(2022) 21:276
Sissoko et al. Malaria Journal
https://doi.org/10.1186/s12936-022-04298-0
Malaria Journal
Open Access
RESEARCH
Social representations of malaria
in a southern malian community:
an ethnographic qualitative study
Bourema Sissoko1,2* , Mohamed Yunus Rafiq3, Jiaqi Rosemary Wang3 and N’bamori dite Naba Sissoko4
Abstract
Background: Malaria is one of the prime reasons for medical consultation and the major cause of morbidity and
mortality in Mali. To assess and understand the dynamics of social representations of malaria, the anthropological
research was conducted in the Wayerema II neighbourhood of the health district of Sikasso, southern Mali.
Methods: This was an ethnographic study conducted qualitatively in 2011 and 2016 through informal conversations,
70 semi-structured interviews, and participant observations with key actors. The observations, conversations, and
interviews investigated local people’s perceptions and knowledge about malaria, and how and to what extent the
cultural and popular representations of the disease can have an impact on therapeutic routes.
Results: Mosquitoes are the principal agent of the transmission of malaria. However, the ubiquitous yet casuallyclaimed aetiological agents, causative, nosographic entities differ from—although sometimes integrated into—the
biomedical dimension. For example, some communities perceive Kono, a complicated and pernicious form of malaria
that often occurs among children, to originate from a supernatural force. “Bird disease” is another term used for Kono
in Mali and other West African countries. Thus, overall, Kono is defined through the entanglements with cultural factors, namely the idiosyncratic habits, customs, and beliefs of the population of Wayerema II neighbourhood in the
health district of Sikasso, Southern Mali. Wayerema II residents particularly tend to link therapeutic recourse amongst
the afflicted not only to biomedical models but to sociocultural and popular perceptions and representations of
malaria.
Conclusion: In the findings, self-medication through both traditional and modern medical techniques was the most
frequent therapeutic modality. Hence, the integration of local popular knowledge with the biomedical register can
contribute to a comprehensive understanding of social representations and perceptions of malaria, and qualitative
improvements in the malaria control programme.
Keywords: Ethnography, Malaria, Perceptions, Social representations, Therapeutic routes, Mali
*Correspondence: sissokobourma@yhaoo.fr
2
Faculty of Foreign Languages, Southwest Forestry University, 296 Bailongsi,
Kunming, Yunnan 650224, China
Full list of author information is available at the end of the article
Background
Malaria is an endemic disease, which is predominant in
the tropical zones of sub-Saharan Africa. In 2020, malaria
was reported with an estimated 241 million cases and
627,000 deaths worldwide, with most cases occurring in
the World Health Organization (WHO) African Region
(greater than 90%). The WHO African Region bears a
disproportionately high share of the global malaria burden. In 2020 this region was home to 95% of all malaria
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licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativeco
mmons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.
Sissoko et al. Malaria Journal
(2022) 21:276
and 96% of malaria mortality (deaths). Children under
five years of age accounted for about 80% of all malaria
deaths in the Region. In the Sahel sub-region of Africa,
most childhood malaria mortality and morbidity occur
during the rainy season [1–3].
In Mali, malaria is the primary reason for medical consultation during the season of high transmission (June–
October). According to the Système Local d’Information
Sanitaire (SLIS) 2018, health facilities recorded 2,345,481
malaria cases for the entire year [4]. Malaria was the trigger for a high number of deaths in 2018, with 1178 documented [4].
With the statistical data in mind, in Mali and following the example of other African and Central American
countries, it is certain that socio-cultural representations
and other popular aetiologies are determinants in the use
of health care [5–8]. Moreover, Tieman Diarra examines
the role of representations in shaping the choices about
therapists and therapeutic itineraries in the Bankoni
neighbourhood, Commune I of the district of Bamako,
Mali, arguing that conceptual understandings of the disease would considerably result in differences in people’s
medical choice, especially between conventional and
biomedical treatment: “some [patients] started with traditional therapy and ended up with biomedicine, others
alternate between them or even resort to both medicines
simultaneously” [9].
Indeed, it is believed that representations play an
important role in framing practices and may pose very
profound influences on a societal level. Social representations are used to explain that recourse would be essentially determined by the financial situation of patients
and/or their families, and they can also be used to explain
and understand recourse and therapeutic routes. Anne
Luxereau focuses on the situation in Maradi, Niger, and
states: “people’s ideas about health and illness remain
prevalent in shaping or guiding their choices, and determine therapeutic itineraries” [10].
It is under this context that this work has been undertaken to assess the community’s perceptions of malaria
in the Wayerema II area in the health district of Sikasso
and analyse how the socio-cultural representations of
disease can affect the therapeutic routes taken by malaria
patients. The results of this study can also contribute to
an understanding of the people’s knowledge, attitudes,
practices, and beliefs about malaria for improving the
National Malaria Control Programmes (NMCP) in
Sikasso and Mali.
Structurally, this article first discusses the research
methodology, then the social and modern representations of malaria, the socio-economic impacts, and finally
the therapeutic itineraries of the patients and/or their
families.
Page 2 of 11
Methods
Study area
This article is based on fieldwork on social representations of malaria in the neighbourhood of Wayerema II,
in the health district of Sikasso, Sikasso region, southern
Mali. According to the 2009 general census, Sikasso is
the second-largest Malian city, with 225,753 residents. Its
initial area, which is 28,530 square-kilometres (km), comprises 15 neighbourhoods, referred to as “quartiers”. The
municipality of Sikasso is the capital of Sikasso region,
the third administrative region of Mali; Sikasso region
is also a crossroads between Mali, Ivory Coast, Guinea,
Burkina Faso, and Togo.
Located in the Sudanese zone, Sikasso experiences a
tropical Sudanese climate characterized by rainfall varying from 1300 to 1500 millimetres per year with a prevalence of 62%. This level of rainfall makes Sikasso prone to
malaria. The region covers an area of 76,480 km2 which is
5.7% of the national territory with a density of 31 inhabitants per km2. Accessibility to health care is 58% within a
radius of 5 km and 80% within a radius of 15 km [11, 12].
Study design
It also applied a descriptive, qualitative, and inductive
design. This study was approached with an ethnographic
fieldwork focus, which used observation participants,
informal conversations, and semi-structured interviews
related to key informants and/or actors. This fieldwork in
the health district of Sikasso was complemented by bibliographical research of the perceptions, knowledge, preventions, and treatments of malaria.
