Symbolic Representations and Treatment of Health in African Traditional Medicine: The Example of Malaria in Baoulé-Agba of C ô te d ’ Ivoire

This study was accomplished from focus groups and from semi-directive discussions with chiefdoms and traditional therapist in Baoulé-agba’s communities in Côte d’Ivoire. It allowed understanding the link between symbolic representations and levels of treatment in traditional medicine from the example of malaria. Three symbolic representations characterize malaria in Baoulé-agba’s medical culture. It is symbolisms linked to the animal, to color and to physical force. Wildlife symbol is the cat which certain elements bring closer to the sick man of malaria. The coloring of certain parts of the body of the sick man of malaria points out the degree of seriousness of disease. In effect, color allows differentiating the white malaria of the yellow malaria. The symbolism of physical force establishes difference between the male malaria and the female malaria or the serious malaria and the simple malaria. These symbolisms constitute indicators of seriousness or lesser seriousness of the malaria and they orientate the therapeutic route based in general on traditional medicine. This one is composed of three levels of therapeutic appeals according to the degree of seriousness of disease. The symbolic representations, which characterize the socio-cultural perception of Baoulé-Agba linked to the malaria, constitute reference elements for the efficient fight against this disease in this community.


Introduction
Malaria is a disease that occurs mostly in the tropical zones of Africa and predominantly in south of the Sahara. It is endemic throughout the year. Several health programs have been implemented in an attempt to eradicate it. After the Roll Back Malaria initiative (RBM), today we have the Millennium Development Goals (MDGs), of which one of the components of objective 6 is to fight against malaria. It is noted that significant progress has been made in this direction at the preventive level based on insecticidal nets especially in the endemic areas. Despite this remarkable progress, "about 250 million cases of malaria were recorded in 2008, resulting in 850,000 deaths. Nearly 90% of these deaths occurred in Africa, especially in children under 5 years" [1].
In Côte d'Ivoire, malaria accounts for 10% of consultations. Rural area is the most affected with a special emphasis on pregnant women and children. In Baoulé-Agba (Baoulé Subgroup located in east-central Côte d'Ivoire), malaria is a disease well-known from the symbolic representations that reflect the different forms of this disease. At the level of its severity, malaria is perceived as a common ordinary disease except some forms that are critical. Its treatment is usually focused on herbal medicine combining divination and medicinal plants.
What are the symbolic representations of malaria? What is the therapeutic route to be followed on the basis of these symbolic representations? These two fundamental questions build the framework of this manifestation based on the target groups and semi-structured interviews with Baoulé-agba chiefdoms and traditional healers (men and women). The Baoulé-agba is a sub-group of the Baoulé (People localed in the center of Côte d'Ivoire) ethnos group occupying the east-central of Côte d'Ivoire. They can be located mainly in the Subprefectures of Dimbokro, Daoukro, M'bahiakro, Bocanda, Ouellé et Kouassi-Kouassikro.

Symbolic Representations of Malaria
The symbol is defined by Guy Rocher as "something that takes the place of something else or something that replaces and evokes something else" [2]. The symbol can be a word or an image used to communicate or express a reality. Its function is to "achieve, to make abstract, mental or moral realities of society visual and tangible".
The symbols are not absent from Baoulé culture. They are present and are highlighted through proverbs and sayings. For example, Baoulé say "Your foot does not hit and stirs your cheek" which signifies "he became rich without working" [3]. Baoulé culture is hence rich in images. Thus, the metaphor, the similarity and the analogy are often used to explain, understand, appreciate and describe any natural or anthropogenic factors. That is why, in Baoulé, "the concrete and pictorial vocabulary does not prevent from achieving fairly general or universal ideas. Instead, the symbol and image are often better suited to a deep thinking as pure abstractions" [4].
In the context of disease, including malaria, three symbolic orders can be accepted. This is the animal symbolism, the symbolism of color and the symbolism of physical force.
-What is the relationship between the disease "malaria'' and animals ''cat''?
The involvement of the pet ayankan in ethno medical terminologies of malaria in Baoulé-Agba can be explained in terms of the similarity of disease symptoms with the pet "cat". Indeed, symptoms such as asthenia or weakness of the body and the eyes of yellow and white colors of the patient with malaria are assimilated to the nonchalance and to the yellow or white colored eyes of the cat. Therefore, the pets 'cat' which is well-known becomes an eponymous animal, a symbol of reference to explain and understand malaria. However, it should be noted that the term ayankan does not apply to all forms of malaria.
A common term that is attached to djangouman remains rarely used. This can be understood by its linguistic borrowing. Indeed, the word djangouman would be of malinke origin and would therefore be a derivative of djangoumani, which signifies ''cat''. The cohabitation of the Baoulé-Agba and the Malinke (Dioula) would have promoted the use of this term in the Baoulé-Agba vocabulary.

