In rural Ugandan communities the traditional kinship by cdy38532

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									Annals of Tropical Medicine & Parasitology, Vol. 94, No. 5, 485± 495 (2000)



In rural Ugandan communities the traditional
kinship/clan system is vital to the success
and sustainment of the African Programme
for Onchocerciasis Control
BY N. M. KATABARWA*
Carter Center, Global 2000 River Blindness Program, P.O. Box 12027, Kampala, Uganda
F. O. RICHARDS JR
Global 2000 River Blindness Program, Carter Center, One Copenhill, Atlanta, GA 30307,
U.S.A.
AND R. NDYOMUGYENYI
Ministry of Health, P.O. Box 1661, Kampala, Uganda
Received 5 April 2000, Revised 5 May 2000,
Accepted 8 May 2000


In rural Ugandan communities where onchocerciasis is meso- or hyper-endemic, control of the disease is
now being carried out using a strategy of community-directed programmes for the annual distributio n of
ivermectin to all persons eligible to take the drug. For these programmes to achieve their annual target
coverage of at least 90% of the population eligible to take ivermectin, and to continue to sustain themselves
for 10± 15 years or more, even after external donor funding ceases, it has been found essential to replace
the initial community-based strategy, imposed from outside, by a community-directed strategy developed
by the community members themselves. Furthermore, it is essential for success that full use be made of
the traditional social system, which is very strong in all rural communities in Uganda. This system is based
on patrilineal kinships and clans, governed by traditional law, and in it women pay an important role. If
this system is ignored or by-passed by government health personnel or by the sponsors and promoters of
the programme, the communities are likely to fail to reach their targets.
   When rural communities increase in size and complexity, following development and the arrival of
migrant families, they become semi-urbanized. The kinship/clan system is then weakened, community-
directed drug distributio n is much more dif® cult to organize, and coverage targets are not often achieved.
This effect is of minor importance in a rural disease, such as onchocerciasis, but is likely to be of greater
signi® cance in the control of diseases, such as tuberculosis and lymphatic ® lariasis, which thrive in urban
environments.



Several programmes of mass chemotherapy to                ship: national health services participating
control major parasitic and infectious diseases           with international donor agencies, non-
in developing, tropical countries are now be-             governmental development organizations
ing supported by the World Bank and exe-                  (NGDO), and major pharmaceutical compa-
cuted by the World Health Organization in                 nies. Most of these programmes are based on
partnership with the Ministries of Health in              the fundamental, ® nal common pathway of
the affected countries. An important feature of           community participation and involvement
this effort is that of public/private partner-            (Katabarwa et al., 1999a).
                                                             One of the most successful of these pro-
  * E-mail: rvbprg@starcom.co.ug; fax: 1 256 41 250376.   grammes is the use of ivermectin (as Mectizan

ISSN 0003-4983 (print) ISSN 1364-8594 (online)/00/050485-11         Ó   2000 Liverpool School of Tropical Medicine
Carfax Publishing
486   KATABARWA ET AL.


