhealthj.com/content/11/1/5 rapport and were eager to share skills, information and Table 3Factors that triggerpabboje(N = 97)1 knowledge once in the field. In the camp they appeared Factors/agents Frequency(%) shyandwithdrawninthepresenceoftheoldermen.The Freshmilkduringtheearlyrains 71.1 rapportwithteammemberinthefieldandthecomrade- Freshmaizeduringtheearlyrains 48.5 shipwasmuchstrongerthanwhatthefemaleteammem- Roastedmaizeinearlyrains 36.1 ber witnessed among the women. Except the illness was Sightoraromaofmaize 11.3 so severe as to prevent herding the herders were often Consumptionofmaize 6.2 lefttoresolveanyhealthissuestheymayencounterwhile Greetingapersonwithpabboje 4.1 herding.They freelypurchasedwhatevermedicinesthey Others(e.g.brightcolours,flowers) 20.6 wantedandused thematwillevenintheabsenceofany 1multipleresponsesallowed ailment.Onmanyoccasions,theherderswouldpurchase vialsofinjectablechloroquineorantibiotics,breakitwith the teeth and swallow the content. It was believed to be The symptoms of pabboje include weakness of the more effective than pills in the absence of an injection. body, naadaago (stretching of the body), feeling cold Therewasverylittleregardtoexpirationordistinguish- and desire to sit in the hot sun, lack of appetite. Other ingbetweenantibioticsandantimalariaandwouldsome- diseases may exhibit similar symptoms but pabboje is times take multiple medicines at the same time. The unique because it gives intermittent respite to enable herderswouldchewherbsand rootsofvariousplantsas one carry out one’s duties. well as modern medicines for different reasons: to keep Once it did not go away on the next day, we begin to warm,preventorhaltanemergentfever,orcolds. suspect other types of djonte which could be caused by witches or evil spirits but we must wait for a week to be Cultural epidemiology of fever certain it is not pabboje —informal conversation, Ardo, Nomads perceived Pabboje, a type of fever that recurs Bororo on alternate days as the most common health problem A group of Fulani women articulated the generally with 87.6% reporting that they had within the past six held view months (Table 2). Pabbojeis naturalwitheveryFulaniandisnotcaused They acknowledged other ailments of concern to by anything. It is harmless but when one eats, smells or nomads as ringworms (19.7%) and diarrhoea (17.3%), seessomethingpabbojedoesnotlikeitwakesupandgives Cough (dambi), and foot cracking (pe-i). a little trouble which disturbs ones work.—Focus group They described symptomsof pabbojeashotnessof the discussion,marriedwomen. body,fatigue,headache,shivering,painsinthejoints,diar- MypabbojebecomesunhappywhenIdrinkmilkduring rhoea,vomitingandlossofappetite.Pabbojeisnascentin theearlyrains.Manypeopledon’thavepabbojeduringthe theFulanibutcanbetriggeredintoactiveformwhenone dry season although they drink milk at that time. It can drinksfreshmilkduringearlyrains, eatsorperceivesthe only be because the milk we drink in the rainy season is aromaoffreshmaizebeingroastedorcooked,orobserves different.Cattlegrazeonfreshgrassintherainyseasonthe brightly coloured agents (red or yellow) such as maize milk from such cattle may be the one that wakes up the flowers(Table3). sleepingpabbojeintheFulani.—Indepthinterview,healer They noted that however, the frequency and severity andJauro,Bororo differs between individuals. While some have a single episode annually others have up to four, at onset or end Perceived severity and Patterns of Distress of the rain and others at both seasons. Most Fulani nomads had experienced at least two annual episodes of pabboje but they do not associate it Table 2Frequency ofdiseases in the camps with death. Although pabboje was merely a condition Self-reporteddiseases Numberinterviewed Frequency(%)1 for being a Fulani, and not an illness, nevertheless it was Pabboje 374 87.6 mentioned as cause of depression since it interfered Ringworms/Skinproblems 84 19.7 with performance of normal tasks and with carrying out Diarrhoeaandabdominalpain 74 17.3 one’s responsibilities in the camp. Backandjointspain 56 13.1 Pabboje starts with general body weakness and a desire Dysentery 38 8.9 to sit in the hot sun. One will then have naadaago (a Worms 27 6.3 kind of body stretching that happens when one has just Cough 16 3.7 woken up), the body will be hot, intense headache but Others 3 0.7 one will feel cold and begin to shiver. Some people will Numberofrespondents 427 100.0 vomit.——Key informant Interview, Young male herder, 1Proportionreportingtheyhadthecondition Jahun Akogunetal.InternationalJournalforEquityinHealth2012,11:5 Page7of10 http://www.equityhealthj.com/content/11/1/5 Pabboje behaves differently in different people. May be Until recently, I did not know any modern treatment this is because of what wakes it up. I don’t know. In for pabboje. I would wait until the episodes of my pab- some people, pabboje will be so mild that it does not boje has come and passed— Informal conversation, interfere with herding while it will be very severe in Ardo Kiri others.–Informal conversation, herder, Bororo Some women keep antimalaria purchased from local WhenIusedtogoherding,mypabbojewouldnotcome vendors at home for treating pabboje in children. in the morning but will allow me take the animals far At the store we just ask for medicine for ciwonfulani afieldthenitwillstartwhenthesunisontopofthehead, (Fulani problem). We give two tablets. If the child is too ataboutnoon. Iwouldthenhavetoreturnhome.Iknow young, we give syrup. The child vomits and then becomes thefollowingdayitwouldnotcomesoIwouldgoherding well again. Pabboje starts in the night or early in the the animals. But on the third day, I would wait in the morning–Focus group discussion, Young mothers, Kiri tent till noon for it to come and surely it would come. The elderly believe that the treating pabboje had That is how I used to manage the three and sometimes “made it more severe” and many would rather not use four episodes that I used to have every year.- Informal any modern medicines in cases of pabboje. conversation,Ardo,Kiri Modern drugs, like quinine for treating pabboje disap- The distinguishing symptom of pabboje is that act of peared then there was nivaquine and later chloroquine coming on days one, three, five before dis-appearing. injectionwhichwasveryeffectivewithsomepeople.How- Djonte is like pabboje that does not go away but that ever, many of us do not treat pabboje because modern remains persistent drugs will only make pabboje go away for a short time Djonte is very dangerous. It will not allow you to herd only to return with more virulence. The only drug I did the animals at all. not hear people complain about is the one your group —Informal conversation, Male herder, Kiri bringstous.——Indepthinterview,Ardo,Jahun The nomads would ignore fever until the third recru- Pabboje is distinguished from djonte because the for- descence.Howeverifsymptomspersistedbeyondthe7th merrecurswhilethelatterdoesnot.Wheneversomeone day,itwasclassifiedas djonte(fever)duetoothercauses has djonte itwill be assumed to be pabbojeexceptwhen andnotpabboje.Nomadsarerelievedwhendjonteisdue provenotherwise.Themainproofisforitnottogoaway to pabboje and perceive other types of fever with much and comeback again. There are other types of djonte anxiety. which the nomads consider very dreadful since they However, its interference with duties has made it interfere severely with normal activities. Ifit is not pab- necessarytocurtailitsrecurrenceortoreduceitsseverity boje, then it is caused by evil spirits or witches and to a level that normal activities such as herding could shouldbetreated byplacingleavesofbaobabonredhot continue. Some traditional method of preventing the charcoalandinhalingthesmoke. recurrence of pabboje is, at dawn after the first recur- One such djonte is djonte kippindirde considered the rence to take a handful oflebol (butter from cow milk), most precarious of the djonte and can only be removed venturefarintothebush,andplacethelebolbetweenthe by traditional healers since it is caused by hendu (evil leaf of barkeje (a shrub with broad leaves), fold the leaf spirits) or mutte’en or karama’en (witches). and then let go of it immediately. One should neither Buudi or Buule (plural) may also cause djonte. Fever lookbacknoreverreturntotheparticularspot.Thenext due to buudi is milder than pabboje. Although the vic- personthatpasseswouldtaketheillnessfromthevictim tim feels weak and has hot body there will neither be and thus hinder subsequent episodes from emerging. shivering, or feeling cold. Although buudi may subside Anotherapproachistocutanun-ripepawpawfruitinto and escalate; it does not follow any regular pattern like four equal partsandsoak themin milk that isbeen pre- pabboje. Buudi can be felt when the inflamed part is paredforpendiidam(yoghurt)andallowtoferment.The touched. pawpaw wouldthen be removed and the yoghurt served Besides djonte, pabboje, other diseases that nomads to the patient to drink. This will reduce the severity of regard as intrinsic waiting to be externally triggered are pabboje. Cotton leaves may also be boiled and drunk in Doiru (tuberculosis), peewol (rheumatism), and sadaure ordertoreducetheseverityofpabboje.Yet,anotheranti- (leprosy or dermatitis). dote is to take a handful of guinea corn with the left Nomads take measures to protect themselves from hand and bury it under dingaali (a woody plant with mosquitoesbecausetheyareanuisance,suckblood,and broad bitter leaves) on the second day of pabboje. This maycauseitchingatthepointofbite.Insecticidetreated action will bury the pabboje within, and prevent it from nets, clothing (especially when asleep), herbs burned to “wakingup”onthethirdday.Insomecasespabbojemay create smoke and plant repellents are used to prevent remain buried forever unable to wake up even when man-mosquito contact. Herders hang certain plants triggered. around the body while in the field and place some at Akogunetal.InternationalJournalforEquityinHealth2012,11:5 Page8of10 http://www.equityhealthj.com/content/11/1/5 different parts of the tent to repel mosquitoes. Among Table4Reasonsforpreferringonesourceofintervention theBororo,childrensleepamong thelarge animalssuch to the other (N =97)1 ascattletopreventmosquitobite.An8-yearoldnomadic Reasons Frequency Fulanichildspokeforhiscolleagues (%) We sleep among the cows so that the mosquitoes do Paymentconditionisflexibleandcanbenegotiated 49.5 not see us to bite. The cattle are big and the mosquitoes Distance:theplaceisnotfarfromcampsite 42.3 bite them instead. Timespentinthefacilityisshortandconvenient 38.1 Serviceisgoodandreliefisobtained 30.9 Decision-making and health service utilization StaffoffacilityarefriendlyandrespecttheFulani 22.7 Since the live-in exercise did not yield much informa- Typeofdrugandmodeofdispensingcanbe 22.7 negotiated tion from observed practices, the team depended on Servicesandsuppliesarealwaysavailable 20.6 conversations and the survey results. Although most Others 2.0 nomadic Fulani (79.4%, N = 97) knew the location of the nearest health facilities, only a few (5.8%) visited or 1multipleresponsesallowed,verticalcomparisononly knew someone who had visited any in the past six months. Self-treatment with a variety of antimalaria antimalaria for the management of fevers in the camps. drugs and antibiotics is very common particularly However they expressed concern about time and dura- among the young male (herders). We observed them tion of training as well as how participation would affect purchase antibiotics and vials of injectable medicines their nomadic life. If required they would be keen to displayed on a mat laid on the market floor, break the contribute to the purchase of drugs, to support the vial open with the teeth and swallow the content. camp own resource person (CORP) during training and The mother of a febrile child would inform the father to compensate for time if the acquired skills would be whose responsibility it was to decide the course of used solely for the benefits of fellow camp members. action. When an adult was severely ill and unable to communicate, the most elderly male would decide the Discussion course of action to be taken. When illness is severe That majority of the camps had moved in and out of the enough as to be life threatening one in ten women same area for more than 15 years confirm the predict- would take a child to the health facility without the con- ability of migratory patterns of nomadic communities. sent of the father. Male children informed their fathers Their highly developed communication skills and when they fell ill while female children notified mothers. respect for hierarchy are advantages that health authori- If the head of a family was not available, the brother or ties could take for developing appropriate intervention other person to whom the household was entrusted programme that nomads would accept. would take decisions in his absence. However, no action The recorded prevalence of malaria in the survey is would be taken until the 7th day when the type of not surprising. A previous study in Northeastern Nigeria djonte is determined. If fever persisted without any reported up to 58.7% prevalence of Plasmodium falci- recurrent pattern it would be assumed to be severe and parum [15]. Malaria transmission in northeastern treated as such. Once a decision was made the father Nigeria is seasonal and reaches the peak at the onset would allocate resources (money, donkey and advice) to (May/June) and end (September/October) of rainy sea- enable the mother implement it. It is in rare cases that a son when anopheline mosquito breeding sites are abun- father would take the child to the health facility. dant. Although the breeding sites dry up in most parts In recent times, nomadic Fulani patronise private of Northeastern Nigeria during the intensely hot and health facilities but hardly public ones. The reasons dry months (February/April), focal transmission abound were similar irrespective of clans or camp. Payment con- in isolated sites such as water holes and perennial river dition (49.5%), distance from camp (42.3%) and the beds. Nomads are exposed to this focal but intense politeness of the health care provider are the most transmission when they camp near water holes in con- important considerations when making a decision to sideration of the need of their animals. Unlike most patronise a health facility. Nomads spend as much as $8 sedentary communities, nomadic populations are there- in the purchase of antimalaria medicines most often (of fore exposed to malaria transmission throughout the unknown and doubtful origin) from itinerant vendors at year and thus deserve special attention by control pro- local markets (Table 4). grammes. In Mali, disproportionately low prevalence of Nomads are very much concerned about their inability malaria among Fulani tribe when compared with other to benefit from regular health service and expressed tribes had been associated with an unidentified genetic willingness to participate in the distribution of insecti- factor [16]. Such association is difficult to infer in this cide treated nets (ITN) and in the administration of study. Akogunetal.InternationalJournalforEquityinHealth2012,11:5 Page9of10 http://www.equityhealthj.com/content/11/1/5 The nomadic Fulani have a highly well developed the- the community will participate in intervention to ensure ory of causation of febrile illnesses and are able to dis- ownership of intervention process and outcome. First tinguish between different types of fevers. The the nomads’ migratory movement and settlement pat- perception of pabboje as different from other types of terns within a health district should be identified, djonte but personal to the Fulani nomads is probably, as described and a plan developed for approaching and Imperato [17] explained, a means of coping with the dis- negotiating their participation in malaria control. The ease. Whereas pabboje provided respite for them to cultural epidemiological description of the disease is meet their obligations and duties to their family and ani- also useful for planning intervention strategies particu- mals (pulaaku) other types of djonte do not and are larly the development of information, education and therefore dreaded. This is perhaps the reason for regard- communication strategies. ing pabboje as a problem of the nomadic Fulani popula- tion. The intermittent distress due to pabboje still Conclusions provides some respite for performing one’s duty as Despite the view expressed by some nomads that the Fulani. The fact that it is regarded as nascent, requiring use of Western medicine might have worsen the disease, a trigger factor to make it come alive probably explains majority attest to the relief offered by Western medicine the focus of traditional intervention which is to negoti- and accept it if it is made accessible to them. The com- ate the return of pabboje to its dormant status without munity directed intervention strategy is the basis for recurring or to reduce its severity but not completely increasing that accessibility. The challenge before the clearing it. health system is to apply the community directed inter- The gradual acceptance of treatment of pabboje indi- vention approach that has worked well with settled cates a change in awareness that malaria control inter- communities to the nomadic lifestyle. vention programmes need for developing a control programme for the nomads. The market which serves as Acknowledgements a key meeting point for collection and dissemination of TheinvestigationwassupportedbygrantnumberA10626toOAfromthe information among nomads could be exploited by the SpecialPro-grammeforResearchandTraininginTropicalDiseases,World health authority for interactive communication. HealthOrganization(WHO/TDR).WearegratefultoAbuAdamuYahayawho facilitatedthecontactwiththenomads,toArdoSubairu,Tuga,Nduruwa Nomads will most likely continue to patronize the pri- andtheirclansforenthusiasticcollaborationandtoNehaShaofTheJohns vate health facility abandoning the public health facility HopkinsUniversitywhoreviewedthestudytoolsattheearlystage. to sedentary community populations as observed in Authordetails another study in Nigeria [18]. It is unlikely that commu- 