Linkages between sumaya and food
In explaining the causes of sumaya, the respondents also identified dietary, environmental, and biomedical reasons. An intriguing suggestion from the respondents of this study was the explanation that sumaya can be caused by fatty food such as shea butter, fruits with acidic properties such as oranges, and sweet foods like wild fruits and corn. The respondents’ claims about the association between food and malaria were mostly general; however, they pointed to two intriguing ideas. The first idea is that “opened” sweet foods such as bananas and corn are more likely to cause malaria. If “open” here means how the banana or corn is preserved in opposition to “closed,” as in eating it fresh meaning never preserved, then this idea confirms existing studies about the association between food and diseases. Association of fatty, sweet, or acidic food to malaria is part of a growing discussion among Africans from different countries on changing lifestyles and their relations to food and in turn, how new dietary patterns create conditions for diseases like high blood pressure, diabetes, and sometimes cancer [7, 17]. In Julie Livingstone’s Improving Medicine, she writes that liver cancer is caused by the combination of “subclinical infections with hepatitis and aflatoxins in poorly stored African grain” [27]. While malaria is different from cancer, the participants’ claims about food as the causative agent for diseases collaborate African patients and health care providers’ discourse that links the two together [7].
Another related idea about the role of food in causing malaria connects back to sumaya banakise. As noted, the term seems to describe either a person’s potential to contract malaria or a form of dormant malaria. In addition to weakened immunity, our respondents suggested that “the grain of malaria” can also be triggered by the intake of fatty food. This does not necessarily mean the expression of sumaya banakise comes from a different condition than a compromized immune system. The interpretation of these explanations is to show that Wayerema II residents consider malaria from not a singular cause but multifactorial including the product of synergistic interactions between the type and state of food and its interactions with existing physiological conditions such as having the presence of the “malaria grain.”
Biomedical explanations: causes and symptoms
If this study has created the impression that the residents of Wayerema II only conceptualize malaria through supernatural expressions that are not the case. Like in other African countries, Malians are living in a medically pluralistic society employing various traditions and cultures, such as biomedicine, to treat and explain their ailments [10, 28, 29]. Some informants explained the causes of malaria particularly through a biomedical lens [30, 31]. Both Wayerema II residents and healthcare workers or traditional therapists have an understanding of the clinical symptoms of malaria. The informants who practise traditional medicine also recognize the same symptoms as those diagnosed by biomedical practitioners such as fevers, shivering, headcheaches, vomiting, and body ache. Moreover, residents are also aware that mosquitoes cause malaria.
The data collected from health workers in the CScom of Wayerema II, Csréf (referral hospital of the city or referral health centre) of Sikasso, and paediatric services of Sikasso regional hospital pointed out that the nosographic entities (symptoms) appear mainly in rainy periods, which is from June to October. This period is also called the high malaria transmission season because of the factors that promote the multiplication of the disease’s pathogen. This observation lends credence to Wayerema II’s description of sumaya as a phenomenon related to “wetness” or the wet season. The difference between biomedical explanations and what we might call “indigenous” explanations is that the latter is multifactorial bringing in biomedical, spiritual, and environmental causes together in a specific manner.
Residents’ knowledge of symptoms and causes of malaria through a biomedical lens is in part fuelled by the efforts made by the Malian government in collaboration with its partners, such as the World Health Organization (WHO), United Nations Development Programme (UNDP), and media campaigns involving print, radio, and television industries. In fact, among those agencies working on traditional medicine such as the Department of Traditional Medicine, traditional therapists and herbalists have associations and collaborations with the National Malaria Control Programme (NMCP) to promote long-lasting insecticidal nets (LLINs), generic drugs, and free care for children under five and pregnant women in all Malian tiered health structures from regional hospitals to village dispensary [3, 18, 32]. In a way, Wayerema II’s residents’ rich accounts of malaria are micro-expression of larger state interventions to control malaria and shape peoples’ attitudes to malaria that often prioritize biomedical models to the subordination of local, situated responses and epistemologies [33].
Sumaya and environmental causes
It is interesting to note that the respondents’ explanations of sumaya are connected with the environment such as seasonal variation. Mrs. Charlotte’s biomedical explanation quoted in the "Results" section also points to moisture or wetness as a site and occasion when malarial agents actively develop. Such views coincide with findings from some other studies that examine how African subjects interpret their disease in light of seasonal variations [7, 30, 31].
The indigenous explanation of aetiologies seems more diverse, combining environmental and supernatural factors, while the biomedical explanations focus on the agents and female anopheles as vectors. Nevertheless, some similarities in vectors can still be spotted between both explanations. First, in both accounts there is a vector present therein: for Wayerema II residents, it is the bird and for biomedical practitioners, the female Anopheles gambiae. In the indigenous explanation, kono, pernicious malaria, is caused by a witch bird, a kind of social poison in Wayerema II. In the biomedical realm, the vector is the mosquito, but the “poison” is P. falciparum. Again, it is not implying that biomedical terms equate to indigenous systems, which are various per se, but pointing to some intriguing parallels and perhaps syncretism, as in a mixture of ideas, paradigms, and theories that are both indigenous and more or less “western” that have percolated in these communities over many decades. This qualitative study cannot ignore that biomedical practice in Africa has lasted for over one hundred years and therefore cross-fertilization of ideas has been happening in a bidirectional way in urban areas of Mali [31, 34].
