Mwembeni and Jaira villages, Pangani district

Mwembeni village is about 8 km from Pangani town and lies on the main road that links Muheza town to the coast. It is one of three villages that form part of Madanga ward, and one of eight villages that form part of Madanga division. According to census data published in 2006, 1126 people live in Mwembeni. The village is divided into four sub-divisions: Mzia, Mwembeni, Makuyuni and Nunda. It is socially diverse, with Christians (Protestant and Catholic) and Muslims (Sunni and Shia) living side-by-side. The Christians are predominantly Makonde, and the Muslims are predominantly Zigua and Zaramo. There is inter-marriage between these groups, although tensions exist between Muslim groups (focused in particular on rival imams) as well as between Muslim and Christian groups. It is not unusual for Muslims to talk about the Makonde as migrants or ‘refugees’ from Mozambique, in spite of the fact that they have lived in the village for two and even three generations. Many of their homes are located at some distance from the village centres, in some cases in remote places. Mwembeni village has one primary school and one small madrasa (Islamic school). It also has several mosques and churches (both of the most basic variety). A small number of people have access to piped water from a tap every other day, and there are ten households with access to electricity, two of whom have a satellite dish. Broadly similar characteristics apply to Jaira village, which lies a few kilometres north of Mwembeni. According to Ministry of Health data collected in 2004, an estimated 539 people live in this village.

The majority of adults in Jaira and Mwembeni own or rent plots of land that they cultivate. Others are employed on a temporary basis as farm labourers. A diverse array of crops are grown including cassava, maize and rice. Coconut, orange, mango and banana trees are grown too, though most people do not have access to all these types of fruit trees. A small number of people fish for prawns in the river, and these are mainly sold in Pangani town. It is important to note that very few people have regular, salaried work. Historically, the large-scale production of sisal at nearby estates was an important source of regular employment, and explains the presence of so many Makonde. However, decline in the global demand for sisal has led to a decline in production and the laying off of staff. As part of the surveys on drug uptake discussed below, adults living in Mwembeni and Jaira were asked what they considered to be the most serious problems facing them: 58% mentioned unemployment and 26% mentioned inadequate health facilities.

Kigombe and surrounding villages, Muheza district

Kigombe is a small town that lies on the coastal road linking the town of Tanga to the town of Pangani. Although it is geographically much closer to Pangani, it is actually part of Muheza district. It takes around two hours to drive to the district capital. Access to the sea provides fishing opportunities to those with access to nets and boats, but the majority of people rely upon the cultivation of cassava, maize and rice to survive, just as they do in Mwembeni. Fifty-three per cent of surveyed adults highlighted unemployment as the most serious problem they faced compared with 31% who mentioned inadequate health facilities. There are several schools in Kigombe, including a madrasa, and there are also several mosques and a government dispensary. The population is mostly Muslim, but in common with Mwembeni, there is a Christian minority, generally living a little further inland at the edges of the sisal fields. Also like Mwembeni, there are divisions among the Muslims, but of a more intense nature. ‘Radical’ Islam has a presence (with some openly sympathetic to Al Qaida in 2007). There are also divisions between more orthodox Sunni Muslims and Muslims who are members of the Sudanese Ansar sect. In contrast to Mwembeni, Kigombe is characterized by the amplified call to prayer from rival mosques at night time. Other divisions relate to political activism, with the local chairman being a member of Civic United Front (CUF), a political party opposing the government.

Local ideas about illness and misfortune

Before addressing the specific issue of drug uptake for the treatment and prevention of lymphatic filariasis, it is helpful to note that the study populations were found to draw upon a broad range of ideas to understand illness and misfortune. Interpersonal and spiritual aspects of well-being are often used to interrogate biomedical understandings, with many kinds of illness being discussed in relation to the Swahili word uchawi. The term uchawi may be translated as ‘witchcraft’, but it does not necessarily have the same connotations as the English word. The majority of people interviewed in depth talked about uchawi as being a constant threat, and many were surprisingly open about the specific individuals who they suspected were most likely to use it. Even in the semi-structured interviews, which were inevitably less probing, large numbers of people stated that uchawi presented a problem. Those thought to be responsible are mostly local healers or Christian migrants.