1CommonHeritageFoundation,No.1BishopStreet,Box5124,Yola,Nigeria. nities could be convinced to accept the sharing of lim- 2FederalUniversityofTechnology,Yola,Nigeria.3AdekunleAjasinUniversity, ited consumable health resources with temporary guests Akungba,Akoko,Nigeria.4SpecialProgrammeforResearchandTrainingin TropicalDiseases,WorldHealthOr-ganization,Geneva27,Switzerland. whose population and health needs may often over- whelm that of the local population. In Nigeria allocation Authors’contributions of resources and services are carefully computed and OBAconceived,designedandcoordinatedthestudy;MAGandJAB reviewedtheprotocolsandimprovedtheintellectualcontentwhileSNand shared between spheres of governance at the federal, AOAcoordinatedprevalencesurvey,analyzedandinterpretedthedata,OTO state, local government area and community according contributedtothedesignandreviewedthefinalmanuscriptforintellectual to set criteria which takes into consideration the census quality.TheprotocolhadtheethicalapprovaloftheNationalHealth ResearchEthicsboardofNigeriaandtheethicsreviewcommitteeofthe of the community. The nomads are not often included WorldHealthOrganization.Allauthorsreadandapprovedthefinal at the planning stage. Although communication technol- manuscript. ogy-driven empowerment combined with simple rapid Competinginterests diagnostic tools and creative packaging of medicines Theauthorsdeclarethattheyhavenocompetinginterests. may increase access to fever management services, it is yet to attract the attention of potential investors [19] Received:12October2010 Accepted:31January2012 Published:31January2012 The most plausible strategy is an intervention that is nomadic community-managed, and that exerts minimal References pressure on pre-allocated resource of the sedentary 1. Sheik-MohammedA,VelemaJ:Wherehealthcarehasnoaccess:the community. nomadicpopulationsofsub-SaharanAfrica.TropMedandInterHlth1999, 4(10):695-707. The community directed intervention (CDI) approach 2. AilouS:“Whathealthsystemfornomadicpopulations?”.WrldHlthFor that has been made popular in the control of onchocer- 2010,13:311-314. ciasis in Africa is probably the most viable option for 3. BriegerW,OkeG,OtusanyaS,AdesopeA,TijaniJ,BanjokoM:Ethnic diversityanddiseasesurveillance:GuineawormamongtheFulaniina increasing access of the nomads to malaria intervention predominantlyYorubadistrictofNigeria.TropMedandInterHlth1997, services [20,21]. The approach requires that the health 2(1):99-103. authorities and partners negotiate the means by which Akogunetal.InternationalJournalforEquityinHealth2012,11:5 Page10of10 http://www.equityhealthj.com/content/11/1/5 4. BriegerW,OtusanyaS,OkeG,OshinameFO,AdeniyiJO:Factors associatedwithcoverageincommunitydirectedtreatmentin ivermectinforonchocerciasiscon-trolinOyoState,Nigeria.TropMed andInterHlth2002,7(1):11-18. 5. DaoM,BriegerW:ImmunizationforthemigrantFulani:identifyingan under-servedpopulationinsouthwesternNigeria.IntQuartCommHlth Educ1995,15(1):21-32. 6. AkogunO:Astudyonpresumptivediagnosisandhomemanagementof childhoodmalariaamongnomadicfulaniinDemsa,Nigeria.MPH, SchoolofPublicHealth,UniversityoftheWesternCape;2008,80. 7. OmarM,OmarM:HealthforAllbytheYear2000:whataboutthe nomads?DevelopmentinPracticeReaders1999,9(3):23-31. 8. AdriansenH,NielsenT:Goingwherethegrassisgreener:Onthestudy ofpas-toralmobilityinFerlo,Senegal.HumanEcology2000, 30(2):215-226. 9. FederalMinistryofHealth,Nigeria:StrategicPlanforRollingBackMalaria inNigeria2001-2005.Abuja:FederalMinistryofHealth;2001,45. 10. ImperatoP:NomadsoftheWestAfricanSahelandthedeliveryofhealth servicestothem.SocSciandMed1974,8:443-457. 11. GordonAJ:Culturalidentityandillness:Fulaniviews.CultMedPsychiatry 2000,24(3):297-330. 12. BellD,RouelG,MiguelC,WalkerJ,LillibethC,AllenS:DiagnosisofMalaria inremoteareaofthePhilippines:Comparismoftechniquesandtheir accep-tancebyhealthworkersandthecommunity.BulletinofWHO2001, 79:933-941. 13. RennieW,HarveyS:Developmentandtestingagenericjobaidfor malariarapiddiagnostictests(RDT):FieldReportofQualityAssurance project.WHOprojectreport2004,47. 14. PagnoniF,ConvelboN,TiendrebeogoJ,CousensS,EspositoF:A Community-basedprogrammetoprovidepromptandadequate treatmentofpresumptivemalariainchildren.TransRoySocTropMed Hyg1997,91:512-517. 15. MoltaNB,DanielHI,WatilaIM,OgucheSO,OtuTI,AmehJO,GadzamaNM: Efficaciesofchloroquine,pyrimethamine/sulphadoxineand pyrimethamine/sulphaleneagainstP.falciparuminnortheasternNigeria. JTropMedHyg1992,95(4):253-9. 16. ModianoD,PetrarcaV,SirimaBS,NebiéI,DialloD,EspositoF,ColuzziM: DifferentresponsetoPlasmodiumfalciparummalariainwestAfrican sympatricethnicgroups.ProcNatlAcadSciUSA1996,93(23):13206-11. 17. ImperatoP:Problemsinprovidinghealthservicestodesertnomadsin WestAfrica.TropDoc1975,5:116-123. 18. OtusanyaSA,BriegerWR,TitiloyeM,SalamiKK,AdesopeA:Ethnic variationsinhealth-seekingbehavioursandattitudesbetweenFulani herdersandOrubafarmersinsouthwesternNigeria.TropDoct2007, 37(3):184-5. 19. AkogunO:RoboticHealthAssistant(Feverkit)fortheRational ManagementofFeversamongNomadsinNigeria.NursLeadersh(Tor Ont)2011,24(2):58-67. 20. AkogunO,AuduZ,WeissM,AdelakunA,AkohJ,AkogunM,RemmeH, KaleO:Community-DirectedTreatmentofonchocerciasiswith IvermectininTakum,Nigeria.TropMedandInterHlth2001,6(3):232-43. 21. TheCDIStudyGroup:Community-directedinterventionsforpriority healthproblemsinAfrica:resultsofamulticountrystudy.BullWHO2010, 88:509-518. doi:10.1186/1475-9276-11-5 Citethisarticleas:Akogunetal.:Febrileillnessexperienceamong Nigeriannomads.InternationalJournalforEquityinHealth201211:5. Submit your next manuscript to BioMed Central and take full advantage of: • Convenient online submission • Thorough peer review • No space constraints or color figure charges • Immediate publication on acceptance • Inclusion in PubMed, CAS, Scopus and Google Scholar • Research which is freely available for redistribution Submit your manuscript at www.biomedcentral.com/submit

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Akogunetal.InternationalJournalforEquityinHealth2012,11:5 http://www.equityhealthj.com/content/11/1/5 RESEARCH Open Access Febrile illness experience among Nigerian nomads Oladele B Akogun1*, Minnakur A Gundiri2, Jacqueline A Badaki3†, Sani Y Njobdi2†, Adedoyin O Adesina1† and Olumide T Ogundahunsi4† Abstract Background: An understanding of the febrile illness experience of Nigerian nomadic Fulani is necessary for developing an appropriate strategy for extending malaria intervention services to them. An exploratory study of their malaria illness experience was carried out in Northern Nigeria preparatory to promoting malaria intervention among them. Methods: Ethnographic tools including interviews, group discussions, informal conversations and living-in-camp observations were used for collecting information on local knowledge, perceived cause, severity and health seeking behaviour of nomadic Fulani in their dry season camps at the Gongola-Benue valley in Northeastern Nigeria. Results: Nomadic Fulani regarded pabboje (a type of “fever” that is distinct from other fevers because it “comes today, goes tomorrow, returns the next”) as their commonest health problem. Pabboje is associated with early rains, ripening corn and brightly coloured flora. Pabboje is inherent in all nomadic Fulani for which treatment is therefore unnecessary despite its interference with performance of duty such as herding. Traditional medicines are used to reduce the severity, and rituals carried out to make it permanently inactive or to divert its recurrence. Although modern antimalaria may make the severity of subsequent pabboje episodes worse, nomads seek treatment in private health facilities against fevers that are persistent using antimalarial medicines. The consent of the household head was essential for a sick child to be treated outside the camp. The most important issues in health service utilization among nomads are the belief that fever is a Fulani illness that needs no cure until a particular period, preference for private medicine vendors and the avoidance of health facilities. Conclusions: Understanding nomadic Fulani beliefs about pabboje is useful for planning an acceptable community participatory fever management among them. Background campsareoftenignoredtotheextentthatlessthan3%of When compared to the urban populations, rural com- childrenbelow2yearsmaybenefitfromfullimmunization munities are poorly served by the health system, but in serviceinsomeareas[5]. comparison with nomads, the gap between nomads and Althoughdisproportionatelymoreexposedtoinfectious rural settled communities is even wider [1]. diseasessuchasmalaria,nomadsremainisolatedfromthe First, the formal health system appears ill-adapted for ongoing malariamanagementcampaigns[6,7].Account- extending services to constantly mobile communities of ing formorethan 10%ofAfrica’soveralldiseaseburden, nomads[2]andlocalauthoritiesoftendisregardtheexis- malariaisresponsibleforupto20%ofmaternaldeathsin tence of nomads with respect to health service delivery. health facilities in sub-Saharan Africa [8]. In Nigeria, Forexample,inSouthwesternNigeria,guinea wormcase malaria remains the most important cause