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

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1 Tropical Medicine and International Health volume 2 no. 1 pp january 1997 Ethnic diversity and disease surveillance: Guinea worm among the Fulani in a predominantly Yoruba district of Nigeria William R. Brieger 1, Ganiyu A. Oke 2, Sakiru Otusanya 3, Aziz Adesope 3, Jamiu Tijanu 3 and Muyiwa Banjoko 3 1 African Regional Health Education Centre, College of Medicine, University of Ibadan, Nigeria 2 Ibarapa Community Health Programme, College of Medicine, University of Ibadan, Nigeria 3 Ifeloju Local Government, Southwest Zone, Nigerian Guinea Worm Eradication Programme, Nigeria Summary 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. keywords Guinea worm eradication, Fulani, Yoruba, village-based reporting correspondence W. R. Brieger, African Regional Health Education Centre, College of Medicine, University of Ibadan, Ibadan, Nigeria Introduction In a multi-ethnic nation such as Nigeria it is not uncommon to find that people of more than one ethnic group co-exist even in the smallest unit of local administration. Ifeloju Local Government Area (LGA) in Oyo State, Nigeria is typical of the ethnic mix. The dominant ethnic group among the estimated population of are the Yoruba. Eighty per cent of the population are found in the 5 major towns, while the remainder are dispersed in more than 300 farm hamlets. Fulani settlements, known as gaa, are scattered throughout the LGA, and a cluster of Ohori villages is located in the north-west. Nearly half of the farm hamlets have migrant farm labourers resident for most of the year. This case study focuses primarily on the largest minority group, the Fulani. 99 C 1997 Blackwell Science Ltd

2 The nomadic Fulani are a cattle-rearing tribe found throughout the sahel and savannah of West Africa from Sengal to Cameroon (Ezeomah 1983). The Fulani trace their origins back to Senegal and began their nomadic wanderings, which eventually brought them as far east as Bornu in north-east Nigeria, in the 13th century (Hunwick 1965). They reportedly reached Hausaland (northern Nigeria/ southern Niger) in the 15th century (Hunwick 1965) and conquered most of northern Nigeria (St. Croix 1972). A detailed study was undertaken in 1991 to locate all Fulani settlements in Ifeloju LGA (Dau 1992). Sixty gaa were found with a total population of 2197 or approximately 2.1% of the estimated LGA population. Each gaa averaged 5.5 families. More than one-quarter of the gaa had been located at their present site for a year or less, while 10% had been in the area over 20 years. The average stay was 9.7 years. By local convention, most gaa are named after the nearest Yoruba farm hamlet, thus Gaa Abukele is located about 1 km from Abule Abukele. The two ethnic groups usually share the same water source but otherwise have little formal interaction. This naming system tends to obscure the presence of the Fulani in the area. The relationship of the Fulani with the Local Government authority is an ambivalent one. On one hand, the Fulani appear to be ignored, with poor access to primary health care services. For example, only 2% of Fulani preschool children had received full childhood immunization compared to an estimated 40% of all children in the LGA in 1991 (Dau & Brieger ). On the other hand, LGA tax collectors harass Fulani disproportionately in the local farm markets because of the generally held assumption that cattle ownership equates with wealth (Brieger 1991). Guinea worm disease Guinea worm infection (dracunculiasis) is a disabling helminthic infection endemic to Africa, Yemen and South Asia where communities have no access to potable water supplies. The one-metre-long parasite is found in subcutaneous tissues of the human host, most frequently in the lower limbs, which often come in contact with ponds, step wells and other unsafe water sources. The mature Guinea worm causes a blister on the host s skin, from which it emerges to expel larvae when the blister comes in contact with water. The tiny larvae are then swallowed by small crustaceans of the cyclops species and develop for approximately 14 days into an infective stage. Once people drink water containing infected cyclops, the larvae are introduced into their body, migrate through the stomach wall, and mature over the next 9 12 months until the cycle repeats itself. Guinea worm is not a killer disease, but a silent and neglected disabler of the farming populations on whom nations depend for their food supply (Brieger & Guyer 1990). Beginning in the late 1980s, national governments and international agencies declared their intentions to eradicate the disease. Since that time there has been a precipitous decline in the number of cases world-wide. Surveillance has played a central role in keeping track of the disease during all phases of eradication (Richards & Hopkins 1989). Passive surveillance of clinic records pointed to broad geographic areas of prevalence and thus aided subsequent active case search activities, which were used to target interventions. As intervention took place monthly reporting mechanisms were developed to monitor programme progress. Finally, follow-up monitoring and case searches can be used to verify elimination. The year 1995 was set as the deadline for achieving eradication, but in reality planners knew that logistical, political and cultural factors would make Guinea worm a stubborn opponent. One such factor has been the difficulty in identifying and tracking Guinea worm cases among ethnic minority groups in rural areas with dispersed populations, and this factor is the focus of this paper. Experience in Ifeloju LGA of Oyo State, Nigeria, has shown that minority populations fall into a blind spot among health staff who belong to the majority group, thus limiting the identification and targeting of endemic minority settlements. Guinea worm surveillance in Ifeloju The first national case search organized by the Nigeria Guinea Worm Eradication Programme 100 C 1997 Blackwell Science Ltd

