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Social Science & Medicine ] (]]]]) ]]]]]]

Where there is no state: household strategies for the

management of illness in Chad
Lori Leonard
Department of International Health, Johns Hopkins School of Public Health, 615 North Wolfe Street, Room E5032,
Baltimore, MD 21205, USA

The current structure of the health care system in Chad, which is characterized by a weak public health system and a
nascent and largely unaffordable private sector, raises questions about how low-income households manage illnesses.
These questions are also compelling because of claims about the potential of oil-related investments to restructure the
current landscape of care over the next 2530 years. This paper focuses on household strategies for treating episodes of
malaria reported in an on-going, longitudinal study of household health and access to care in Chad. Treatment of
malaria outside the health care system is widespread in endemic areas, therefore it is not surprising that low-income
households in this study rely heavily on unregulated drug markets for care. However, the paper shows how selfmedication and the use of these drug markets are shaped by the current organization and delivery of care, and are not
simply the outcome of a lack of information about the dangers associated with such practices. The paper also shows the
consequences of this particular constellation of services for health in low-income households. We see, for example, the
emergence of regimes for managing illness that consist of keeping debilitating symptoms at bay through the use of
intermittent, sub-optimal therapies that provide a temporary reprieve but not a cure. We also see that households
ignore health problemsabsorbing them into the experience of everyday lifethat might elsewhere demand attention.
When illnesses appear as crises it is often because cash-strapped households are unable to sustain this type of
management regime, and easily treatable problems spiral out of control. Whether and how the experiences of the lowincome households described in this paper will be impacted by the public investment of oil revenues in the health sector
is the question our longitudinal study is designed to address.
r 2004 Elsevier Ltd. All rights reserved.
Keywords: Chad; Malaria; Pharmaceutical markets; Self-medication; Health sector reform; State

This paper looks at how households in urban Chad
manage illnesses. The present moment represents a
particularly interesting time to examine household
responses to illness in Chad. Two principal reasons for
this are evoked in the paper. First, little is known about
Tel.: +1 410 502 7396; fax: +1 410 614 7553.

E-mail address: (L. Leonard).

how households navigate within the structures of care

that have taken shape over the last several decades.
Structural adjustment programs, weak export markets,
and the cost of addressing multiple health crises,
including HIV/AIDS, have contributed to the development of a health care system characterized by a weak
public sector, a limited number of affordable alternative
sources of care, and an extensive illicit market for
pharmaceuticals. These developments are not specic to
Chad (Gilson & Mills, 1995; Standing, 2002; Zaidi,

0277-9536/$ - see front matter r 2004 Elsevier Ltd. All rights reserved.


L. Leonard / Social Science & Medicine ] (]]]]) ]]]]]]

1994). Second, understanding how households manage

illnesses will make it possible to assess the impacts of
anticipated investments of oil revenues in the health
sector and to gauge the contributions of enhanced public
sector nancing to public health. These investments,
which began in 2004, are expected to continue over
2530 years and to reshape the current landscape of care
in Chad.
The data presented in this paper come from an ongoing, longitudinal study of the impact of the development of the oil industry on household health in Chad
(Leonard, 2003). This study is carried out with 120
households, including 40 households in three localities: a
village, a small town, and an urban neighborhood. This
paper focuses on the households in the urban locality,
where health facilities are most plentiful and where
physical distance as an impediment to the use of health
care services is minimized. The paper also focuses on
household decision-making in the context of reported
cases of malaria, though for comparative purposes data
on household management of other illnesses are
provided. Malaria is of particular interest because it is
the most frequently reported illness in our household
surveys and because it is the most common reason given
for seeking care at health care facilities throughout the
country (Ministe`re de la Sante Publique, 2002).
In endemic areas, treatment of malaria outside the
health care system has been widely documented
(McCombie, 2002). High rates of self-medication1 for
malaria are attributed to its endemnicity and to peoples
recognition of its symptoms; to low levels of literacy or
education; or to a lack of awareness of the consequences
of taking improper dosages of drugs that are counterfeit,
adulterated, or outdated. These arguments assume a
rm distinction between, on the one hand, the services
provided by licensed or trained practitioners, however
these are dened,2 and, on the other hand, the free-forall of unregulated and unlicensed care available for
purchase on the market and use in the home. Health
The term self-medication is used in a general sense to refer to
the act of taking medicines without the advice or supervision of
a formally trained health worker, including instances when one
household member provides treatment to another. It is
recognized that this distinction is not usually clear-cut; some
instances of what appears to be self-medication have antecedents involving the health care system, such as when
household members take drugs left in stock from a previous
illness episode in which a practitioner was consulted.
International organizations, such as the Pan American
Health Organization (PAHO) and the World Health Organization (WHO), and national governments have sponsored
initiatives to train community health workers to diagnose and
treat cases of malaria. Among the largest and longest-running
programs of this kind are the Volunteer Collaborator Networks
of Latin America and the Village Voluntary Malaria Collaborator Program of Thailand (see Okanurak & Ruebush, 1996).

care professionals claim that the ready availability of

medications from unlicensed drug sellersreferred to as
tchoukous or Dr. Djim in Chadencourages selfmedication, and that untrained drug sellers provide care
that exacerbates existing conditions, introduces new
ones, and contributes to drug resistant disease. Despite
their merits, these claims mask how existing organizational and institutional arrangements are bound up with
the everyday practices of the sick and their caretakers.
This paper has two aims. The rst is to show how
institutional practices in Chad are implicated in household responses to malaria and other illnesses. The
emphasis on institutional practices is not meant to
negate household members agency or their role in the
problem of inappropriate pharmaceutical use. In their
work on household decision-making about health in
Delhi, India, Das and Das (2003) have argued that
binaries such as agency and structure or patients beliefs
and physicians prescribing practices are of limited value
in understanding pharmaceutical use in local contexts.
Part of the argument advanced in this paper is that
household members actions cannot be taken as
straightforward evidence of a casual attitude about an
endemic disease like malaria or a lack of awareness
about the hazards of poor quality medications and
incorrect dosing. Rather, household members use of
sub-optimal treatment strategies, including self-medication with pharmaceuticals acquired in unregulated drug
markets, is a by-product of the organization of the
health sectoror part of a particular assemblage of
care. This assemblage and households modes of
operating within it have consequences in addition to
the clinical problems so often cited. A second aim of the
paper is to look at household regimes of illness
management that have grown up around the rationing
of care, and at how these modes of thinking about and
responding to illness are re-dening health as a
commodity and illness as a condition that households
can afford to attend to, however partially.

