Ethnic diversity and disease surveillance: Guinea worm among the Fulani in a predominantly Yoruba district of Nigeria.

Guinea-worm eradication has been progressing internationally and efforts at case containment have begun in most endemic countries. Case containment rests on the assumption that in previous phases of eradication most if not all endemic settlements have been identified. Experiences in the predominantly Yoruba communities of Ifeloju Local Government Area (LGA) in Oyo State, Nigeria, however, have shown that the settlements of ethnic minority groups may be overlooked during initial case searches and subsequent programmes of village-based reporting. The migrant cattle-herding Fulani are found throughout the savannah and sahel regions of West Africa. Nearly 3000 live in 60 settlements in Ifeloju. An intensive case search identified 57 cases in 15 settlements. The assumption that village-based health workers (VBHWs) in neighbouring Yoruba farm hamlets would identify cases in the Fulani settlements, known as gaa, proved false. Only 5 endemic gaa were located next to a Yoruba hamlet that had a VBHW, and even then the VBHW did not identify and report the cases in the gaa. Efforts to recruit VBHWs for each endemic gaa are recommended, but only after LGA staff improve the poor relationship between themselves and the Fulani, whom they view as outsiders. The results also imply the need for Guinea worm eradication staff in neighbouring LGAs, states and countries to search actively for the disease among their minority populations.

Dracunculiasis (guinea worm disease) in the Bume (Nyangaton) people of South Omo, Ethiopia.

A village-to-village search for active dracunculiasis cases was carried out in an endemic area of the Bume (Nyangaton) tribe of South Omo Region, Ethiopia. A total of 21 cases, of which 6, 5, and 10 had pre-emergent, emergent and complicated Guinea worm disease, respectively, were identified. Twenty-two worms, ranging from 1-3 per patient, were removed mainly from the lower limbs; worm appearance seems to be associated more with the right limb. Adults between the ages of 20-30 years are highly affected and infection appears to be sex-related as 14/21 (66.7%) of the cases are females. Water procured from water-holes drug in dry river beds provides an ideal situation for the transmission of dracunculiasis amongst the tribesmen. The knowledge, attitudes and perceptions of the Bume people towards the disease and the public health significance of dracunculiasis are discussed in relation to the current goal of the national and global Guinea worm eradication programme.

Learning from local knowledge to improve disease surveillance: perceptions of the guinea worm illness experience.

Surveillance is an essential tool in any campaign to eradicate disease; guinea worm (dracunculiasis), which is targeted for eradication before the year 2000, is no exception. One criterion of an eradicable disease is that it be easy to recognize as the program advances. Few experts doubt that the experience of a meter-long subcutaneous worm protruding through a painful ulcer can be missed or confused with another disease, thus ensuring that guinea worm meets this criterion. Field experiences of anthropologists and health educators have shown that one should never assume that community perceptions of illness experience coincide fully with medical case definitions of disease. This paper describes efforts to learn how the Yoruba people of southwestern Nigeria perceive sobia, the local name for guinea worm. Qualitative methods including informal interview, village discussion and participant observation were used to discern a pattern of illness presentation and progression. Interestingly, local perceptions were found to include a variety of illness manifestations beyond the common clinical case definition of an emergent worm, thus creating the potential for a high level of false positive reports. Local knowledge was then used to design a pilot project that trained volunteers to become part of the surveillance network for the national eradication program. The volunteers, who were largely illiterate, were able to distinguish between cultural and clinical definitions, and submit quite accurate reports on the guinea worm status of their villages. Among the 164 volunteers, only two submitted false reports due to incorrect disease definition. In contrast local government health workers who were conducting village searches during the same period were significantly more likely to register false positive reports. The culturally sensitive training based on local knowledge received by the village volunteers is thought to have contributed to their superior performance.