3 (NIGEP) covered the transmission season. Three more annual case searches took place before the national surveillance strategy changed to monthly reporting by volunteer village-based health workers (VBHWs) in mid A review of all available annual national surveillance reports through 1994 shows no Fulani settlement in Ifeloju LGA listed by its own name. A pilot project was undertaken by researchers in to develop a market-based system for gathering Guinea worm surveillance data from VBHWs during their regular attendance at farm markets in Ifeloju (Brieger & Kendall 1992). Two gaa who frequented one of the markets were included in the programme. A summary of the villages in the market-based programme, including the gaa, were forwarded to the LGA, but this did not stimulate the inclusion, in 1991, of any Fulani settlements in the first group of 92 hamlets where efforts were made to recruit VBHWs by the LGA to serve as Guinea worm scouts. A report dated 15 February 1994 by the LGA Guinea Worm Coordinator on a perceived outbreak of the disease did not include any gaa by name, although the assumption existed that the VBHW from the namesake hamlet would check on his neighbouring gaa and report cases. This assumption turned out to be false in many hamlets. In May 1994 we had the opportunity to assist UNICEF in conducting a case search to aid in targeting the location of borehole wells. During that effort, previous official NIGEP village lists were culled for endemic villages. Inquiries were also made in markets and villages about potential cases in neighbouring settlements. Over 200 hamlets were visited, yielding 85 endemic ones. Eleven Fulani gaa with a population of 150 were also surveyed. Three gaa were found to have a total of 9 cases during that period ( ). Again these names were forwarded to the LGA, the NIGEP Zonal Office and the UNICEF Water and Sanitation Programme Officer, and again, no names of gaa appeared on subsequent endemic village lists. Finally, in December 1995, as a result of involvement in an onchocerciasis research project covering 40 farm settlements in Ifeloju, researchers identified two endemic gaa. As before, these settlements were not on the official endemic village list. This stimulated the researchers in collaboration with the NIGEP staff based in Ifeloju to embark on an active search for Fulani settlements. At that point, the NIGEP staff were actively monitoring 58 endemic Yoruba farm hamlets in Ifeloju LGA where VBHWs were compiling monthly reports. Methods First it was necessary to make a list of all Fulani settlements. Names of gaa were collected from previous work. Interviews with Fulani leaders were also held to expand the list. During regular villagebased record collection, the NIGEP staff inquired from Yoruba villagers about nearby gaa. This resulted in a list of 70 gaa names. A traditional case search is a full population study wherein names of all residents are listed and their Guinea worm status during the period of study is recorded. A case is defined as the emergence of a white thread-like worm from an ulcer in the skin during the period under study, in this case from September 1995 to the point of interview in February March This corresponds to the normal Guinea worm transmission season in Ifeloju LGA when most cases would be expected to occur. Due to time and logistical constraints, a modified case search procedure was used: all persons present in the gaa were asked if anyone had Guinea worm since the previous September. Those who had were interviewed to verify their experience of the disease corresponded with the case definition. For positive cases, the person s name was recorded on the regular case containment record forms in use by NIGEP. Also, interviewers obtained estimated population figures and opinions from group discussions with leaders of the gaa. Results Efforts to trace the 70 gaa resulted in finding only 60 in place. The others had relocated and joined with another settlement or had left the area completely. Among the 60, 8 were newly settled, among them a group who had migrated back from Benin Republic where they had lived for the past 5 years. In contrast, several gaa had been settled in the area for years. One gaa was found to shift back and 101 C 1997 Blackwell Science Ltd

