Table Of ContentAkogunetal.InternationalJournalforEquityinHealth2012,11:5
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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.
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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
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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.
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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
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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
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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
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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
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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
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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
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doi:10.1186/1475-9276-11-5
Citethisarticleas:Akogunetal.:Febrileillnessexperienceamong
Nigeriannomads.InternationalJournalforEquityinHealth201211:5.
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