Managing risk through treatment-seeking in rural north-western Tanzania: Categorising health problems as malaria and nzoka

Abstract

This paper examines how risk is perceived by lay populations in response to two aetiologically connected but conceptually divided diseases – malaria and nzoka . Using case study data from an ethnographic study of risk perceptions in north-western Tanzania, we explore the relevance of risk as a concept within a community exposed to traditional and modern value systems, a pluralistic health care system and syncretic treatment-seeking behaviour. We found that the concept of risk was a useful heuristic device, but that what was categorised as risk reflected different social circumstances. The findings reinforce the evidence for risk and risk perception as cultural products. Using empirical examples of experiences with malaria and nzoka , we highlight difficulties in illness recognition, particularly with common symptoms such as high fevers and convulsions in this case. We show how risky decisions over appropriate treatment-seeking were informed by processes of categorisation and re-categorisation as the patient and their family negotiate a solution to illness. We show how this process of risk re-categorisation is framed by social context, hinges on peer and professional advice and responses to treatment, and how this process often continues after treatment ends through recovery or death. We conclude by emphasising the way in which awareness of categorisation as a risky practice in illness management increases the salience of treatment-seeking considered as risk, exacerbating the ‘actual’ risks of experiencing illness.

Keywords:

• risk
• risk perception
• uncertainty
• risk management
• public health

Notes

1. We use italics to denote words in Swahili (national language of Tanzania) and bold italics to denote words in Sukuma (local ethnic vernacular).

2. Emic represents ‘local’ or internal perspectives as opposed to ‘etic’ which represents external perspectives.

3. Mchango (Swahili) or nzoka (Sukuma) are used to describe a common indigenous illness within Tanzania and elsewhere in SSA which is directly translated as ‘invisible worms’ or ‘invisible snake’. The category is composed of several subgroups with differential aetiologies, and has been linked to pneumonia, convulsions, infertility in women, hernia and non-specific stomach problems. It is characterised by its invisibility to biomedicine. In this paper we use the Sukuma term nzoka more frequently to reflect emic usage. Refer to more details on these categories later in this paper.

4. Uwezekano means possibility.

5. Literal translation of kubahatisha is ‘to take a chance’.

6. Agnes’ description of her child's illness was as ‘degedege’. This is translated directly as ‘convulsions’. Biomedical usage of the term ‘degedege’ refers to convulsions as a symptom, but it is not clear from her account whether Agnes is using the same reference, or whether she associates this with the nzoka disease she believes killed her child. Other research in Tanzania has highlighted this same connection between degedege and malaria (Muela et al. 2002; Kamat 2006).

7. The research assistant (RA), a resident of Nyanguge, felt it important to intervene at this point to explain the nzoka disease. His account is then confirmed by the informant.