of childhood detectionscouts“forgot”toincludevisitstonomadcamps morbidity and mortality. In 2000, malaria accounted for [3],andivermectindistributioninthecontrolofonchocer- 63.4%ofallreporteddiseases,with50%ofthepopulation ciasis,oftenmarginalizednomadicFulanisettlements[4]. havingatleastonemalariaepisodeleadingtobetween30 Locatedontheoutskirtofsettledcommunities, nomadic and50%inpatientadmissionsand50%outpatientvisitsto healthfacilities[9]. *Correspondence:[email protected] The typical Fulani household has a headman, his †Contributedequally wives, children and dependents [10]. About 15 house- 1CommonHeritageFoundation,No.1BishopStreet,Box5124,Yola,Nigeria hold units aggregate in an area to form a wuro (camp) Fulllistofauthorinformationisavailableattheendofthearticle ©2012Akogunetal;licenseeBioMedCentralLtd.ThisisanOpenAccessarticledistributedunderthetermsoftheCreativeCommons AttributionLicense(http://creativecommons.org/licenses/by/2.0),whichpermitsunrestricteduse,distribution,andreproductionin anymedium,providedtheoriginalworkisproperlycited. Akogunetal.InternationalJournalforEquityinHealth2012,11:5 Page2of10 http://www.equityhealthj.com/content/11/1/5 and many wuro constitute a gure. Nomadic Fulani oftenconsistsofseveralgroupsofconcentrictentsinhab- dependence on herbal remedy and private medical out- itedbyanomadiccommunity.Severalsuchcommunities lets in health seeking is well documented. may be located in a particular place within 5 kilometers Despite currentGovernmenteffortsto reduce thedis- ofeachotherunderaclanleader[10].Theclanisasub- ease burden through distribution and promotion of group within the larger Fulani tribe that claim descent insecticide treated nets (ITN) usage, simple diagnostic from a common ancestor or share a perceived kinship. tools, behaviour change communication, appropriate TheclanoftentakesnamesoftownssuchasJahun,Kiri, chemotherapy, intermittent preventive treatment and Bodewatodenoteitsoriginorthatofitsfoundingances- community management of febrile illnesses, access to tor.Thesharingofthestipulatedcommonancestryisthe theseservicesremainachallengetothe nomads.Oneof symboloftheclan’sunity.Themigratoryroutesareclan the major health issues in Africa is how beliefs about based and the group passes through the symbol of the health and illness are used in health care delivery since clan (suchasKiriforthe KiriFulaniclan)duringa cycle the concept of illness is informed by cultural identity ofmigration.Itisnotuncommontofindwithinthesame [11]. For example the Fulani express the sense of differ- clan, another set of groups that attempt to distinguish ence between them and other groups through the man- themselves from the other group members as a subclan ner in which they acknowledge illness. Being Fulani basedonanagnateofthesamesymbolicprogenitor[10]. meansperseverance,strengthofcharacter,disciplineand Members of the same clan usually camp in a particular providingleadershipoverothers.Thelackofunderstand- areaoccupyingsometimesabout3kilometersradius,and ing of their cultural experiences with malaria is a hin- sharethesameroutesandmovementtiming. drance to integrating them into the malaria control Three main nomadic Fulani clans use the Benue- programme.Yetifnotaddressed,nomadswillremainan Gongolavalley fortheirdry season stopover.Atthepeak epidemiologically significant group when the disease is ofthedryseasons,forty-eightcamps(estimatedpopulation eventuallyreducedtoalevelbelowpublichealthimpor- of12,000) dotted theentirearea accordingtotheirclans. tance amongsettledpopulations.Astudyonthemalaria The Kiri undergo a migration within a radius of 30-100 illness experiences of nomadic Fulani communities that kilometers and have a sedentary phase of old people, the camp in the valleys of rivers Benue and Gongola of Jahunmigrateoveralongerdistancebutusethevalleyon Northeastern Nigeria during the dry season was con- anannual basis whiletheBororo(Bodyelclan) arecross- ductedpriortodevelopmentofanappropriateinterven- bordernomadstravellingover800kmandonlyreturning tionprogramme. tothevalleyonceineverythreeyears.Mostofthecamps had moved in and out of the valley in the past 15 to Methods 20years.MembersoftheKiriclanclaimthatasfarasthey The study wascarried out betweenNovember 2003 and could recall their great grandfathers had camped in the April2004.Amixedapproachcombiningtraditionalbio- valleyaswell. logicaltechniqueswithethnographicmethodswasused. While the Kiri and the Jahun may spend up to 5 Informal conversations, unstructured interviews, group months in the valley the Bororo hardly spend 3 months discussion, andliving-in-camptechniqueswere used for before moving on. Camps of particular clans arrive and collecting information from nomads about their febrile leave the valley at different times thus providing oppor- illnessexperiences.These werethencomplimentedwith tunity for collecting data from different members of the householdandmalariaprevalencesurveys. same clan throughout the dry season (November to May). A typical nomadic Fulani household unit consists Study population of a set of concentric tents (built with reed, millet or The nomadic Fulanicampcommunitiesofinterestwere corn stalks) in a semi-circle overlooking where animals concentratedattheconfluenceofriversBenueandGon- are tethered. It is composed of a man, his sons, younger golainNortheasternNigeria(Latitude9°13’Nand9°46’N brothers, first cousins and other dependents. A house- and Longitude 11°30’E and 12°10’E) spreading out over hold is a unit of economic activity headed by a jom five Local Government Areas (LGAs). An extensive wuro, or household head. The basic settlement of the SavannaSugarfarmprojectirrigationschemesituatedin Fulani is the wuro (camp) that is composed of 12-20 the area provides abundant vegetation all year round. household units and headed by a Jauro or bulama. Each Withanopenvegetationofshrubsandherbaceousplants wuro is part of a cluster of several other wuro in an area muchfavouredbyanimals,theareaservesasamajordry belonging to the same clan. A collection of wuro is seasonstop-postfornomadsintheirnorth-southmigra- called the gure over which the eldest among brothers is tory cycle. The camp is a settlement where the nomads the Ardo or clan leader. The Ardo wields the greatest maketemporaryshelter.Thecampvariesinsizedepend- influence in nomad leadership hierarchy. The Ardo has ing on the number of households inhabiting it. A camp responsibility for coordinating movements, mediating Akogunetal.InternationalJournalforEquityinHealth2012,11:5 Page3of10 http://www.equityhealthj.com/content/11/1/5 disputes within the clan, negotiating with settled local intendeddurationintheircurrentlocationandwillingness community leaders or ordering a combat. The Savanna to participate in a study on febrile illness. The team Sugar Irrigation farm project encouraged a set of camp returned to the Ardo at least three more times to offer sites with semi-permanent tents where in recent times specificfollowuphealthandveterinaryserviceswhilecon- the elderly nomadic Kiri Fulani and their children tinuing informal conversations, gaining visibility and remain while the youth herd the animals within a radius acceptance and developing useful contact for the subse- of 50 and 100 kilometers. The elderly Kiri now combine quentstage.Serviceswerelimitedtothosewithinthepro- mediatory and negotiation roles with trading in livestock fessionalcompetenceoftheCommunityHealthExtension at the local markets which may give rise to the sedentar- worker and the Veterinary Assistant in the team and ization of the next generation. They do not cultivate includediarrhealandfevermanagementandofferofrefer- crops at the moment. The Kiri keep goats and sheep in ral support. The Ardo was encouraged to invite other addition to cattle while the Jahun and Bororo keep only eldersoftheclan(particularlytheJauro,thecampleaders) cattle. tothemeetings.Thisprovidedadditionalopportunityfor Anorganizationwithpreviousexperienceworkingwith informal conversations with other elders of the clan and nomads was consulted to learn how the nomads may be for documenting their knowledge and febrile illness approachedand their participationinthe research nego- experience. The conversations sought information on tiated.Alocalguidewithexperiencecarryingoutveterin- knowledge oflocal terminology, vocabularies and usages ary services among the nomads and with whom the aboutfebrileillnessesandmalaria.Specificinformationon nomads had developed some trust was assigned to the febrile illness recognition and classification, response to teamforthepurposeofintroducingandguidingtheteam perceivedcasesofsevereillnessaswellashowthehealth through the social and cultural norms of the nomadic systemservedthemwasalsosought.Thelocalguide’srole Fulani. diminishedwitheverysubsequentvisitandfinallystopped TheSarkinsanuorSarkinFulani(aninformalposition whensufficientrapporthaddevelopedbetweenthe Ardo foraFulanielderwhoservesasaliasonfornomadsatthe andtheteam.Theprovisionofbasichealthandveterinary local government office or at the traditional court of the services during the study was very helpful in trust- localchief)wascontactedandalistofArdowascompiled