Morbidity, mortality, and health-seeking behaviour in rural Senegal: local understanding and representation of disease across method of treatment

Background: Ethnomedical nosologies in many parts of the world, including west Africa, encompass both naturalistic (related to mechanisms of contagion and pollution) and personalistic (related to spiritual and supernatural malevolence) causes that are at times fundamentally at odds with the biomedical model. We explored cultural models in a rural population in the Fatick region of Senegal related to the use of ethnomedical and biomedical therapies and examine dimensionality of schemas and associated behaviours motivating and affected by the choice of therapeutic model. Methods: We collected innovative disease-narrative histories as part of the Niakhar Social Networks and Health Project (NSNHP) from more than 100 in-depth semistructured interviews held with a random sample of area residents aged 16–91 years. These interviews, transcribed and extensively coded for computer-assisted analysis, contain information about the use of interpersonal resources and helping around illnesses, symptomology, perceived causes of illness, and treatment options pursued, their costs, respondents' understanding of them, and their perceived efficacy. We compared schemas and behaviours surrounding treatment in biomedical institutions (pharmacies, health centres, and hospitals) with those in ethnomedical intuitional settings (traditional spiritual healers, ethnobotanical practitioners, oracles, and religious healers). Findings: Health seeking behaviour in this population is not restricted exclusively to biomedical or ethnomedical treatment. Rather, individuals and families seek efficacious solutions to illness and medical crises from both sequentially or simultaneously, with indigenous cultural schemas concerning nosology supportive of both ethnomedical and to a lesser extent (particularly in the case of infectious disease) biomedical treatment. At the same time, we noted a near universal duality of cause and treatment; certain illnesses are perceived to be treatable only by ethnomedical, others only by biomedical therapy. We report that although perceived cause can affect choice of therapeutic venue, perceived efficacy of previous treatment (both proximal and within respondents' social networks) could be equally responsible for shaping schemas invoked by respondents when discussing their illness and choice of therapeutic venue. Interpretation: Insights such as those gained here could be used to develop measures of cultural and ideational context for use in survey-based demographic and health research projects, using the example of the instrument developed for the NSNHP. Funding: National Institute of General Medical Sciences

Differential and persistent risk of excess mortality from Hurricane Maria in Puerto Rico: a time-series analysis

Summary: Background: Hurricane Maria struck Puerto Rico on Sept 20, 2017, devastating the island. Controversy surrounded the official death toll, fuelled by estimates of excess mortality from academics and investigative journalists. We analysed all-cause excess mortality following the storm. Methods: We did a time-series analysis in Puerto Rico from September, 2017, to February, 2018. Mortality data were from the Puerto Rico Vital Statistics System. We developed two counterfactual scenarios to establish the population at risk. In the first scenario, the island's population was assumed to track the most recent census estimates. In the second scenario, we accounted for the large-scale population displacement. Expected mortality was projected for each scenario through over-dispersed log-linear regression from July, 2010, to August, 2017, taking into account changing distributions of age, sex, and municipal socioeconomic development, as well as both long-term and seasonal trends in mortality. Excess mortality was calculated as the difference between observed and expected deaths. Findings: Between September, 2017, and February, 2018, we estimated that 1191 excess deaths (95% CI 836–1544) occurred under the census scenario. Under the preferred displacement scenario, we estimated that 2975 excess deaths (95% CI 2658–3290) occurred during the same observation period. The ratio of observed to expected mortality was highest for individuals living in municipalities with the lowest socioeconomic development (1·43, 95% CI 1·39–1·46), and for men aged 65 years or older (1·33, 95% CI 1·30–1·37). Excess risk persisted in these groups throughout the observation period. Interpretation: Analysis of all-cause mortality with vital registration data allows for unbiased estimation of the impact of disasters associated with natural hazards and is useful for public health surveillance. It does not depend on certified cause of death, the basis for the official death toll in Puerto Rico. Although all sectors of Puerto Rican society were affected, recovery varied by municipal socioeconomic development and age groups. This finding calls for equitable disaster preparedness and response to protect vulnerable populations in disasters. Funding: Forensic Science Bureau, Department of Public Safety, and Milken Institute School of Public Health of The George Washington University (Washington, DC, USA)