donated by Merck & Co., Inc.) to control           personnel, from the government health-care
onchocerciasis, with its associated skin lesions   services, the NGDO concerned and the inter-
and `river blindness’. In Uganda this pro-         national health-care agencies that were pro-
gramme started in 1992, as a co-operative          moting onchocerciasis control, initially took
venture between the Ugandan Ministry of            very little account of the social structures in
Health and three NGDO, namely the River            Ugandan rural communities, or the skills
Blindness Foundation (now the Global 2000          necessary to stimulate the involvement of
River Blindness Program), and, to a lesser         these communities in such a health pro-
extent, the Christoffel Blinden Mission and        gramme. Trained only in `modern’ or `west-
Sight Savers International. Since 1997 the         ern’ health-delivery systems, they were often
efforts of these organizations have received       reluctant to allow community members to
additional support from the World Bank/            make decisions regarding the design and im-
World Health Organization African Pro-             plementation of programmes (Foster, 1987)
gramme for Onchocerciasis Control (APOC),          and, by portraying themselves as being in
which is now active in a number of African         charge, they reduced the capacity of com-
countries where onchocerciasis is endemic, in-     munity members to assume the ownership of
cluding Uganda. The aim of this programme          their programmes or to integrate control mea-
is to control onchocerciasis by means of an-       sures with their day-to-day activities. Some-
nual mass distributions of ivermectin to all       times they would also impose certain demands
communities where human infection with             on community members without considering
Onchocerca volvulus is meso- or hyper-             workable alternatives. It therefore came about
endemic. Since control depends largely on the      that, in many places, the programme, although
ability of ivermectin to reduce and ultimately     being nominally community-based, in fact
to interrupt transmission, by killing mi-          involved little more than a request for `com-
cro® lariae and by interfering with their em-      munity tolerance’ or `community compliance’,
bryonic development, treatment must                with little or no decision-making or responsi-
continue for 10± 15 years or more in order to      bility being devolved onto community mem-
achieve success and eradicate the adult worms.     bers.
                                                      The failure of many community-based
                                                   health programmes to become self-sustaining
   THE EARLY STAGES OF THE                         has also been attributed to the limited knowl-
   IVERMECTIN DISTRIBUTION                         edge of the programme staff, their consultants
PROGRAMME IN UGANDA AND THE                        (whether expatriate or locally trained), and
        MISTAKES MADE                              their donors, concerning the community
                                                   members’ culture. The tendency is to rate the
The original strategy of the programme was to      local culture as irrelevant or backward to the
invoke community participation and to ap-          development process, when compared with
point and train community-based distributors       `western’ knowledge and technology (Mander-
(CBD) to distribute the ivermectin to the          son, 1998). In the absence of any trained
inhabitants of the affected communities. The       anthropological or other experienced social-
`annual treatment objective’ (ATO) was             science expertise, no proper account is taken
de® ned as the treatment of all persons in the     of the depth and validity that existing tra-
community who were eligible to take iver-          ditional systems offer to the structuring of
mectin. A coverage of at least 90% of the          rural communities
ATO within a period or 2 months each year             In many rural communities in Uganda, it
was considered to be the level that would need     was observed that individual CBD were as-
to be achieved if the programme were to be a       signed various duties that occupied much of
success.                                           their time and yet were supposed to be under-
   Unfortunately, as is often the case with        taken on a voluntary basis. Not unnaturally,
such programmes (Stone, 1992), the relevant        such CBD often asked for some remuneration
                                         KINSHIPS AND ONCHOCERCIASIS CONTROL                      487


to compensate for their loss of time. Where the    the ivermectin-distribution programme in
programme refused such remuneration, the           Uganda, which now receives support from
CBD often dropped out of the programme;            APOC, has adopted and implemented the
where the programme did provide remuner-           strategy of `community-directed treatment
ation, the CBD tended to become more ac-           with ivermectin’ (CDTI). This strategy, which
countable to the programme sponsors and staff      is described below, is leading to much higher
than to their own community folk. As a result,     community success rates and is raising good
their performance did not reach, let alone         prospects for continued, long-term, self-
maintain, the expected level.                      sustainment of the programme. In rural Ugan-
   Some communities did indeed appoint their       dan communities the strategy depends greatly
own health workers, one per community or per       on the understanding of the community `kin-
parish, who were paid by the programme             ship and clan system’, which is also described
organizers to carry out the ivermectin distri-     below.
bution. In these circumstances, when external
donor funding ends, as almost inevitably it        The Roles of the National and of the
will, it is likely that the CBD will lose their    District Government Health Services in
bene® ts. They will then stop working, the         the Ugandan CDTI Programmes
programme will collapse and, in all probability,   At the national level, the Ministry of Health is
the blame will be put unjustly upon the com-       responsible for ordering supplies of ivermectin
munity members.                                    (donated free by the Mectizan Donation Pro-
   Where the externally supported, health-care     gramme of Merck & Co., Inc.), for its duty-
programmes lured or even coerced the com-          free importation and for its distribution to the
munity members to provide monetary incen-          districts. Continued support from donors and
tives to the CBD, so as to sustain the activity    government health services at the national and
after the donors have quit, the results have       district levels is essential for the sustainment of
been disastrous. Some sections of the com-         the programme and the community-directed
munity never contributed towards monetary          distribution process.
incentives while enjoying the bene® ts of the         At district level in the CDTI programme,
programmes. On the other hand, those who did       the district health authorities are responsible
contribute often received poor or no services.     for:
In addition, those CBD who received monetary
incentives were usually selected only by certain   (1) initiating the annual mobilization and
sections of the community and hence were not           health education of the communities;
trusted by other sections. Therefore, the con-     (2) training the community-directed distribu-
tribution of monetary incentives to CBD was            tors (CDD), who have been selected by
perceived as a loss by those sections of the           the community members;
community that had not taken part in the           (3) delivering supplies of ivermectin and
selection of the CBD. This state of affairs            other medicaments to ® xed points, from
created mistrust and animosity within the com-         which the communities can collect them;
munity, and resulted in divisions that were        (4) providing advice and support in the man-
very dif® cult to heal and which hampered              agement of any severe adverse reactions
community involvement in the health-care               associated with the ® rst-time therapy of
programme.                                             patients with onchocerciasis;
                                                   (5) collecting reports from the CDD at the
                                                       end of each distribution exercise;
THE     CHANGE TO COMMUNITY-                       (6) analysing data, writing reports and pro-
        DIRECTED TREATMENT WITH                        viding feedback to the communities;
             IVERMECTIN                            (7) accounting for the resources received from
                                                       government or donors; and
Since 1998, and learning from past mistakes,       (8) providing, at appropriate and agreed times
488     KATABARWA ET AL.