building. andappointmentsmade to visit.Every contactteam visit With the assistance of the Ardo, camps were selected hadatleast3researchteammemberscomprisingculture from each of the community of camps. Clan representa- specialist, facilitator, and a note-taker, one of whom is tion and duration in the valley were important consid- either a veterinary or health personnel. Diaries and field erations in camp selection. The Ardo facilitated entry to notes were used for documenting information and the camps and introduced the team and the objective of impressions. the study to the Jauro. Team training Formal interviews and discussions Membersoftheresearchteamhadpreviousexperiencein Information from the informal contacts and conversa- communityinteractiveresearchandwerefluentinHausa tions with clan elders was used for developing in-depth and/orFulfulde, thelanguageoftheFulani. The research interview and group discussion guides. Group discus- teamreceivedanorientationonFulaniculture.Sincetape sions were held with women (young, mothers, grand- recordingwasnotusedattheonsettoavoidsuspicionand mothers), herders (young males) and children. In-depth misunderstandingthatarelikelytooccurduringthefirst interviews were held with camp leaders, local specialists meeting,teammembersweretrainedonnotetakingtech- (such as traditional healers). Specific questions on clini- niques.Inordertoensurequality,fieldnoteswerejointly cal signs, causality, meanings and perceived incidence reviewed by all the team members that were present rates were asked. duringparticularinteraction. Muchoftheinteractionwaseitheratdawnorlateinthe evening in order to synchronize with their daily routine. Contact and Informal conversations with clan leaders The nomadicFulanifollowaveryfirmroutinethatcom- During the first visit to the Ardo, the local guide intro- mencedatabout4hours(GMT+1)andendedatabout21 ducedtheteamandinitiatedinformalconversationsabout hours(GMT+1)whentheanimalshadbeentetheredand thehealthoftheiranimalsandtheirfamily.Conversations thedailyschedulecompleted.Informantswereselectedto werethendirectedtofebrileillnesses,accesstoinsecticide representrelevantdiversityineachcommunity(age,gen- treatednetsandantimalariamedicinesbeforetheobjective der,locationandclass).Inordertoavoidinterviewfatigue ofthevisitwasintroduced.Inorder to ascertainthatthe specific but few questions were asked about experience studiedpopulationwouldbearoundlongenoughtocom- with febrile illness to the exclusion of other aspects that plete the study, inquiries were made about the clan’s wasdiscussedwithotherinformants. Akogunetal.InternationalJournalforEquityinHealth2012,11:5 Page4of10 http://www.equityhealthj.com/content/11/1/5 The data from the camps were used for developing ICTDiagnostics,SouthAfrica.ParaHitfisanimmunodiag- household survey questionnaires that were administered nostic test that provides in vitro qualitative test for the to four members (male and female parent of under-five detectionofP.falciparum(Pf)-specificHistidineRichPro- child,unmarriedherders)ofthehouseholdwhereformal teinII[12,13].Rapiddiagnostictestkitsareusefulforthe interviews were not held. This allowed the collection of promptmalariadiagnosisincommunitysurveys[14].The information from this category of people whose experi- currentstudyispreliminarytoaninvestigationonmalaria ences would not otherwise be represented in the study, managementamongchildrenundertheageoffiveyears andtocheckforconsistencyandgeneralizabilityofinfor- sincetheyareespeciallyvulnerable. mation from the other sources. The data were thenana- The quantitative approach was used to assess malaria lyzedandthederivedinformationusedfordevelopingan prevalenceinchildrenandculturalepidemiologicalindica- observationandinformalconversationguides. tors:frequencyofself-reportedexperienceofvariousdis- eases in order to estimate the perception of disease Live-in experience burdenandagreementoncausation.Qualitativeapproach Inordertounderstandthecontextwithinwhichinforma- assessed the domains of knowledge, causation, severity, tion was obtained, three households with at least three perceived burden and pattern of treatment seeking under-five children andthatare willing tohost the team response to illness. Quantitative data were entered into were selected from each clan for a 7-day live-in-camp EPI INFO (version 3.3.2) and analyzed with IBM SPSS experience.Typicalfamilydecision-makingprocesseswith Statisticsversion18whilequalitativedatawereprocessed respecttocare-giving,healthandillnessbehaviorsuchas withAtlasTi. gender roles, extended family influence and age were documentedintheprocess.Attentionwasgiventofamily Results care, recognition of febrile illnesses, home remedies ShrubsandherbaceousplantscharacterizetheBenueriver (orthodox or traditional), health service usage, nursing valleyattractingnomadstothelimitedgrazingareasparti- care and recuperation. The 3-member team comprised a cularly during the dry season. Although 28 camps were health and veterinary assistant led by a facilitator (teams counted during the study, the team was informed that A,B,C).Theteammemberssharedthesametentbuiltby therewereprobably160campsatdifferentlocationswith the women and interacted within limits of the culture. a total estimated population of about 10,000 nomads at Each member of the team selected a particular skill to thetime.TheinitialrealizationwasthatthetermBororo, acquire during the live-in experience. For example the which non-Fulani people erroneously use to describe all woman member spent much of the time with the eldest Fulaninomadsonlyapplytoaparticularclan.Thosewho womaninthecampbutinteractedwithotherwomenpar- didnotbelongtotheclanfeltoffendedwhenerroneously ticipatingintheireverydaytasks(learningtomilkthecow, referred to as Bororo. The research team talked to more prepareyoghurtormilletmeal).Similarly,amalemember than 72 nomads during the qualitative data collection oftheteamspent muchofthetimewiththeherdersand while 97 respondents participated in the survey. More participated in herding and tendering the animals. The males participated in the survey (60.8%) than females thirdmembersharedthetimewiththeeldersoftheclan (39.2%). The malaria survey involved 691 under-five andwheredecorumpermitted,accompaniedtheArdoin children. someofthemissionstothelocalcommunityandmarkets, The test kit detected only Plasmodium falciparum and to resolve misdemeanors at the local court. These parasite antigen in blood. Infection was similar in both offered opportunity for obtaining information on their male (37.0%) and female (36.6%) but not between age- migrationandfever management practices.Thearrange- groups (Table 1). mentalsoallowedtheresearcherstobeasunobtrusiveas Infection was lowest among children that were less muchaspossible.Notesweremadebyeachteammember than 12 months but highest among two and four-year at intervals. Every evening the team shared information olds. Clan was not an important factor in infection with andcomparedobservations.Theeveningdiscussionsalso malaria parasite provided opportunity for identifying issues that required furtherunderstanding. Clans, camps and lifestyle Altogether 72 individuals participated in either informal Malaria prevalence survey conversations,group discussions orinthe key informant A subteam (D) carried out a malaria prevalence survey interviews.Thewomenandchildrensleepinsidethetents amongunder-five yearoldcampmembersusingarapid whilethemensleepoutside, unprotected frommosquito diagnostic test kit, ParaHit f developed by Program for bites. The Bororo children (5-12 years) sleep among the Appropriate Technology (PATH) and manufactured by animals to “prevent mosquito bites”. Irrespective of the Akogunetal.InternationalJournalforEquityinHealth2012,11:5 Page5of10 http://www.equityhealthj.com/content/11/1/5 Table 1Prevalence ofmalaria infection amongunder-5 children No.Examined %Infected Significance Age(years) ≤1 237 27.4 P<0.05,Chisqr:18.6,Significant 2 151 45.5 3 131 34.1 4 172 45.1 Sex Male 349 37.0 P>0.05,Chisqr:0.013,NotSignificant Female 342 36.6 clancampmembers’dutiesandinteractionsaresegregated couldposeamajorobstacletoobtaininginformationon by age and sex (elderly, married male, unmarried male, health among nomads using the live-in approach. How- marriedfemale,unmarriedfemale)andin-lawscouldnot ever thisiscompensatedbya rapidbuilt-upof trustand socially mingle. Responsibilities and duties are well rapportandenrichmentofthequalityofinformationcol- defined.Womentakecareoffood,children,andthetents lected during lay conversations and discussions while in whiletheyoungherdtheanimals.Theeldersserveasliai- thecamp. sontootherclansandtothelocalcommunitypopulation. Very few childhood fevers were managed in the camp They gather news about pasture, potential conflict and duringthelive-inperiod.Ontwooccasionsthehousehold patternsoflocalpoliticsthatmayaffectthem.Amongthe headbroughtantibioticspurchasedfromthelocalmarket BororoandtheKiri,herderswouldspendaboutonehour forthetreatmentofdiarrheaina7-yearold.Althoughwe studyinginArabicattheendoftheday’swork. weretoldthatthiswasacommonpractice,theparticular