Data collection and selection of study participants
The distinctive geo-medical landscape in this region has
made it a vital site for malaria-related studies, which
can fill in the gap left by the limited amount of previous
scholarship with such a focus. To assess and understand
the dynamics of social representations of malaria, the
semi-structured interviews, informal conversations, and
participant observations were conducted in the Wayerema II neighbourhood of Sikasso in southern Mali.
The results of this study presented here are derived
from data gathered through an ethnographic study,
which was conducted by the lead or first author (B.S.) in
May-August 2011 and March 2016. It included a 6-month
ethnographic immersion in the study community, during
which B.S. used interviews as well as participant observations. He also, kept communicating with some of the
respondents using social media platforms like Facebook
and WhatsApp. The research work focused on the local
perceptions, social representations of malaria, and the
therapeutic itineraries for healthcare among people in
this community, in the health district of Sikasso.
Sissoko et al. Malaria Journal
(2022) 21:276
Page 3 of 11
Furthermore, different interview guides with open
questions were developed and addressed to the key
informants (patients, health workers, traditional therapists, and mothers). The number of these informants was
selected using a convenient sampling approach. All interviews were conducted in Bambara, the national language,
and in French. B.S. carried out a total of 60 interviews in
2011 (phase 1), and a different additional 10 in 2016 with
only mothers, health workers, and traditional therapists
(phase 2). Overall, he conducted a total of 70 semi-structured interviews involving fifteen health workers, fifteen
pregnant women, twelve mothers, five heads of families,
five community elders, ten youths, six traditional therapists, and two local authorities during the two phases
(Table 1).
The participant observation was conducted to elucidate the questions of perceptions, representations, and
practices. It was also made possible through immersive
experiences in the health structures, along with other
sub-communities in Wayerema II, processes of which
were considered helpful. It allowed for better familiarization with the key actors and informants in order to better understand their mentality and perceptions. The first
author kept field notes throughout the study period to
capture significant events, interactions and moments.
A note for reflexion: “I, B.S., include my own experiences as a Malian and a resident of Sikasso municipality.
Growing up in Wayerema II, my family, friends, and I contracted malaria on many occasions. It is these experiences
and the effects of my malaria on my life and that of my
kin that sparked my early interest in social experiences of
malaria. I don’t include my experiences as representative
of all Wayerema residents nor as privileged information;
rather I include my experiences as a participant observer
to reinforce what my respondents are already reporting
about malaria in their lives”.
The collected data were reviewed by going through the
entire corpus while noting the emerging themes. Upon
the second time reading, the themes were re-organized
Table 1 Demographic information of the selected participant
Informants
Number
Age
Health workers
15
20–60
Pregnant women
15
18–45
Children’s mothers
12
18–60
Heads of family
5
25–60
Community elders
5
65–80
Youths
10
15–40
Traditional therapists
06
40–75
Local authorities
02
50–60
thematically before interpretation. After that, the themes
were respectively analysed in light of their correlations to
the main research question [13].
Data analysis
The semi-structured interviews were audio-recorded,
transcribed, and translated from Bambara into French,
then later into English by the lead author (B.S.). The transcripts were examined and analysed for items/themes relevant to our research objective. All transcripts were then
imported into Microsoft Word 2010 Software.
An inductive anthropological approach has followed
privileging the community’s views and using participant
observation to better access the social representations
and biomedical knowledge of the inhabitants of Wayerema II regarding malaria. Furthermore, the data were initially sorted by relevant themes before in-depth analysis.
The first author (B.S.) also utilized the thematic analysis
approach to code and categorize these qualitative data
[14, 15].
For purely ethical reasons, the consent and approval
of all informants were sought upstream (in advance),
using proper explanations of the objectives and purposes
of our study. We have ensured to keep the respondents
anonymous, by assigning each respondent an identification number. The names of all our informants mentioned
in this paper are pseudonyms. The ethical approval was
obtained through the Faculté des Lettres, Langues, Arts
et Sciences Humaines (FLASH), Université de Bamako,
Mali.
Results
The results of the interviews (n = 70) present the social
characteristics of participants of the sample groups
for the semi-structured interviews. The participants
included health workers (n = 15), with respectively 10
in CScom (Centre de santé Communautaire, or Community Health Centres), 02 in CSréf (Centre de Santé
de référence, or Referral Health Centre), and 02 in the
paediatric service in Regional Hospital of Sikasso;
pregnant women (n = 15), who were interviewed either
at the CScom or home after some primary connections
built and also with the help of the first author B.S.’s
fieldwork at the CScom; the heads of family (n = 05);
the community elders (n = 05), with 1 imam, 1 Catholic priest, and a Chief of Neighbourhood included in
this variant group; and—furthermore—youth (n = 10)
with 05 males and 05 females aged between 15 and
40; mothers (n = 12) who were selected and inquired
in order for knowing or understanding their opinions,
and informing us more deeply about their sick children; Traditional therapist or healers (n = 06) including 03 women and 03 men, aged 40–75. They and 02
Sissoko et al. Malaria Journal
(2022) 21:276
of their patients were interviewed in their house where
a piece/room was managed for consultation. In addition, the young people (3 women and 2 men) were
their patients and got involved during the participant
observation among the traditional therapists (traditherapists). We stayed connected and interviewed
them a few days later at their home. Lastly, the local
authorities (n = 02), the first one was a mayor of the
secondary town hall of Wayerema II, and another a
municipal advisor for sanitation and hygiene at the
main or central town hall of Sikasso. Participants were
largely Muslims, a few were Christians and African
spiritualists or “Animists”.
Cultural and modern representations of malaria
For the interviewed residents of Wayerema II, the sociocultural conception of malaria is conveyed through
the word sumaya. Their understandings of malaria are
shaped through their experiences related to the disease,
constructed through expressions and discourses surrounding it, and particularly influenced by existing religious, supernatural, and environmental factors. In this
regard, Vamara, an elder, 70-year-old, told us: “Sumaya
is a very bad disease which killed our child. You see
my son [His son here refers to B.S., he called him that
because B.S. was the same age as his last-born child,
and this is very common in Malian culture], sumaya is
more problematic in the rainy season [June-October in
Sikasso] because of our humid environment, and it is
raining more in Sikasso region than others in Mali. So
during this season we always have malaria”.