      and places, the supporting resources, skills   directed drug distributors (CDD) and treat-
      and services that are absent at the com-       ment centres. Members of the programme
      munity level.                                  staff then tell the selected distributors and
                                                     the community leaders how to store the
                                                     ivermectin safely, how to determine dosage,
Implementing CDTI in the                             how to manage adverse side reactions, how to
Communities and Integrating it with                  keep proper records, and how to prepare
the Community Agenda                                 reports. The communities are then left to
The objective of promoting community direc-          organize their own distribution exercises. In
tion is to render the ivermectin-distribution        Uganda, a community, once prepared in this
programmes capable of being sustained by the         way and allowed to plan and implement its
community members at their level. To put             own CDTI, almost always achieved and sus-
this into effect successfully demands a sound        tained the desired coverage of 90% of the
understanding of the cultural factors that           eligible target population (Katabarwa and
in¯ uence the involvement of community               Mutabazi, 1998).
members in health-care programmes. Account              The approach to the communities targeted
needs to be taken of vital community aspects,        for CDTI starts with meetings in the com-
such as the social structures, legal systems,        munity, to explain the purpose and the strat-
resource mobilization, and sharing systems.          egy of treatment. Success depends on meeting
    The concept of community-directed treat-         with groups of a signi® cant number or a
ment with ivermectin has been developed to           `critical mass’ of community members and
replace the vaguer term: community-based             their leaders, in order to inform them about
treatment programmes. The latter, in the con-        onchocerciasis and its control and the need for
text of Ugandan onchocerciasis control, were         community-directed activities to be adopted.
usually associated with inadequacy or failure.       The CDTI strategy includes the community
The newer, CDTI strategy involves searching          assuming responsibility for the following:
for the correct and appropriate information
that can be used to maximize community               (1) selecting their own CDD, who must be
involvement, both in decision-making and in              members of the community, and having
the assignment of appropriate programme re-              them trained by the district health author-
sponsibilities to community members for the              ities at a time and venue chosen by the
betterment of their own health. The results of           community;
a multi-country study of CDTI for onchocer-          (2) deciding whether the distribution shall be
ciasis control (WHO, 1996) and of the work of            from house to house or from a central site
Katabarwa et al. (1999b) in Uganda have re-              and, if the latter, choosing its location;
vealed that communities are better able to           (3) deciding how many CDD there shall be,
achieve their target coverage when the com-              which sections of the community each
munity members themselves actually make the              shall cover, when the distribution shall
decisions as to how the programme should be              take place, and how the CDD shall be
organized within the community.                          supported;
    The CDTI programme functions in the              (4) assuming responsibilities for collecting
following way. The district health personnel             ivermectin from a central place not very
® rst explain the purpose, principles, and               far from the community;
 bene® ts of the programme to the communities        (5) safely storing a supply of ivermectin for
 by means of participatory health education.             the subsequent treatment of absentees and
 That done, the communities are then empow-              non-eligible individuals (such as the preg-
 ered to make all the local management deci-             nant or sick) who could not take the drug
 sions and carry out the treatment, without              at the time of mass treatment in the com-
 external interference. The community mem-               munity;
 bers ® rst select their own, community-             (6) recognizing the rare severe adverse reac-
                                        KINSHIPS AND ONCHOCERCIASIS CONTROL                   489