AmongtheJahunandtheKiri,younggirls(7-11years) actionwasasaresultofourpresenceotherwisewenoted participate in herding. The elders and women patronize thatattemptsweremadetoexhaustotherhomeremedies the nearest markets while the young tend the animals. beforepurchasingmodernmedicinesfromlocalmedicine Onlytheveryyoungandinfirmareleftinthecampduring vendors.Theteamwitnessedfourcasesofchildhoodfever theday.Informationgatheringandcommunicationisvery managementwhilethehealthteammemberwaswiththe criticaltothenomadiclifestyle.TheArdospendsasignifi- herdersand couldnot returnto camp for the night. The cant proportionofthe time inthe courtof the sedentar- observations were corroborated with information from ized local community chief or in the market scooping conversations and discussions. The household head on information that could be useful for the safety of camp receiving information about a member of the household membersandanimals.Acampcouldrelocatewithinafew being ill will assess the severity. The opinions of other minutesofadecisiontodoso.TheArdoisresponsiblefor men and in some cases suggestions of the old women the decision to relocate. The use of mobile handheld weretakentoaccount.Oftenthehouseholdheadwillnot phonesisverycommonamongthenomadsforenhancing make knownhisdecision but would leavethe camponly communication between the herders and the Ardo. The toreturnlaterinthedaywithmedicinesforthetreatment team (A, B) witnessed the relocation of five camps com- of the ill person. In exceptional cases the individual may prisingthousandsofheadsofcattletoapositionofabout be takentoa healthfacility but the team didnotwitness 25 kilometers upstream within an hour to avoid a local this. The team had an opportunity to observe a boka crisiswhichturnedouttobearuse. (medicine man) manage a non-malaria ailment. The The Bororo youth (both male and female) plait and womenseemedtohaveagreaterinfluenceonthedecision adorntheirhairand clotheswithbrightlycolouredorna- of the household head than acknowledged. They often ments.Aradio(withwhichtheyarelinkedtotheoutside influencethehouseholdheadbythemannerinwhichthe world) is an indispensable part of dressing as they herd ailmentisdescribed.Inordertoinfluence the household animalsin the fields.The Jahun arewitty, inquisitive but head’s decision they often give examples of those with extremelywaryofoutsiders. similar illness in some other place and how or where it Camp live-in observations posed some challenge as wasmanaged.Althoughthedecision-makeroftenignored wordswentroundthattheteamwasinterestedinhealth. thewomentheeventual actionseemedto havetheinflu- At the onset many ailments were brought to the team. enceoftheolderwomenwhoservedasnurseandadmin- However the splitting of the team helped reduce the istermedicinestochildrenandotherwomen. number as it became known that they would only meet It was much easier to observe the herders than activ- thehealthpersonnelmemberoftheteaminthenightor itiesinthe camp. The presence ofa guest hadvery little early in the morning. The provision of basic health care effect on their activities. The herders easily developed Akogunetal.InternationalJournalforEquityinHealth2012,11:5 Page6of10 http://www.equityhealthj.com/content/11/1/5 rapport and were eager to share skills, information and Table 3Factors that triggerpabboje(N = 97)1 knowledge once in the field. In the camp they appeared Factors/agents Frequency(%) shyandwithdrawninthepresenceoftheoldermen.The Freshmilkduringtheearlyrains 71.1 rapportwithteammemberinthefieldandthecomrade- Freshmaizeduringtheearlyrains 48.5 shipwasmuchstrongerthanwhatthefemaleteammem- Roastedmaizeinearlyrains 36.1 ber witnessed among the women. Except the illness was Sightoraromaofmaize 11.3 so severe as to prevent herding the herders were often Consumptionofmaize 6.2 lefttoresolveanyhealthissuestheymayencounterwhile Greetingapersonwithpabboje 4.1 herding.They freelypurchasedwhatevermedicinesthey Others(e.g.brightcolours,flowers) 20.6 wantedandused thematwillevenintheabsenceofany 1multipleresponsesallowed ailment.Onmanyoccasions,theherderswouldpurchase vialsofinjectablechloroquineorantibiotics,breakitwith the teeth and swallow the content. It was believed to be The symptoms of pabboje include weakness of the more effective than pills in the absence of an injection. body, naadaago (stretching of the body), feeling cold Therewasverylittleregardtoexpirationordistinguish- and desire to sit in the hot sun, lack of appetite. Other ingbetweenantibioticsandantimalariaandwouldsome- diseases may exhibit similar symptoms but pabboje is times take multiple medicines at the same time. The unique because it gives intermittent respite to enable herderswouldchewherbsand rootsofvariousplantsas one carry out one’s duties. well as modern medicines for different reasons: to keep Once it did not go away on the next day, we begin to warm,preventorhaltanemergentfever,orcolds. suspect other types of djonte which could be caused by witches or evil spirits but we must wait for a week to be Cultural epidemiology of fever certain it is not pabboje —informal conversation, Ardo, Nomads perceived Pabboje, a type of fever that recurs Bororo on alternate days as the most common health problem A group of Fulani women articulated the generally with 87.6% reporting that they had within the past six held view months (Table 2). Pabbojeis naturalwitheveryFulaniandisnotcaused They acknowledged other ailments of concern to by anything. It is harmless but when one eats, smells or nomads as ringworms (19.7%) and diarrhoea (17.3%), seessomethingpabbojedoesnotlikeitwakesupandgives Cough (dambi), and foot cracking (pe-i). a little trouble which disturbs ones work.—Focus group They described symptomsof pabbojeashotnessof the discussion,marriedwomen. body,fatigue,headache,shivering,painsinthejoints,diar- MypabbojebecomesunhappywhenIdrinkmilkduring rhoea,vomitingandlossofappetite.Pabbojeisnascentin theearlyrains.Manypeopledon’thavepabbojeduringthe theFulanibutcanbetriggeredintoactiveformwhenone dry season although they drink milk at that time. It can drinksfreshmilkduringearlyrains, eatsorperceivesthe only be because the milk we drink in the rainy season is aromaoffreshmaizebeingroastedorcooked,orobserves different.Cattlegrazeonfreshgrassintherainyseasonthe brightly coloured agents (red or yellow) such as maize milk from such cattle may be the one that wakes up the flowers(Table3). sleepingpabbojeintheFulani.—Indepthinterview,healer They noted that however, the frequency and severity andJauro,Bororo differs between individuals. While some have a single episode annually others have up to four, at onset or end Perceived severity and Patterns of Distress of the rain and others at both seasons. Most Fulani nomads had experienced at least two annual episodes of pabboje but they do not associate it Table 2Frequency ofdiseases in the camps with death. Although pabboje was merely a condition Self-reporteddiseases Numberinterviewed Frequency(%)1 for being a Fulani, and not an illness, nevertheless it was Pabboje 374 87.6 mentioned as cause of depression since it interfered Ringworms/Skinproblems 84 19.7 with performance of normal tasks and with carrying out Diarrhoeaandabdominalpain 74 17.3 one’s responsibilities in the camp. Backandjointspain 56 13.1 Pabboje starts with general body weakness and a desire Dysentery 38 8.9 to sit in the hot sun. One will then have naadaago (a Worms 27 6.3 kind of body stretching that happens when one has just Cough 16 3.7 woken up), the body will be hot, intense headache but Others 3 0.7 one will feel cold and begin to shiver. Some people will Numberofrespondents 427 100.0 vomit.——Key informant Interview, Young male herder, 1Proportionreportingtheyhadthecondition Jahun Akogunetal.InternationalJournalforEquityinHealth2012,11:5 Page7of10 http://www.equityhealthj.com/content/11/1/5 Pabboje behaves differently in different people. May be Until recently, I did not know any modern treatment this is because of what wakes it up. I don’t know. In for pabboje. I would wait until the episodes of my pab- some people, pabboje will be so mild that it does not boje has come and passed— Informal conversation, interfere with herding while it will be very severe in Ardo Kiri others.–Informal conversation, herder, Bororo Some women keep antimalaria purchased from local WhenIusedtogoherding,mypabbojewouldnotcome vendors at home for treating pabboje in children. in the morning but will allow me take the animals far At the store we just ask for medicine for ciwonfulani afieldthenitwillstartwhenthesunisontopofthehead, (Fulani problem). We give two tablets. If the child is too ataboutnoon. Iwouldthenhavetoreturnhome.Iknow young, we give syrup. The child vomits and then becomes thefollowingdayitwouldnotcomesoIwouldgoherding well again. Pabboje starts in the night or early in the the animals. But on the third day, I would wait in the morning–Focus group discussion, Young mothers, Kiri tent till noon for it to come and surely it would come. The elderly believe that the treating pabboje had That is how I used to manage the three and sometimes “made it more severe” and many would rather not use four episodes that I used to have every year.