QR82. M8 Ed5 
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G365787 THE BALME LIBRARY
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SPATIAL PATTERNS OF MYCOBACTERIUM ULCERANS 
INFECTION (BURULI ULCER) IN THE AKWAPIM SOUTH
DISTRICT
BY
OHENE KESSON EDMUND
A THESIS SUBMITTED TO THE DEPARTMENT OF 
GEOGRAPHY AND RESOURCE DEPARTMENT, 
UNIVERSITY OF GHANA, LEGON, IN PARTIAL 
FULFILLMENT OF THE REQUIREMENTS FOR THE 
AWARD OF THE MASTER OF PHILOSOPHY (M.PHIL)
DEGREE
AUGUST 2001
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Dedication
I dedicate this work to my brother-in-law Mr. John Opoku, Miss Evelyn Ohene 
Kesson and other brothers and sisters for their immense contribution towards my 
education. May the Lord bless you.
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Declaration
I, Ohene Kesson Edmund hereby declare that except where references were 
duly cited and acknowledged, this document is an outcome of my own research 
initiative supervised by Naa Professor John. S. Nabila and Dr. S. Agyei-Mensah. It 
has neither been presented in whole or in part to any examining body for another 
degree.
Signature :..........................................................................
Candidate : Ohene Kesson Edmund
Date   i o S . ..... ......................%  ..........
Signature . /V  .
Principal Supervisor: Naa Professor John. S.Nabila
: .......Date
Signature
Co-Supervisor : Dr.S. Agyei-Mensah
.........Date
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Acknowledgement
I thank the Lord Almighty for His divine care and seeing me through this stage 
of my academic career. I owe a special debt of gratitude to my supervisors, Naa 
Professor John. S. Nabila and Dr. S. Agyei-Mensah for their guidance, advice and 
comments throughout the various stages of writing this thesis.
I am also grateful for the kindness and help offered by Dr. Frank Bonsu of the 
Disease Control Unit of the Korle Bu Teaching Hospital and Dr. Tinkorang, the 
District Director of Health Services, Akwapim South District. Others are Mr. D. K. 
Opare, the District Environmental Health Officer, Akwapim South, the health 
personnel at the Buruli Ulcer Dressing Centre at Pakro and the staff of the Disease 
Control Unit of the Ministry of Health, Nsawam. I am also thankful to Mr. Ebenezer 
Ntiri for his immense assistance during the fieldwork at Buokrom. Others who helped 
in this direction were the women’s leader at Tabankro, Madam Esi, and Yaw Asrabgo 
also of Tabankro and not forgetting all the chiefs or regents who granted permission 
for the exercise to take place in their communities.
My sincerest thanks also go to Dr. R. Koffie of the Council for Scientific and 
Industrial research Institute (CSIR), Accra, for his pieces of advise.
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Abstract
This study is about the spatial patterns of the Mycobacterium ulcerans 
infections (Buruli ulcer) in the Akwapim South district. The Triangle of Human 
Ecology model was used to account for the observed spatial patterns of the disease.
The spatial distribution of the disease was mapped through the residential 
addresses of the patients as shown in the district medical records. The endemic 
communities were stratified into three segments namely the high, low and non­
endemic areas or zones. The settlements for the study were then randomly selected 
from each stratum. This was proceeded by the selection of the target population 
according to the research objectives. Primary data were collected from three sources 
namely the household heads, Buruli ulcer patients and the health personnel 
(including the District Director of Health Services). Besides this, direct personal 
observation of the natural environment as well as interviews with certain individuals 
yielded primary information this study.
The study looked out for the magnitude of the problem, the underlying factors 
of the spatial patterns and the socio-economic impact on the populace. Children were 
found to be more vulnerable to infection than adults. Thus prevalence decreased with 
age with an overall slight female predominance in incidence. It was further 
discovered that the quality of the natural environment to a very large extent 
influenced the spatial variations of the disease. It was more prevalent along 
watercourses and low-lying areas but non-existent on high grounds with better 
drainage. This confirms the research proposition and findings elsewhere that the 
disease is more prevalent along water bodies.
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Low patronage of health care facilities influenced by the socio-economic status 
of the respondents and the skewed distribution of such facilities was observed to 
have contributed to the incidence of the disease in the communities. For it is believed 
that accessing a health facility for advice earlier could have lessened the scourge. 
Restricted access to health facilities thus varies from place to place and this reflects 
in the spatial patterns of the disease.
The disease, it was discovered had adversely affected the socio-economic 
lives of the patients themselves and their families due to prolonged treatment. This 
supports the fact by some scholars that prolonged treatment or hospitalization can 
bring untold hardships to both patients and their families.
Efforts by the health authorities in the district to check the spread of the 
disease were thwarted resource constraints. The study concludes that the disease is 
a socio-economic problem, thus recommendations have been made, which if 
implemented will reduce incidence in the future.
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Table of contents
Title
Dedication.......
Declaration... 
Acknowledgement...
Abstract...........
List of figures...
List of tables...
List of plates...
Page
i
ii
iii 
v 
xi
xi
xii
CHAPTER ONE:
1.0 RESEARCH PROBLEM AND CONCEPTUAL FRAMEWORK
1.1 Introduction... .........................................................
1.2 Statement of the problem... ..............................................
1.3 Literature review..........................................................................
1.3.1 Meaning of Buruli ulcer.....................................................
1.3.2 Clinical manifestation of Buruli ulcer................................
1.3.3 Mode of transmission........................................................
1.3.4 Spatial variation of the disease........................................
1.3.5 Consequences of the disease.........................................
1.3.6 Factors underlying spatial variation of diseases..............
1.3.7 Evidence of disease and the natural environment..........
1.4 Conceptual framework................................................................
1.4.1 Elaboration of the Triangle of Human Ecology model......
1
...1
...4
...12
...12
...14
...17
...18
...21
...23
...25
...27
...27
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1.4.2 Justification of the model for the study................
1.5 Research objectives.........................................................
1.6 Research propositions ...............................................
1.7 Justification of the study....................................................
CHAPTER TWO: 
2.0 THE STUDY AREA AND RESEARCH METHODOLOGY
2.1 Introduction.....................................................................
2.2 The study area .........................................................
2.2.1 Location and size...................................................
2.2.2 Vegetation..............................................................
2.2.3 Climate...................................................................
2.2.4 Topography and drainage... ........................
2.2.5 Soils and ecological zones....................................
2.2.6 Population..............................................................
2.2.7 Health facilities.......................................................
2.2.8 Water and sanitation..............................................
2.2.9 Structure of the local economy..............................
2.2.10 Economic activities... ...................................
2.2.11 Transportation network..........................................
2.3 Research methodology.....................................................
2.3.1 Sources of data......................................................
2.3.2 Research instruments and target population......................
vii
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...33
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...34
35
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...35
...35
...37
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...38
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...39
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...42
...43
...43
...43
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2.3.3 Sampling design and size... ...
2.3.4 Data analysis and presentation.......
2.3.5 Data limitations.................................
...46
...47
...44
CHAPTER THREE:
3.0 THE MAGNITUDE AND SPATIAL PATTERNS OF BURULI ULCER 49
3.1 Introduction... ...............................................
3.2 The magnitude of the problem..........................................
3.3 Risk factors and transmission dynamics... ...............
3.4 Geographical distribution of the disease... ...............
3.5 Observed demographic dimensions of Buruli ulcer patients..
3.5.1 Sex...................................................
3.5.2 Age......  ... ... ... ...
3.5.3 Occupation... ........................
3.5.4 Religious background of the patients
3.5.5 Marital status....................................
3.5.6 Educational background..................
3.5.7 Ethnicity............................................
3.5.8 Travel history of patients ...
Conclusion ...................................