    tions and referring individuals suffering         bers whom they were to treat had to be
    from them to local health authorities; and        short, so that the task of distribution
(7) changing the treatment approach if it is          could be ® tted in conveniently with the
    found to be unsuitable after the ® rst            daily chores of the CDD and other com-
    round of treatment.                               munity members.
                                                  (4) When the areas of distribution of iver-
  When attempting to integrate a health-care
                                                      mectin were divided along the lines of
programme into the community, there are
                                                      kinship or of the traditional social-support
certain issues that the organizers of donor-
                                                      groups, known as engozi (Katabarwa,
supported and government-sponsored pro-
                                                      1999), the communities achieved their
grammes, and the health personnel employed
                                                      target coverage and sustained the pro-
by them, must understand if they are to obtain
                                                      gramme from year to year. By contrast,
their desired objectives. Chief among these are
                                                      when they followed the demarcation of
the following:
                                                      communities by local government of® cials
(1) Provision of correct information to com-          using government-determined village
    munity members.                                   boundaries, the result was a failure to
(2) Encouraging the community members to              reach the annual coverage target.
    meet, discuss and take decisions which           These processes allow the community
    affect their performance.                     members to become stakeholders in the CDTI
(3) Understanding the social structures (e.g.     and to see themselves as partners in health-
    kinship/clan groups) and cultural systems     care delivery. The communities investigated
    (e.g. social codes) of the communities        by Katabarwa et al. (1999b) are in four dis-
    which, in turn, involves close contact and    tricts of Uganda: Adjumani, Moyo and Nebbi
    continued dialogue with community             in the north± west and Kisoro in the south±
    members.                                      west. These communities meet when necess-
(4) Prioritization of health needs and inter-     ary to identify their responsibilities, solve
    ventions.                                     problems and take decisions needed to achieve
(5) Obtaining the trust of community mem-         their objectives (Table 1), and they maintain
    bers.                                         and enjoy the bene® ts that accrue from the
  In the Ugandan CDTI programmes, it was          successful implementation of what they can
found that there were several other important     truly come to regard as their own programme.
considerations (Katabarwa and Mutabazi,           The mean coverages achieved by these com-
1998):                                            munities, as proportions of the eligible popu-
                                                  lation, increased signi® cantly when the
(1) Having more than one trained, com-            community-based strategy of ivermectin dis-
    munity-selected CDD/50± 100 persons in-       tribution in 1997 was replaced with a CDTI in
    creased the chance of good integration.       1998 (83.8% v. 93.8%; P 5 0.02).
    This helped the CDD to accomplish their
    duties within an acceptable time, without
    affecting their domestic chores and, at the
    same time, it encouraged delegation of the    THE IMPORTANCE OF THE KINSHIP/
    work.                                         CLAN SYSTEMS IN THE SOCIAL AND
(2) The selection of CDD from within their        CULTURAL STRUCTURES OF RURAL
    kinship/clan groups greatly increased the     UGANDAN COMMUNITIES AND ITS
    acceptability of the health-care pro-         RELATIONSHIP TO HEALTH-CARE
    gramme, as well as facilitating the mobi-              PROGRAMMES
    lization of other group members and
    in¯ uencing their compliance.                 In all rural communities in Uganda, patrilineal
(3) The distance between the homes of the         kinshipÐ the successive links between the
    CDD and those of the community mem-           male parent and his childrenÐ is the most
490    KATABARWA ET AL.