Symbolism of color
The colors associated with malaria allow distinguishing two forms of malaria (Table 1). These are: White malaria: This form of malaria seems to be the least serious and one of the most frequent. The distinctive characteristics of this form of malaria can be at two levels: -at the level of the patient's mood; -at the level of the patient's body color.
On the humoral level, the patient sleeps a lot and becomes quiet. It occurs due to asthenia with anorexia and general tiredness. This is what leads to the feeling of heaviness and the nonchalance of the patient. The distinctiveness of the patient with white malaria is one of the elements of assimilation to the cat.
The coloring of the body of the patient results in pallor of the latter. That is why it is called as white malaria. It increases at the level of certain parts of the body such as the eyes, the nose, and the corners of the mouth, palms and soles. However, two recurring elements are the hallmarks of ''white'' malaria. This is, indeed, the whiteness of the skin of eyes and the urine which is colorless. It is therefore from these two core elements that the patient is subject to suffer from white malaria.

Yellow malaria:
It is similar to white malaria. Its peculiarity is the yellowing of the body parts of the patient. This is therefore the yellow color which is the element of particularization of the disease, which makes this form of malaria ''yellow malaria'' (djèkoidjo ôkloè). The term ôkloè is a standard color that simultaneously refers to the colors red, orange and yellow. But linguistically, terminological clarification may be made to differentiate between the three colors. However, the term ôkloè for malaria refers to yellow color. As for ''white malaria'', the distinctive elements of "yellow malaria" relate to the yellowing of the eyes, the tip of the nose, corners of the mouth, palms, the soles of the feet and the urine. The element that characterizes this form of malaria is the yellowing of the urine and the integuments of the eyes. These two key elements allow diagnosing the disease.

Symbolism of physical force
Physical force is symbolized in Baoulé-agba culture by man and woman (Table 2). Actually, the man represents strength, physical power because of his muscles while the woman represents the physical impotence. From this perspective, we distinguish male malaria from female malaria.
Female malaria: It is also called as djèkoidjo bla which in French means "female malaria". This form of malaria could correspond at the biomedical level as ordinary malaria. It is the most common. Since female malaria is identical to white malaria, so they have the same events.
Male malaria: Male malaria in Baoulé-Agba is one of the most severe forms. However, this form of malaria is uncommon. Male malaria is also characterized by the yellow coloration of certain parts of the body of the patient as in the case of yellow malaria. However, what is particularly characterized is the mood of the patient. Indeed, unlike torpor to which the yellow malaria patient is subject, male malaria patient is restless and his words are delusional. Consequently, he becomes brutal and is a constant threat to his entourage "He acts like a fanatical dog and he is ready to bite" describes a traditional healer during our interviews. The patient is therefore often chained to    Furthermore, analysis of the term male characterizing malaria allows understanding the relationship between man and woman in some African societies. Indeed, the male sex is considered to be strong unlike the female which is considered to be weak. It is within this context that the delirious and stirrer malaria (djèkoidjo yassoua) is assimilated to man contrary to the malaria "nonchalant"(white malaria) assimilated to woman.
Forms of malaria analyzed in this study are not specific to a given age; everyone is at risk of being affected by it. However, the pursuit of treatment depends on the type of malaria.

Therapeutic Routes Related to Forms of Malaria
Health is perceived in Baoulé-Agba as a sign of the harmonious relationship between the individual and the protective deities. The imbalance between these two entities is expressed by the "disease which is a relapse that affects the body with pain or explicit suffering" [5].
The symptoms of the disease immediately announce the beginning of the quest for healing. In Baoulé rural areas, recognizing the symptoms of malaria, i.e., the clinical diagnosis determines the type of therapy. Indeed, for the same disease, several symptoms can be associated. This allows identifying the form of malaria that determines the type of therapy. We observe pretty much exclusiveness of the traditional medicine to treat malaria in the Baoulé-Agba. This is explained by this community's perception of modern medicine as ineffective in treating certain forms of malaria, particularly male malaria. In fact, injections and infusions which often use modern medicine would be for Baoulé-Agba, a complicating factor which in most cases is fatal for the patient. On analysis, this is not the infusion which is responsible for the death but rather the advanced state of the disease, modern medicine is solicited in the last stage of the disease. Therefore, the patient affected by this form of malaria is treated in many cases with traditional medicine.
In Baoulé-agba medical culture, the therapeutic route of malaria comprises essentially three levels of treatment. This is the home remedy, the traditional therapy and the divination.