Study methodology
Since 2002 we have been collecting data from 40
households, comprising approximately 362 people, in
Walia. This urban neighborhood was recently annexed
to the capital city of NDjamena, but does not yet
benet from municipal services. The households were
selected by knocking on every nth door; however, since
the neighborhood is not zoned and building has
occurred haphazardly, the selection process is better
described as one in which households were selected to
cover the geographic space of the neighborhood. Since
the beginning of our study two households have moved.
When households move we try to follow them; however,

L. Leonard / Social Science & Medicine ] (]]]]) ]]]]]]
Table 1
Descriptive information for households (n 40) in Walia
Household characteristics


Households that rent their dwelling

Households that own a television set 9
Households that own a car
Households where at least one
member reports salaried employment
Households that produce crops for
subsistence purposes
Households that report food
shortages during the year


these households moved to other parts of the country

and thus had to be replaced by neighboring ones.
Household size ranges from two to 32 members,
though the average household size is nine. Sixteen
households consist of nuclear families with no additional
kin or other members, six are polygamous, and four are
headed by women. More than seven different ethnic
groups are represented in our sample; approximately
two-thirds of the sample are Christian and one-third are
Muslim. The households are also diverse in terms of
socio-economic status as measured by access to cash and
availability of material assets. For instance, most
households (n 31) have a bicycle; 11 have a motorcycle; and two have a car. Eight households do not own
a mode of transportation. Among the households, there
were 40 children under the age of ve and three adults
over the age of 59. Additional descriptive information
about the households is provided in Table 1.
The data presented in this paper come from household surveys and from interviews with health care
practitioners and drug sellers who work in and around
the neighborhood. The surveys and interviews were
conducted by two eldworkers who live in the capital,
but not in Walia. Our household surveys follow an 18month cycle. Weekly surveys are conducted alternately
in the rainy and dry seasons over 16 consecutive weeks.
These are followed by monthly surveys, which continue
to use the 1-week retrospective reporting period, for the
remainder of the 18-month period. In the weeks covered
by the surveys eldworkers record all illnesses experienced by household members and the actions taken to
deal with these problems.3 They also collect information
about household revenues and expenditures for the
week. Illnesses are self-reported. Fieldworkers note any
condition that is considered from the households
perspective to constitute an illness. Some of the
The questionnaires used in this study were adapted from
those used in a longitudinal study of household health and
access to care conducted in Delhi, India by Veena Das and
Ranendra Kumar Das (see Addlakha et al., 2000).

conditions recorded, such as stiff neck, itching, or

swelling of the right leg, may not be signicant from a
clinical perspective.
From January through December of 2003, when
household surveys were conducted once per month, the
eldworkers conducted follow-up interviews with households that reported an episode of malaria. In the context
of the monthly surveys each illness reported was counted
as an illness episode. When we conduct household
surveys over 16 consecutive weeks we can obtain a more
rened count of illness episodes because we can follow
the chronological trajectory of each illness over time and
more accurately determine whether it is a continuation
of an illness reported in the previous week or a new case
of illness. The purpose of the follow-up interviews was
to gather a narrative of the malaria episode, including
information our survey questionnaires failed to capture
(e.g., evaluations of different sources of care and
medicines, the impact of expenditures on the household). This meant that the eldworker returned to the
household the week after the case of malaria was
reported to elicit a detailed account of the episode and
the therapeutic actions taken. As part of this follow-up
interview, eldworkers gathered information about
medications that were taken and where they were
obtained, and attempted to track these medicines to
their source. Practitioners and drug sellers were interviewed about how they diagnose and treat cases of
malaria and observations of diagnostic and treatment
practices were conducted in health care facilities and in
open markets where medicines are sold.

Institutions and illnesses

There are 32 ofcial sources of health care within a
15-km radius of the households we follow in Walia.
Ofcial sources are dened here as state-licensed
facilities, whether public or private. Most of these
sources of care are at distances that can be traversed
in less than 1 h on foot. These include nine government
facilities and 23 private facilities. In addition, we
counted 18 practitioners who operate informally out of
their homes. Some of these practitioners have clinical
training, such as retired government employees or
government employees who provide private services on
the side, but most have no qualications. Table 2 shows
the numbers and types of ofcial facilities in proximity
to our study site.
There are eight health centers near Walia; the
Catholic Church runs the health center closest to the
study locality. In decentralizing the Chadian health
system in 1991, health centers were established as
peoples rst point of contact with the health system.
They provide basic, primary care, including vaccina-

L. Leonard / Social Science & Medicine ] (]]]]) ]]]]]]

Table 2
Sources of state-sanctioned care within 15 km of the study site
by type of facility
Type of facility

State-recognized facilities


Health center or
District hospital
National reference
Specialty clinic
Private clinic

For prot








tions, pre-natal care, assistance with uncomplicated

deliveries, and treatment for common childhood illnesses. National health policy calls for 642 health
centers, or one for every 10,000 people (Ministe`re de la
Sante Publique, nd). However, in 2002, only 407 health
centers (63 percent of the number planned) were
functional, and, as is the case for the health center in
Walia, religious and other non-governmental organizations ran most of these facilities.
A number of secondary and tertiary health facilities
are also within walking distance of our study site.
District hospitals serve as referral sites for health
centers. One of the citys four district hospitals is
3.5 km from Walia and is the public facility closest to
the neighborhood. The nearest government-run health
center is 6 km away. The national reference hospital, a
university teaching hospital with the most specialized
services in the country, specialty clinics for maternal and
child health and leprosy, and a feeding center for
malnourished children are also accessible by foot.
User fees are charged by all of the public and private,
non-prot facilities listed in the table. The government
adopted user fees in 1994 to raise revenues for the health
sector, at a time when this form of cost-recovery was
already in place in health centers run by religious and
non-governmental organizations. Public spending on
health care has increased every year from 1998 to 2001,
the last year for which data are available, but remains
low. In 2001, health sector expenditures represented 12.3
percent of the government budget (personal communication, Ministe`re de la Sante Publique). On a per
person basis, this translates to $5.24US, or less than half
of what the World Bank estimates is needed for basic
primary care (World Bank, 1993). External funding
covers 80 percent of the health budget. User fees are set
at the district level and vary from locality to locality.
They are lowest in primary care facilities and increase as