Sumaya is of Bambara origin and refers to humidity
and freshness in its literal sense (suma means freshness, coolness, humidity, and ya means situation in
Bambara). The connotation herein is also related to the
rainy season or winter highlighting the rain-triggered
freshness from June to October. Therefore, the term
itself is associated with coldness and rain/humidity as
seasonal factors, corresponding to the period with very
strong multiplication of Anopheles gambiae, the common type of mosquito in these areas.
With regard to the relevant symptoms, in an interview, Alice, a 23-year-old female student said, “sumaya
comes with vomiting, fever, chills, general stiffness, and
kono. Dizziness is also a sign of sumaya.”
Alice’s representations of malaria coincide with the
understanding the lead author, B.S., had of the disease
growing up in Sikasso. B.S. learned in his childhood
that malarial conditions are accompanied by vertigo,
vomiting, heightened body temperature, and anorexia,
all interpreted by kin and neighbours as a manifestation
of sumaya.
Page 4 of 11
Aetiologies of malaria: food, “malaria grain”
and parasitic infection
The informants used the terms sumaya and palu interchangeably to describe the causes of malaria. In French,
malaria is called Paludisme. Palu is an abbreviated form
of the original French word used in communication on
a daily basis. Residents of Wayerema II identified fruits
and burning sun as one cause of malaria. According to
Batoma, a 38-year-old pregnant woman diagnosed with
malaria in the CScom (Centre de santé Communautaire,
or Community Health Centres) of Wayerema II, “the
wounds or sore in the belly [kononandjoli in Bamanakan],
the burning sun and fatty food are the causes of sumaya.’’.
Likewise, another informant also attributed the causes
of sumaya to food.
Nafissa, a 19-year-old female fruit seller said, “Foods
which are planted like bananas, eggs and unprotected
foods (which have been exposed to open air) [are causes].
Also, oranges, mangoes, shea nuts are the causes of
sumaya.”
A respondent explained malaria through a concept
of a “potential” or “dormant malaria” locally known as
sumaya banakise.
Our respondent, Massita, a 38-year-old pregnant
housewife and CScom (Community Health Centres)
patient noted, “The sumaya seed already exists in everyone’s body, especially in the rainy season or during the cold
season. All it takes is a few triggers, such as oily and fatty
foods, for the disease to break out”.
Wayerema II residents also attributed sumaya to supernatural factors. The word kono emerged as a key term in
explaining this causal factor. The interviewee, Mr. Zanga,
a 70-year-old farmer explained, “The disease of the kono
is related to a malefactor bird. This demonic or evil bird
flies over the roofs of houses during the twilight [fitiri] and
puts an evil substance in the breasts of the nannies. When
these nannies are going to breastfeed, they do it with their
poisoned breasts. Then the evil bird will attack the soul of
the children through manifestations of febrile convulsion.
You can see the child caught by kono imitating the gestures
of the flying bird. The child beats his arms against the
ground, which usually leads to death.”
Further, another excerpt from our observation illustrated very well how malaria is related to kono, and
vice-versa in Zoumana’s family. Zoumana, a 48-year-old
trader, had a little boy named Lassana, a 3-year-old, who
had been ill for two days. On the morning of the third
day after the first author (B.S.)’s arrival, Lassana’s father
informed him that his wife and son were in the Cscom
now. B.S. asked him how? Zoumana replied that the
kono took his baby Lassana, and they took him to the
traditional practitioner after putting water on his body
and head by themselves. The traditional practitioner/
Sissoko et al. Malaria Journal
(2022) 21:276
therapist massaged him with some products and told
them to bring him the next day. Unfortunately, Lassana
lost consciousness this morning because of kono and they
quickly took him to the CScom. He (B.S.) went to the
CScom, and the little Lassana was hospitalized for very
severe malaria. The medical doctor in chief of Cscom, Dr.
Guindo told him Lassana was convulsed when they came
here. (Participant observation, and informal conversation
in the family of Zoumana, Wayerema II, June 2011).
The informants recognized the relations between the
urban ecological environments which makes it an ideal
breeding ground for mosquitoes. They also know that
the root cause of malaria is the bite of Anopheles gambiae contaminated with the most common and dangerous pathogen in Africa and worldwide, the Plasmodium
falciparum.
Mrs. Charlotte, a 43-year-old midwife working in a
CScom, recognized the connection between mosquitoes and the urban environment of Wayerema II. She
explained, “Intra residential crops, grasses, stagnant
water, wastewater, and non-existence of gutters, promote
the multiplication of mosquitoes. Furthermore, the palu is
caused by the bite of the infected female Anopheles.”
Mr. Boubacar, a high school teacher, aged 41, concurred with Mrs. Charlotte, pointing out the relationship between malaria and the environment. Similar to
her, Boubacar was very specific about the identity of the
agent. He explained, “The puddles of stagnant water, the
wastewater of the neighbourhood are the places favourable to the development and the multiplication of mosquitoes. These cause the spread of malaria through the bite of
the female anopheles. So the only cause of malaria is the
bite of the infected female anopheles.”
Knowledge about signs and symptoms of malaria
The symptomatology of malaria in Wayerema II is multiple. Most respondents are aware of the clinical symptoms of malaria, including fever, yellowish vomiting,
chills, general stiffness, kono, and vertigo. However, in
their explanations, the narrative about biomedicine and
biomedical methods has to some extent distinguished
itself from the local and popular descriptions by confirming malarial diagnostics with the use of rapid diagnostic
tests.
According to Mrs. Sanata, a 50-year-old CScom nurse,
“some of the malaria symptoms we see here are fever,
headache, nausea, dizziness, joint weakness, abdominal
pain, diarrhoea, and chills. Besides, our way to certify
someone has malaria is the blood test.”
Such was the case of Binke, a 64-year-old traditional
therapist, who told us, “The symptoms of sumaya are
constipation, diarrhoea, headache, general fatigue, stomach pain, dizziness, vomiting, kono, and chills.” Similar to
Page 5 of 11
Sanata, binke listed pain, chills, and diarrhoea as symptoms of malaria.
Therapeutic routes: self‑treatment
This section describes the steps the inhabitants of Wayerema II follow to treat malaria. One common therapeutic route is self-treatment, either before—or sometimes
concurrently with—hospital treatment. For instance,
the therapeutic route for Mamadou, which is presented
next, involves self-medication as a first response, and
only when it fails would he consult the CScom. One of
the family members of Mamadou, a 65-year-old farmer,
described to us how he treated sumaya:
“Mamadou’s treatment starts with going to the small
bush to cutting some leaves and tree roots like N’golobe,
Sekoufali, Kosafune, and N’galama. Then his wife prepares these leaves and/or roots, and he drinks the decoction well done. He would not go to CScom unless these
products cannot treat him or his family members”.