...49
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...65
...66
...66
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...69
...71
CHAPTER FOUR:
4.0 FACTORS UNDERLYING THE OBSERVED SPATIAL PATTERNS 72
4.1 Introduction...  72
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4.2 Buruli ulcer and the natural environment.................................................72
4.3 Utilization of health services in relation to the incidence
of Buruli ulcer...........................................................................................75
4.3.1 Utilization and distance............................................................... 75
4.3.2 Ability to pay for health care........................................................81
4.3.3 Educational status and the utilization of health services by 
Households with respect to the incidence of the disease...........83
4.4 Lifestyles or behaviour and Buruli ulcer... ..................................... 91
4.4.1 Scarcity of drinking water and poor hygiene...............................91
4.4.2 Water contact activities that predispose the
population to infection.................................................................. 94
4.4.3 the role of health w o rke rs .........................................................96
4.5 Conclusion................................................................................................98
CHAPTER FIVE:
5.0 CONSEQUENCES OF BURULI ULCER INFECTION AND
STRATEGIES TO CHECK ITS SPREAD 99
5.1 Introduction... ......................................................99
5.2 Effect of the disease on the human body (Physical effect)................. 99
5.3 The stigma attached to the disease......................................................100
5.4 Effect on marriage... ...................................................................102
5.5 Effect on socio-economic activities...................................................... 103
5.5.1 Effect on education........................................................... 103
5.5.2 Effect on economic activities...................................................... 105
5.5.3 Impact on health resources.........................................................108
5.6 Strategies to check the spread of the disease... ..........................109
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5.7 Conclusion. .110
CHAPTER SIX:
6.0 SUMMARY, CONCLUSION AND RECOMMENDATIONS
6.1 Summary...........................................................................
6.2 Conclusion........................................................................
6.3 Recommendations... ..............................................
Bibliography... .........................................................
Appendices... .......................................................
112
...112
...114
...115
...122
...128
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List of figures
Figure 1.1: Spatial distribution of Buruli ulcer cases in Ghana.....................  7
Figure 1.2: The Triangle of Human Ecology... ................................... 28
Figure 2.1: Map of the study area..................................................................36
Figure 3.1: Spatial patterns of the Buruli ulcer in the
Akwapim South district....................................................................59
Figure 3.2: The sex distribution of the observed patients by residence.............. 61
Figure 3.3:The age distribution of the observed patients by residence...............62
Figure 3.4: Occupational distribution of the observed patients by residence... 64
Figure 3.5: The religious background of the patients by residence.................  65
Figure 3.6: Educational profile of the observed patients by residence  67
Figure 3.7: Ethnic background of the p a tie n ts .............................................. 68
Figure 3.8: Travel history of the observed patients by residence....................  70
Figure 5.1: Effects of treatment on education of patients................................ 104
Figure 5.2: Economic effects of Buruli ulcer infection... ............................106
List of tables
Table 1.1: Reported cases of Buruli ulcer cases in Ghana by
regions between 1993 and 1997... ................................... 5
Table 1.2: Number of districts reporting cases of Buruli ulcer
by regions in 1999...  6
Table 1.3: Sex distribution of Buruli ulcer cases by
regions in Ghana, 1999 ......................................................... 8
Table 2.1: Buruli ulcer endemic areas by sub-districts and reported cases
between 1998 and 1999 in the Akwapim South district............. 45
Table 2.2: Selected settlements and sample size for the study...................46
Table 3.1: Reported Buruli ulcer cases per district in the Eastern
region in 1999.............................................................................. 50
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Table 3.2: Some ten communities with high cases of the Buruli ulcer in the
Table 3.3:
Table 3.4 
Table 4.1 
Table 4.2 
Table 4.3
Table 4.4 
Table 4.5 
Table 4.6
Table 4.7: 
Table 4.8:
Akwapim South district.....................................................
Age and sex distribution of reported Buruli ulcer 
cases in the Akwapim South district between
August 1998 and March 2000 ...................................
Respondents’ perceptions on the cause of the disease
Utilization of health services by residence.......................
Respondents’ choice of medical treatment by residence... 
Responses on the time gap between infection and
first visit to a health facility... ...................................
Educational status of household heads by residence... 
Utilization of health services by education per household 
Knowledge of cause of the disease according to the 
educational level of household heads and patients
by residence.....................................................................
Knowledge of the cause of the disease by zone.............
Source of drinking water for communities as indicated by 
the patients according to residence.................................
. .  51
...52
...53
...77
...80
...82
...84
...86
...88
...90
...92
List of plates
Plate 1: Early ulcer... ...16
Plate 2: Late ulcer... ...16
XII
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CHAPTER ONE 
1.0 Research Problem and Conceptual Framework
1.1 Introduction
Buruli ulcer is an emerging disease caused by mycobacterium ulcerans (from 
the family of bacteria, which cause tuberculosis and leprosy). It brings about severely 
deforming ulcers, mainly in children and women who live in rural areas near rivers or 
wetlands. The disease in recent years, has become a significant source of human 
suffering in many parts of the world, especially in West Africa where there has been a 
large number of cases in the last ten (10) years (WHO, 1998; Asiedu, 1999). This 
situation finds expression in the words of the World Health Organisation's (WHO) 
Regional Director for Africa, that "the incidence of Buruli ulcer is rapidly growing in 
West Africa, and that almost all countries along the Gulf of Guinea are now affected" 
The disease has been reported in at least twenty-seven (27) countries around the 
world, mostly in the humid tropics (Asiedu, 1999). Currently, 25 percent of all 
infection end up with a permanent disability (WHO, 2000).
It is ranked as the third most common mycobacterium disease among humans 
after tuberculosis and leprosy (WHO, 1998; Asiedu, 1999). The World Health 
Organisation (WHO) estimates that the growing incidence of the disease in Africa will 
one day surpass the scourge of leprosy. In some regions, it already poses more of a 
health care problem than tuberculosis (WHO, 1998). For instance in an endemic area 
in La Cote d’ Ivoire, new cases increased more than threefold between 1987 and 
1991 (Marston et. al., 1995). Approximately ten thousand cases have been recorded 
since 1978 in Ivory Coast, and up to 16% of the population in some villages are
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afflicted (WHO, 1998). Over two thousand three hundred cases have been reported 
since 1989 in Benin, and in Ghana up to 22% of villages are afflicted in some areas 
(WHO, 1998). In addition to a large increase in new cases documented in Benin 
between 1986 and 1996, there has been an outward spread of the disease from 
initially restricted foci (Aguiar et. al., 1997). This suggests that the disease is more 
endemic in some areas than others.
Buruli ulcer most commonly affects poor people in remote areas with limited 
access to health care, poor transportation system and lack of potable water (Asiedu,
1999). The problem is particularly tragic because it is children who are the most 
vulnerable. It is difficult to assess the burden of the disease at the global and national 
levels. Therefore there is a huge under-reporting of it. This makes the reported cases 
seem like the tip of an iceberg (Johnson, 1999). Awareness of the disease is 
generally low in the medical community and the general public alike (WHO, 2000). 
Though the disease is dreadful, seeking medical care is delayed partly due to 
poverty, difficult geographic access to health facilities, attribution of the illness to 
superstition, low literacy level, stigmatisation and failure to make a diagnosis at the 
early stages. These factors combine to worsen affliction caused by the disease 
(Asiedu, 1999).
The disease apart from its medical implications has social, economic and 
cultural dimensions. The impact on health services and scarce health resources is 
great. The high cost of care can affect health institution's ability to recover cost. 
Complications are frequent and severe, and hospitalisation is prolonged and costly. 
Treatment cost per patient far exceeds per capita health spending.
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Socially, prolonged periods of hospitalisation can disrupt a child's schooling 
and the working lives of adults. A patient's income generating ability could be 
adversely affected. This in turn can affect the health and welfare of children in the 
family.
In the long-term, people deformed by the disease may be rendered 
unemployed and will have to depend on family members for sustenance. In the midst 
of the growing incidence of the disease and the associated complications, it could 
have adverse substantial effect on rural populations where it is very common. This is 
because their main economic activities would be severely affected.
Recognising Buruli ulcer as an emerging public health threat, the WHO in 
1997 established the Global Buruli Ulcer Initiative with the aim of raising awareness 
about the disease, mobilising support to assist endemic countries, promoting and co­
ordinating scientific research and bringing together all interested parties. In this 
regard, the WHO in 1998 held an International Conference on Buruli ulcer in 
Yamoussoukro, La Cote d’ Ivoire. Its aim among other things was to share 
information and further develop a global strategy for Buruli ulcer control and 
research. Heads of state, health ministers, scientists and representatives of 
international organisations attended the conference. Representatives from more than 
twenty (20) countries who attended the conference signed the Yamoussoukro 
Declaration on Buruli ulcer and pledged to control further spread of the disease. The 
remarks made by the then Director-General of the WHO that "we have an enormous 
task ahead as we begin the fight against this disease (Buruli ulcer)" underscores the 
gravity of the situation. Considering the gravity of the situation on hand, participants
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at the conference pledged to intensify action against Buruli ulcer as part of the 
primary health care, provide simple surgical facilities for the treatment of the disease 
in its early stages, and improve and sustain health education programmes at all 
levels. The initiative has so far focused on three West African states: Ghana, Benin 
and La C6te d’Ivoire (WHO, 2000).