services become more specialized. User fees in health

centers are generally in the range of 200300FCFA
($0.40$0.50) per patient per visit. Additional charges
are levied for diagnostic tests, medicines, and health
books in which diagnoses and prescriptions are noted.
Research on the impact of user fees suggests that they
impede access to care for the very poor while raising
revenues only marginally (Holloway, Gautam, & Reeves, 2001; Haddad & Fournier, 1995). While no
systematic studies have been conducted in Chad, fragile
household economies and poor quality of care are
thought to contribute to low rates of use of the health
system such that these cost-sharing schemes are estimated to generate less than $0.25 per person per year
(Swiss Tropical Institute, 1998).
In some settings private sources of care have
proliferated to absorb some of the demand for health
services (Mbatia & Bradshaw, 2003). The number of
private, for-prot sources of care in Chad has grown
steadily since 1985 when the rst clinic of this type was
registered. However, private, for-prot care is rare
outside the capital city. In 2002, a total of 80 private
facilities were registered with the Ministry of Health; 70
of these were in NDjamena, and upon inspection only
23 were operational (Lamtouin, Nadjitolnan, & Oumar,
2002). Our inventory, conducted in 2003, turned up
nineteen private facilities within 15 km of Walia.
Included in this count are private clinics, diagnostic
laboratories, and pharmacies that offer diagnostic and
treatment services. There is also a thriving illicit market
for pharmaceuticals, with distribution networks that
blanket Walia and other urban areas and extend to most
rural villages.

Household management of illnesses

In the 12 weeks covered by our household surveys in
2003 we documented 289 episodes of acute illness,
including 69 episodes of malaria. The number of chronic
conditions (e.g., diabetes, hypertension) reported was
small, and these cases are not considered here. Most of
the 289 illnesses reported to the eldworkers would be
classied as clinically acute conditions. Yet, in some
instances, as in the case of dental caries, the illness
lingered for months. Malaria was the most common
illness reported, accounting for 20 percent of all acute
illness episodes. The distribution of malaria cases by
month corresponds to the general seasonal pattern in
national data reported by the Ministry of Public Health
(Ministe`re de la Sante Publique, 2002). The number of
cases is highest in the rainy season, from June through
October, with an additional spike in December.
The strategy households used most frequently when
dealing with an episode of malaria was to purchase



No script
For prot



Govt facility Private medical facility

Private pharmacy

Unregulated sector
Source of treatment for malaria
Ofcial sector

Table 3
Sources of treatment for 69 episodes of malaria reported in Walia in 2003

healer or

Drug sellers

No script


Family stock one
or friends


L. Leonard / Social Science & Medicine ] (]]]]) ]]]]]]

pharmaceuticals in the market without consulting a

practitioner or obtaining a prescription (see Table 3).
As shown in Table 3, the use of herbal medicines for
malaria is rare; thus, the terms pharmaceuticals,
medicines, and drugs are used interchangeably to refer
to manufactured or synthetic products. Drugs were
purchased in the market in 68 percent of the episodes
documented. A practitioner was consulted in 30 percent
of the episodes. Practitioners in the ofcial sector were
consulted in 10 of the 69 episodes, or under 15 percent of
the time. This level of use of ofcial health services is low
relative to other endemic regions (McCombie, 1996).
Consultations in government facilities were particularly
rare; only two people sought treatment at a public
facility. Private, non-prot facilities were consulted more
frequently than either government or for-prot clinics.
Only one household accessed care at a private, for-prot
facility. Practitioners who worked out of their homes
were consulted more frequently than practitioners in the
ofcial sector. Three cases of malaria were treated with
roots, leaves, or herbs; however, these treatments were
always used in combination with other drugs.
The categories of practitioners and sources of care
presented in Table 3 do not represent rm distinctions that
hold in practice, just as models of medical pluralism that
distinguish biomedicine from traditional or folk
medicine fail to account for the considerable interplay
between these groups (Cocks & Dold, 2000). For example,
household members reported paying market-based drug
sellers to inject them with medicines acquired elsewhere or
to come to their homes to provide treatment. The use of
herbal medicines, while not common, was reported as a
precursor or a complement to other types of therapy, and
drugs stored at home came from sources listed under other
headings in the table, but could not always be traced with
certainty to a particular one. The licensed practitioners
working out of their homes are generally government
employees who are retired or provide services on the side
while continuing to use public resources. Thus, these
categories overlap and intersect in ways not captured in the
divisions suggested by the table.
Whether or not a practitioner was consulted, none of
the household members who reported an episode of
malaria took curative therapies that would be considered adequate following national or World Health
Organization (WHO) treatment guidelines. For example, the recommended dosing for treatment of malaria
with chloroquine is 25 mg base/kg divided over 3 days
(Bloland, 2001; Programme Nationale de Lutte Antipaludique, 1993). Typical treatment regimens reported
by household members consisted of several 100 mg
tablets of chloroquine taken at once or in a single day.
Less frequently household members reported receiving
one or two injections of quinine over as many days. This
falls far short of most recommended formulations,
which require the administration of much larger doses


L. Leonard / Social Science & Medicine ] (]]]]) ]]]]]]

Table 4
Household patterns of treatment seeking for malaria versus other acute illnesses
Characteristics of treatment seeking

Malaria Other acute illnesses

Number of illness episodes reported

Percentage of illness episodes in which a health care practitioner was consulted
Percentage of illness episodes in which a health care practitioner in the ofcial sector was consulted
Percentage of illness episodes in which medication was taken in the week the illness was reported


of quinine over a period of 7 days (Bloland, 2001; White,

Many of the drugs taken were of questionable
efcacy, but not simply because they were acquired
through illicit markets. The national malaria control
program has documented levels of chloroquine resistance as high as 45 percent in the south of the country
(personal communication, PNLP). Clinic-based rates of
chloroquine treatment failure were estimated at 30
percent in 2002 (WHO, 2003), an increase of 20 percent
over the previous year and of nearly 65 percent since
1995 (Ministe`re de la Sante Publique, 2002). Cases of
treatment failure with sulfadoxine pyrimethamine,
which is reserved for use by hospitals when resistance
to chloroquine has been conrmed, have increased
nearly 60 percent since 1997. Similar trends in other
parts of Africa have prompted some governments to
switch to new, more effective combination therapies.
However, national drug policies and treatment guidelines in Chad continue to indicate the use of antimalarials that have lost much of their potency (PNLP,
Household patterns of treatment-seeking for other
acute illnesses are similar to those for malaria (see
Table 4). Of the 289 episodes of acute illness reported in
our surveys, 220 were attributed to illnesses other than
malaria. A practitioner was consulted in 58 of these
episodes, or 26 percent of the time. Use of the ofcial
health sector is low for any acute illness, and not just
malaria. Consultations in state-recognized facilities
occurred in less than 18 percent of the episodes of acute
illness not attributable to malaria compared to 15
percent of the episodes of malaria. For both malaria
and other acute illnesses, most household members took
medicines in the week the illness was reported; however,
household members were more likely to take medicines
for malaria than for other acute illnesses.
There are different pathways that lead to the patterns
of illness management shown in Table 4. Household
decision-making about treatment-seeking is complex,
and the reasons for self-medication and the use
of market-based drug vendors in response to an episode
of malaria vary across the households in our
sample. Three different pathways are illustrated in the
cases that follow.