- Informal any modern medicines in cases of pabboje. conversation,Ardo,Kiri Modern drugs, like quinine for treating pabboje disap- The distinguishing symptom of pabboje is that act of peared then there was nivaquine and later chloroquine coming on days one, three, five before dis-appearing. injectionwhichwasveryeffectivewithsomepeople.How- Djonte is like pabboje that does not go away but that ever, many of us do not treat pabboje because modern remains persistent drugs will only make pabboje go away for a short time Djonte is very dangerous. It will not allow you to herd only to return with more virulence. The only drug I did the animals at all. not hear people complain about is the one your group —Informal conversation, Male herder, Kiri bringstous.——Indepthinterview,Ardo,Jahun The nomads would ignore fever until the third recru- Pabboje is distinguished from djonte because the for- descence.Howeverifsymptomspersistedbeyondthe7th merrecurswhilethelatterdoesnot.Wheneversomeone day,itwasclassifiedas djonte(fever)duetoothercauses has djonte itwill be assumed to be pabbojeexceptwhen andnotpabboje.Nomadsarerelievedwhendjonteisdue provenotherwise.Themainproofisforitnottogoaway to pabboje and perceive other types of fever with much and comeback again. There are other types of djonte anxiety. which the nomads consider very dreadful since they However, its interference with duties has made it interfere severely with normal activities. Ifit is not pab- necessarytocurtailitsrecurrenceortoreduceitsseverity boje, then it is caused by evil spirits or witches and to a level that normal activities such as herding could shouldbetreated byplacingleavesofbaobabonredhot continue. Some traditional method of preventing the charcoalandinhalingthesmoke. recurrence of pabboje is, at dawn after the first recur- One such djonte is djonte kippindirde considered the rence to take a handful oflebol (butter from cow milk), most precarious of the djonte and can only be removed venturefarintothebush,andplacethelebolbetweenthe by traditional healers since it is caused by hendu (evil leaf of barkeje (a shrub with broad leaves), fold the leaf spirits) or mutte’en or karama’en (witches). and then let go of it immediately. One should neither Buudi or Buule (plural) may also cause djonte. Fever lookbacknoreverreturntotheparticularspot.Thenext due to buudi is milder than pabboje. Although the vic- personthatpasseswouldtaketheillnessfromthevictim tim feels weak and has hot body there will neither be and thus hinder subsequent episodes from emerging. shivering, or feeling cold. Although buudi may subside Anotherapproachistocutanun-ripepawpawfruitinto and escalate; it does not follow any regular pattern like four equal partsandsoak themin milk that isbeen pre- pabboje. Buudi can be felt when the inflamed part is paredforpendiidam(yoghurt)andallowtoferment.The touched. pawpaw wouldthen be removed and the yoghurt served Besides djonte, pabboje, other diseases that nomads to the patient to drink. This will reduce the severity of regard as intrinsic waiting to be externally triggered are pabboje. Cotton leaves may also be boiled and drunk in Doiru (tuberculosis), peewol (rheumatism), and sadaure ordertoreducetheseverityofpabboje.Yet,anotheranti- (leprosy or dermatitis). dote is to take a handful of guinea corn with the left Nomads take measures to protect themselves from hand and bury it under dingaali (a woody plant with mosquitoesbecausetheyareanuisance,suckblood,and broad bitter leaves) on the second day of pabboje. This maycauseitchingatthepointofbite.Insecticidetreated action will bury the pabboje within, and prevent it from nets, clothing (especially when asleep), herbs burned to “wakingup”onthethirdday.Insomecasespabbojemay create smoke and plant repellents are used to prevent remain buried forever unable to wake up even when man-mosquito contact. Herders hang certain plants triggered. around the body while in the field and place some at Akogunetal.InternationalJournalforEquityinHealth2012,11:5 Page8of10 http://www.equityhealthj.com/content/11/1/5 different parts of the tent to repel mosquitoes. Among Table4Reasonsforpreferringonesourceofintervention theBororo,childrensleepamong thelarge animalssuch to the other (N =97)1 ascattletopreventmosquitobite.An8-yearoldnomadic Reasons Frequency Fulanichildspokeforhiscolleagues (%) We sleep among the cows so that the mosquitoes do Paymentconditionisflexibleandcanbenegotiated 49.5 not see us to bite. The cattle are big and the mosquitoes Distance:theplaceisnotfarfromcampsite 42.3 bite them instead. Timespentinthefacilityisshortandconvenient 38.1 Serviceisgoodandreliefisobtained 30.9 Decision-making and health service utilization StaffoffacilityarefriendlyandrespecttheFulani 22.7 Since the live-in exercise did not yield much informa- Typeofdrugandmodeofdispensingcanbe 22.7 negotiated tion from observed practices, the team depended on Servicesandsuppliesarealwaysavailable 20.6 conversations and the survey results. Although most Others 2.0 nomadic Fulani (79.4%, N = 97) knew the location of the nearest health facilities, only a few (5.8%) visited or 1multipleresponsesallowed,verticalcomparisononly knew someone who had visited any in the past six months. Self-treatment with a variety of antimalaria antimalaria for the management of fevers in the camps. drugs and antibiotics is very common particularly However they expressed concern about time and dura- among the young male (herders). We observed them tion of training as well as how participation would affect purchase antibiotics and vials of injectable medicines their nomadic life. If required they would be keen to displayed on a mat laid on the market floor, break the contribute to the purchase of drugs, to support the vial open with the teeth and swallow the content. camp own resource person (CORP) during training and The mother of a febrile child would inform the father to compensate for time if the acquired skills would be whose responsibility it was to decide the course of used solely for the benefits of fellow camp members. action. When an adult was severely ill and unable to communicate, the most elderly male would decide the Discussion course of action to be taken. When illness is severe That majority of the camps had moved in and out of the enough as to be life threatening one in ten women same area for more than 15 years confirm the predict- would take a child to the health facility without the con- ability of migratory patterns of nomadic communities. sent of the father. Male children informed their fathers Their highly developed communication skills and when they fell ill while female children notified mothers. respect for hierarchy are advantages that health authori- If the head of a family was not available, the brother or ties could take for developing appropriate intervention other person to whom the household was entrusted programme that nomads would accept. would take decisions in his absence. However, no action The recorded prevalence of malaria in the survey is would be taken until the 7th day when the type of not surprising. A previous study in Northeastern Nigeria djonte is determined. If fever persisted without any reported up to 58.7% prevalence of Plasmodium falci- recurrent pattern it would be assumed to be severe and parum [15]. Malaria transmission in northeastern treated as such. Once a decision was made the father Nigeria is seasonal and reaches the peak at the onset would allocate resources (money, donkey and advice) to (May/June) and end (September/October) of rainy sea- enable the mother implement it. It is in rare cases that a son when anopheline mosquito breeding sites are abun- father would take the child to the health facility. dant. Although the breeding sites dry up in most parts In recent times, nomadic Fulani patronise private of Northeastern Nigeria during the intensely hot and health facilities but hardly public ones. The reasons dry months (February/April), focal transmission abound were similar irrespective of clans or camp. Payment con- in isolated sites such as water holes and perennial river dition (49.5%), distance from camp (42.3%) and the beds. Nomads are exposed to this focal but intense politeness of the health care provider are the most transmission when they camp near water holes in con- important considerations when making a decision to sideration of the need of their animals. Unlike most patronise a health facility. Nomads spend as much as $8 sedentary communities, nomadic populations are there- in the purchase of antimalaria medicines most often (of fore exposed to malaria transmission throughout the unknown and doubtful origin) from itinerant vendors at year and thus deserve special attention by control pro- local markets (Table 4). grammes. In Mali, disproportionately low prevalence of Nomads are very much concerned about their inability malaria among Fulani tribe when compared with other to benefit from regular health service and expressed tribes had been associated with an unidentified genetic willingness to participate in the distribution of insecti- factor [16]. Such association is