It is worth noting that, before an individual can be adequately motivated to 
learn and accept better health practices, that person must appreciate a definition of 
existence of disease, evaluate such a disease as constituting a threat to personal 
and public well-being and take positive steps to alleviate such a threat. Unfortunately, 
most illiterates as well as some literate individuals do not believe that poor hygienic 
conditions can lead to an outbreak of epidemics, which can impact adversely on the 
population in terms of diseases. Diseases caused by insanitary conditions will be 
reduced if and when communities have enough safe water and practice good 
hygiene. This really poses a big problem to countries experiencing Buruli ulcer.
From the national situation of the Buruli ulcer, it can be concluded that the 
disease, if not checked now, will in the future pose a serious health threat to the 
Ghanaian society. It is against this background that this research focuses on the 
spatial patterns of the disease in the Akwapim South District.
1.2 Statement of the problem
The first case of Buruli ulcer in Ghana was reported at the Korle-Bu Teaching 
Hospital in Accra in 1971 (Bayley, 1971). Since then, cases have been described in 
riverine rural areas in the country. Ninety-six cases were described in the Asante
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Akim North District (van der Werf et. al., 1989) and ninety cases in the Amansie West 
District (Amofa et. al., 1993 & 1998). Thus the number of reported cases has been 
increasing since 1993, with its attendant socio-economic and health implications. 
Between 1993 and 1997,nearly two thousand cases were reported. Six of the ten 
regions and thirty-five of the one hundred and ten districts of the country were 
affected but the exact magnitude of the problem is not yet known. This points to the 
fact that the disease is emerging as a big threat to society and something ought to be 
done in order to reduce its incidence. Table 1.1 shows the reported cases of Buruli 
ulcer by administrative regions of Ghana between 1993 and 1997
Table 1.1:Reported cases of Buruli ulcer by regions between 1993-1997
Region 1993 1994 1995 1996 1997 Total
Ashanti 300 153 95 83 139 770
Central 25 58 82 112 89 366
Greater Accra 29 47 66 14 567 723
Eastern 11 - - 11
Volta 5 - - - 5
Brong Ahafo - 4 1 4 9
Western - - - - - -
Northern - - - - -
Upper West - - - - -
Upper East - - - - - -
Total 370 262 244 213 795 1884
Source: Ministry of Hea th, 199f
The situation as it was between 1993 and 1997 has changed significantly. 
Results of the National Buruli Ulcer Case Search, conducted by the Ministry of Health 
in 1999 showed an appreciable increase in the incidence and prevalence of the 
disease. Reported cases according to the survey results now stand at over six 
thousand. It showed an increasing geographical spread of the disease. Cases have so 
far been recorded in all the ten administrative regions. All but eighteen of the one
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hundred and ten districts in the country reported incidence of the disease (Ministry of 
Health, 1999). This is shown in Figure 1.1.
Table 1.2 shows the districts in Ghana reporting incidence of the disease 
according to the results of the National Case Search for Buruli ulcer, Ghana, 1999. 
This distribution as shown on the map (Figure 1.1) indicates a uniform regional 
distribution but not so at the district level.
Table 1. 2: Number of districts reporting cases of the Buruli ulcer per region in
1999
Region
Number 
of districts
Number
reporting
cases
Number
reporting
zero
cases
Number 
reporting 
less than 
5 cases
Number 
reporting 
5 or 
more 
cases
Ashanti 18 15 3 0 15
Brong Ahafo 13 9 4 4 5
Central 12 12 0 0 5
Eastern 15 14 1 0 14
Greater Accra 5 4 1 1 3
Northern 13 10 3 2 8
Upper East 6 6 5 1 0
Upper West 5 3 2 1 2
Volta 12 9 3 4 5
Western 11 9 2 1 8
Total 110 90 20 13 77
Source: Ministry of Health, Accra, 1999
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FIG.1.1 NATIONAL BURULI ULCER CASE SEARCH, 1999.
DISTRIBUTION OF CASES BY DISTRICT
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The statistics shown in Tables 1.1 and 1.2 show the geographical distribution 
of the disease. They exhibit significant regional differences. Interestingly, it is 
prevalent in rural areas where it is believed, conducive environmental conditions 
prevail for the microbe to thrive. This uneven spatial trend suggests an association 
between the disease and the environment (natural and social). Differences in the 
environment partly explain much of the spatial variations in the geographical 
distribution.
Besides the spatial trend, the disease further exhibits demographic patterns. 
Children and women are the most vulnerable group. However, the sex ratio is not 
static. It varies from region to region. Results of the National Case Search Survey 
undertaken in 1999 revealed a slight male dominance in the cases analysed. This 
information is shown in Table 1.3. It is interesting to note that the prevalence rate in 
Ghana decreases with age.
"able 1.3: Sex distribution of cases by regions in 1999
Region Male Female Total
Ashanti 705 698 1403
Brong Ahafo 159 181 340
Central 658 556 1214
Eastern 238 172 410
Greater Accra 567 597 1164
Northern 81 74 155
Upper East 36 61 97
Upper West 42 52 94
Volta 97 106 203
Western 207 153 360
Total 2790 2650 5440
Source: Ministry of Health, Accra, 1999
The incidence of the Buruli ulcer as it is in the other parts of the world, is very 
high in rural areas in Ghana. Some of these areas lack basic social amenities such as
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health facilities, potable water and good transportation system to mention a few. Lack 
of these facilities to some extent deters people from seeking medical care when the 
need arises. That apart, poor transportation system hinders spatial accessibility 
patterns to health facilities.
Buruli ulcer has caught the attention of medical personnel in the Akwapim 
South District in recent times. It is becoming a serious public health problem in the 
district. It exhibits a patchy spatial pattern with high incidence in the remote parts of 
the district. It was first detected in August 1998 with over seventy cases in one of the 
five administrative sub-districts. A total of seventy-six cases were recorded in the 
district at the end of that year. This has branded the area as the Buruli ulcer endemic 
zone. These initial disease foci have spread to other communities in the remaining 
sub-districts by the beginning of 1999. However, the incidence of the disease in 
these new areas is not as high as it is in the initial foci. In other words, the magnitude 
in those areas is not as much as it is in the Pakro-Dego sub-districts. Thus some 
communities are described as more prone to the disease than others. Despite the 
number of cases reported so far, there are others who have the disease but are yet 
to report at any of the various health facilities for medical attention. This makes the 
reported cases seem like the tip of an iceberg in the district.
By the end of April 2000, over one hundred cases had been registered in the 
whole district. These include clinical observations, pathological data and socio­
demographic information as a means of establishing the geographical distribution of 
endemic communities.
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The spread of the foci into other areas suggests a correlation between the 
disease and the environment. It is interesting to note that all the foci of the disease 
are located mainly in the remote rural areas of the district characterised by lack of 
health facilities, poor transportation system and lack of good drinking water.
The disease, apart from its spatial variations also exhibits demographic 
patterns. It has affected people aged between three (3) and seventy (70). Most of the 
cases involve children or teenagers aged between three (3) and eighteen (18) years. 
The prevalence rate decreased with age; for over half of the reported cases involved 
people aged less than twenty years. Interestingly, there is a slight male dominance. 
In addition to these demographic facts, no seasonal variations in incidence were 
observed perhaps due to the accumulated cases over time.
The incidence of the disease has been associated with lack of safe water in 
the areas designated as endemic. This is because some of the communities that have 
the disease do experience water shortage due to drying up of major water bodies as a 
result of deforestation. In addition to the drying up of water bodies during the dry 
season, some of the areas with the disease do not have adequate pipebome water as 
an alternative source of safe water supply. This compels the people to depend on 
unprotected ponds as the main source of water supply.