Illness as its management: Abdou Ousmanes chronic

Abdou Ousmane4 is an elderly, widowed man who
reported episodes of malaria in ve of the 12 survey
weeks. The eldworkers nd visits to Mr. Ousmanes
household difcult, in that the old man is frequently
without company, has nothing to eat, and has no one to
assist him with small errands and household chores.
When he talks about his illnesses these themes occupy a
prominent place in his narratives. Once, for example, he
fell ill with malaria after taking a cold bath. The bath
was his rst in 4 days, and Mr. Ousmane told the
eldworker that he went to the well himself to fetch his
bath water because his son, Idriss, was in NDjamena.
Twenty-two-year old Idriss lives with his father, but
makes frequent and extended trips to the city, leaving
the old man on his own. Three grandchildren also come
to stay from time to time when their mother, Mr.
Ousmanes daughter, brings them from the city. Mr.
Ousmane linked the onset of other episodes of malaria
to waking in the middle of the night and walking
outdoors because he heard noise and thought a thief
might be in the concession; going out in a rainstorm to
secure the covering over his latrine; and being run down
from having nothing to eat.
Mr. Ousmane, who is in his 70s, has no income of any
kind. Too old and too ill to work, he survived for a time
by selling his possessions; his mattress was one of the
last items he sold, just after we met him in 2002. At
present, he relies heavily on his children, grandchildren,
and neighbors to bring him food and small amounts of
money for soap, tea, and medicines. Each time Mr.
Ousmane reported a case of malaria he used the small
sums of cash that he had available, usually ranging from
100 to 500FCFA, to buy drugs in the market. Once, his
son spent 6000FCFA, of which 1000FCFA was taken
on credit, when Mr. Ousmane was sick for six days. That
time the tchoukou came to their house and gave the old
man 600 mg of quinine mixed with vitamin A by IV for 2
days, as well as 480 mg tablets of Bactrim Fortes and

The names of all household members have been changed.

L. Leonard / Social Science & Medicine ] (]]]]) ]]]]]]

500 mg tablets of paracetemol for the same number of

On the other occasions, his therapies consisted of
chloroquine and paracetemol taken orally in variable
doses. In July, for example, he reported a headache and
dizziness the morning after he had gone out checking for
thieves. Because his son was away, he described forcing
himself to walk to the market, where he bought four
500 mg tablets of paracetemol and one 100 mg tablet of
chloroquine. When the eldworker visited Mr. Ousmane
later that same day, the old man said that he did not feel
well despite taking all of the tablets; he was able to stand
up, but he could not see farther than 10 m away. The
following month, Mr. Ousmane again reported an
episode of malaria. When the eldworker visited him
the following week, he said he had not seen his son in 10
days and had been bed-ridden for the entire week after
going out in the rain to check on the roof of his
outhouse. His daughter had come for a visit earlier in
the week and had brought him 4 kg of our and
500FCFA, which he used to buy six 100 mg tablets of
chloroquine in the market. He had taken all six tablets in
1 daytwo each in the morning, at noon, and again at
nightbut reported no change, and wondered if it was
not because he had not been eating well. In November,
during Ramadan, Mr. Ousmane reported another
episode of malaria. This time his son bought four
100 mg tablets of chloroquine and four 500 mg tablets of
paracetemol in the market, which he took in two equal
dosesone in the morning and one at night. The
following day he felt better; his fever had abated, but he
was still dizzy. In December, however, he was sick again
with fever, chills, and a headache. Periodically he went
outside to sit in the sun but could not warm up, and
spent nearly three days in bed. When a cousin came for a
visit he gave Mr. Ousmane 100FCFA to buy paracetemol.
It is unclear whether any of the illness episodes
reported in this case were clinical cases of malaria. Over
the 1-year period in which these interviews were
conducted Mr. Ousmane never saw a health care
practitioner or underwent diagnostic testing of any
kind. Certainly some of the old mans symptoms suggest
the possibility of other problems. In fact, practitioners
working in ofcial health facilities reported that even
when patients seek their services diagnostic tests are used
infrequently. This is because they lack equipment; their
equipment is not functioning; the electricity supply is too
irregular; or because, given patient loads, routine testing
and follow-up is not feasible. Only six of 69 episodes of
malaria were clinically conrmed, though 21 people
consulted a practitioner, and 15 of them were over the
ages for which symptom-based, presumptive treatment
is recommended (Chandramohan, Jaffar, & Greenwood,
2002; Nicoll, 2000). One patient who received care at a
government facility reported receiving a blood test for

malaria, as did two patients who received care in a

recognized private facility. Three of the six tests were
provided by moonlighting or retired government employees; in two of these cases the tests were conducted at
government facilities, but were offered to the household
members as part of a side practice. In endemic regions
the propensity to label any febrile illness as malaria is
well documented; however, some studies show that
household perceptions of malaria accord well with
clinical diagnoses (von Seidlein et al., 2002). At the
same time, diagnostic ambiguity and the indiscriminate
use of cover terms are themselves symptomatic of a
particular organization of care. In this sense, whether
Mr. Ousmane suffered from malaria or from some other
illness or combination of illnesses matters little to the
arguments made here.
The patterns of illness reporting and treatmentseeking that surface in Mr. Ousmanes narratives show
how illness, including a clinically acute problem like
malaria, can be experienced as a persistent presence and
not as a time-delimited phenomenon in low-income
households. More than this, they show that Mr.
Ousmanes illness is recognized and reported at key
momentswhich correspond to times when money is
available in the household. When cash becomes available Mr. Ousmane or his son are able to purchase small
amounts of paracetemol or chloroquine to tamp down
the old mans symptoms. The symptoms of illness might
temporarily recede following these treatments but there
is never the sense that Mr. Ousmane has been cured.
Thus, in some important sense, the ability to take
therapeutic action becomes constitutive of illness, and
the reporting of illness is contingent upon the households ability to buy health. When money is not
available, illness is simply absorbed into the experience
of everyday life.
We see evidence of this in our household surveys,
which are characterized by low levels of illness reporting.
For instance, in our rst 16-week round of consecutive
weekly surveys in Walia, a total of 174 episodes of acute
illness were reported. Fully 60 percent of the household
members reported no illness at all in this timeframe.
Households report almost no clinically chronic conditions in our surveys despite widespread evidence of the
growing burden of chronic illnesses in low-income
countries (Murray & Lopez, 1996). We have argued
elsewhere that the low levels of illness reporting and the
virtual absence of chronic conditions cannot be interpreted as evidence of the health of Chadian households
(Leonard, 2003). Rather, in populations like this one,
which are characterized by short life expectancies, high
rates of infant and child mortality, and chronic food
shortages, these patterns of household reporting reect
the way that health services are organized and care is
dispensed. This results in people putting up with
conditions that would be notable elsewhere.

