Joshua Schkrohowsky and Dr. Bruce Chadwick, Sociology

Introduction

The Buruli ulcer (BU), caused by Mycobacterium ulcerans, has been identified by the World Health Organization (WHO) as one of the leading endemic tropical diseases in West Africa (2). M. ulcerans, at the site of infection, forms a subcutaneous nodule. This nodule, unless immediately excised, leads to a progressive deteriorating cavity beneath the epidermis followed by the ulceration of the overlying skin (1).

The Ga district is considered the most endemic area in Ghana, West Africa, containing over 1500 documented active cases. There are 150 villages within the Ga district. One of these villages, Obakrowa is the setting of the presented research. According to the chief, Nii Ashepi Lampki, about 600 people live in Obakrowa (this is inferred to include the surrounding small settlements under his jurisdiction). The closest health facility is 12 miles, about 35 minutes by car, from Obakrowa in the district capital, Amasaman. This is only a small 15-bed health center. There is no district hospital in the Ga district.

There is an urgent need for the development of early detection surveillance strategies and outreach health education. If BU is identified early, the nodule can be removed by simple excision and the disease is eliminated. Also, the construction of adequate treatment facilities and increased access to them is vital. In order to do this a better understanding is needed about the local attitude and beliefs of the people regarding BU.

Objective

This study provides a foundation of specific information regarding health care and BU gathered from indigenous people of the Ga district in order to better serve their health needs. Research determined area specific hindrances to early treatment of the BU. Also, it probed into the ideology and beliefs of the local population regarding the causes of BU and its possible treatment(s). The gathered data will be used in the development of area specific surveillance methods of BU.

Methods

Permission and acceptance was immediately acquired from Nii Ashepi Lampki, chief of the Obakrowa village. The first week’s stay, beginning with the pouring of libations with the village elders, was invested in becoming familiarized with the people and them with us. Weeks two and three were dedicated to observation and interviews.

In order to accomplish the research objectives, a research questionnaire was developed, focusing on two types of questions. The first set was used to determine what was known and believed about the BU among the indigenous population. The other questions were designed to realize how treatment can be rendered to BU sufferers more quickly. Those interviewed were picked at random from the village. An interpreter was present during all interviews.

Result

Interviewing of the local people in Obakrowa regarding their beliefs towards BU and common hindrances of early treatment was random in selection. 90% of those selected for interviewing have had BU themselves or within their immediate family. These interviews are analyzed in the following paragraphs.

Believed causes of BU

Three weeks was not enough time to really understand the people and gain their confidence in order for them to confide their real beliefs with me. Most interviewees answered that they did not know the cause of BU, which of course was true. Yet later I found out they all had their speculations but did not divulge them freely with me because they were afraid to look superstitious in front of Westerners. Thus this information could have been extracted through wording the questions differently and gaining a greater trust with the people. But I found this out too late. Two older people did tell me of their belief that BU is the work of the devil or punishment.

Treatment of BU

Every single person interviewed had gone to a traditional healer first. After experiencing the ineffectiveness of traditional medicine the people sought medical treatment. By this time the BU was far along in the disease process and past easy treatment. One older woman showed no faith in Western medicine and actually believed strongly that it causes more damage. These ideas and practices of the people will be discussed further in the section under hindrances.

Local hindrances to early treatment

Several years ago most people in the villages did not believe Western medicine could help them but this mentality has changed. Also back then the nearest hospital to treat BU was in Accra, making it extremely time consuming and expensive to seek treatment. As for today, the hindrances of early treatment are different.

Of those interviewed, 30% claimed they did not recognize BU themselves till it had already ulcerated. And even when they did finally notice the disease, it took them, on average, two weeks to seek any kind of treatment.

The key hindrance today is the distance and accessibility to proper health care. The people of the villages still hold a strong belief in traditional medicine and since these healers are located in practically every village, they are turned to first. Every single person interviewed first sought out traditional medicine before considering going to the health clinic. And usually by the time they end up at a hospital the disease has progressed and, as in the case of one woman, drastic measures are taken, such as amputations. In the interviews, I determined that they presently believe in Western medicine as much as traditional. For the people it is just much easier to find traditional medicine close to home which also allows them to continue doing their daily routine at home or in the fields, which is a matter of survival for these people. Many cannot spend the time needed to recover in a hospital or their families would starve.

On a positive note, several interviewees expressed that if they contract BU again they would turn immediately to the proper care at the hospital.

Conclusion

It was evident that not enough time was spent in order for the local people to confide many of their personal beliefs with me. I was at least able to determine that, although the people still put a lot of trust in traditional medicine, their attitude towards Western medicine has improved. Previously it was believed that lack of transportation and cost of medical care were the key obstacles to proper medical care for the local people of the Ga district. Yet according to the current data gathered among the people in the Obakrowa village this is not a major factor hindering proper treatment. Distance to and accessibility of proper care is the most pressing problem. The local people seek the closest care possible, thus turning to traditional healers first of all and most often. In order to overcome this problem and encourage early treatment of BU, clinics need to be set up or strengthened in the villages. This will allow easy access for villagers into the health care system at an early first point of contact where they can either be treated or referred on to Amasaman Health Center. If clinics had the training and capability to perform minor excisions this would greatly contribute to the control of BU. Also, a surveillance system within smaller outreaching villages needs to be set up, in which outreach village workers could document and triage new BU patients to the nearest health clinics.

The people of Ghana learn quickly. A small educational program among the villages needs to also be organized in which the people are taught how to identify BU early and what is the proper route for effective treatment.

If such a system of outreach workers and small clinics were set up throughout the Ga district people would be more likely to receive the early treatment needed. The BU could be kept under tight watch until more is known about its prevention and then this same system would be used in educating the populace about these new discoveries in BU control.

Concurrent activities

As Volunteer Director of Humanitarian Aid Relief Team (HART), I spent much of my initial time in Ghana preparing for the incoming field research teams. In this time I made sure accommodations within the villages were fixed and adequate, that transportation had been arranged, and that the proper people were ready for our teams to arrive. I had meetings with the HART-Ghana Board and with the District Health Assembly for the Ga district. We placed researcher for two months in five villages throughout the Ga district performing similar anthropological research to my own. Their findings are being assessed currently and a report is being put together to present to the WHO. Also a six-member team of volunteers worked out of Amasaman in order to lay a skeleton foundation of an outreach program within many of the villages.

References

1. Portaels, F., H. Traore, K. De Ridder, and W. M. Meyers. 1998. In virto susceptibility of Mycobacterium ulcerans to Clarithromycin. Antimicrobial Agents and Chemotherapy. 42:2070-2073.
2. George, k. M., D. Chatterjee, G. Gunawardana, D. Welty, J. Hayman, R. Lee, and P. L. C. Small. 1999. Mycolactone: a polyketide toxin from M. ulcerans required for virulence. Science. 28:854-857.