The observation of Robert’s family involved the example of a 5-year-old boy. The boy’s name was Nicolas
and he had mild signs of malaria. He had some clinical
signs (fever, headache, and high body temperature), and
he could not play with his cousins in their house. Little Nicholas’ grandmother, Alphonsine, a 70-year-old,
observed his condition and talked with his mother. Then,
grandmother, Alphonsine took care of her little boy by
washing his body with Tabakoumba and djala roots, giving him papaya and ngalama decoctions, and massaging
him with shea butter (shitulu) while reciting incantations
(Participant observation of Robert’s family in Wayerema
II, March 2016).
It was also found that, in addition to plants, the incantations cited for shitulu (butter/oil of Butyrospermum
parkii) were used to treat malaria. This shea butter is a
remedy for several kinds of disease in the study area and
elsewhere in Mali. It can be used with or without incantations, kilishi in Bambara because it had therapeutic virtues in itself. As for the kilishi, it had a magico-religious
and transformative or metamorphosing power. Applied
when added to shea butter/oil, these magical formulas or
kilishi treat the child when put on his body.
Socioeconomic impacts of malaria
The effects of malaria on people are manifold, and the
attention pay close to not only the medical but socioeconomic consequences on the lives of Wayerema II residents. Sumaya interferes with agricultural cycles and can
lead to the shortage of labour needed for food production in Wayerema II, which still largely depends on agriculture. This is what Mr. Mamadou, a 65-year-old farmer,
told us about its subsequent effects: “The period when
malaria prevails in our country also coincides with our
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production period of agriculture which is the rainy season.
It was during this period that we left for the field. But last
year the sumaya struck down my three young men and
we did not have a good harvest. So it affected my family’s
revenue.”
Sagara is a 55-year-old repairman of Jakarta motorcycles shop living in Wayerema II. When he suffered from
malaria, it was his wife who managed in hard conditions
to support and take care of the family financially until her
husband’s recovery. (Participant observation in Wayerema II, July 2011).
Discussion
This ethnographic study explored the individual perceptions and socio-cultural representations of Wayerema
II residents in Sikasso town in southern Mali regarding
malaria, and how these conceptual understandings or
explanatory narratives affect Wayerema II’s therapeutic
routes. The results thematically are presenting and discussing below.
Respondents like Alice quoted above associate malaria
with seasonal and environmental factors such as humidity and freshness produced during the heavy rainy season
in central Mali. Associating malaria with seasonal and
environmental factors suggests a miasmatic understanding of malaria. This finding corroborates other studies
from sub-Saharan Africa that show a miasmatic understanding of the disease is part of the diverse disease
explanatory framework used by Africans to make sense
of their somatic and social conditions [7, 16–19]. However, in contrast to European theories of miasma that
view disease as products of rotten matter and odour, the
theory of Wayerema II is miasmatic insofar as it sees the
environment as the cause of disease and not because of
decomposition and the “bad air” it produces [20]. Wayerema II sees the freshness and humidity as the causes
of the diseases and not necessarily the decomposition of
matter and its derivatives.
However, in the same description of sumaya-related
symptoms, Alice also mentioned kono, further complicating local cultural and social conceptions of malaria.
In popular understanding and our respondents’ descriptions, kono refers to an “evil bird,” a supernatural and/
or witchcraft-related cause of symptoms. Analysts can
describe fever and dizziness as symptoms of sumaya,
but for respondents in this study, kono operates both as a
symptom; that is a sign of sumaya but also as a causative
agent per se. In other words, kono is caused by a different agent, a supernatural force but not environmental or
seasonal conditions—yet it is referenced when our subjects spoke about sumaya. In doing so, the informants of
this study were suggesting both a miasmatic and supernatural layer of disease representation [7, 16, 20–22]. It
Page 6 of 11
appears the respondents sometimes mix sumaya, and
kono together because kono’s symptoms, such as convulsions, resemble possessions or epilepsy, which is locally
classified as a supernatural disease.
The participants of this ethnographic study did not
always separate symptoms from aetiology in their understanding of malaria. This affirms the work of social
scientists who have suggested that among African communities such as the Wayerema II, the interest is more
about creating meaning and accessing the boundaries
between the normal and the pathological [23, 24]. Does
the shift from more somatic physical conditions to those
in the mental or cognitive category demand a different
explanation? This could be the case because communities
view sumaya as seasonally and environmentally linked,
while kono is more of a supernatural presence. The shift
in representation of the disease could be a factor in how
the disease progresses from one state to the other.
The term kono was not confined to the Wayerema II
community. Other studies in Mali and Burkina Faso
have documented the use of the term Kono, sometimes
called “bird illness” used to describe convulsions among
children [7, 16–18], and among the Wolof communities in Senegal where it is also called sibiru, meaning
“warm body” [6, 24, 25]. Kono and sibiru are used interchangeably in these communities, including Wayerema
II. Apart from the variations and linkages between kono
and sibiru, in many African communities, malaria is
attributed to “witch birds’’ or supernatural forces in the
sky [21, 22, 26]. The inclusion of kono as a symptom or
part of sumaya, judging from the former’s characteristics and intensity, indicates a severe form of malaria or
even cerebral malaria. It could be widely acknowledged
that if sumaya is a general representation of malaria or its
milder forms, then kono refers to a more severe form of
malaria such as cerebral malaria in the biomedical paradigm [16, 18].
But the explanation of sumaya as a general form of
malaria and kono as a severe form of malaria is complicated by the respondents’ notion of sumaya banakise,
which means the grain of malaria. As they (the respondents) noted in explaining that sumaya banakise “the body
is in the state of expectation malaria”. This term seems to
point to both an individual’s potential and vulnerability
to contracting the disease and/or a latent state of malaria.
It implies individuals have (variable) potential to contract malaria or arouse previously dormant malaria when
one ingests acidic, sweet, and fatty foods that trigger the
onset of the disease [7, 17].
While the participants’ explanation seems to refer to
a grain of malaria as something related to the person’s
immunity or the presence of P. falciparum, it does not
foreclose the possibility that the presence of sumaya
Sissoko et al. Malaria Journal
(2022) 21:276
banakise is related to kono or other supernatural causes.