L. Leonard / Social Science & Medicine ] (]]]]) ]]]]]]

money, one can buy a reprieve from ones symptoms: in

most of the 69 episodes of reported malaria household
members were buying a few tablets of chloroquine or
paracetemol or some other drug that worked when
used in the past. As in the case of Mr. Ousmane, this
makes it possible to go on, though not to be free of the
problem. Over time, the patterns of illness reporting and
treatment seeking that emerge from our surveys suggest
that low-income households use intermittent underdosing or therapeutic half-measures to keep illnesses
under control. Rather than suggesting the absence of
morbidity, the low levels of illness reporting that
characterize our household surveys are thus indicative
of the inability to attend to discomforts that might
elsewhere be cause for therapeutic intervention.

Table 5 shows the households reported revenues and

expenditures for the survey weeks. Over the 12 survey
weeks Idriss reported sporadic income earned as an
assistant carpenter. He earned money in four of the 12
weeks covered by our surveys in amounts ranging from
3000 to 7500FCFA. The only other household revenues
reported during the survey weeks came from occasional
small gifts and from credit taken in the form of cash. No
revenues were reported in the survey weeks that fell in
the last 6 months of the year, and in the weeks covered
by our surveys household expenditures far surpassed
income. Because our follow-up interviews occurred the
week after our household surveys, not all of the revenues
and expenditures described in Mr. Ousmanes therapeutic narratives appear in the table.
In Mr. Ousmanes household, expenditures on health
care represent nearly 20 percent of spending in the
survey periods, and 36 percent of the households
reported revenues. Most of the households spending
on health care was in response to Mr. Ousmanes
illnesses. For low-income households like this one, the
costs of seeking care in the ofcial health sector
represent an extraordinary outlay of cash that can
rarely be made. The xed costs of seeking care at a
health center are approximately equal to the average
daily expenditure on food of 400FCFA: user fees are
200FCFA in health centers; a health book is 100FCFA;
and chloroqine is 10FCFA per tablet, or roughly
150FCFA for a complete curative dose. The cost of
care is higher when diagnostic tests, additional prescriptions, transportation costs, return visits for therapies
that are not successful, and other, unpredictable,
chargesdiscussed in more detail laterare added.
When low-income households bypass the ofcial
sector and seek treatment in the market it is to obtain
reliefsoulagementand not a cure. For small sums of

There are also cases when illness escapes this type of
management regime, presents as a crisis, and intrudes
upon life to such an extent that it simply cannot be
ignored. This occurs when households operating in
subsistence mode are unable to engage in the kind of
maintenance dosing that, while stopping short of curing
household members, is frequently able to keep illnesses
under control. I illustrate this with the case of the
Tadjibeye family and 7-year-old Sagina, who died
following a reported episode of malaria.
Ngaralta Tadjibeye and his wife Hortence had four
children; Sagina, who was seven when he died, was their
youngest. The Tadjibeyes house, which they rent for
2000FCFA per month, is located just off the main road
that cuts through Walia, down a steep embankment
from the bottom of which passing trafc can still be seen

Table 5
Reported expenditures for the Ousmane household by category and survey period







Health care


Tea & sugar

















L. Leonard / Social Science & Medicine ] (]]]]) ]]]]]]

and heard. The roadway is the source of the familys

livelihood. Ngaralta repairs tires for a living and spends
the better part of every day along the side of the road
waiting for someone to experience a at. Hortence brews
millet beer and sells it to travelers and neighborhood
customers in one of many roadside cabarets. Income
from these activities is sporadic; on slow days the family
often has nothing to eat.
Sagina fell sick in the middle of the dry season in 2003.
His father reported that he had a fever and no appetite
and that he refused to eat anything. After 2 days, during
which Sagina did nothing but lie on a mat on the
ground, Ngaralta went to the market and bought some
medicines for him, including tablets of Bactrims,
paracetemol, and chloroquine. After a few days of
taking these medicines Sagina seemed to get better, and
for 2 days in a row he got up and went out to play with
his friends. But after this short reprieve, Sagina fell sick
again, and this time his parents knew the case was
serious. Their son could not speak and his father
described his chest as blocked. He took Sagina to
see a retired nurse who lives in Walia and sees patients
out of his home. The nurse gave the child an injection of
quininehalf of a 600 mg vialand cough syrup, and
charged Ngaralta 1250FCFA for the consultation and
the medicines. As Ngaralta was leaving the nurses house
he decided to take his son to see a voyant, who also lives
in Walia, to see if he might be able to provide some help.
The voyant, who charged Ngaralta 100FCFA for the
consultation, said that a sorcerer had put a brick on
Saginas chest and that because his parents had waited
so long to bring the child to him, it was going to be
difcult to do anything. However, if Ngaralta paid
20,000FCFAa sum the family could not hope to earn
in many monthsthe voyant said he would do his best
to try and remove the brick. Having used all of his
resources already, Ngaralta could do nothing except
bring his son home. The following day, at 4:00 in the
morning, Sagina died, and his parents had to borrow
3000FCFA for the burial.
When illnesses present as crises, households often
appear to have acted in ways that are irrationalin this
instance, doing nothing for a couple of days, buying
drugs on the local market, or consulting a voyant.
However, behind these acts are economies that are so
tenuous that any substantial pre-crisis intervention is
almost unthinkable. In households, like the Tadjibeyes,
that are barely eking out a living, taking action any
sooner than is absolutely necessary puts the entire family
at risk. In fact, Ngaralta discussed this trade-off directly
in recounting the events that led up to Saginas death.
One of the ideas behind the primary health care
movement, which was to be operationalized in Chad
through the creation of a network of health centers that
provide basic care and low-cost medicines, was to
eliminate the need for these types of calculations by

creating a safety net for households living at the margins

of sustainability. Because this net does not function for
very low-income households even where health facilities
exist, these households have to take the chance that the
illness will pass and the child will get up and play again
after a few days rest, and, failing that, that the child will
be restored to a measure of health after taking some pills
acquired in the market.