                                              TABLE 1
              Mean treatment coverages in the meso- or hyper-endemic communities of four
              Ugandan districts, using community-based treatments (CBT) in 1997 and
                             community-directed treatments (CDT) in 1998

                                                              Treatment coverage (%)

              District               No. of communities         1997          1998

              Adjumani                       79                  86            97
              Kabale                         26                  89            96
              Kisoro                         31                  84            86
              Nebbi                         637                  76            96
              All four                      773                  83.8          93.8




basic structure organizing individuals into so-      is based on descent from a common ancestor,
cial groups. It is within and through these          the land is generally held collectively. Where
structures that marriage, property, inherit-         family homesteads are scattered, the land be-
ance, and community welfare of the social            longs to individual families, but it can be
system are organized. Community loyalties            subdivided and handed over to sons, especially
still divide along kinship lines, rather than in     after they marry. However, under this tra-
accordance with political or administrative          ditional, family-homestead culture, the right
dictates. The typical kinship group, or clan,        to sell a family’s land to outsiders does not
comprises 50± 100 persons, depending on the          rest solely with the individual owner. The
numbers of wives taken by its male members           other kinsmen may refuse to allow the sale or
and the children produced by these marriages.        demand that they have the ® rst chance to
As kinship groups grow, they may split (along        purchase it before an outsider is allowed to
matrilineal lines in polygamous families, or         buy the land. Thus, in most districts, out-
when brothers separate as a result of disputes       siders do not have easy access to lands already
or in search of more land for their children),       occupied by the kinship group or clans. In
thus forming sub-clans which still maintain          some cases, a father’s gift of land to his
their allegiance to the original family clan in      married son only carries the right to cultivate
the event of any external threat. In the north-      and not the right to sell, and most of the
ern and central districts of Uganda, families        cultivated land is considered as belonging to
tend to be organized into homesteads that are        the clan.
clustered relatively close together (i.e. within a      In rural communities, kinship groups may
radius of 50± 100 m). In the rest of the coun-       also have a much wider array of functions.
try, homesteads are mainly scattered, with the       They often serve as the basic units for pro-
exception of Kabale district, where clustering       duction and distribution of produce, storage of
is observed. In every case, groups of home-          cultural, technical and `magical’ knowledge,
steads tend to belong to close relatives who         religious cults that worship spiritual beings
can trace their descent from one male individ-       (who are themselves considered as members of
ual and who belong to the same clan or               the kinship group), and even political repre-
sub-clan, with the exception of those women          sentation. It is the kinsmen who ensure that
from other clans who have married into these         their elders and the sick are looked after, that
patrilineal families.                                mothers and children are protected and pro-
   In areas where family homesteads are lo-          vided for, and that there is enough labour to
cated in kinship clusters, whose membership          produce food for the community. This `social
                                          KINSHIPS AND ONCHOCERCIASIS CONTROL                     491


safety net’ is admirably exempli® ed by the            Service to one’s own kinship group falls
traditional, social-support systems, known as       under the division-of-labour and distribution-
the engozi in south± western Uganda                 of-wealth functions of the traditional system.
(Katabarwa, 1999).                                  If such service is decided by the traditional
   It follows that, in rural Uganda, a sound        kinship institution, it is given happily without
knowledge of the role of kinship is essential if    question, and without negotiating `incentives’,
one is to understand the social dynamics of         for it is the means of survival of the kinship
any community and the way in which these            members. In contrast, the demanding of mon-
will in¯ uence the acceptability, management,       etary incentives for services rendered to those
sustainability and ultimate success or failure of   outside one’s group is quite in order, and is,
any community-directed, health-care pro-            indeed, encouraged. Interestingly, however,
gramme. To date, rural health programmes            items (such as food, drink, or labour in the
have not taken the kinship issue seriously or       home or on the farm) that are provided in the
even bothered to consider its importance in         course of communal service are considered as
health-care delivery. As a result, it is not        the due rights of anyone who provides this
surprising that community members’ apparent         service. Their role is to reduce pressure on the
`refusal’ to participate fully in these well-in-    individual providing the service, while at the
tended programmes has frustrated both               same time strengthening kinship ties with the
government and donor-supported health pro-          recipient of the service.
grammes. In their frustration, the programme           Avoidance of kinship duties, or refusal to
personnel usually give up truly meaningful          recognize kinship-authority institutions, is a
attempts to involve the community. Instead,         serious offence, with dire, even draconian,
they `hire’ one or two community members            consequences. For example, if a member of
and pay them to accomplish the necessary            the engozi social-support system does not re-
tasks. As a short-term remedy, this may well        spond when requested to carry a patient to
provide donors with quick results, but it is a      hospital, he could face a ® ne equivalent to
policy that is incompatible with long-term          U.S.$5.00 or 20 litres of local beer. If he failed
sustainability of the health interventions.         to pay this ® ne, it would be increased after 1
                                                    day to U.S.$20.00. If he still refused to pay,
                                                    he and his family would face the wrath of his
                                                    kinsmen, and could be denied communal
THE IMPORTANCE OF SOCIAL LEGAL                      labour in their ® elds or even be banished from
           SYSTEMS                                  the community.
                                                       Women who marry into or belong to a
In the rural Ugandan communities there are          kinship group are required to care for the
two legal systems. There is the common law,         children of other mothers who are sick, tend
which was established ® rst by the colonial         their crops, prepare food for the sick, and to
government and is now enforced by the local-        provide food at burial ceremonies. Any
government structures. The common law ap-           woman refusing to perform these duties with-
plies to everyone in the community. The             out good reason would be branded a witch and
second system is the traditional legal system,      thus, according to traditional belief, as a per-
enforced by clans and kinship groups. These         son who will bring bad omen and death to her
traditional systems have ensured the survival       kinship group or clan. The consequences of
of the communities throughout the centuries         this are dire. She might no longer bene® t from
and retain a great in¯ uence in society. Their      community labour in her ® elds, or she might
codes govern, among other things, gover-            be denied carriage to hospital if she fell sick.
nance, resolution of con¯ ict, the acquisition      The other womenfolk might withdraw their
and distribution of wealth and land, distri-        emotional support from her, and the resultant
bution of labour, care of the sick and children,    loss of face may even lead her husband to
and choice of marriage partners.                    marry another woman.
492    KATABARWA ET AL.