Considering the serious health, social and economic impact associated with 
the disease, it is seen as a big threat to the economic and social lives of the people in 
these areas. Socially, children are the most vulnerable group afflicted. They may lose 
their education since treatment is prolonged or they may be compelled to work to 
support their ailing parents or guardians. This will result in loss of manpower in the
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future. The economic activities of affected adults will be crippled and this will impact 
negatively on the family in diverse ways.
Ever since the disease was first detected in the district, serious efforts have 
been made to alleviate the plight of the afflicted and to halt its further spread. The 
Disease Control Unit of the Ministry of Health in the district, in collaboration with the 
Village Health Committees are prevailing upon those with the disease to show up for 
treatment yet response to the call according to the health workers is not encouraging. 
The question to address is why people with the disease are not showing up for 
treatment.
It can be concluded from the discussion that although the disease is on the 
increase, its spatial distribution continues to be uneven. In addition, the Akwapim 
South District has a majority of its population engaged in agriculture. Unfortunately, this 
dreadful disease is threatening the well being of the people, which if not checked, will 
in the future grind all economic activities to a halt. Hence, the disease is worth studying 
so as to understand the spatial patterns of the disease in order to come out with 
recommendations that will help alleviate the socio-economic problems that it brings 
about.
From the discussion so far the research questions are as follows:
1. What is the socio-economic impact of the disease on the communities?
2. Oral evidence gathered in the endemic communities indicates that the 
disease has been in existence for decades. The question then is, how 
come the disease did not receive attention from both health personnel 
and the public until recently.
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3. What mechanism has been put in place by the District Health 
Management Team to identify unreported cases for treatment?
The lack of any study on the spatial patterns of the Buruli ulcer in the Akwapim 
South District makes this study relevant. Existing work on the disease has focused 
attention on the mode of transmission of the causative microbe and who is affected. 
This interests medical scientists, epidemiologists and demographers who are currently 
researching Buruli ulcer. Not much interest has been shown in the identification of 
Buruli ulcer origins to highlight variations in socio-demographic and ecological factors 
that seem to promote differentials in Buruli ulcer incidence. The geographer's interest 
in the region, disease ecology, location and allocation of health resources, the use of 
appropriate health interventions and the use of maps for illustration are therefore 
needed to make a more meaningful contribution to health planning and development.
The research assumes that the principal underlying factor in the spatial 
patterns of the disease in the Akwapim South District is the natural environment, which 
may show variation among the different sub-districts within the district. The 
identification of high-and low-risk Buruli ulcer areas in the district is the subject of 
study. The results of this investigation, it is envisaged will help health authorities in the 
district and elsewhere to adopt strategies to curb the disease.
1.3 Literature review
1.3.1 Meaning of Buruli ulcer
Buruli ulcer is a skin ulcer caused by infection of the skin by Mycobacterium 
ulcerans (van der werf et.al., 1989; Asiedu, 1999). It has various geographic names
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such as Baimsdale ulcer, Kasong ulcer, Kakerifu ulcer, Tora ulcer, Mexican ulcer, and 
Kumusi ulcer just to mention but a few (Asiedu et. al., 1998).
The causative organism was first described by MacCallum, who discovered 
acid-fast bacilli in a biopsy from a leg ulcer in a young child from Baimsdale, Australia 
in 1940 (Asiedu et. al., 2000). Before 1948, the disease was already known in Africa. 
Large ulcers, caused by mycobacterium ulcerans, were described by Sir Albert Cook in 
1897 (van der Werf et. al., 1989; Asiedu, 1999; Asiedu et. al., 2000). In the period 1923 
to 1935, Kleinschmidt, a missionary physician in north-east Congo, observed 
undermined skin lesions in acid-fast bacilli (Meyers et. al., 1974).
In Africa, the history of Buruli ulcer can be divided into two main periods 
namely before 1980 and after 1980 (Asiedu et. al., 2000). There were many important 
publications before 1980 on the disease in several African countries namely 
Cameroon, the Democratic Republic of the Congo, Gabon, Ghana, Nigeria and 
Uganda. There were suspected cases in the Central African Republic, Kenya, Sudan 
and Tanzania, but these were never confirmed (Asiedu et. al., 2000). The most 
significant contributions came from the Democratic Republic of Congo and Uganda.
A new focus of Buruli ulcer emerged in West Africa, after 1980 (Asiedu et. al.,
2000). There has been a growing incidence of Buruli ulcer in several West African 
countries, especially in Benin, La C&te d’Ivoire and Ghana.
The geographic area in Uganda having the first large number of identified 
patients gave these lesions their popular appellations, Buruli ulcer (Dodge and Lunn, 
1962; Asiedu, 1999; Asiedu et. al., 2000). Geographic names for the disease are 
useful only in local foci. This is because the word "Buruli" for instance, cannot be
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applied to all parts of the world that are not situated in the Buruli district in Uganda. To 
this end, a non -geographic name is preferred to the large numbers of the synonyms. 
Thus, Pradinaud et. al.,(1998) proposed non- geographic names such as Cutaneous 
ulcer caused by Mycobacterium Ulcerans or Skin Ulcers caused by Mycobacterium 
ulcerans or perhaps better, Mycobacterium ulcerans skin ulcers. These non­
geographic names will be acceptable to all irrespective of geographic location.
It (Buruli ulcer) affects people in remote rural areas with restricted access to 
health facilities. About 70% of cases are children up to fifteen (15) years (Asiedu, 
1999). Any part of the body can be affected, however, the disease is most common in 
the limbs or the exposed parts of the body. It can also affect any racial group.
1.3.2 Clinical manifestation of the disease
The disease starts as a painless swelling in the skin as shown in the plate. A 
firm and painless nodule one to three centimetres in diameter (Asiedu 1999; WHO, 
1998) develops under the skin teeming with mycobacteria. Unlike other 
mycobacteria, Mycobacterium ulcerans produces a toxin, which destroys tissue and 
suppresses the immune system (WHO, 1998; Travis, 1999). The nodule, when 
raptures initiates the development of the ulcer. Sometimes bones, breasts, genitalia 
just to mention but a few are destroyed causing grossly deforming ulcers, peculiar to 
Buruli ulcer and easy to recognise. When lesions heal, scarring may cause restricted 
movement of limbs and other permanent disability.
Three different clinical stages of development of the disease can be 
described. These are the pre-ulcerative stage marked by painless and sometimes
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itchy nodule. Second, the ulcerative stage involves the development of lesions and 
the post- ulcerative stage which is a complication resulting directly from the disease 
such as contracture deformities, loss of sight and amputation. Plates 1 and 2 show 
development of Buruli ulcer at early and advanced stages respectively.
Treatment with antibiotics has been disappointing (Sciencenews, 1999) 
especially where there is an extensive ulceration. The futility of some past antibiotic 
use may reflect the fact that Africans or people with the disease generally do not visit 
physicians until far into the disease's progression. To this effect, early diagnosis of 
Mycobacterium ulcerans infection is crucial especially when scientists suspect that 
the microbe may sometimes reside in the body for months or years before it starts to 
eat away tissues.
Now, the only available treatment for Buruli ulcer is surgery to cut out the 
lesion, with a skin graft if necessary. In severe cases (for instance when bones
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Stages of development of Mycobacterium ulcerans infection
Plate 1: Early stage in the development of ulcer. 
Source: Asiedu, 1999
Plate 2: Late uicer, characterized by extensive laceration 
Source: Asiedu, 1999
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are destroyed) amputation may be necessary. Thus early detection and surgical 
removal of small nodules could prevent complications (Asiedu, 1999). Not many 
people die from the disease.
1.3.3 Mode of transmission
The route of transmission of the causative organism (Mycobacterium ulcerans) 
is poorly understood. However, considerable evidence suggests that direct or indirect 
trauma on the skin provides a passage for the organism into the skin. In support of 
this hypothesis, most cases occur on exposed surfaces, particularly over bony parts 
of the body and in children who have higher (conscious or unconscious) trauma rate 
and less tough skin than adults. It has been found out that it does not occur on the 
trunks of Caucasians who usually keep that part of their body covered. It rather 
occurs mainly on the lower leg Radford (1974). This suggests that incidence rate is 
high in the exposed parts of the body.