The point is researchers cannot make a leap of interpretation that sumaya banakise is simply organic and not
related to the supernatural [8, 19, 21]. Unravelling the
local conceptions of malaria is complex and contextspecific. It is not the purpose of this study to reconcile
the different representations of malaria, nor to translate
it into biomedical terms and theories, For example, while
biomedicine demarcates nosography, aetiology, and diagnosis in separate containers, we are not entirely sure if
our subjects do the same. The aim is to understand how
residents of Wayerema II made sense of and explained
malaria in their own terms and discourses.
Aetiology of malaria
Linkages between sumaya and food
In explaining the causes of sumaya, the respondents also
identified dietary, environmental, and biomedical reasons. An intriguing suggestion from the respondents of
this study was the explanation that sumaya can be caused
by fatty food such as shea butter, fruits with acidic properties such as oranges, and sweet foods like wild fruits
and corn. The respondents’ claims about the association
between food and malaria were mostly general; however,
they pointed to two intriguing ideas. The first idea is that
“opened” sweet foods such as bananas and corn are more
likely to cause malaria. If “open” here means how the
banana or corn is preserved in opposition to “closed,” as
in eating it fresh meaning never preserved, then this idea
confirms existing studies about the association between
food and diseases. Association of fatty, sweet, or acidic
food to malaria is part of a growing discussion among
Africans from different countries on changing lifestyles
and their relations to food and in turn, how new dietary
patterns create conditions for diseases like high blood
pressure, diabetes, and sometimes cancer [7, 17]. In Julie
Livingstone’s Improving Medicine, she writes that liver
cancer is caused by the combination of “subclinical infections with hepatitis and aflatoxins in poorly stored African grain” [27]. While malaria is different from cancer,
the participants’ claims about food as the causative agent
for diseases collaborate African patients and health care
providers’ discourse that links the two together [7].
Another related idea about the role of food in causing
malaria connects back to sumaya banakise. As noted, the
term seems to describe either a person’s potential to contract malaria or a form of dormant malaria. In addition to
weakened immunity, our respondents suggested that “the
grain of malaria” can also be triggered by the intake of
fatty food. This does not necessarily mean the expression
of sumaya banakise comes from a different condition
than a compromized immune system. The interpretation of these explanations is to show that Wayerema II
Page 7 of 11
residents consider malaria from not a singular cause but
multifactorial including the product of synergistic interactions between the type and state of food and its interactions with existing physiological conditions such as
having the presence of the “malaria grain.”
Biomedical explanations: causes and symptoms
If this study has created the impression that the residents of Wayerema II only conceptualize malaria through
supernatural expressions that are not the case. Like in
other African countries, Malians are living in a medically
pluralistic society employing various traditions and cultures, such as biomedicine, to treat and explain their ailments [10, 28, 29]. Some informants explained the causes
of malaria particularly through a biomedical lens [30, 31].
Both Wayerema II residents and healthcare workers or
traditional therapists have an understanding of the clinical symptoms of malaria. The informants who practise
traditional medicine also recognize the same symptoms
as those diagnosed by biomedical practitioners such
as fevers, shivering, headcheaches, vomiting, and body
ache. Moreover, residents are also aware that mosquitoes
cause malaria.
The data collected from health workers in the CScom
of Wayerema II, Csréf (referral hospital of the city or
referral health centre) of Sikasso, and paediatric services
of Sikasso regional hospital pointed out that the nosographic entities (symptoms) appear mainly in rainy periods, which is from June to October. This period is also
called the high malaria transmission season because of
the factors that promote the multiplication of the disease’s pathogen. This observation lends credence to
Wayerema II’s description of sumaya as a phenomenon
related to “wetness” or the wet season. The difference
between biomedical explanations and what we might call
“indigenous” explanations is that the latter is multifactorial bringing in biomedical, spiritual, and environmental
causes together in a specific manner.
Residents’ knowledge of symptoms and causes of
malaria through a biomedical lens is in part fuelled by the
efforts made by the Malian government in collaboration
with its partners, such as the World Health Organization (WHO), United Nations Development Programme
(UNDP), and media campaigns involving print, radio,
and television industries. In fact, among those agencies
working on traditional medicine such as the Department of Traditional Medicine, traditional therapists and
herbalists have associations and collaborations with the
National Malaria Control Programme (NMCP) to promote long-lasting insecticidal nets (LLINs), generic
drugs, and free care for children under five and pregnant women in all Malian tiered health structures from
regional hospitals to village dispensary [3, 18, 32]. In a
Sissoko et al. Malaria Journal
(2022) 21:276
way, Wayerema II’s residents’ rich accounts of malaria
are micro-expression of larger state interventions to control malaria and shape peoples’ attitudes to malaria that
often prioritize biomedical models to the subordination
of local, situated responses and epistemologies [33].
Sumaya and environmental causes
It is interesting to note that the respondents’ explanations
of sumaya are connected with the environment such as
seasonal variation. Mrs. Charlotte’s biomedical explanation quoted in the "Results" section also points to moisture or wetness as a site and occasion when malarial
agents actively develop. Such views coincide with findings from some other studies that examine how African
subjects interpret their disease in light of seasonal variations [7, 30, 31].
The indigenous explanation of aetiologies seems more
diverse, combining environmental and supernatural factors, while the biomedical explanations focus on the
agents and female anopheles as vectors. Nevertheless,
some similarities in vectors can still be spotted between
both explanations. First, in both accounts there is a vector present therein: for Wayerema II residents, it is the
bird and for biomedical practitioners, the female Anopheles gambiae. In the indigenous explanation, kono, pernicious malaria, is caused by a witch bird, a kind of social
poison in Wayerema II. In the biomedical realm, the
vector is the mosquito, but the “poison” is P. falciparum.
Again, it is not implying that biomedical terms equate to
indigenous systems, which are various per se, but pointing to some intriguing parallels and perhaps syncretism,
as in a mixture of ideas, paradigms, and theories that are
both indigenous and more or less “western” that have
percolated in these communities over many decades. This
qualitative study cannot ignore that biomedical practice in Africa has lasted for over one hundred years and
therefore cross-fertilization of ideas has been happening
in a bidirectional way in urban areas of Mali [31, 34].