KINSHIP FACTORS IN COMMUNITY-                         a result of the cost associated with its distri-
DIRECTED    TREATMENT   WITH                          bution.
          IVERMECTIN                                     Another reason why community members
                                                      refuse to pay monetary incentives to externally
Incentives                                            appointed CBD lies in a cultural phenomenon
In Uganda, the mean per-capita income is less         in rural Uganda, known as the levelling mech-
than U.S.$200/year and the per-capita                 anism. Basically this means that when a mem-
government allocation to health services is           ber of a kinship or a clan acquires wealth, he
, U.S.$10/year (Anon., 1999). Disease pre-            is expected to share it with his kinsmen for the
 vention and control is costly and can only be        greater good of them all. On this basis, the
 afforded if everyone in each community col-          kinship members would steadfastly refuse to
 laborates and contributes, not only to the costs     pay any monetary incentives to a CBD who
 of the user fees in government- or missionary-       was not a member of their clan, for any money
 sponsored clinics, but also towards the intra-       that he received, whether from them or from
 community        management         of    control    the promoters of the programme, would be
 programmes, such as CDTI. Although iver-             lost to the kinship and/or clan. In contrast,
 mectin is provided free of charge to the Ugan-       when a CDD was a member of the clan, he
 dan onchocerciasis-control programme, its            would be bound to serve the clan free of
 distribution costs (transport, `per diems’ for       charge, but all would understand that, if the
 staff, time spent and labour lost in childcare       CDD did receive any money from the external
 and the gardens etc) can only be affordable by       programme organizers, it (at least in part)
 these generally poor communities through uti-        would eventually `trickle down’ from the
 lization of the kinship system. Utilization of       CDD, under the levelling mechanism, to the
 the kinship/clan system, and its associated          general bene® t of his kinship/clan.
 traditional laws, greatly facilitates mobilization
 of the communities for resource sharing in the       Acceptance of Tablets from Kinsmen
 course of the control programme.                     The fear of witchcraft or poison being admin-
    Katabarwa et al. (1999b) observed that the        istered along with the medicine that is being
 members of those communities with success-           handed out by an outsider is often suf® cient
 ful CDTI programmes (that achieved and sus-          grounds for refusing to take the ivermectin
 tained their annual target coverage) had             that is being offered. As one woman in Kisoro
 usually selected their kinsmen as CDD for            district put it: `Suppose they put something
 distributing the ivermectin. Those communi-          harmful in this medicine. I can’t give a chance
 ties that relied upon externally appointed           to the devil where my life and those of my
 CBD (i.e. CBD who are not relatives of the           family members are involved. I will only get
 community members) generally failed to meet          medicine from the community members I
 the desired treatment coverage. In most com-         know and trust’. She trusts mainly those re-
 munities, externally appointed CBD could,            lated to her in the community and her hus-
 with impunity, demand monetary or other              band; that is the `world’ she knows and
 material incentives (e.g. umbrellas, boots, T-       understands. Traditional clan or kinship-
 shirts, coats, bags etc) from all those who were     group leaders, or the leaders of local engozi
 not their kith and kin, and they would often         systems, are usually able to sort out such
 withhold their services if these were not forth-     problems among their followers and persuade
 coming. The CBD were not constrained by              them to accept the tablets. They are also of
 the social code that governs the behaviour of        great help in identifying patients with severe
 kinsmen, and once monetary incentives were           adverse reactions to ivermectin, counselling
 given, the demand for more was triggered,            them and the community about why the side-
 and a cycle of alienation of the community           effects have occurred, and helping those affec-
 from the programme continued until treat-            ted to reach health centres, when necessary. In
 ment with the `free medicine’ was withheld as        this way, the traditional system prevents the
                                         KINSHIPS AND ONCHOCERCIASIS CONTROL                  493