Further evidence by Meyers et. a!., (1974) supports the direct entry by the 
causative organism into the skin. It was reported in that study that 8% of the patients 
surveyed in the Bas region in Zaire remembered an event of specific trauma at the 
ultimate site of the lesion.
Lastly, the disease is rarely transmitted from one patient to another. However, 
the possibility of case-to-case transmission person cannot be ruled out (Bruce, 1998).
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1.3.4 Spatial variation of the disease
Buruli ulcer shows an interesting patchy distribution around the tropical as well 
as in the temperate areas of Australia (van der Werf et. al., 1989). It occurs in 
isolated foci where it may be common, separated by large areas in which it is rare or 
absent. This suggests lack of even spatial spread of the disease. The disease is 
commonly found in remote rural villages near slow-flowing or marshy parts of the 
tropical and sub-tropical regions of Africa, Asia, Latin America and the Western 
Pacific (WHO, 1998; Asiedu, 1999). Because all major endemic foci are in wetlands 
of tropical or sub-tropical countries, environmental factors must be seen to be playing 
a crucial role in the survival of the aetiology agent. It can therefore be concluded that 
the disease is associated with riverine rural areas. However, the association is not 
very clear (Bruce, 1998; Asiedu et. al., 2000).
Muelder (1988) noted that the more families depend on surface water for their 
daily needs, and the closer they live to it, the more probable infection becomes. In a 
review of all identified cases of Buruli ulcer in Uganda in 1970, Barker noted that all 
the five hundred and seventy-two (572) cases lived within thirty miles of the river Nile, 
especially around water-courses, or swamps where the river flowed through flat and 
swampy lands. In the same study but reported elsewhere, there was evidence of a 
progressive fall in incidence with increasing distance from the river Nile in two 
districts. It was then postulated that there was an initial focus of infection beside the 
river Nile, which gradually spread away from the river after major floods, which 
occurred in Uganda between 1962 and 1964 (Bruce, 1998).
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The spatial spread of the disease has also been associated with 
environmental changes. There have been focal outbreaks followed from flooding and 
man-made topographical modifications such as dams (Asiedu et. a i, 2000; WHO, 
1998). This goes further to buttress the fact that the disease is associated with slow- 
flowing and stagnant water-bodies.
According to Hayman and Asiedu (2000), infection occurs only after significant 
environmental changes or disturbance. In the Baimsdale district in Australia where 
first cases were diagnosed, there had been the worst floods in the district, when all 
roads and rail links were cut. Furthermore in Uganda, Barker examined cases of 
Mycobacterium ulcerans infection in the Busonga district on the east of the Victoria 
Nile, north of Lake Victoria (Barker, 1972). Although cases were known in other parts 
of the country, there were no known cases in that district before 1965. It was then 
postulated that the outbreak was related to unprecedented flooding of the lakes in 
Uganda between 1962 and 1965 as a result of heavy rainfall (Hayman and Asiedu, 
2000; Lunn 1962).
Evidence from Nigeria also indicates that infections have occurred among 
Caucasians living on the campus of the University of Ibadan after 1965 (Oluwasanmi 
et. at., 1976), when a small stream flowing through the campus was dammed to 
make an artificial lake. The first case reported in La C6te d'Ivoire was a seven-year- 
old French boy who lived beside Lake Koussou, an artificial lake in the centre of the 
country. Evidence from Liberia has it that there have been cases in the north of the 
country following the introduction of a swamp rice field to replace an upland one 
Ziefer et. ai., (1981). The agricultural change was accompanied by the construction of
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dams on the Mayor River to extend the wetlands. In Papua roe\M'<iUinea, the disease 
occurs mainly near the Sepik and Kumusi rivers. The disease in Papua New Guinea 
spread after the flooding and devastation that followed the eruption of Mount 
Lamington in 1951 (Asiedu et. al., 2000).
The outbreak of the disease on the Philip Island in Australia was temporally 
associated with the formation of a small swamp that backed up behind a newly 
constructed vehicle track Veitch et. al., (1998). Improved drainage in this area was 
followed by a cessation of cases in the immediate vicinity of the marsh. The following 
year, cases continued to occur close to a kilometre away to the west of the swamp on 
a golf course near a spray irrigation system that used a mixture of recycled sewage 
and ground water.
In the Ashanti Region of Ghana, all the three districts through which the river 
Offin flows have reported cases of Buruli ulcer. Similarly, cases of the disease have 
been recorded in the river Densu and Afram basins. Whilst the former has made rural 
areas in the Greater Accra Region more prone to the disease than farther away from 
it, the latter predisposes some sections of the Afram Plains to infection.
Lastly, it is believed that deforestation and increased agricultural activities may 
have significantly contributed to the recent marked increases in the incidence of 
mycobacterium ulcerans infections especially in West Africa. From the instances 
cited, it can be said that the disease has a strong water connection.
It has been observed that the disease prevalence in areas with environmental 
changes is about 180 per 100,000 population, while in those areas without 
environmental changes, it is about 20 per 100,000 (Portaels, 1998). The discussion
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so far points out that topographical modifications indirectly induce flooding and the 
accompanying stagnation swampy conditions.
1.3.5 Consequences of the disease
Buruli ulcer has serious economic, health and social impacts (WHO, 1998; and 
Asiedu, 1999). Therefore with the growing incidence of the disease and the 
complications currently associated with it, the long-term socio-economic impacts of 
Buruli ulcer on the rural economy could be substantial (Asiedu and Etuaful, 2000). 
The World Health Organization estimates that 25 per cent of all infection end up with 
a permanent disability. For instance, Asiedu and Etuaful (1996) observed ten limb 
amputations, twelve contracture deformities, one patient lost the sight in one eye, and 
two deaths due to tetanus. These observations were made out of 102 reported cases 
at the Agoroyesum Catholic Hospital in the Amansie West District between 1994 and 
1996. This makes economic and social cost of the disease very high.
The economic cost of the disease can be divided into direct and indirect based 
on a study into the socio-economic implications of the Buruli ulcer in Ghana (Asiedu 
and Etuaful, 2000). The former comprises the cost of treatment and the latter, the 
productivity losses incurred by both the patient and the healthy attending relative, the 
cost of feeding the patient and the attending relative, and other miscellaneous 
expenses. They concluded from their study that Buruli ulcer is very expensive to treat 
since the average cost of treatment per patient is far more than what most people 
can afford let alone the poor. Besides this, it exerts enormous stress on health 
resources. This is so because the Yamoussoukro Declaration on Buruli ulcer tasks
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governments to provide free medical care to those afflicted by the disease, as is done 
for those suffering from tuberculosis and leprosy (Asiedu, et. al., 2000). Free medical 
treatment will hamper a health facility's ability to recover cost.
Treatment of the disease in its advanced stages of development requires a 
prolonged hospitalisation of the patient. Asiedu and Etuaful (1996), in a study into the 
socio-economic implications of the disease in Ghana, observed that the average 
hospitalisation was 186 days in 1994, 103 days in 1995 and 102 days in 1996. 
Hospitalisation of a patient requires concomitant 'hospitalisation' of a healthy relative 
to provide indirect care such as cooking and washing of the patient's clothing just to 
mention a few (Asiedu et. al., 2000). Clearly, the issue of hospitalisation is a huge 
burden on the patients and their families. In countries without social programmes to 
take care of the disabled, families constitute the social safety net and, in case of 
illness and disability, the burden falls on the poor family. The long-term care of 
people disabled by the disease by the family could lead to great loss of productivity 
and poverty (Asiedu and Etuaful, 2000).
The indirect consequences of the sickness in adults are that children have to 
drop out of school or are forced to work to support the family. This could also happen 
to adults suffering from Buruli ulcer. This is because hospitalisation of a patient 
requires the need to have an attendant relative, usually a woman. The indirect effect 
this has on the children is the lack of parental care of those left behind at home.
The majority of those affected by the disease are children up to fifteen years. 
Prolonged morbidity often leads to serious disruption of school or even 
discontinuation of schooling. Also, complications such as amputations and
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contracture deformities are frequent, and children disabled by the disease would not 
be able to work in the field. Those children would grow into adulthood and become a 
burden to society.