Notions about interpersonal and spiritual causes of affliction are also connected with beliefs about and experiences of spirit possession. Those local healers with high status were all found to be members of Swahili possession cults. In common with Giles (Reference Giles1987, Reference Giles, Behrend and Luig1999), it became apparent that, unlike most possession cults in other parts of Africa, these cults are closely connected with local hierarchies, and are expensive to join. Possession is viewed as something dangerous and frightening, but paradoxically, also carries high status and the possession cults operate as a parallel means of interpreting the spirit world to that of Islam. Indeed some of the practices observed were strikingly un-Islamic (such as the ritual drinking of sheep blood). To the authors' knowledge, no Christians were directly involved in these cults. It is also important to note that considerable emphasis was placed on the training of healers at public séances. For example, more than a dozen healers were present at a ritual that went on for several days at one of the villages of Kigombe and half a day was allocated to discussions between healers attending the ritual and those who had become new members of the cult and would in the future be acting themselves as healers. Emphasis was placed on the appropriate relationships they should have with their patients, implicitly contrasting them with the kinds of treatment expected at clinics. Their treatments involved a combination of local remedies, concocted from locally available substances, with spiritual and moral interpretations of affliction. The findings of respected healers carried weight, and were not necessarily complementary with biomedical interpretations and treatments, including those for lymphatic filariasis.

Uptake of drugs at villages in Pangani and Muheza districts, 2004–2007

By July 2007, three rounds of treatment had been distributed, free of charge, over a four-year period for lymphatic filariasis. These took place in 2004, 2006 and 2007. In both districts, registers were distributed by staff from the Ministry of Health to village-based drug distributors prior to the first round of treatment in 2004. This enabled a detailed record to be made of the names and ages of people living in each household with a view to keeping a year-on-year record of the proportion of adults and children receiving drugs for the treatment and prevention of lymphatic filariasis.

In Mwembeni village, distributors were found to have kept meticulous records of the number of adults and children aged five and above who took the drugs for lymphatic filariasis. According to these registers, 59% of adults and children eligible for treatment received the drugs in 2004; whereas 46% of them received treatment in 2006 and 34% received treatment in 2007. In short, the registers suggested there had been a decline in the uptake of drugs. Data derived by selecting a 20% random sample of households and then interviewing one adult from each selected household also indicated a decline. That is, 71% of adults interviewed in Mwembeni said that they received treatment in 2004; whereas 49% received treatment in 2006 and 35% received treatment in 2007. These data are presented in Table 1.

Table 1. Uptake of drugs for the treatment and prevention of lymphatic filariasis among adults in Pangani district, Tanga region, 2004–2007

^a In Mwembeni village, the total number of people listed in the drug distributors’ registers that were eligible for treatment was 345 in 2004, 869 in 2006 and 901 in 2007. The fact that fewer people appeared to be eligible for treatment in 2004 can almost certainly be attributed to the fact that some of the registers had been lost.

^b In Jaira village, the total number of people listed in the drug distributors’ registers that were eligible for treatment was 475 in 2004, 386 in 2006 and 386 in 2007. The fact that fewer people appeared to be eligible for treatment in 2006 and 2007, compared with 2004, is probably attributable to the fact that some of the registers had been lost.

The table also shows that very similar findings were recorded in neighbouring Jaira village. The Jaira registers suggested that 55% received treatment in 2004; 43% received treatment in 2006 and 42% received treatment in 2007. In common with Mwembeni, a 20% random sample of households was taken from the 2004 Ministry of Health drug distribution registers. One adult was interviewed from each selected household, and data emerging from these interviews also conveyed a decline in the uptake of drugs. That is, 56% adults received treatment in 2004, 50% received treatment in 2006 and 38% received treatment in 2007.

Ministry of Health registers documenting the uptake of drugs in Kigombe and surrounding villages could not be located. However, data collected in the course of undertaking semi-structured interviews suggested a downward trend. Table 2 shows that 47% of those interviewed in Kigombe said they received treatment in 2004, 45% received treatment in 2006 and 22% received treatment in 2007. A different picture emerged in the northern part of Muheza district. In the village of Bwembwera, interviews indicated that 47% received treatment in 2004, 69% received treatment in 2006 and 65% received treatment in 2007; whereas in Magila, 40% received treatment in 2004, 43% received treatment in 2006 and 70% received treatment in 2007.