Therapeutic routes
The study was interested in linking how our respondents
understand and interpret malaria through drawing from
their social and cultural understanding and how such
conceptions influence their therapeutic resources [5, 6,
8–10, 19, 21, 26, 28, 35, 36]. Arthur Kleinman’s notion of
therapeutic routes instructive in explaining and understanding the process and decisions-making inherent in
the respondent’s health seeking-behaviour. Arthur Kleinman has theorized that a therapeutic route comprises
three stages, and it begins with the subject’s sensing a
malady and his/her inclination to interpret it within the
frame of illness per se. Such illness perception is what
it refers to as the first stage of a malady (illness), where
Page 8 of 11
an individual feels a sense of imbalance or anomaly that
might be linked to a certain name of the illness. This
would give rise to the second stage: the subject communicates with a healthcare provider, healer, or kin about
his/her experience, which may lead to the further recognition of the malady. This process allows the subject to
justify his/her role as a patient by having the abnormal
state (or sickness) socially recognized. Furthermore, the
third stage involves the act of defining an illness in nosographic terms, which enters the biomedical dimension
and is grounded upon the nomenclature of the sick state
by the therapist [37, 38].
This study also revealed that the practice of self-medication is more often the first resort in case of sickness
manifestations such as headache, fever, and dizziness.
Considering the case of Mamadou that we recounted in
the "Results" section, he used plants and herbs for selfmedication often. Mamadou, moreover, described it as
“the easiest thing in the world.” By this, he means selfmedication can be an everyday practice. It also signifies
that he has the knowledge of plants as cures and can by
himself distinguish which are easily available and relatively inexpensive for use. The Wayerema II residents
usually use the decoction of “bitter” plants such as Combretum Micrathum (golèbè), Vernonia Colorata Will
(kosafunè), and Anoeissus leiocarpus (n’galama). Mamadou case and others reinforce the observation that upon
the appearance of a disease, the first response takes place
at home and draws from situated knowledge of healing.
Thereafter other routes follow not necessarily in linear
order as in starting with a traditional healer and then a
biomedical doctor.
Self-medication, as the first therapeutic recourse to
deal with ailments like malaria, fever, headaches, and
other diseases, has been reported by other authors in
African and Asian contexts [6, 8, 17–19, 33, 35, 39–43].
There are some minor differences in details with this
therapeutic recourse given the prevailing conditions.
It was found that when a person is sick, especially with
signs of a complicated case of malaria, he/she would consult family or a local therapist. These remedies used are
various but generally can be classified into three types:
(1) the traditional sector comprised of traditional healers,
herbalists, or marabouts (Muslim healers), (2) the formal
sector, which includes hospitals, community health centres, CSréf, private hospitals, and (3) the informal sector, such as street vendors, drug peddlers, and the health
workers practicing “privately.” These practices are the
main routes that the Wayerema II residents use to heal,
in line with the results of previous studies [9, 21, 23, 43].
They are also the main factors in cases of severe malaria
and cases of pre-transfer in the community health centre
(CScom) of Wayerema II.
Sissoko et al. Malaria Journal
(2022) 21:276
It can also add that plants used for self-treatment are
often “dose-free’’ and can be “effective’’ against malaria.
Often people would only go to the community health
centre or a health facility after the disease worsens or
approaches towards kono. Sometimes, malaria cases
brought to the CScom are more severe, but also bettertreated. Indeed, the agents of CScom must evacuate the
patient(s) to the CSréf or regional hospital of Sikasso. In
the meantime, self-medication can be “modern.” Modern self-medication is practised in Wayerema II using
anti-malarial pharmaceutical products, such as Maloxine, Madar, Quarcitem, and Co-arinate. Self-medication
is also done with anti-malarials from street vendors of
illicit medicine or “pharmacies par terre,’’ literally meaning “pharmacies on the ground”, with these anti-malarials
being “counterfeit.’’ These products contain “fatokèni’’
(sudrex), “sampinrin” (ibumole), and “bérébila” (ipucup),
which mean respectively in English, the “little fool,” the
“lightning,” and the “leave the stick and get on the feet
quickly.” These designations and terms are not accidental because they reflect the effects of these “fake drugs’’
on people. These products are often used because of the
high cost of malaria treatment which is unaffordable
for certain social groups, especially the underprivileged
ones. The treatment of mild malaria costs about 5–8
USD, while treatment for a complicated case costs about
18–27.5 USD [36, 44–46]. Probably linked to financial
affordability, these participant observations in Wayerema
II and other studies have established that self-medication
is the main therapeutic route for Wayerema II populations and other African communities in Western Africa
such as Nigeria, Senegal, Burkina Faso, and Côte d’Ivoire
[7, 19, 25].
Sumaya and socio‑economic impacts
Another socio-economic consequence of malaria is
absenteeism and loss of productivity, especially for
farmers and people involved in informal sectors. Many
Malian families (nuclear, limited, or extended) depend
on income generated by a single person who fulfills family needs such as the allocation of food, education, and
health. For example, if the latter falls ill to sumaya, the
social, economic, and psychological burden would fall
onto the whole family. Mamadou, whose story was
recounted above, used the term “three valid arms” to
describe the sense of powerlessness and precarity when
three of his sons got sick from malaria and therefore,
were unable to help with farming obligations. The term
both captures the level of impact it has on her as a parent, but personally: their sickness signified the loss of her
own body parts. This term lays bare the serious impact of
malaria on the whole family, even if merely one individual gets sick. The situation is dire for people who depend
Page 9 of 11
on farming, like Mamadou. The affliction of her three
“valid arms” put her food and financial plans in a precarious situation.
This study coincides with some other studies conducted in sub-Saharan contexts that show the socio-economic impact of malaria at the family level and the ways
in which it shapes therapeutic recourse [25, 36, 46]. First,
the financial cost of treatment is very high and modest
heads of families often prefer to take care of themselves
at home or pay for drugs from alternative vendors. As
such, intra-household self-treatment or intra-domiciliary self-treatment saves time and money for parents.
The income per capita for Malians is 2.5 USD per day in
2020 according to the World Bank. Treatment of simple malaria costs 4–8 USD, and for treatment of severe
malaria, the number rises to 25–35 [3, 36, 45]. The cost of
simple treatment is twice the daily earnings and for complicated malaria almost one fifth of monthly earnings.