Liefooghe et. al.,(1995) concluded in a study on the consequences of 
tuberculosis in Pakistan that this disease may lead to stigmatisation. Similarly, Buruli 
ulcer with its cosmetic problems could lead to stigmatisation, social isolation, 
diminished marriage prospects and divorce particularly among women. Since women 
play enormous roles in rural economies, their contributions could be reduced 
considerably if they are left with a permanent disability because of the disease. Such 
disability could potentially limit their ability to carry out activities such as trading, 
farming, obtaining water and breast-feeding (Asiedu and Etuafui, 2000). The inability 
to perform these tasks could negatively reduce their income generating potential and 
the health and welfare of their children.
1.3.6 Factors underlying spatial variation of diseases
Apart from environmental exposures, there are other factors that could 
influence the spatial variation of diseases. According to Davey and Wilson (1964), 
faulty habits of living are important factors in maintaining diseases in a community. 
Low economic and social levels are associated with apathy, ignorance and low 
standards of personal hygiene. These faulty habits as raised by Davey and Wilson 
(1964) facilitate contact between human beings and pathogens, to make certain 
localities or seasons more unhealthy than others. Health and for that matter disease
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problems are thus environmental problems and as such are amenable to techniques 
of spatial analysis used by geographers (Howe, 1990).
There are two main ways of seeking explanation for spatial variations in the 
occurrence of diseases. The first method involves the identification of the natural foci 
of the disease. This presupposes environmental factors such as climate, biotic and 
biological conditions, which suggest "disease regions". This method primarily 
determines the importance of environmental factors in the development and survival 
of the disease agent. It can therefore be concluded here that features of the natural 
environment account for some of the spatial variation in diseases. Diseases can 
therefore be associated with specific natural environment. For instance, there was a 
link between marsh fever and stagnated waters in the southeast England (Dobson, 
1992).
The second method emphasises secondary disease agents, which are usually 
related to human or host factors (lyun, 1983). By this, health hazards can be 
interpreted by the association of artificial factors, that is, properties of differential 
living conditions rather than the 'natural' foci of disease. (Shannon and Spurlock, 
1976). The socio-economic characteristics which contribute greatly to the cause and 
spread of many diseases may for that matter include age, gender, ethnicity, 
behaviour and life-style (lyun, 1983). These factors therefore influence the patterns of 
morbidity and could be responsible for spatial variations in morbidity and mortality 
levels.
In a study in Nigeria, lyun (1983) asserts that low-income earners suffer 
particularly from communicable, poverty and ignorance associated diseases.
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Besides, age group, religion and life styles appear to be important determinants of 
differences in the level of illness of disease's victim. Buruli ulcer is a type of illness 
that always takes its victims unaware due to how it starts coupled with poor 
knowledge about the disease among the public and even health personnel. Its start is 
deceptive thus, people tend to underestimate its potential as a serious affliction.
Shannon and Spurlock (1976) and lyun (1983) have it that, it is of utmost 
importance to hammer on secondary factors such as differential living conditions 
rather than natural biological factors in interpreting health hazards. These factors are 
very crucial in determining the prevalence and distribution of Buruli ulcer in the 
Akwapim South District. Several socio-economic variables such as age gender, 
literacy level, health seeking, community problems, variations in living conditions in 
the sub-districts have been put forward as important co-factors responsible for 
variations in Buruli ulcer prevalence in the Akwapim South District. It is worth 
mentioning that these social, economic and cultural variables vary from place to 
place. This will therefore lead to variation in spatial patterns of the disease, which is 
the subject under study.
1.3.7 Evidence of disease and the natural environment
According to Dobson (1992), the idea that the atmospheric and environmental 
influences might affect patterns of disease and mortality is particularly associated with 
Hippocrates. The Hippocratic concept of 'airs, waters, and places' received significant 
and renewed attention in the seventeenth and eighteenth centuries (Dobson, 1992). 
Physicians began to ask why disease varied according to locality or season, why
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certain environments seemed more conducive to ill-health than others, and, in turn, 
whether such knowledge could be used to intervene, ameliorate, manage or avoid 
unhealthy sites (Jordanova1979; Riley, 1987). The meaning of this assertion is that the 
natural environment appears to influence and impinge on the health and well being of a 
locality and its residents. Thus, diseases were associated with the environment. For 
instance, 'bad airs' and its association with marshland topography were blamed for the 
cause of marsh fevers in Southeast England (Dobson, 1992).
Mortality levels in marshland localities were reckoned unusually high and 
residents and visitors complained bitterly about the marsh fevers they encountered in 
such localities. It was concluded that the noxious stenches that emanated from the 
stagnant marsh waters were primarily responsible for such hazardous conditions 
(Dobson, 1992)." The natural environment and ecological features have been proved 
to be critical determinants of the patterning of morbidity and mortality in southeast 
England (Dobson, 1992).
The discussion so far suggests that there is a correlation between the natural 
environment and disease. That is cause and effect of disease occurrence. Later, 
attention was shifted away from the natural environment, and focused on attributes of 
man-made environment in conjunction with the conditions of the population (Dobson, 
1992). This change of focus suggests a shift from ecological cause and effect (that is 
associating diseases with the natural environment) to a situation which takes into 
account, elements of human behaviour as well as the quality of the 'human' 
environment. This provides a broader environmental framework that could be extended 
to explain and include disease pathways associated with all sorts of insanitary
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conditions. All ranges of foul habitats, and any number of hazardous practices and 
crowded occasions that would have brought together humans and their disease 
pathogens to make certain localities or seasons more unhealthy than others. The 
broader environmental framework suggests that for one to seek for a unidirectional 
relationship between one factor, such as climate, and morbidity data, in real terms runs 
counter to what is known to be the complexity of local and individual disease patterns 
and their environmental influences.
1.4 Conceptual Framework
1.4.1 An elaboration of the Human Ecology Model
The Triangle of Human Ecology of disease, propounded by Meade et. al., 
(1988), provides clues as to why human diseases and health vary over the surface of 
the earth. It has proved very useful in accounting for the spatial patterns of diseases 
such as elephantiasis in Northern Ghana (Hunter, 1996). Three variables namely: 
habitat, population and behaviour form the vertices of the triangle that encloses the 
state of human health. It is shown in Figure 1.2.
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Figure 1.2: The Triangle of Human Ecology model
HABITAT (ENVIRONMENT)
POPULATION BEHAVIOUR
Source: Meade et. al., 1988
Habitat is that part of the environment within, which people live and 
which directly affects them. It is composed of houses and workplaces, naturally 
occurring biotic and physical phenomena, health care services, transportation, 
and government. Elements of population composition include age structure, 
ethnicity and literacy. Behaviour on the other hand, is the observable aspect of 
culture. It springs from cultural precepts, economic constraints, social norms, 
and individual psychology. It includes mobility, roles, cultural practices and 
technological interventions.
People through their behaviour are able to create habitat conditions, 
which expose them to or protect themselves from habitat conditions, and move 
elements of the habitat from one place to another. The habitat therefore offers 
opportunities and hazards to the population, which can modify its behaviour.
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Spatial patterns of the mycobacterium ulcerans infection (Buruli ulcer) are 
interplay of factors. An understanding of these spatial patterns like any other disease, 
makes imperative an understanding and interpretation of the ecological factors 
prevalent in the diseased environment. In the case of Buruli ulcer, the environment 
(both physical and non-physical) is the most important factors in accounting for the 
incidence and its spatial spread.
The development of human ecology has been associated with the application 
of the ecological approach in several specialized areas. Human ecology denotes the 
pattern of human interaction with the physical environment, such as behaviour and the 
environmental interactions. Based on the definition of human ecology, cultural and 
environmental factors become part of the concept (human ecology), and they provide 
clues to the spatial patterns of diseases including Buruli ulcer. The environment is 
therefore relevant to this study into the spatial patterns of the disease in the Akwapim 
South District. This is based on the assumption that the observed spatial patterns of 
the disease are the result of the interplay of different ecological factors some of which 
have general significance throughout the area while others have limited reference, 
applying merely to specific locations where Buruli ulcer may be more prevalent.
McKenzie (1961) classified these ecological factors generally into four namely: 
geographical, economic, cultural and political-administration. The geography includes 
topography and drainage as it pertains in this study. The economic component is made 
up of a wide range of phenomena such as occupational distribution and standards of 
living of populations. The cultural aspects cover the arts, moral attitudes that influence 
the distribution of population and services while the political -administration includes
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measures such as rules governing local utilities. From the discussion above, 
McKenzie's ecological classification is seen as a dilation of the three vertices of the 
Triangle of Human Ecology.