difficult to infer in this cide treated nets (ITN) and in the administration of study. Akogunetal.InternationalJournalforEquityinHealth2012,11:5 Page9of10 http://www.equityhealthj.com/content/11/1/5 The nomadic Fulani have a highly well developed the- the community will participate in intervention to ensure ory of causation of febrile illnesses and are able to dis- ownership of intervention process and outcome. First tinguish between different types of fevers. The the nomads’ migratory movement and settlement pat- perception of pabboje as different from other types of terns within a health district should be identified, djonte but personal to the Fulani nomads is probably, as described and a plan developed for approaching and Imperato [17] explained, a means of coping with the dis- negotiating their participation in malaria control. The ease. Whereas pabboje provided respite for them to cultural epidemiological description of the disease is meet their obligations and duties to their family and ani- also useful for planning intervention strategies particu- mals (pulaaku) other types of djonte do not and are larly the development of information, education and therefore dreaded. This is perhaps the reason for regard- communication strategies. ing pabboje as a problem of the nomadic Fulani popula- tion. The intermittent distress due to pabboje still Conclusions provides some respite for performing one’s duty as Despite the view expressed by some nomads that the Fulani. The fact that it is regarded as nascent, requiring use of Western medicine might have worsen the disease, a trigger factor to make it come alive probably explains majority attest to the relief offered by Western medicine the focus of traditional intervention which is to negoti- and accept it if it is made accessible to them. The com- ate the return of pabboje to its dormant status without munity directed intervention strategy is the basis for recurring or to reduce its severity but not completely increasing that accessibility. The challenge before the clearing it. health system is to apply the community directed inter- The gradual acceptance of treatment of pabboje indi- vention approach that has worked well with settled cates a change in awareness that malaria control inter- communities to the nomadic lifestyle. vention programmes need for developing a control programme for the nomads. The market which serves as Acknowledgements a key meeting point for collection and dissemination of TheinvestigationwassupportedbygrantnumberA10626toOAfromthe information among nomads could be exploited by the SpecialPro-grammeforResearchandTraininginTropicalDiseases,World health authority for interactive communication. HealthOrganization(WHO/TDR).WearegratefultoAbuAdamuYahayawho facilitatedthecontactwiththenomads,toArdoSubairu,Tuga,Nduruwa Nomads will most likely continue to patronize the pri- andtheirclansforenthusiasticcollaborationandtoNehaShaofTheJohns vate health facility abandoning the public health facility HopkinsUniversitywhoreviewedthestudytoolsattheearlystage. to sedentary community populations as observed in Authordetails another study in Nigeria [18]. It is unlikely that commu- 1CommonHeritageFoundation,No.1BishopStreet,Box5124,Yola,Nigeria. nities could be convinced to accept the sharing of lim- 2FederalUniversityofTechnology,Yola,Nigeria.3AdekunleAjasinUniversity, ited consumable health resources with temporary guests Akungba,Akoko,Nigeria.4SpecialProgrammeforResearchandTrainingin TropicalDiseases,WorldHealthOr-ganization,Geneva27,Switzerland. whose population and health needs may often over- whelm that of the local population. In Nigeria allocation Authors’contributions of resources and services are carefully computed and OBAconceived,designedandcoordinatedthestudy;MAGandJAB reviewedtheprotocolsandimprovedtheintellectualcontentwhileSNand shared between spheres of governance at the federal, AOAcoordinatedprevalencesurvey,analyzedandinterpretedthedata,OTO state, local government area and community according contributedtothedesignandreviewedthefinalmanuscriptforintellectual to set criteria which takes into consideration the census quality.TheprotocolhadtheethicalapprovaloftheNationalHealth ResearchEthicsboardofNigeriaandtheethicsreviewcommitteeofthe of the community. The nomads are not often included WorldHealthOrganization.Allauthorsreadandapprovedthefinal at the planning stage. Although communication technol- manuscript. ogy-driven empowerment combined with simple rapid Competinginterests diagnostic tools and creative packaging of medicines Theauthorsdeclarethattheyhavenocompetinginterests. may increase access to fever management services, it is yet to attract the attention of potential investors [19] Received:12October2010 Accepted:31January2012 Published:31January2012 The most plausible strategy is an intervention that is nomadic community-managed, and that exerts minimal References pressure on pre-allocated resource of the sedentary 1. Sheik-MohammedA,VelemaJ:Wherehealthcarehasnoaccess:the community. nomadicpopulationsofsub-SaharanAfrica.TropMedandInterHlth1999, 4(10):695-707. The community directed intervention (CDI) approach 2. AilouS:“Whathealthsystemfornomadicpopulations?”.WrldHlthFor that has been made popular in the control of onchocer- 2010,13:311-314. ciasis in Africa is probably the most viable option for 3. BriegerW,OkeG,OtusanyaS,AdesopeA,TijaniJ,BanjokoM:Ethnic diversityanddiseasesurveillance:GuineawormamongtheFulaniina increasing access of the nomads to malaria intervention predominantlyYorubadistrictofNigeria.TropMedandInterHlth1997, services [20,21]. The approach requires that the health 2(1):99-103. authorities and partners negotiate the means by which Akogunetal.InternationalJournalforEquityinHealth2012,11:5 Page10of10 http://www.equityhealthj.com/content/11/1/5 4. BriegerW,OtusanyaS,OkeG,OshinameFO,AdeniyiJO:Factors associatedwithcoverageincommunitydirectedtreatmentin ivermectinforonchocerciasiscon-trolinOyoState,Nigeria.TropMed andInterHlth2002,7(1):11-18. 5. DaoM,BriegerW:ImmunizationforthemigrantFulani:identifyingan under-servedpopulationinsouthwesternNigeria.IntQuartCommHlth Educ1995,15(1):21-32. 6. AkogunO:Astudyonpresumptivediagnosisandhomemanagementof childhoodmalariaamongnomadicfulaniinDemsa,Nigeria.MPH, SchoolofPublicHealth,UniversityoftheWesternCape;2008,80. 7. OmarM,OmarM:HealthforAllbytheYear2000:whataboutthe nomads?DevelopmentinPracticeReaders1999,9(3):23-31. 8. AdriansenH,NielsenT:Goingwherethegrassisgreener:Onthestudy ofpas-toralmobilityinFerlo,Senegal.HumanEcology2000, 30(2):215-226. 9. FederalMinistryofHealth,Nigeria:StrategicPlanforRollingBackMalaria inNigeria2001-2005.Abuja:FederalMinistryofHealth;2001,45. 10. ImperatoP:NomadsoftheWestAfricanSahelandthedeliveryofhealth servicestothem.SocSciandMed1974,8:443-457. 11. GordonAJ:Culturalidentityandillness:Fulaniviews.CultMedPsychiatry 2000,24(3):297-330. 12. BellD,RouelG,MiguelC,WalkerJ,LillibethC,AllenS:DiagnosisofMalaria inremoteareaofthePhilippines:Comparismoftechniquesandtheir accep-tancebyhealthworkersandthecommunity.BulletinofWHO2001, 79:933-941. 13. RennieW,HarveyS:Developmentandtestingagenericjobaidfor malariarapiddiagnostictests(RDT):FieldReportofQualityAssurance project.WHOprojectreport2004,47. 14. PagnoniF,ConvelboN,TiendrebeogoJ,CousensS,EspositoF:A Community-basedprogrammetoprovidepromptandadequate treatmentofpresumptivemalariainchildren.TransRoySocTropMed Hyg1997,91:512-517. 15. MoltaNB,DanielHI,WatilaIM,OgucheSO,OtuTI,AmehJO,GadzamaNM: Efficaciesofchloroquine,pyrimethamine/sulphadoxineand pyrimethamine/sulphaleneagainstP.falciparuminnortheasternNigeria. JTropMedHyg1992,95(4):253-9. 16. ModianoD,PetrarcaV,SirimaBS,NebiéI,DialloD,EspositoF,ColuzziM: DifferentresponsetoPlasmodiumfalciparummalariainwestAfrican sympatricethnicgroups.ProcNatlAcadSciUSA1996,93(23):13206-11. 17. ImperatoP:Problemsinprovidinghealthservicestodesertnomadsin WestAfrica.TropDoc1975,5:116-123. 18. OtusanyaSA,BriegerWR,TitiloyeM,SalamiKK,AdesopeA:Ethnic variationsinhealth-seekingbehavioursandattitudesbetweenFulani herdersandOrubafarmersinsouthwesternNigeria.TropDoct2007, 37(3):184-5. 19. AkogunO:RoboticHealthAssistant(Feverkit)fortheRational ManagementofFeversamongNomadsinNigeria.NursLeadersh(Tor Ont)2011,24(2):58-67. 20. AkogunO,AuduZ,WeissM,AdelakunA,AkohJ,AkogunM,RemmeH, KaleO:Community-DirectedTreatmentofonchocerciasiswith IvermectininTakum,Nigeria.TropMedandInterHlth2001,6(3):232-43. 21. TheCDIStudyGroup:Community-directedinterventionsforpriority healthproblemsinAfrica:resultsofamulticountrystudy.BullWHO2010, 88:509-518. doi:10.1186/1475-9276-11-5 Citethisarticleas:Akogunetal.:Febrileillnessexperienceamong Nigeriannomads.InternationalJournalforEquityinHealth201211:5. Submit your next manuscript to BioMed Central and take full advantage of: • Convenient online submission • Thorough peer review • No space constraints or color figure charges • Immediate publication on acceptance • Inclusion in PubMed, CAS, Scopus and Google Scholar • Research which is freely available for redistribution Submit your manuscript at www.biomedcentral.com/submit

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