rare adverse effects of treatment from escalat-    level interfered with community decision-
ing into a general rejection of the treatment      making, such as the selection of CDD and
programme.                                         treatment centres, this coverage was never
                                                   achieved.
Role of Gender
Dif® culties based on the gender of the CBD        THOSE WITH MORE THAN ONE CLAN, EACH
also arise when treatment is being offered         OCCUPYING A SPECIFIC AREA (60%)
across kinship or clan boundaries. CBD were        In this category, community members had to
seen as potential sexual partners for any adult    be correctly assembled within clan-speci® c ar-
person of the opposite sex in another kinship      eas. Clans were then empowered to select
group or clan, especially when house-to-house      their distributors and treatment centres, con-
distribution was the mode of ivermectin distri-    veniently and appropriately located according
bution. If male, their presence in the home-       to clans. When this approach was successfully
stead was not welcomed by the males of the         executed, communities achieved their target of
group visited; if female, their presence was       90% coverage. When programme staff inter-
resented by the females. In either case, the net   fered with these decisions, or did not mobilize
result was often a drop in treatment coverage,     a suf® cient number of speci® c clan members
and a feeling that the distribution programme      to attend and make decisions, the distribution
was intrusive or threatening.                      was beset by mistrust, accusations and coun-
   Although relatively few women have been         ter-accusations, and the target coverage was
involved in ivermectin distribution, they have     never reached.
been keenly interested in having access to
information on the programme, and in being         THOSE WHERE INDIVIDUAL HOUSEHOLDS FROM
involved in the decision-making processes.         MANY DIFFERENT CLANS, OR EVEN FROM DIF-
Within their kinship groups, women are im-         FERENT TRIBES, RESIDE IN ONE COMMUNITY
portant opinion leaders, and their ideas are       (3%)
equally respected by their men folk. Thus,         These communities were usually of the semi-
support of the programme by women has been         urban type. Since onchocerciasis is primarily a
essential, even though women have not often        rural disease, experience with applying CDTI
been physically involved in distribution of the    in a semi-urban environment is limited. In
ivermectin. Women usually attend health-           semi-urban communities one ® nds a mixture
education meetings with community mem-             of families from different clans and tribes,
bers, and are often very active participants.      displaced from their villages, and no longer
Most comments and questions during such            necessarily linked to land ownership. Close
meetings come from women, and often                proximity and lack of known kinship lines
women will boo and stop drunken or stubborn        leads to mistrust. As Katabarwa et al. (1999b)
men from talking nonsense.                         reported, mobilization of the population in
                                                   such communities was much more dif® cult
Effects of Migration and Urbanization              and cumbersome than in rural communities
During distribution of ivermectin in 1998 and      (Table 2). In 1998, rural communities
1999 to a total of 1730 communities, three         achieved a mean coverage of 87.8% for the
categories of community were observed.             eligible population whereas the semi-urban
                                                   communities       achieved      only    63.3%
THOSE WHERE ONLY ONE CLAN DOMINATES                (P 5 0.049). Similarly, during 1999, rural
(37%)                                              communities treated 94.3% of the eligible
In this category, when the CDTI approach           population whereas the semi-urban communi-
was used and the dominant clan was engaged         ties treated only 71.0% (P 5 0.028). More
in the process, 90% coverage of the treat-         health-education sessions and visuals (poster
ment-eligible population was achieved. How-        and pamphlets), more video shows, radio jin-
ever, when programme staff from the district       gles and other activities were required to mo-
494   KATABARWA ET AL.