Table 2. Self-reported drug uptake for the treatment and prevention of lymphatic filariasis among adults in Muheza district, Tanga region, 2004–2007

^a Kigombe includes Kigombe East and Kigombe West. Kigombe East includes the sub-villages of Sinawe, Gawani and Jitingeni and Kigombe West includes the sub-villages of Ndone and Mchangani.

Uptake of drugs among adults in Pangani and Muheza districts, 2008–2010

In July–August 2011, 118 semi-structured interviews were undertaken with a random sample of adults in Mwembeni, Pangani district, to assess the proportion of adults that had received ivermectin and albendazole for the treatment and prevention of lymphatic filariasis since 2007. As indicated in Table 3, the self-reported uptake of drugs was below 50% for the period 2008 to 2010. A brief follow-up survey was also carried out in Jaira village. Taking a sample of randomly selected households near the trading centre, seventeen adults were interviewed, with 70% of them stating they had received the tablets. Follow-up research was also undertaken in Kigombe town and surrounding villages during this time. One hundred and forty-four semi-structured interviews were undertaken and Table 3 shows that the self-reported uptake of drugs remained below 50% from 2008 to 2010.

Table 3. Self-reported drug uptake for the treatment and prevention of lymphatic filariasis among adults in Mwembeni, Pangani district, and Kigombe, Muheza district, 2008–2010

Official district statistics on the uptake of drugs in Pangani and Muheza districts, 2004–2010

Official statistics submitted to the Ministry of Health from Pangani district differ from the information recorded in the Ministry of Health village drug distribution registers. That is, the overall uptake of drugs for lymphatic filariasis among adults and children more than five years old was reported to be 67.6% in 2004, 78% in 2006, 76.5% in 2007 and 75.2% in 2010. Aware of the possibility that these aggregate figures may reflect much higher levels of drug uptake in other parts of the district, a decision was made in 2007 to go through all the available official village-based, drug distribution registers for Pangani district in order to double-check the accuracy of the official figures. In addition to the registers for Mwembeni and Jaira, registers were found for six of the 33 villages that constitute Pangani district. These villages were: Barabani, Chakaloboko, Mahakamani, Boza, Kimanga and Msaraza Bushiri. Not all registers for these villages were found to be complete for all three recorded rounds of drug distribution, but according to the registers available, drug uptake fell short of the sustained high coverage levels that are required to eliminate lymphatic filariasis. To be more specific, the uptake of drugs among the 4755 adults and children listed in the available registers as eligible for treatment in 2004 ranged from 49% in one village to 93% in another village, and the average uptake for all eight villages was 65%. However, the uptake of drugs declined in all villages except one in 2006. That is, uptake ranged from 81% to 35%, and the average uptake among the 7823 adults and children listed as being eligible for treatment was 46%. In 2007, there were further declines in the majority of villages. Uptake ranged from 81% in one village to 7% in another village and the average uptake was 34% among the 6436 adults and children listed as being eligible for treatment.

The average figure for 2004 was thus very similar to that in the officially submitted report, but the high drug uptake reported in 2006 and 2007 in the official records submitted to the Ministry of Health did not correspond with the drug uptake data recorded in the village registers. While it is possible that the uptake of drugs is higher in other parts of Pangani district, this is an unlikely scenario. Many of the villages for whom drug distribution registers could not be found were located south of Pangani town. This part of the district is often inaccessible to district staff as it involves crossing the Pangani River by a ferry that is prone to mechanical breakdowns. Technical difficulties aside, budgetary constraints at district headquarters restrict the frequency with which staff can visit villages and facilitate the distribution of drugs – not least because many of the villages are located a considerable distance south of the river. As a result, difficulties go unnoticed and tend to increase, rather than decrease, over time. (These difficulties are discussed further on in this article.)

It was much harder to elicit comparable data about the uptake of drugs in Muheza district. In 2007 and 2011, considerable efforts were made to talk to district officials in Muheza as well as associated officials at a ward, village and sub-village level, but no Ministry of Health registers could be located in 2007, and only a small number could be located in 2011. In addition, it was difficult to make much sense of the information presented in the registers that could be located as they only provided a list of the names of people that had received treatment in 2010. In other words, in common with the registers located in Mwembeni in 2011, it was not possible to use the information to assess the proportion of people in any one village that had received treatment.