Uncertain resources, uncertain results

Not all of the households in our sample are as cashstrapped as the Ousmanes or Tadjibeyes. Yet even
when cash is available we see that households rely
disproportionately on unregulated sources of care to
treat acute episodes of illness. The Koumadji household
is a case in point. The household, which is comprised of
14 members, is headed by Raphael Koumadji, a man in
his 60s, and his wife Pauline, who is approximately 10
years younger. Five of the Koumadji children live in the
household, as does Paulines older brother and his wife.
Several of the Koumadji children are married; their
spouses and children are also household members, along
with two children sent by relatives to continue their
studies. No one in the household has salaried employment, but most adult members conduct remunerative
activities. Mr. Koumadji grows millet and rice and
works as a butcher in the dry season. His brother-in-law
repairs radios, one of his sons works as an electrician,
and the women sell beignets and fried sweet potatoes.
The Koumadji family owns their house and reports a
few other assets, such as a radio, a bicycle, and seven
Table 6 shows revenue and expenditure data for the
household for 11 of the 12 survey weeks; no data could
be collected from the household in the fth survey week.
The household reported revenues in every week that we
interviewed them, although these revenues varied substantially from week to week. In all but three weeks of
the surveys, the household reported more revenues than
expenditures, but revenues in the early part of the year,
when the household harvested and sold rice, were
signicantly higher than in later months. The household
spent money to hire people to help in Raphaels elds
and to pay for school fees and supplies. Otherwise, the
spending categories are the same as those reported in
Abdou Ousmanes household. Food represents the
largest category of expenditure, but health care ranks
much lower as a category of expenditure than in the
Ousmanes case.
During the survey periods, two cases of malaria were
reported in the Koumadji household. Benjamin, who
was 33 and is Raphael and Paulines oldest son, fell ill in
April. Benjamin reported that his head ached, and by

L. Leonard / Social Science & Medicine ] (]]]]) ]]]]]]


The decisions made by the Koumadji household

involve more complex calculations than in the previous
cases, where the households precarious nances virtually precluded access to care, apart from occasional
purchases of small quantities of medicines in the market
or crisis-driven interventions. The availability of cash in
the Koumadji household at the time of an illness episode
also inuences the kind of care that is sought.
Benjamins episode of malaria, for example, occurs
early in the year, after the harvest and sale of rice, when
household revenues are higher than at any other time. In
contrast, Fideles case occurs at a relatively lean time of
the year, after the household has invested in planting
rice and millet elds, when food prices are highest, and
when children are returning to school. But the availability of cash is not the only determinant of the patterns
of treatment seeking we observe in this household. The
household recognizes a difference between ofcial and
other sources of care, but this difference is not as stark
as the rhetoric about the dangers of self-medication
suggest. Paulines decision to take her son to the health
center when he initially fell ill can be read as evidence of
a degree of trust in the expertise available at that
institutiondespite the lack of diagnostic capabilities
discussed earlier. However, this trust has real limits.
Once the health center provides conrmation that
Fideles illness is indeed a case of malaria, the household
makes decisions about how to treat him and uses
different sources of care almost interchangeably. In the
sections that follow I try to establish the basis for the
households actions, focusing on two dimensions of care:
the pharmaceuticals used to treat malaria and other
illnesses and how these products circulate, and the ways
that therapeutic regimens for malaria are constituted
whether or not households therapeutic itineraries
include contact with a health care institution.

evening he had developed a fever that kept him awake

through the night. In the morning he went to see a
neighbor who is a physician and sees patients out of his
house. The physician, who works in a government
facility at some distance from Walia, took a blood
sample and later told Benjamin that the test he
conducted at his workplace showed that he had malaria.
The physician treated Benjamin with injections of
quinine over a period of 4 days. Raphael and Pauline
paid 4000FCFA for the treatment, including 2500 for
the medicine and 1500 for the consultation.
Months later, in a week not covered by our surveys,
Benjamins younger brother Fidele fell ill. The family
later reported that Pauline took Fidele, who was 13, to
the church-run health center in Walia because he was
vomiting and had a fever. The nurse diagnosed Fidele
with malaria without any tests and gave his mother a
prescription for medicines that the family later reported
they had not been able to ll, and that had been lost by
the time the eldworker collected information about
Fideles case. Instead, Fidele was treated with a few
pills of chloroquine and paracetemol that the family had
in stock. After taking this treatment, Fidele seemed to
get better. However, when the eldworker came to the
household shortly after these events to conduct the 10th
weekly survey, Fideles mother reported that he had
fallen sick again after walking under the hot sun. This is
when Fideles episode of malaria was rst picked up by
our surveys. Fideles fever had returned, he had begun
vomiting again, and his urine had turned dark yellow.
For two days, Fidele had been unable to go to school or
leave his bed. During this time Raphael went to the
market and bought two vials of quinine (600 mg) for
1500FCFA. A neighbor who is a student in medical
school was called upon to administer the injections over
a 2-day period.

Table 6
Reported expenditures for the Koumadji household by category and survey period