Although the geography, economic and cultural factors differ in the Akwapim 
South District, it is the geography of the district which significantly manifests in the 
spatial variation of Buruli ulcer.
1.4.2 Justification of the model for the study
According to May (1954,1958), the incidence of a disease requires the co­
existence of some causative organism and a host simultaneously. This will create the 
foci of a disease. In order to understand the health and disease therefore, it is 
necessary to go beyond the biological determinants of disease. That is disease 
aetiology would be better understood in a broader context since diseases have both 
biological and social meanings. To this end, much epidemiological and geographical 
researches accept the biological definition of disease but extends the biomedical 
model {which considers disease as internal malfunctioning of the body Kelvyn and 
Moon (1987)}, by considering explanations that involve social and environmental 
causes. Failure on the part of a research to incorporate these two variables may not 
yield fruitful explanation for spatial occurrence of disease. In as much as social and 
environmental factors vary spatially, disease patterns are likely to vary.
Focusing narrowly on the biological determinants of disease aetiology is to 
ignore multiplicity of factors namely habitat, population and cultural behaviour that 
affect disease patterns. The relevance of the Triangular Model of Human Ecology to
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this study therefore is that, it captures other dimensions of disease that would have 
been ignored by a pure biological study. Since this study goes beyond the biological 
determinants of the disease, the model as discussed above will be relevant to the 
study. The disease ecology model has been used to explain the patterns of a large 
number of diseases. For instance, the correlation between stagnant water and malaria 
in Southeast England (Dobson, 1992) was established. It has also provided a 
theoretical framework for understanding the aetiology and, spatial patterns of 
elephantiasis in northeast Ghana (Hunter, 1992).
This study considers how the habitat, population characteristics and the 
cultural behaviour interact together in an evolving and interactive system to explain the 
spatial patterns of Buruli ulcer in the district. The environment for the purposes of this 
study is classified into physical and social.
The habitat as implied in this study consists of the physical or the natural 
component and the built environment. The former is concerned mainly with the 
topography and the quality of drainage and how it influences the geographical 
distribution of the disease in the study area. The natural habitat provides favourable 
conditions for the causative organism to survive. The constructed part of the natural 
environment is concerned with the availability and accessibility of health facilities and 
health personnel. It also considers the transportation system as a means of connecting 
communities without health facilities in the study area. Accessibility of health facilities is 
considered from two angles namely physical accessibility and economic accessibility. It 
must be noted that health facilities are concentrated in the urban areas of the district 
thereby depriving the rural areas the opportunity of easy physical access. Effective
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transportation system is therefore required to connect these remote villages to the 
health facilities. Economic accessibility is also influenced by the income of the 
populace. A problem arising from physical and economic access may adversely affect 
the health status of the populace that cannot patronize such health facilities.
The relevance of the model to the study again lies in the fact that it highlights 
the socio-economic characteristics of the populace. Such population characteristics as 
age structure and sex affect so many dimensions of health status. The socio-economic 
background of the population in the district is not uniform. Consequently, it is likely to 
create differential living conditions that can influence the incidence of the disease in the 
district.
Lastly, the study considers how cultural behaviour of the populace can expose 
them to infection by Mycobacterium ulcerans in the study area. The creation of habitat 
conditions such as poor hygiene in some communities predispose the population there 
to infection. In addition, people are engaged in so many socio-economic activities such 
as agriculture and swimming that involve hazards. Education as a component of 
behaviour can improve the health status of an individual. Health education by health 
personnel about the disease can reduce harmful exposures to infection in the study 
area.
It can therefore be concluded that the environment both physical and social 
could play a very important role in the geography of Buruli ulcer in the district. The 
human ecology of disease model considers factors as outlined in accounting for the 
spatial variation of diseases.
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1-5 Research Objectives
The main objective of the study is to examine the problem of Buruli ulcer in the 
Akwapim South District and the factors that underlie its spatial trend. Specifically, the 
study addresses the following:
1. To find the nature and magnitude of the disease as it varies temporally 
and spatially in the Akwapim South District, and to map out the 
observed spatial patterns of variation in the prevalence of the Buruli 
ulcer.
2. To investigate the underlying factors of its spatial variation in the 
district.
3. To examine measures that have been put in place to minimise the 
incidence of the disease.
4. To ascertain the consequences of the disease on the population and 
the perception of the people on Buruli ulcer in relation to causes.
5. Recommend measures that could help prevent further spread of the 
disease.
1.6 Research propositions
The study was guided by the following propositions:
1. The natural environment is a determinant factor in the spatial variation 
of Buruli ulcer in the Akwapim South District.
2. Socio-economic factors influence the incidence of Buruli ulcer in the 
district.
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3. Bad hygienic practices are a predisposition to infection by 
mycobacterium ulcerans, the causative organism of the disease.
1.7 Justification of the study
Current data largely focus on the medical aspect of the disease, which 
interests medical scientists. Lack of socio-economic data therefore makes this study 
relevant. The study besides its academic purpose has practical implications. This is 
because such information is very important for health managers in planning for Buruli 
ulcer surveillance to identify cases at their embryonic stage of development. A 
successful establishment of a permanent, ongoing surveillance system requires a 
survey (if data do not exist) to establish the extent and burden of the disease. With 
this data in hand, health managers can easily identify a more cost-effective strategy 
for active surveillance in endemic areas at a reduced cost.
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CHAPTER TWO 
2.0 The Study Area and Research Methodology
2.1 Introduction
It is imperative to know the physical and the socio-economic background of 
the area where the study was undertaken. This could help one to establish a link 
between the disease and the physical and socio-economic characteristics of the 
study area. In this chapter therefore, the physical background, distribution of health 
facilities, population, the economy and the infrastructural development of the study 
area have been outlined. The chapter also focuses attention on the research 
methodology.
2.2 The study area
2.2.1 Location and size
The Akwapim South District is located south-south-east in the Eastern Region 
of Ghana, between latitudes 5° 45'N and 5°58', and longitude 0° 07'W and 0° 27' W as 
shown in Figure 2.1.
Administratively, it is one of the fifteen districts in the Eastern Region. In terms 
of size, it covers an area of about 103 square kilometres. It shares a common 
boundary with the Akwapim North District in the north and Suhum- Kraboa Coaltar and 
West Akim Districts in the west. Its eastern and southern neighbours are the Ga and 
Tema Districts respectively. The district capital is Nsawam.
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2.2.2 Vegetation
The study area falls within the moist semi-deciduous and the coastal savanna 
vegetation zones. The moist semi-deciduous forest was once a part of the closed 
forest but human activities have degraded it into secondary forest. The main 
characteristic of this forest is that the trees shed their leaves during the dry season as 
a defensive mechanism against loss of moisture. Frequent use of farmlands within the 
forest has resulted in the appearance of grass species in the vegetation zone (Dickson 
and Benneh, 1988)
2.2.3 Climate
The climate is the wet-semi equatorial type. This climatic zone experiences 
two exceptional periods of rainfall. The mean annual rainfall is between 125 and 200 
cm (Dickson and Benneh, 1988). The rainy seasons occur after the two equinoxes, 
and this encourages two farming seasons based on the rainfall regime.
The months of March and April record the highest temperatures of about 30°C 
(average monthly). The lowest is recorded in the month of August, about 26°. During 
the rainy season, average monthly relative humidity is high between 75-80 % and 
lowest of 70-80 % during the rest of the year. The dry season in this area is quite 
sharp.
2.2.4 Topography and drainage
Mountains and lowlands dominate the topography. That is the district generally 
shows a rolling land with hills and ridges. Its relief falls into three broad divisions: the
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Densu Plains, the Pompon narrow land and the Akwapim-Togo ranges (Dickson and 
Benneh, 1988). The Densu plains comprise almost the entire southern half of the 
Densu basin. They are broad and strongly undulating with occasional isolated peaks 
such as Amama hill and Nyanao Hill (Dickson and Benneh, 1988). Bordering the 
Densu plains on the east are the Akwapim-Togo ranges which run in a south-west to 
north-east direction. A westerly projection from these ranges forms the watershed for 
the Densu River.