Nevertheless, summary statistics compiled at a district level (and subsequently presented as part of a regional report submitted to the Ministry of Health in Dar es Salaam in 2009), recorded an uptake of drugs in the district of 81% in 2006, 76% in 2007 and 81% in 2008. The neglected tropical diseases co-ordinator for Muheza district also reported coverage of 83% in 2009 and 83% in 2010 – whilst acknowledging that the uptake of drugs was less in Kigombe as official returns suggested an uptake of 69% in 2009 and 65% in 2010 (personal communication, August 2011). While these figures are lower than the 100% uptake reported to the research team by a district official in Muheza in July 2007, they are still much higher than those recorded in the course of interviewing randomly selected adults at selected villages in Muheza district.

Assessing the accuracy of data recording the uptake of drugs

Discrepancies between the figures derived from semi-structured interviews, the official district figures, and the figures in the village-based registers raise important questions about the relative merits of the methods employed to elicit information on drug uptake. With respect to data arising from semi-structured interviews, is it really possible for large numbers of adults to accurately remember whether or not they have received a particular combination of drugs over an extended period of time? Is it possible that some informants muddle up the years that they received them and the years that they did not? Is it appropriate to assume that informants receiving drugs during MDA actually swallowed them? Whatever is done to alleviate anxieties and ensure that those being interviewed recount events as accurately as possible, is it possible for informants to try and second-guess the ‘correct’ answer to be polite or to just make the researchers leave them alone?

Identical questions emerged whilst undertaking research on social responses to MDA for the treatment of schistosomiasis and soil-transmitted helminths in northern and south-eastern Uganda (Parker et al., Reference Parker, Allen and Hastings2008, Reference Parker, Allen, Pearson, Peach, Flynn and Rees2012; Parker & Allen, Reference Parker and Allen2011). Here it was found that those interviewed clearly recalled treatment, partly because praziquantel tablets, which are used to treat schistosomiasis, are unusually large, pungent and unpalatable. In addition, the free distribution of biomedical drugs to treat adults is a rarity and not something easily forgotten. Indeed, it is widely commented on and the issue is less whether or not people remember, and more whether or not they are willing to say what happened to the drugs once they had received them. In some cases it became clear that instead of swallowing them immediately, they had kept all or some of their dose for future use if they felt ill, or to give to relatives and friends.

The situation was found to be slightly different with respect to MDA for lymphatic filariasis in coastal Tanzania, not least because the drug, ivermectin, is small, easy to swallow and does not have an unpleasant smell. Albendazole is equally straightforward to consume. Nevertheless, few people struggled to recall whether or not they had received free treatment – partly because it was so unusual to offer free medicines to adults and partly because it was considered to be very strange indeed to ask all adults to swallow medication, irrespective of whether or not they felt ill. In fact, the vast majority of people interviewed were remarkably forthcoming about their reasons for accepting or rejecting treatment and, more often than not, they asked pertinent questions about the rationale for the control programme that shed further light on why, for example, some people accepted treatment in the early years of the programme and subsequently declined treatment; while others declined treatment but subsequently accepted treatment for one or two years, before deciding to reject treatment again.

In general, data recording the uptake of drugs from semi-structured interviews undertaken at randomly selected households are, in most cases, likely to more accurately convey the proportion of adults that received the tablets than the data embedded in the official Ministry of Health registers by village-based drug distributors. There are several reasons for this. First, villages can be quite dispersed and drug distributors were sometimes found to be unaware of all people living in the village. Second, social divisions within a village can often affect the kind of people recorded. In Mwembeni, for example, the long-standing differences between Muslims and Christians were found to have influenced the number of people registered. Some of the resident Christian Makonde were dismissed as ‘refugees’, or even ‘not real people’. Third, short-cuts are often taken in the time-consuming job of handing out tablets. Close discussion with the distributors and people receiving drugs revealed that the protocol of observing consumption was often not followed. In several instances, it was found to have been largely set aside, in a similar manner to the practice noted above with respect to praziquantel distribution in Uganda. As a result, it is not known if those who are recorded as having taken the drugs have actually swallowed them. Thus, drug uptake data in the village-based distribution registers may overestimate, rather than underestimate, actual consumption.