Limitations
In our study, a qualitative ethnographic approach was
developed with random sampling. This study has a limitation in that it does not represent the perceptions and
social representations of all communities and health professionals in the District of Sikasso. As information was
collected only using anthropological methods and tools,
triangulation was unnecessary and could not be done,
the study’s limitation also. Nevertheless, to the authors’
knowledge, this is one of the first studies conducted in
the urban endemic malaria area in Mali to explore and
examine the social representations, therapeutics routes,
and treatments of people regarding malaria.
Conclusion
The finding of this study shows that the residents of Wayerema II in the health district of Sikasso have complex
knowledge of the aetiologies, and the nosographic entities of malaria, its seriousness, and preventive measures
against the vector or pathogenic agent. Wayerema II residents’ conception of malaria did not amount to a unified
“indigenous” explanatory model nor did it neatly fit the
biomedical paradigm. Fundamentally, integrating local
and popular knowledge of malaria into the biomedical
registry must be a priority for understanding the knowledge itself, and the attitudes, beliefs as well as practices
associated with it, which significantly shape ways of prevention and treatment. One possible implication of this
knowledge is to recruit traditional healers in referral to
formal health centres and involvement in malaria health
campaigns that draw out the merits of traditional and
biomedical paradigms.
Furthermore, this study has shown how much the
anthropological data, in an urban context, carry to (re-)
Sissoko et al. Malaria Journal
(2022) 21:276
consider in an understanding of the choice of therapeutic routes and health seeking-behaviour adopted,
which provide insights into the development of the
programme, and new strategies fighting against malaria
in Africa in general, and in Mali in particular.
Abbreviations
SLIS: Système Local d’information Sanitaire; CSCom: Centre de Santé Communautaire (Community Health Centre); WHO: World Health Organization; UNDP:
United Nations Development Programme; NMCP: National Malaria Control
Programme; LLITN: Long-Lasting Insecticide-Treated Net; CSréf: Centre de
Santé de référence (Referral Health Centre); ACT: Artemisinin-based Combination Therapies.
Acknowledgements
We would like to express our gratitude to the people of Wayerema II, and the
health workers of the municipality of Sikasso for their availability and ongoing
participation in the data collection of this project. We would also like to thank
Prof. Huang Jian Bo, Associate Prof. Horacio Ortiz, Dr Chaka Diakite, and Mrs.
Oumou Sissoko for their useful comments and suggestions that helped to
improve the quality of this study. Many thanks should also go to Johnson
Keyba Swai, and Dr Sauman Singh-Phulgenda for editing our manuscript.
Author contributions
BS conducted the fieldwork and drafted the manuscript; YMR reviewed and
contributed to the manuscript; NNS contributed to the manuscript, and JRW,
NNS, YMR, BS reviewed, edited, and validated the manuscript. This work was
the collaborative research between the junior researchers, BS of East China
Normal University, and NNS of Nanjing Medical University, China, and young
scholars MYR and RJW of New York University Shanghai, China. All authors
read and approved the final manuscript.
Funding
No funding for this research.
Data availability
The datasets during and/or analysed during the current study are available from the corresponding author on reasonable request.
Declarations
Ethics approval and consent to participate
The ethical approval was obtained through the Faculté des Lettres, Langues,
Arts et Sciences Humaines (FLASH) in 2011, Université de Bamako, Mali. Written Informed consent from all participants in this study was obtained.
Consent for publication
This study included Informed Consent, which reported to informants the
objective of this study and the use of data for the publication of their results.
And all the authors read and approved the final manuscript.
Competing interests
The authors declare that they have no competing interests.
Author details
1
Institute of Anthropology, School of Social Development, East China Normal
University, Minhang District, 500 Dongchuan Road, Shanghai 200241, China.
2
Faculty of Foreign Languages, Southwest Forestry University, 296 Bailongsi,
Kunming, Yunnan 650224, China. 3 Department of Social Sciences, New York
University Shanghai, 1555 Century Avenue, Pudong New District, Shanghai 200122, China. 4 School of Pediatrics, Nanjing Medical University, Nanjing,
China.
Received: 29 December 2021 Accepted: 22 September 2022
Page 10 of 11
References
1. Alonso PL. Malaria: a problem to be solved and a time to be bold. Nat
Med. 2021;27:1506–9.
2. WHO. World Malaria Report. Geneva: World Health Organization; 2021.
3. PNLP, CNMP. Plan National De Suivi and evaluation 2018–2022. Bamako:
Minister of Health; 2018.
4. DGSHP. Mali Annuaire Statistique du Système Local Information Sanitaire
(SLIS). Bamako; 2018.
5. Cáceres L, Calzada JE, Gabster A, Young J, Márquez R, Torres R, Griffith M.
Social representations of malaria in the Guna indigenous population of
Comarca Guna de Madungandi, Panama. Malar J. 2017;16:256.
6. Faye SL. Mode de représentation du paludisme chez l’enfant et recours
aux soins en milieu rural sereer: Niakhar, F.S.M.d.D.A., UCAD. Sénégal:
FLSH; 2001.
7. Some DT, Zerbo R. Etiologie atypique du paludisme: perceptions et
strategies locales de prevention dans le departement de Gaoua, Burkina
Faso. Med Trop. 2007;67:43–6.
8. Pell C, Straus L, Andrew EV, Meñaca A, Pool R. Social and cultural factors
affecting uptake of interventions for malaria in pregnancy in Africa: a
systematic review of the qualitative research. PLoS ONE. 2011;6:e22452.
9. Diarra T. Représentations et itinéraires thérapeutiques dans le quartier de
Bankoni, 177–191. In: Brunet JJ, editor. Se soigner au Mali: une contribution des sciences sociales, douze expériences de terrain. Paris: ORSTOM;
1993.
10. Luxereau A. Le corps vivant, la santé, les remèdes à Maradi (Niger). In:
Urbanisation et santé dans le Tiers Monde: transition épidémiologique,
changement social et soins de santé primaires. 1989;319–331.
11. Ministère de la Santé. et de l’Hygiène Publique du Mali. Enquête
démographique de santé du Mali 5 Édition (EDSM V). Bamako; 2014.
12. DGSHP. Carte Saniatire Revisée du Mali. Bamako; 2019.
13. Van Campenhoudt L, Quivy R, Marquet J. Manuel de recherche en sciences sociales. 5th ed. Malakoff: Dunod; 2017.
14. Emerson RM, Fretz RI, Shaw LL. Writing ethnographic fieldnotes. Chicago:
University of Chicago Press; 2011.