4 Table 1 Guinea worm status of Fulani gaa and nearby Yoruba hamlets Guinea worm status of gaa Guinea worm status of hamlet (%) Yes No No hamlet Total Yes 5 (20) 6 (17) 4 (80) 15 ( 25) No 15 (80) 29 (83) 1 (20) 45 ( 75) Total 20 (33) 35 (58) 5 ( 9) 60 (100) forth between two hamlets on an annual basis. Another interesting point is that 5 of the gaa were independent, i.e. not located next to and thus not sharing a name with a Yoruba hamlet. A few gaa were said to be permanent. According to the residents of gaa Olompupo, We have been living within the Yoruba society for a long time, and cannot even speak the Fulani language very well any more. We like this location because it is good for farming. We do not have cows any more. Unfortunately, this long association with the people of Ifeloju has not resulted in much integration. The LGA does not recognize our people as part of this society or even as Nigerians. The only way we are bound to them is through the tax collectors, who sometimes arrest us. This sentiment of marginalization was also expressed in another 4 discussion groups. Leaders of only 17 gaa reported that they had heard of the Guinea worm programme. Of those, only 5 had direct contact with a VBHW or LGA staff member. In 15 (25%) of the gaa, reports of at least one Guinea worm case in the study period were confirmed (Table 1). The majority (10) of these gaa were situated next to hamlets that had no reports of Guinea worm or were independent. In the 5 gaa located next to a hamlet that did have Guinea worm cases during the study period, no cases among Fulani had been reported by the neighbouring VBHW as seen in their monthly record books. The estimated population of the 60 settlements was A total of 57 cases (1.9% prevalence) were reported to have occurred in the period under study, or an average of 3.8 affected persons in the 15 endemic settlements. During the group discussions, the consensus among the Fulani elders was that they have never really benefited from the local health, veterinary or social services. Most utilize private health and veterinary clinics. Some were aware of LGA efforts to sink borehole wells and were concerned that their settlements had been left out in spite of the fact that they pay taxes. Another noted that, People from the LGA have visited us twice before about Guinea worm and promised to help us, but they have never returned. The only visible government service to the Fulani in the area is a school established by the Federal Government for migrant children. Discussion The number of endemic gaa identified in this exploratory work effectively increases the number of outlying settlements under surveillance by 26%. The results also indicate that the current VBHW monthly surveillance system is inadequate for obtaining accurate information on the Guinea worm status among the Fulani in Ifeloju LGA. Encouraging better outreach by the VBHWs in endemic Yoruba hamlets is necessary, although this would not help identify the majority of Fulani (67% of gaa) who live next to non-endemic hamlets or in independent gaa. Another logical consideration would be the recruitment and training of VBHWs for endemic gaa. A drawback to this approach is the mobility of the population, but having VBHWs as a means of communication with the Fulani would be valuable. Another potential drawback is the poor relations between the LGA staff and the Fulani. Efforts must be made to improve relations and show that the LGA staff are reliable before the Fulani will trust them and take their promises seriously. The migrant school could also play a role in health education about Guinea worm and serve as a meeting point where reports about newly emergent Guinea worm cases could be collected. Another venue for communication could be the periodic farm markets. The NIGEP staff already use these markets as a focal point for monthly VBHW meetings. Previous research has shown that the Fulani attend these markets and so could easily be incorporated into such meetings. The chief of the local Fulani holds monthly meetings with gaa leaders, and 102 C 1997 Blackwell Science Ltd

5 this would be another important opportunity to collect and disseminate information about Guinea worm. Finally, although this report focused on one LGA in one state, the findings should serve as a lesson for other LGAs and for national eradication programme planners. Many Fulani in Ifeloju report that they have migrated from other states (Kwara and Ogun) as well as at least 3 surrounding LGAs in Oyo State (Dau 1992). Among the present set of gaa are international migrants, i.e. those who had lived recently in Benin Republic. The results imply an annual turnover of approximately 20% of the Fulani settlements. Not only do these findings point to the need for all staff in such locations to identify and monitor minority settlements on a regular basis, but they also show that migrant groups might easily transport the disease to other localities where, if local authorities are blind to their ethnic minority populations, as has been the case in Ifeloju, Guinea worm could silently establish itself. References Brieger WR (1991) A Farm Market Based System for Detecting Guinea Worm Endemic Villages in Southwestern Nigeria. Dissertation, School of Hygiene and Public Health, The Johns Hopkins University, Baltimore, USA. Brieger WR & Guyer J (1990) Farmers loss due to Guinea worm disease: a pilot study. Journal of Tropical Medicine and Hygiene 93, Brieger WR & Kendall C (1992) Learning from local knowledge to improve disease surveillance: perceptions of the Guinea worm illness experience. Health Education Research 7, Dau MYJ (1992) Knowledge, Opinion and Coverage of Immunization among Fulanis in Ifeloju Local Government Area, Oyo State, Nigeria. MS thesis, Department of Preventive and Social Medicine, University of Ibadan, Nigeria. Dau MYJ & Brieger WR ( ) Immunization for the migrant Fulani: identifying an underserved population in southwestern Nigeria. International Quarterly of Community Health Education 15(1), Ezeomah C (1983) Statistical Survey of Nomads in Ten Northern States. Nomadic Education Unit, University of Jos, Nigeria. Hunwick JO (1965) Islam in West Africa. In A Thousand years of West African History (eds AFA Ajayi & I Espie), Ibadan University Press, Ibadan. pp LarM(1989) Aspects of Nomadic Education in Nigeria. FAB Educational Books, Jos, Nigeria. Richards F & Hopkins D (1989) Surveillance: the foundation for control and elimination of dracunculiasis in Africa. International Journal of Epidemiology 18(4) St. Croix FW (1972) The Fulani of Northern Nigeria. Gregg International Publications, England. 103 C 1997 Blackwell Science Ltd