This is not to suggest that the data in the Ministry of Health registers are always inaccurate. On the contrary, some drug distributors went to great lengths to carefully record the names, ages and sex of the people they gave drugs to. However, the consistency of registration between distributors was found to vary; and it was often impossible to judge the quality of the recorded data without checking them. In most cases, they provided, at best, a partial picture of the proportion of people in a specific geographical area that had received treatment.

A more worrying issue is that the summary statistics compiled at a district level on drug uptake suggest much higher levels of drug uptake than data eliciting drug uptake among adults in the course of interviews. While the latter data only refer to adults, it is likely that they provide a useful proxy of the extent to which MDA programmes reach adults and children at the selected study sites. The reasons are straightforward: mass treatment occurs through village drug distributors, rather than school teachers; and if adults are willing to receive (and possibly consume) tablets for themselves, then they are almost always willing to receive tablets for their children. Similarly, if they reject medication for themselves, then they are likely to reject treatment for their children. It is also worth noting that in those instances in 2004 and 2005 when village drug distributors recorded the numbers of people living in a village on a household-by-household basis in the Ministry of Health registers and whether or not each person had received drugs, there was a similar discrepancy – with drug uptake being much lower in the registers than the aggregate figures recorded at a district level. Senior district officials, when asked to comment on the discrepancies, were quick to set aside the higher figures. One of them disarmingly observed: ‘people are just sitting down and cooking the numbers’. He went on to express frustration with the treatment programme by saying ‘this programme has no legs’. This was a literal reference to the shortage of fuel and other resources enabling staff to spend the requisite time in villages explaining the rationale for mass treatment. He was, in short, not surprised by the lower drug uptake figures emerging from field-based research. This view was shared by others working at district headquarters. In short, there is no doubt that the uptake of drugs is low at the selected study sites (and rates of take-up in other highly endemic coastal villages in Pangani and Muheze districts are likely to be similar). Why is this the case?

Fear of treatment

Mass drug administration for mabusha and matende generated anxiety and scepticism among the majority of adults, with informants questioning the motives behind the free distribution of drugs by the Tanzanian government and international agencies. A young man from Jaira, for example, said: ‘There is something strange going on. If the government want to help us, they should distribute malaria drugs for free, not matende and mabusha.’ Similarly, a 40-year-old man from Mwembeni commented that, ‘there is no sign [on the drug] that it is for mabusha or matende … you have to trust in the government to swallow the tablets … trust matters a lot. If you don't trust them, you can't swallow the drug … the programme doesn't come with enough knowledge.’ Meanwhile, in Kigombe, a man in his 50s justified not taking the tablets in the following way: ‘In this village we cry for water … they haven't brought water for free, but they've brought drugs for free. Why? These free drugs have to be for an experiment … that is why I reject them.’ These kinds of comments were typical in locations with low drug uptake and highlight the fact that the rationale for distributing tablets for mabusha and matende, free of charge, was poorly understood. Acutely aware that clinic-based biomedical practitioners tend to diagnose infections before administering drugs, and confused why such an approach was deemed unnecessary by the Tanzanian government in this case, rumours circulated about the ‘real’ intentions behind the free distribution.

A very prevalent concern was the idea that the drugs had been designed to reduce population growth. As one man in Kigombe put it: ‘they are lying about this drug. It is not for mabusha or matende … [it is] a family controlling pill …’. Younger men discussing this issue tended to emphasize the idea that the tablets reduced their sexual energy. For example, at a village meeting in Mwembeni, a young man summarized the views of others when he said, ‘They are afraid … they say if you are infected [and you] take the drug then your penis will never erect again.’ It was a view echoed at a comparable group discussion at Kigombe, where a man in his mid-30s proclaimed that ‘[People from the] rich countries send us this drug to reduce our malehood energy and to make us infertile, because the wazungu (white people) were fed up giving us help every day.’ For others, the focus was more on the way the tablets might be intended to prevent conception, a view that was probably supported by the reluctance of some drug distributors to give the tablets to women who said they were pregnant. For example, a man in his 60s living in Mwembeni commenting on local views said, ‘They say if you take the drug, you will never give birth … they believe the government has failed to convince them to enter into family planning.’ Women were particularly likely to say something comparable. Thus, a young woman from Kigombe commented that, ‘These drugs are coming from Europe. We know women in Europe have two children and their intention is to make Africans like Europeans. They think we can't manage so many children, that we can't provide proper education, health care and home environment.’