Therapeutic routes
The study was interested in linking how our respondents understand and interpret malaria through drawing from their social and cultural understanding and how such conceptions influence their therapeutic resources [5, 6, 8,9,10, 19, 21, 26, 28, 35, 36]. Arthur Kleinman’s notion of therapeutic routes instructive in explaining and understanding the process and decisions-making inherent in the respondent’s health seeking-behaviour. Arthur Kleinman has theorized that a therapeutic route comprises three stages, and it begins with the subject’s sensing a malady and his/her inclination to interpret it within the frame of illness per se. Such illness perception is what it refers to as the first stage of a malady (illness), where an individual feels a sense of imbalance or anomaly that might be linked to a certain name of the illness. This would give rise to the second stage: the subject communicates with a healthcare provider, healer, or kin about his/her experience, which may lead to the further recognition of the malady. This process allows the subject to justify his/her role as a patient by having the abnormal state (or sickness) socially recognized. Furthermore, the third stage involves the act of defining an illness in nosographic terms, which enters the biomedical dimension and is grounded upon the nomenclature of the sick state by the therapist [37, 38].
This study also revealed that the practice of self-medication is more often the first resort in case of sickness manifestations such as headache, fever, and dizziness. Considering the case of Mamadou that we recounted in the "Results" section, he used plants and herbs for self-medication often. Mamadou, moreover, described it as “the easiest thing in the world.” By this, he means self-medication can be an everyday practice. It also signifies that he has the knowledge of plants as cures and can by himself distinguish which are easily available and relatively inexpensive for use. The Wayerema II residents usually use the decoction of “bitter” plants such as Combretum Micrathum (golèbè), Vernonia Colorata Will (kosafunè), and Anoeissus leiocarpus (n’galama). Mamadou case and others reinforce the observation that upon the appearance of a disease, the first response takes place at home and draws from situated knowledge of healing. Thereafter other routes follow not necessarily in linear order as in starting with a traditional healer and then a biomedical doctor.
Self-medication, as the first therapeutic recourse to deal with ailments like malaria, fever, headaches, and other diseases, has been reported by other authors in African and Asian contexts [6, 8, 17,18,19, 33, 35, 39,40,41,42,43]. There are some minor differences in details with this therapeutic recourse given the prevailing conditions. It was found that when a person is sick, especially with signs of a complicated case of malaria, he/she would consult family or a local therapist. These remedies used are various but generally can be classified into three types: (1) the traditional sector comprised of traditional healers, herbalists, or marabouts (Muslim healers), (2) the formal sector, which includes hospitals, community health centres, CSréf, private hospitals, and (3) the informal sector, such as street vendors, drug peddlers, and the health workers practicing “privately.” These practices are the main routes that the Wayerema II residents use to heal, in line with the results of previous studies [9, 21, 23, 43]. They are also the main factors in cases of severe malaria and cases of pre-transfer in the community health centre (CScom) of Wayerema II.
It can also add that plants used for self-treatment are often “dose-free’’ and can be “effective’’ against malaria. Often people would only go to the community health centre or a health facility after the disease worsens or approaches towards kono. Sometimes, malaria cases brought to the CScom are more severe, but also better-treated. Indeed, the agents of CScom must evacuate the patient(s) to the CSréf or regional hospital of Sikasso. In the meantime, self-medication can be “modern.” Modern self-medication is practised in Wayerema II using anti-malarial pharmaceutical products, such as Maloxine, Madar, Quarcitem, and Co-arinate. Self-medication is also done with anti-malarials from street vendors of illicit medicine or “pharmacies par terre,’’ literally meaning “pharmacies on the ground”, with these anti-malarials being “counterfeit.’’ These products contain “fatokèni’’ (sudrex), “sampinrin” (ibumole), and “bérébila” (ipucup), which mean respectively in English, the “little fool,” the “lightning,” and the “leave the stick and get on the feet quickly.” These designations and terms are not accidental because they reflect the effects of these “fake drugs’’ on people. These products are often used because of the high cost of malaria treatment which is unaffordable for certain social groups, especially the underprivileged ones. The treatment of mild malaria costs about 5–8 USD, while treatment for a complicated case costs about 18–27.5 USD [36, 44,45,46]. Probably linked to financial affordability, these participant observations in Wayerema II and other studies have established that self-medication is the main therapeutic route for Wayerema II populations and other African communities in Western Africa such as Nigeria, Senegal, Burkina Faso, and Côte d’Ivoire [7, 19, 25].
Sumaya and socio-economic impacts
Another socio-economic consequence of malaria is absenteeism and loss of productivity, especially for farmers and people involved in informal sectors. Many Malian families (nuclear, limited, or extended) depend on income generated by a single person who fulfills family needs such as the allocation of food, education, and health. For example, if the latter falls ill to sumaya, the social, economic, and psychological burden would fall onto the whole family. Mamadou, whose story was recounted above, used the term “three valid arms” to describe the sense of powerlessness and precarity when three of his sons got sick from malaria and therefore, were unable to help with farming obligations. The term both captures the level of impact it has on her as a parent, but personally: their sickness signified the loss of her own body parts. This term lays bare the serious impact of malaria on the whole family, even if merely one individual gets sick. The situation is dire for people who depend on farming, like Mamadou. The affliction of her three “valid arms” put her food and financial plans in a precarious situation.
This study coincides with some other studies conducted in sub-Saharan contexts that show the socio-economic impact of malaria at the family level and the ways in which it shapes therapeutic recourse [25, 36, 46]. First, the financial cost of treatment is very high and modest heads of families often prefer to take care of themselves at home or pay for drugs from alternative vendors. As such, intra-household self-treatment or intra-domiciliary self-treatment saves time and money for parents. The income per capita for Malians is 2.5 USD per day in 2020 according to the World Bank. Treatment of simple malaria costs 4–8 USD, and for treatment of severe malaria, the number rises to 25–35 [3, 36, 45]. The cost of simple treatment is twice the daily earnings and for complicated malaria almost one fifth of monthly earnings.