Treatment of white or female malaria
This is a form of ordinary malaria, considered less serious by Baoulé-Agba. Therefore, the medical treatment is done by home remedy. This corresponds to the classification of Kleinman a popular medicine belonging to the family circle and neighbors [6]. Home remedy is the first treatment given to the malaria patient upon recognition of the first symptoms of the disease. Therefore, the medicinal plants used for this purpose are the plants as "popular", i.e. the plants known and used of all without consulting a medical practitioner.
Various species of plants are used in folk medicine. These can be classified into two groups: -dried medicinal plants; -fresh medicinal plants.

Dried medicinal plants:
It is typically roots, bark and dried leaves of plants. The use of these plant extracts is made possible with pharmacopoeia which is a kind of "traditional pharmacy" providing herbal medicines. However, in rural Africa, in general, there is no proper structure for the sale of these drugs. Nevertheless, apart from those made at home by mothers, these medications can be purchased in the market. However, the home remedy also makes use of leaves, roots or fresh bark for the treatment of infantile malaria. These plant extracts are not preserved and they last as long as they are in use. The request for transfer of medicinal knowledge, to a possessor is expressed by the term "Aré bo déwa"; that literally means "take the base, the bottom of the drug". This expression may result in a transfer of medicinal knowledge. To accept the request, the depositary requires money, drink or an animal that symbolizes his agreement. So, after having fulfilled the requirements of the depositary the applicant may acquire the right or permission to use the medicinal remedy for his own purposes. However, in general, the use of so-called popular plants does not take into account these prerequisites of transferring medicinal knowledge.

Treatment of Yellow malaria
Three levels of perception characterize the severity of the disease in Baoulé-Agba.
The first level is the common disease (Ôtia kéklé toukpatchè) which includes common diseases considered'' normal'' because the body which works every day is sometimes affected by the disease.
The second level is that of serious disease (Kéklé toukpatchè) translatable into French with'' prolonged serious disease".
The third level is that of the critical disease (Toukpatchè tè) which can be literally translated in French with "bad disease".
According to the perception of severity in Baoulé-Agba defined above, yellow malaria is at the second level. That is why, unlike white malaria which is treated within the domain of home remedies, the treatment of yellow malaria requires the consultation of a traditional therapist.

Treatment of male malaria
Male malaria is a disease which is on the third level of severity according to the Baoulé-agba perception. Therefore, the dependant traditional practitioner providing treatment switches from traditional therapist to the diviner/healer. This one combines, in medical practice, divinatory art and herbal medicine. Indeed, at this level of disease, according to the belief of Baoulé-agba community, the spirituality is a tangible factor in critical pathological conditions. Thus "the diagnosis of evil first involves the identification of the causative agent which falls within the supernatural [7]". That is why the oracle consults the spirits that reveal the supposed real causes of the male malaria before his medical treatment. At this level of treatment, "animals are sacrificed throughout the therapeutic process as a propitiatory sacrifice to the family and community gods [8]".

Conclusion
The symbolic representations are in Baoulé-Agba, the referents who present malaria into various forms. Therefore, knowing this parasitic disease in this area also requires knowledge of these symbols. Indeed, "our stories and our proverbs contain symbols, figurations immense wisdom and hidden truths" [9]. This is what often explains the fact of seeking treatments is more based on traditional medicine. This emphasizes, in its treatment procedures, on the hierarchy of levels of disease. This leads to three levels of disease that determine the severity of the pathological condition, ranging from the common disease to critical disease by passing through the least of all evils. The relationship that community Baoulé-agba sets up between critical diseases such as male malaria here and the spirituality allows situating the origin of evil and required therapeutic route. That is why, at this level of disease, diviners/healers are most sought to ward off evil.
This furthermore would explain the intervention of divination, genuine mediation between the healer and the spirits preceding the herbal medicine. It is in this context that for Tall, "interpretation of the misfortune is registered in a social logic that goes beyond the organic framework of the sick body" [10].
These socio-anthropological data lead to reconsider the perception of people in the development of programs and strategies against diseases including endemics. Its inclusion should lead to a genuine collaboration between the biomedical sciences, traditional medicine and anthropology of health for the benefit of sustainable human health in Africa.