Concerns about infertility were also connected with the experiences of some of those who had swallowed the drugs. There was considerable discussion about side-effects. A man in his 30s from Mwembeni, for example, described how he took the tablets in 2006 and experienced a strong fever with rashes. He went on to say that he did not take the drug again as he feared the side-effects. Others expressed concern that the drugs exacerbated existing symptoms, and even infected people with mabusha and matende. A woman from Kigombe, for example, said that she did not take the drugs in 2004 as she was pregnant. She subsequently rejected treatment in 2006 and 2007 as she had ‘… seen people infected by those drugs in 2004 … there were some who got body pain and fever. If I took those drugs, I would be infected too …’. In a similar vein, an elderly woman from Mwembeni said: ‘They were afraid that if they took the tablets the busha would get bigger,’ and a man from Kigombe said: ‘They are afraid that if they take the drug they will get matende or mabusha …’. There were, in addition, stories that were even more alarming. A young man from Mwembeni, for example, said: ‘they fear the drugs will kill them …’. He was not the only one to mention this. He went on to explain that, ‘most people do not receive reliable information and knowledge about the drugs.’

These last remarks relate to prevalent doubts about drug efficacy. This is hardly surprising as few, if any, people were aware that it was possible to be infected and asymptomatic and almost all of those with mabusha and/or matende complained that the drugs were not making much or any difference. For example, a man in his 60s from Kigombe had lived with mabusha since his mid-40s and took the treatment in 2004, 2006 and 2007, but declined free treatment in subsequent distributions. He explained that, ‘The drugs make no difference … the weight of my testicles disturbs me.’ His experience was shared by a younger man who had accepted treatment in 2004, but subsequently refused it. He complained: ‘I have hernia and mabusha. When they announced the treatment, they said it would cure me. I took it, but it didn't work. So why take it again? Some other people I know took the drug and then got mabusha, so they didn't take it again either.’ These perspectives were widely shared. A woman in her 30s with matende who had also taken the drugs only once summed up attitudes when she said: ‘We are getting no relief from the medicine … the drugs are not working.’

Divergence between biomedical understandings of lymphatic filariasis and local understandings of mabusha and matende

Widespread fears, anxieties and rumours emerge, in part, from villagers making their own empirical observations about the side-effects associated with treatment and the limited visible efficacy of the drugs. They also draw attention to the disjuncture between biomedical understandings and responses to lymphatic filariasis and local understandings and responses to mabusha and matende, which are perceived locally as entirely separate afflictions. To quote a local healer (mganga) from Pangani: ‘Some people have both mabusha and matende … but they don't come simultaneously. The fact that mabusha can be operated on and matende cannot be operated on, proves that they are different diseases …’.

The majority of people do not attribute a single cause to either mabusha or matende. Indeed, it is not unusual for three or four causes to be mentioned, and for each to be accorded equal weight. This sub-section discusses local understandings and responses to mabusha and matende. In so doing, it becomes apparent that these locally recognized afflictions are understood in a context where virtually everyone, including health care workers at government dispensaries and health centres, draws upon a pluralistic approach to diagnosis and treatment to understand sickness and misfortune.

It is also worth noting that discussions about mabusha, and to a lesser extent matende, can be infused with moral overtones, with spirit mediums sometimes threatening those who are thought to be behaving badly by saying that they will ‘throw a busha’. In Madanga division, for example, there was a ceremony associated with the local possession cult called Mwaka Koga, part of which was held at a sacred well on the outskirts of a village. People gathered spoke to the spirits in the well. At one point in the ceremony, the spirit medium said: ‘Protect us, cure us and treat us so that we can be healthy and have peace and happiness in our lives…. There are some … who see those who come to us as barbaric, uncivilized and ignorant; and they see themselves as educated, civilized and more religious … They only believe in one God … [To them we say:] give them bushas and matende and never cure them, until they come here and beg for forgiveness.’