                                            TABLE 2
                Mean, community-directed treatment coverages in the meso- or hyper-
                          endemic communities of four Ugandan districts

                                              Treatment coverage (%)

                                 Semi-urban communities     Rural communities (%)

                District            1997          1998        1997         1998

                Adjumani             67            70          98           93
                Kabale               69            67          83           93
                Kisoro               42            59          85           95
                Nebbi                75            88          85           96
                All four             63.3          71.0        87.8         94.3



tivate the semi-urban communities. The more         mectin treatments carried out are to achieve
complex lifestyles and time-demands on famil-       their target coverage and become self-
ies in the urban environment made it more           sustaining, they need to be based on com-
dif® cult to bring together a suf® cient number     munity-directed distribution. Such distri-
of community members to make the meaning-           bution, if it is to succeed, must make full use
ful decisions needed to implement a CDTI            of the existing local kinship/clan system.
programme. It was clear that, although neigh-       Similar social systems exist in other African
bourliness and kinship/clan systems were de-        countries and their recruitment into the iver-
termining factors in implementing satisfactory      mectin distribution process is likely to be
ivermectin distribution, the degree of these        critical for success.
qualities as `natural resources’ in semi-urban         In Uganda, it becomes more dif® cult to
communities was very varied.                        achieve satisfactory ivermectin distribution
   The dif® culties in establishing effective       coverage in communities that are becoming
CDTI in semi-urban and urban environments           semi-urbanized, which contain many migrant
are to some extent counteracted by the fact         families, and in which the kinship/clan system
that onchocerciasis usually becomes less en-        is much less strong. This weakening of the
demic as communities enlarge and become             kinship/clan system may become an increas-
more urbanized. As human population densi-          ing problem for community-directed health
ties increase, pollution of local Simulium          programmes aiming to control diseases that,
breeding sites also increases, and there is a       unlike onchocerciasis, thrive in an urban or
consequent reduction in man± ¯ y contact.           semi-urban environment.
However, good penetration of semi-urban                Most health interventionists concerned with
communities is vital to the success of control      enlisting human behaviour and social struc-
programmes for other diseases, such as tu-          ture in the battle against infectious diseases
berculosis and lymphatic ® lariasis, which are      have con® ned themselves to studies of the
transmitted in urban environments and which         `knowledge, attitudes and perception’ (KAP)
also require community direction and owner-         of community members. These KAP studies
ship.                                               aim to identify `false beliefs’, and then provide
                                                    a guide to the best approach to replacing them
              CONCLUSIONS                           with `accurate knowledge’ (Manderson, 1998).
                                                    The attitude of the interventionist tends to be
In rural Ugandan communities where                  that of a saviour of the people, whose mission
onchocerciasis is endemic, if the annual iver-      is to rid them of a `backward’ culture that
                                             KINSHIPS AND ONCHOCERCIASIS CONTROL                       495


promotes disease. Experience in Uganda, on             whether the bonds of friendship and neigh-
the other hand, shows that these so-called             bourliness can replace this, are factors that
`backward’ social and cultural systems are im-         have yet to be studied. The optimal manage-
portant `natural resources’, that can and              ment of disease-control programmes in these
should act as a powerful motivational force for        new environments may depend upon the out-
the prevention and control of disease (and             come of these future investigations.
indeed for the general advancement of the
communities).
   Increasingly more and more people are mi-           ACKNOWLEDGEMENTS .      We are grateful to the
grating from their present rural Ugandan               community members and health workers who
communities towards larger towns or other              willingly provided the vital information for
areas, in search of new opportunities and for-         this study. We are also indebted to Carter
tune. In the process they become separated             Center, Global 2000, APOC and the Ugandan
from their kinship groups. At the same time            Ministry of Health, for ® nancial contributions,
the rural communities are gradually changing           expertise and their promotion of community-
and becoming `modernised’. The effects of              directed treatment programmes for the control
these changes on the kinship system, and               of onchocerciasis in Uganda.


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