Tea & sugar

Hired labor















Health care






School supplies









L. Leonard / Social Science & Medicine ] (]]]]) ]]]]]]

From the pockets of their white coats

No pharmaceuticals are produced in Chad. Medicines
come from the governments essential drug program or
are privately imported, primarily from European countries, Cameroon, India, Nigeria, and South Africa. The
government supplies only public and non-prot health
care facilities with generic drugs through the essential
drug program. The prices of these drugs are set by the
national pharmacy, with the idea that low-cost medicines will facilitate patients access to care, and that the
small mark-ups permitted on their sale will allow health
care institutions to become self-sustaining with regard to
their pharmaceutical supply (Beleyo, 1998). Private
pharmacies carry brand name drugs and specialized
medicines not included on the list of essential drugs.
These medicines are acquired through commercial
importers, ranging from a large pharmaceutical supply
house to individuals who smuggle products from Nigeria
and Cameroon across the border.
In practice, the pharmaceutical market is much more
uid than this. The circulation of generic drugs
illustrates this uidity well. Generic medicines acquired
through the essential drug program are widely available
in local markets. Health care workers are a major
supplier of these pharmaceuticals to market-based drug
vendors (Ngartelbaye, 2004). The misappropriation of
public sector pharmaceuticals has been documented in
other settings where underpaid health workers rely on
their sale to supplement wages that fail to cover the basic
costs of living (McPake et al., 1999). In Cameroon, for
example, van der Geest (1987) estimated that state
agents siphoned off approximately 30 percent of the
pharmaceuticals destined for the public sector in the
southern part of the country. It is difcult to assess the
scale of trafcking in public sector medicines that occurs
in Chad. However, to gauge the possible magnitude of
these transfers we worked with a market-based drug
vendor to record all of his transactions, including sales
and purchases from all sources, from January through
June of 2004. The experiences of one individual cannot
be taken as representative, in a statistical sense, of drug
sellers in the city. However, we chose a vendor who
worked in one of the citys major markets and who was
typical of market-based drug sellers in terms of size of
inventory and volume of clients.
During the 6-month period the vendor purchased just
over $2000US in pharmaceuticals: 58.3 percent of his
purchases were from wholesalers, 32.3 percent were
from health care personnel, and the remaining 9.4
percent were from individuals. The latter category
includes people who re-sold unused portions of previously purchased medicines. Many of the medicines the
vendor purchased from health workers were generic
drugs that had been pilfered from the workplace in small
quantities. For instance, some of the entries made for


purchases from health care workers included ve gauze

wraps ($1.36); a box of 100 tablets of amoxicilline
($5.77); 20 vials of oxytocine ($3.37); and nine vials of
glucose serum ($16.36). Health workers also sold
medicines to the vendor that were marked as medical
samples, including samples of the new combination
drugs for malaria being tested in Chad on a limited scale
as part of a Medecins Sans Frontie`res (MSF)-afliated
research project.
Health care workers misappropriation of medicines
exacerbates shortages in health centers. Because of the
scarcity of medical supplies household members are
often asked to shoulder additional costs for care. During
an observation conducted at a public facility the
eldworker noted that women attending gynecological
and pre-natal consultations were each taxed 300FCFA
for gloves the midwives purchased because the center
had none. In other instances, patients were turned away
at the pharmacy because medicines were unavailable, or
were directed to commercial pharmacies or illicit drug
sellers to purchase products that the pharmacy did not
carry or have in stock. The excerpt that follows comes
from an observation conducted at a government facility:
The pharmacist is a woman. She went out for a while,
leaving her assistant, who does not appear to be very
cooperative, in charge. Two clients showed up. On
one of the prescriptions there is a note indicating that
they are suffering from an infection. The assistant
told him that they dont have Brufens, only ampicilline.5 The patient left with his prescription. A couple
of minutes later a bunch of patients are in line. One
patient slides his health book through the window
just to know the price of the medicines that were
prescribed for him. It was paracetemol, Indocides,
and one other medicine. A woman came with a baby
on her back. In her health book there was a
prescription for Orasel. The assistant told her that
they dont have any and that she should go buy it
under the nimier [a tree located outside the facility
where tchoukous sell their products].
Health workers not only sell medicines to drug
vendors, they also purchase pharmaceuticals from them.
This excerpt raises multiple questions about quality of care
that cannot be addressed in this paper. Brufens, for example, is
an analgesic and anti-inammatory (ibuprofen is the active
ingredient) manufactured in South Africa. It is not on the
essential drug list (though ibuprofen is) and thus is not available
in a public sector facility like the one where this observation was
conducted. Ampicilline, the drug the pharmacist implies might
be a substitute for Brufens, is an antibiotic. From our
observational data it is unclear what type of infection the
patient had, why the clinician would prescribe Brufens for an
infection, or why the clinician would prescribe non-generic
products that are not available in the facilitys pharmacy.


L. Leonard / Social Science & Medicine ] (]]]]) ]]]]]]

These products are in turn sold to patients in health care

facilities. Health care workers purchased $1104US in
pharmaceuticals from the drug seller we worked with in
the 6-month period covered by our records. This
compares to the $2383US spent by individual patients,
with and without prescriptions. The products health
care workers purchased included medical supplies like
syringes, gloves, gauze bandages, and alcohol. However,
they also included virtually every class of drug from
anti-malarials to antiretrovirals. Stories of health care
workers propositioning patients with pharmaceuticals
from the pockets of their white coats are pervasive.
The picture that emergesof itinerant health
care workers hawking pharmaceuticals that have circulated through the open market in the corridors of health
care facilitiesblurs the distinctions between ofcial
practitioners and illicit pharmaceutical sellers that
warnings about the dangers of self-medication seek to

Health for sale

Another reason households bypass ofcial practitioners and resort to market-based care is that the ways
therapeutic regimens for malaria are constituted have
more to do with the resources available to the patient
than with what is clinically indicated, whether or not
care is sought in a recognized facility. Abdou Ousmanes
case shows how the availability of cash determines the
composition of therapeutic regimens purchased in the
market. The low-income households in our sample
systematically responded to episodes of malaria by
using smaller and shorter doses of medicines than are
clinically recommended. These therapeutic errors are
not the inevitable result of self-medication or the use of
market-based drug sellers, as is suggested in the
literature. In fact, we see the same types of therapeutic
regimens among household members who consult a
practitioner and use licensed facilities.
In conducting observations in health care facilities,
the eldworkers repeatedly noted incidents where
patients were unable to obtain prescriptions due to a
lack of money, or where patients asked the pharmacist
to ll partial prescriptions. Practitioners sometimes tried
to help their patients by prioritizing medications for
them or indicating which were absolutely necessary and
which were less so. The eldworkers also recorded
exchanges where patients negotiated the price of services
with practitioners based on their ability to pay.
These exchanges, like the one below between a nurse
at a non-prot health center and a woman whose child
was ill, often came with admonishments about selfmedication or the failure to use preventive measures, or
more general advice (in this case about responsible