Limited and ineffective communication

It has been argued that social mobilization and advocacy is a key component of effective MDA for lymphatic filariasis in Tanzania (Malecela et al., Reference Malecela, Kilima, Mackenzie, Simonsen, Malecela, Michael and Mackenzie2008, p. 117). This is said to comprise everything from radio spots to posters, film shows and the use of mobile megaphones. All this activity is reported to occur in Swahili and to have been incorporated into a set of lymphatic filariasis control ‘programme principles’. While these activities may well have occurred at some locations, it is also the case that they either have not occurred or they have had a minimal effect at the field sites where this research occurred. As a result, very few people understood the rationale for distributing drugs, free of charge, to adults and children. Staff employed at health centres, as well as village-based drug distributors, were thus genuinely confused as to whether the drugs were designed to prevent infection or treat existing infections. With few exceptions, they had no idea that it was possible to be infected and asymptomatic and they were at a loss about how to answer frequently posed questions. These included variations of the following, all of which were posed at village meetings and/or during interviews in 2007 and 2011:

At all sites there was an eagerness to engage in debate and discussion about these issues, and innumerable complaints that the drugs were being given out by local distributors who could not explain how they worked or exactly what they were for. As one young woman from Kigombe put it: ‘there is no information about why you should take the drugs, what the drugs are for and other necessary information to convince people to take the drugs.’ With so many unanswered questions, it is hardly surprising that people questioned the merits of mass treatment.

What appears to be an unwillingness or an incapacity to engage with local concerns of these kinds, and specifically to address matters such as pluralistic approaches to aetiology and treatment in health education materials and training of distributors, is by no means unique to staff working for the National Programme to Control Neglected Tropical Diseases in Tanzania (see, for example, research on the control of schistosomiasis and soil-transmitted helminths in Uganda by Parker et al. (Reference Parker, Allen and Hastings2008) and Parker & Allen (Reference Parker and Allen2011), and research on malaria by Hausmann Muela et al. in Tanzania (Reference Hausmann Muela, Muela Ribera and Tanner1998, Reference Hausmann Muela, Muela Ribera, Mushi and Tanner2002)). It does, however, have unfortunate consequences as it ends up confirming, rather than refuting, existing outlooks and fuels anxieties about the merits of swallowing drugs provided by international donors and distributed through government channels. That said, it would be a great mistake to assume that more extensive and sophisticated communication will be sufficient to improve drug uptake. The current system of rolling out free drugs relies upon voluntary labour to run the programme and this, too, is problematic. The next section discusses this issue.

Too great a reliance on voluntary drug distributors

Village health workers, otherwise known as the ‘community's own resource persons’ (CORPS) take responsibility for distributing drugs for the treatment of mabusha and matende (Malecela et al., Reference Malecela, Mwingira, Mwakitalu, Kabali, Michael and Mackenzie2009b). They are trained through a cascade system. That is, health workers at a national level train health workers at a regional level; regional staff train staff working at a district level; and district staff train those working at a ward and village level (Malecela et al., Reference Malecela, Kilima, Mackenzie, Simonsen, Malecela, Michael and Mackenzie2008). Village drug distributors are not paid for the time they spend handing out drugs within their villages, but they receive a small ‘sitting allowance’ for attending training sessions. While positive statements have been made about the effectiveness and efficiency of the cascade system (Malecela et al., Reference Malecela, Kilima, Mackenzie, Simonsen, Malecela, Michael and Mackenzie2008, Reference Malecela, Mwingira, Mwakitalu, Kabali, Michael and Mackenzie2009b), observations and discussions with health workers and other villagers suggest that the current system does not always run smoothly.

In particular, it overlooks the fact that some villages cover significant geographical areas and there are often significant constraints preventing distributors from taking the time to contact those living on the outer reaches of their village. To walk from home to home, persuading individuals with whom there is little social connection, requires a big commitment. This is expected to occur in addition to a normal day's work, and may need to be done repeatedly, because many individuals may be absent, perhaps fishing or farming or visiting relatives. Crucially, the reliance upon a small number of adults to distribute drugs within each village also assumes that a sense of goodwill and concern extends to all residents equally. In many places, this is not the case.