15. Braun V, Clarke V. Thematic analysis. Washington: American Psychological
Association; 2012.
16. Bonnet D. Représentations culturelles du paludisme chez les Moose du
Burkina. Ouagadougou: Multigraph ORSTOM; 1986.
17. Kampo Y. L’implication des tradithérapeutes dans la prise en charge du
paludisme à Bamako: Cas de l’association des thérapeutes traditionnels
et herboristes du district de Bamako ou « Keneya Yiriwaton » en commune II. Faculté des Lettres, Langues, Arts et Sciences Humaines (FLASH),
Université de Bamako. Bamako (Mali); 2006.
18. Diallo D, Diakité C, Mounkoro PP, Sangaré D, Graz B, Falquet J, et al. La
prise en charge du paludisme par les thérapeutes traditionnels dans les
aires de santé de Kendié (Bandiagara) et de Finkolo (Sikasso) au Mali. Mali
Med. 2007;12:1–8.
19. Kouakou Bah JP. Symbolic representations and treatment of health in
African Traditional Medicine: the example of malaria in Baoulé-Agba of
Côte d’Ivoire. J Infect Dis Ther. 2013;1:110.
20. Awoyemi AO. ‘Miasma’ theory and the possibility of malaria eradication.
Afr J Clin Exp Microbiol. 2005;6:153–8.
21. Rumun AJ, Terungwa M. Perception of malaria and treatment seeking
behaviour among rural dwellers in Nigeria. Glob J Interdiscip Soc Sci.
2015;4:1–6.
22. Jaffré Y, Olivier de Sardan MA, Souley JP A. Représentations populaires
Hausa et Songhay-zarma de quelques maladies (entités nosologiques
populaires). Etude No 17, LASDEL Laboratoire d’études et de recherches
sur les dynamiques sociales et le développement. 2004;1–18.
23. Jaffré Y. Contributions of social anthropology to malaria control, Chapitre
34. In: Tibayrenc M, editor. Encyclopedia of infectious diseases: modern
metholologies. New York: Wiley; 2007. p. 589–600.
24. Fasssin D. Maladie et médecine, 38–49. In: Fassin D, Jaffré Y, editors. Sociétés, développement et santé. Paris: Les Éditions Ellipses; 1990.
25. Faye SL, Lalou R, Adjamagbo A. Soigner les enfants exclusivement à
domicile en cas de paludisme en milieu rural sénégalais: un effet de la
pauvreté? Afr Popul Stud Suppl. 2004;19:222–40.
26. Erhun WO, Agbani EO, Adesanya SO. Malaria prevention: knowledge, attitude and practice in a Southwestern Nigerian community. Afr J Biomed
Res. 2005;8:25–9.
27. Livingston J. Improvising medicine. Durham: Duke University Press; 2012.
Sissoko et al. Malaria Journal
(2022) 21:276
Page 11 of 11
28. Awasthi KR, Jancey J, Clements ACA, Leavy JE. A qualitative study of
knowledge, attitudes and perceptions towards malaria prevention
among people living in rural upper river valleys of Nepal. PLoS ONE.
2022;17:e0265561.
29. Enumah ZO, Rafiq MY, Ayele W. ‘They call us killers’: an exploration of
herbal, spiritual and western medical practices in Mombasa, Kenya. Afr J
Tradit Complement Alternat Med. 2016;13:219–29.
30. Leonard L, Doumbia DS, Sadou S, Mihigo A, Koenker J, et al. Net use, care
and repair practices following a universal distribution campaign in Mali.
Malar J. 2014;13:435.
31. Finda MF, Kaindoa EW, Nyoni AP, Okumu FO. ‘The mosquitoes are preparing to attack us’: knowledge and perceptions of communities in southeastern Tanzania regarding mosquito swarms. Malar J. 2019;18:56.
32. PNLP. Plan Strategique De Lutte Contre Le Paludisme 2018–2022.
Bamako; 2018.
33. Vaughan M. Curing their ills: Colonial power and African illness. Stanford:
Stanford University Press; 1991.
34. Moshi IR, Ngowo H, Dillip A, Msellemu D, Madumla EP, Okumu FO, Coetzee M, et al. Community perceptions on outdoor malaria transmission in
Kilombero Valley, Southern Tanzania. Malar J. 2017;16:274.
35. Bork-Hüffer T. Healthcare-seeking practices of African and rural-to-urban
migrants in Guangzhou. J Curr Chin Aff. 2015;44:49–81.
36. Diallo I, Traoré BC. Gratuité de prise en du paludisme chez les enfants
de moins de 5 ans: contraste de perceptions et de pratiques entre les
acteurs de l’hôpital Gabril Touré. Revue Cailcédrat. 2019;7:121–33.
37. Kleinman A, Good EL. Culture, illness and care: clinical lessons from
anthropologic and cross cultural research. Ann Int Med. 1978;88:251–8.
38. Kleinman A. Patients and healers in the context of the culture: an exploration of the borderland between anthropology, medicine and psychiatry.
Berkeley: University of California Press; 1980.
39. Ruebush TK, Neyra D, Cabezas C. Modifying national malaria treatment
policies in Peru. J Public Health Policy. 2004;25:328–45.
40. Ashikeni MA, Envuladu EA, Zoakah AI. Perception and practice of
malaria prevention and treatment among mothers in Kuje area council
of the Federal Capital Territory, Abuja, Nigeria. Int J Med Biomed Res.
2013;2:213–20.
41. Cogburn MD. Homebirth fines and health cards in rural Tanzania: on the
push for numbers in maternal health. Soc Sci Med. 2020;254:112508.
42. Manzi F, Schellenberg JA, Hutton G, Wyss K, Mbuya C, Shirima K, et al.
Human resources for health care delivery in Tanzania: a multifaceted
problem. Hum Resour Health. 2012;10:3.
43. Hunt NR. A colonial lexicon: of birth ritual, medicalization, and mobility in
the Congo. Durham: Duke University Press; 1999.
44. Langwick SA. Articulate (d) bodies: traditional medicine in a Tanzanian
hospital. Am Ethnol. 2008;35:428–39.
45. Faye SL. Du sumaan ndiig au paludisme infantile: la dynamique des
représentations en milieu rural sereer sinig (Sénégal). Sci Soc Santé.
2009;27:91–112.
46. OMS/WHO. Sommet africain sur le projet Faire Recherche le Paludisme
FRP/RBM. Abuja (Nigeria); 2000.
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