parenting) that entirely obscured institutional complicity

in the illness management regimes of the poor:
A woman brought her child. He was lying down since
last Sunday evening. The nurse asked if the mother
had given her child medicines. The mother said she
gave him one tablet of Nivaquine. The nurse said,
He has been sick for a week and he has only taken
one tablet? The nurse asked, Do you have a
mosquito net at your house? The woman said she
did. The nurse told her to go pay 1,000 FCFA for an
injection for the child. She asked the woman how
many children she had. The woman said she had four
children. The nurse gave her the advice that four
children were enough. The woman said she only had
500 FCFA and not 1,000 FCFA. The nurse told her
to go give the 500 FCFA and get the injection.
Inside and outside health care facilities we see
evidence of what Whyte (1992) referred to as the
indigenization of professional practitioners. Using
Kleinmans (1980) sectoral framework, she described
how the implosion of the public health sector in Uganda
in the 1970s and the subsequent privatization of care led
to changes in social relations between practitioners and
their patients that minimized distinctions between
workers in the ofcial sector and practitioners of folk
medicine. One of the ways that professionals began
acting more like folk practitioners was in tailoring their
treatments to suit customers ability to pay. In Benjamin
Koumadjis case, for instance, the neighborhood physician provided an abbreviated version of what he
elsewhere reported as the recommended treatment for
Apart from the essential drug program and special
vertical programs for AIDS-related drugs and childhood
vaccines, there are no programs to provide free or more
heavily subsidized medicines to the poor in Chad. In the
vast majority of the households we follow purchasing
power is low and income is sporadic and unpredictable.
This means that if prescriptions are acquired they can
rarely be followed. If care is driven by what households
can afford to spend, rather than what is therapeutically
indicated, institutional directives in the form of prescriptions offer households little advantage over marketbased care.

The data presented in this paper capture household
strategies for managing illness at a moment when the
public health system in Chad is under tremendous strain
and few alternative sources of care are available. The
moment is an especially important one in which to
document the experiences of low-income households

L. Leonard / Social Science & Medicine ] (]]]]) ]]]]]]

because the development of Chads oil industry has been

presented as the key to changing all of this. Under a
World Bank-brokered agreement, a proportion of the
revenues from three major oilelds in the south of the
country is to be invested in social service sectors of the
economy, including health (Uriz, 2001). In framing the
oil project as a development initiative, the oil companies,
the World Bank, and the government of Chad are
claiming that oil-related investments have the potential
to change the current organization and delivery of
health care servicesfor example, by expanding access
to public sector services and improving the quality of
care provided in these institutions. While 2004 is the rst
year in which oil revenues have been made available to
the Ministry of Public Health, there has so far been little
debate about what kinds of policies and programs the
government should pursue, or what types of investments
would make a difference for households like those that
we follow.
Our data show that a large part of the demand for
health care in urban Chad is met by unregulated markets
for pharmaceuticals. The proliferation of these markets
has been depicted as the outcome of the inability of the
state to provide services or to provide them efciently or
in ways that make patients comfortable with the receipt
of institutionally based care (Somse et al., 2000). These
arguments present only part of the picture. They fail to
recognize how the operations of the ofcial and
unofcial sectors are mutually sustaining (van der Geest,
1982, 1987; van der Geest, Whyte, & Hardon, 1996). For
instance, on the one hand, low public sector salaries
push health workers to engage in the trafcking of
pharmaceuticals in order to make a living. This results in
the extension of the illicit pharmaceutical market to the
ofcial health sector, but in ways that are often
inefcient and unpredictable: drugs might not be
available, extra, unofcial charges might be levied, and
patients might have to negotiate with individual
providers over the cost of care. On the other hand, the
availability of low-cost, public-sector medicines in the
market means that unregulated drug markets can absorb
some of the demand for care that the resource-strained
health sector cannot accommodate. Thus, the current
structures of care in Chad produce the conditions that
allow for the proliferation of illicit markets for
pharmaceuticals, but they also depend on these markets
in order to function.
One response to these developments has been to
propose that market-based drug vendors be included in
training programs, educational campaigns, and other
public health efforts to promote more rational prescribing practices (Ross-Degnan et al., 1992; Somse, et
al., 2000; Whyte, 1992). Others have advocated the
enforcement of local statutes regulating the sale of
pharmaceuticals, or have called for educational campaigns to inform the population of the hazards of


purchasing medicines in this manner. These strategies,

while practical in the immediate, remove institutional
and organizational structures and the ways in which
they are implicated in the development and growth of
illicit pharmaceutical markets from view. If the health
care needs of households like the Ousmanes, the
Tadjibeyes, and the Koumadjis could be accommodated through ofcial channels it is not clear that we
would see the same patterns of treatment seeking that
our study now shows.
I have argued that it is erroneous to read households
heavy reliance on unregulated drug markets as simply a
matter of convenience or comfort, although these
markets are structured in ways that make them more
accessible and more responsive to patients demands for
care than ofcial institutions (Whyte, 1992). In the same
way, blaming the poor for failed treatments, the spread
of disease, and growing drug resistance obscures the
ways that institutions, evenor perhaps especiallyin
their absence, direct the therapeutic itineraries of lowincome households. Even though the government is
largely absent from the day-to-day delivery of health
services in Chadas evidenced in the number of
functioning public sector institutions, even in the urban
context, and in the small number of household members
that use themthe state is deeply implicated in the
patterns of treatment seeking we recorded.
The proliferation of illicit pharmaceutical markets
and households reliance on these markets for care are
part of a particular institutional and organizational
assemblage, though they are not commonly analyzed in
this way. The growth of illicit markets and their
importance in the therapeutic quests of the poor have
not occurred independently of the ofcial health sector
or as something apart from it. Rather than representing
a parallel structure or an alternative to existing
institutions, illicit markets are an integral componenteven an outgrowth or an extensionof the
current constellation of services. Our surveys show
how health care in such a context becomes a good of
the marketplace rather than a public good (Waitzkin &
Iriart, 2001). In the absence of some minimal threshold
of care available to all, illness becomes a condition that
people can afford to attend to, and therefore one that
low-income households are often obliged to ignore.

I am grateful to a number of institutions for providing
the grants and awards that have allowed me to sustain
the longitudinal study described in this paper. The
funding sources for this project include the Center for a
Livable Future at the Johns Hopkins University, a New
Century Scholars Award from the J. William Fulbright
Foundation and the Council for the International


L. Leonard / Social Science & Medicine ] (]]]]) ]]]]]]

Exchange of Scholars (CIES), the WHO/TDR program,

a Faculty Innovation Award from the Johns Hopkins
University, and the Health, Environment, and Economic Development (HEED) program of the Fogarty
International Center and the National Institutes of
Health. I received helpful comments on earlier drafts of
this paper from Jishnu Das, Veena Das, Ranendra Das,
Joshua Garoon, Siba Grovogui, and James Williams. I
am particularly thankful to my colleagues in Chad,
especially to Tangar Noumassei who has been a part of
this project from the beginning, and to all of the families
in Walia and our other research sites for their
generosity, warmth, and friendship.

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