In Mwembeni, for example, the Makonde are, in social and political terms, much more marginal than their Muslim neighbours. They are often referred to as kafir. As a result, many of them are not even recorded in the village register. In addition, it became apparent that by 2010 a parallel system of drug distribution had emerged. That is, two Muslims were taking responsibility for distributing drugs throughout the village. Christian Makonde living reasonably close to the centre of the village were told to come to a central location to collect drugs, but those living ‘far’ from the centre were not informed of the treatment. A 55-year-old Makonde man, living on the outskirts of the village, summed up the situation when he revealed that he had never heard about the free provision of drugs as: ‘the only information we get is when we have to contribute something … the other news is not delivered.’ By contrast, many of the friends, neighbours and relatives of the drug distributors were being given drugs in their own houses. Somewhat similar issues were also noted in Kigombe, where divisions between political parties, between Muslim factions and between Muslims and Christians all affected distribution activities. As in Mwembeni, many Christians complained that they were not informed about the drug distributions. Moreover, in 2007, one of the imams was reported to have openly opposed distribution activities to his followers, and the distributors lacked the authority or knowledge to challenge him.

Such diverse (and often very locally specific) divisions in what are perceived externally as homogeneous communities obviously affect drug distribution. Indeed, close scrutiny of a programme like Tanzania's National Lymphatic Filariasis Elimination Programme makes manifest social hierarchies and fissures. They become particularly clear in ethnographic research, though they may be hard to enumerate. Although efforts were made to see if it was possible to discern consistent patterns of treatment exclusion in the data that were collected during semi-structured interviews on drug uptake, this did not prove particularly insightful. Political affiliation, for example, was too sensitive an issue to be asked in all interviews, and it was sometimes difficult to assess the accuracy of answers when they were forthcoming. Systematic effects of the manifest conflicts and tensions in the Muslim population were similarly hard to gauge and quantify. However, with respect to drug distributers’ coverage of resident Christians, it was possible to make a basic assessment in Mwembeni. Here, there were some Christians living near the primary school, not far from the village centre, or who had children at the school. They tended to be offered tablets. It was those residing at the periphery of the village that were omitted. Also, a general bias towards offering tablets to Muslims in preference to Christians was discernible in the self-reported uptake data: between 2004 and 2007, 53% of Muslim adults reported taking the tablets in Mwembeni, and 48% of Christians. Ethnographic research on this and other issues revealed that there were marked differences of attitude and commitment among drug distributors. Observations and discussions strongly indicated that it was the most marginal that end up being excluded from the offer of treatment.

Why is self-reported drug uptake higher at some locations?

It remains to be explained why self-reported drug uptake is higher in some places than others. The answer is relatively straightforward. It relates to levels of engagement with the target populations and resulting increased capacity of people to make informed choices. It has already been observed that the proximity of the official sentinel site near Tanga town at Kirare and the visits of medical staff and researchers explain a relatively high self-reported uptake rate, even if it is less than is necessary for long-term control or elimination of the disease. Similar rates were noted in this study, in Bwembwera and Magila in Muheza district and at the small trading centre of Jaira in Pangani district.

The case of Jaira was discussed with district medical staff based at the hospital in Pangani town in 2011. The District Medical Officer commented that the improvement in self-reported drug take-up (from a low of 40% in 2007 to around 70% in 2010) must have been to do with the direct involvement of his staff. Some of his staff had been to Jaira at the time of distribution and had responded personally to the questions and concerns of the population. It was not possible to do so elsewhere due to lack of transport and lack of qualified personnel who might be deployed.

With respect to Bwembwera and Magila, the take-up rates of 68% in 2006 and 65% in 2007 in Bwembwera, and 70% in 2007 in Magila, probably reflect their proximity to Muheza town and to Muheza hospital. It was found that in these locations knowledge about lymphatic filariasis and the rationale for mass treatment had been more adequately communicated than in locations near the coast. In addition, it was reported by informants that surgery had been made available to those men seeking it through an established system of referral, rather than the kind of ad hoc surgery camp that was run in Pangani in 2008. District medical staff additionally noted that higher rates of drug uptake near to Muheza town reflected the better training and larger number of drug distributors than was the case in more remote locations. They were well aware of the difference in levels of engagement within the district, and explained that they just did not have the resources to run a more effective operation at a distance from their base.