The relief pattern makes for significant differences in soils. In low-lying areas, 
the soils are deep, well supplied with moisture and sometimes waterlogged near the 
rivers. The soils are shallower, drier and often stony on the top of the Akwapim-Togo 
ranges (Dickson and Benneh, 1988). Streams and rivers drain the area. The prominent 
among them is the Densu River and its tributaries.
2.2.5 Soils and ecological zones
The principal soil type is forest ochrosols. However, the relief patterns make 
for significant local differences in soils. In lowlands and valleys, the soils are generally 
well supplied with moisture and sometimes waterlogged near the rivers. On the top and 
sides of the ridge and hills, the soils are shallow, dry and often stony.
2.2.6 Population
The population is predominantly rural. The main occupation of the people is 
fanning. Settlers are of diverse ethnic extraction. The major ethnic groups are 
Akwapims, Ewes, Akims and Gas. However, over 90 per cent of the population speak
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the Akan language. The total population of the district according to the 1984
Population and Housing census was ninety thousand, nine hundred and fifty-two
(90952). The provisional report of the 2000 Population and Housing census put the 
total population at one hundred and twenty thousand, five hundred (120,500). The 
population distribution is fairly even among the sub-districts. However, the district 
capital alone has a larger population than the other settlements. In all, there are three 
hundred and forty-one (341) communities in the district.
2.2.7 Health facilities
The district has a number of health facilities. These facilities fall into two
categories namely public and private. The public health facilities on one hand 
comprise the district hospital at Nsawam, Health Posts, Maternal and Child 
Health/Family Planning Centres and Clinics. The private health institutions on the 
other hand are made up of four registered clinics that offer general medical care. 
There are other specialised health facilities such as a herbal centre, an orthopaedic 
centre, three Eye Clinics and three Maternity Homes. Most of these facilities are 
located in the urban areas particularly Nsawam. It is estimated that over 40% of the 
rural population do not have access to these facilities mainly due to bad roads, lack 
of vehicles and high cost of transport fares. Lastly, there are Village Health 
Committees in all the communities. They carry health information to the populace in 
the communities.
The main diseases in the district include malaria, respiratory tract infections 
and gynaecological disorders. Malaria is the commonest as revealed by a Baseline
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study in 1995. The causes of these diseases could be attributed to poor environmental 
situation in the district especially the inadequate potable water supply, toilet facilities 
and low community participation in health educational programmes. In spite of the 
prevalence of diseases especially water-borne and water-related diseases in the 
district, health facilities are poorly patronized.
2.2.8 Water and sanitation
The major source of water supply in the urban areas of the district is pipe- 
borne which serves almost 60% of urban dwellers in the district. The only exception is 
Aburi, which does not enjoy regular water supply owing to low-pressure problem. 
Sakyikrom and Dobro though classified as rural settlements have access to pipe-borne 
owing to their nearness to the water works at Adoagyiri. A greater proportion of rural 
and urban dwellers in the district who do not have access to pipe-bome water rely on 
streams or rivers, wells and boreholes for their supply of water.
However, the streams, wells and rivers dry up during the dry season. In 
addition, boreholes frequent breakdown of the boreholes compounds the already poor 
state of water supplies in the district.
Sanitation situation in the district leaves much to be desired. However, the 
situation is quite better in the rural areas than in the urban areas due to high 
community spirit among the inhabitants.
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2.2.9 Structure of the local economy
The productive sectors can be classified into three namely primary, secondary 
and tertiary economic activities. The primary sector includes agriculture, quarrying and 
hunting. Secondary economic activities involve turning the raw materials extracted at 
the primary stage into finished and semi-finished products (processing). This includes 
manufacturing, construction and all forms of processing. The tertiary economic sector, 
which involves the provision of services, includes financial services, distribution of 
goods and transportation.
2.2.10 Economic activities
Agriculture is the principal occupation in the rural areas of the district. It 
employs a greater proportion of the potential labour force.
The industrial sector appears to be making modest gains. Whereas some 
industrial establishments are doing well, others have suffered setbacks, especially in 
the face of trade liberalisation and privatisation.
The service sector has overtaken the crops and livestock sectors. It now 
employs majority of the labour force particularly in the urban areas. Economic activities 
in this sector include trade, hotels and restaurant/drinking bars, transport and 
communications financial services and services provided by government in public 
administration. Its share of the labour force has increased over the years. Trading has 
become the major economic activity in the district (Baseline Survey, 1995). This is 
because of increasing interaction with Accra. Agricultural produce is the main item of 
trade followed by food selling. This trade has been made possible by the transport
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sector. Hotels, restaurants and financial services are the least developed. However, 
the hotels and restaurants sub-sector is now showing signs of growth especially at 
Aburi where tourist activities thrive most.
2.2.11 Transportation networks
There is the need for an appreciable degree of interaction within and between 
settlements that constitute an economy to enhance development. The nature and 
condition of the communication system, particularly transportation, is therefore 
necessary. Transportation networks, which refers to the distribution and level of road 
and transport systems affects the utilisation of health facilities and marketing in the 
district. The transportation network assumes a radial shape originating from the 
Nsawam-Adoagyiri conurbation to virtually all parts of the district.
The only highway in the district is that of the Accra-Kumasi highway which 
passes through the district capital, Nsawam. It links the southern and northern parts of 
the district and the entire nation. All the other roads in the district link the highway at 
either Nsawam or Adoagyiri. Its total length within the district is about sixteen 
kilometres. Second class roads in the district cover a total distance of about forty and a 
half kilometres. Most parts of these roads have good surface conditions. Third class 
roads connect the rest of the district. Roughly measured, they cover a total length of 
about sixty (60) kilometres. Interestingly, all these class three roads have no bitumen 
surface. They also abound with potholes and bumps due to erosion and rainwater 
deposits on them. During the dry season they get dusty whilst water deposits and 
surface erosion conditions are heightened during the longer rainy seasons. Both
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periods render usage of these roads impassable. Aside all these are myriad of access 
roads not well developed and used occasionally by vehicles. There is no doubt that 
the poor road network would not badly affect transportation system. Lastly, the Accra- 
Kumasi railway line passes through the district.
2.3 Research methodology
2.3.1 Sources of data
Data for the study were obtained from primary and secondary sources. The 
primary data collected were obtained from questionnaires (interviews and self­
administered questionnaires in the field), personal interviews and direct field 
observation. The secondary data on the other hand, were derived from the Internet, 
published books, articles, medical reports, and maps. However, a substantial 
proportion of the data for the study was obtained from the field survey. A preliminary 
survey preceded the actual fieldwork. The essence of this initial survey was to make 
sure that the study was feasible and to decide on which sampling techniques and 
questionnaire design to use.
2.3.2 Research instruments and target population
Questionnaires were the main research instrument. The administered 
questionnaires consisted of self-administered ones and interview schedules for 
illiterates and semi-literate since they could not complete it by themselves. The 
questionnaires consisted of open-ended and closed-ended questions. Other primary 
source of information was the direct personal observation of the natural environment
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and some cultural practices. This formed the basis for drawing inferences in relation 
to the geography of the disease.
The target population to whom the questionnaires were administered was 
household heads, health administrators and patients with active ulcers. Besides, 
some community leaders were also interviewed using questionnaires with questions 
on their communities.
2.3.3 Sampling design and size
Faced with limited time and financial constraints, it was impossible to cover the 
entire district. The settlements were therefore stratified into different zones of 
endemicity based on the available medical records on the disease in the district which 
were obtained from the Disease Control Unit of the Ministry of Health, Nsawam. The 
administrative sub-districts formed the basis of this classification. Aided by a district 
base map, and available medical statistics on the prevalence of the disease, the 
settlements were categorized under their respective administrative sub-districts. It is 
from these statistics that the geographical distribution of the patients was established. 
Patients from outside the district were ignored because their inclusion would not give 
the accurate picture of the geographical distribution of the disease in the district. Based 
on this classification scheme, three levels or zones of endemicity were arrived at, 
namely high, low and non-endemic or "Buruli ulcer" free area.
In all, eight settlements were selected for the study. Four settlements were 
then randomly selected from the high endemic areas while three settlements were
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drawn from the low endemic area. Only one settlement was randomly chosen from the 
low area. This is shown in Table 2.1.
Table 2.1:Buruli ulcer endemic areas by sub-district and reported cases.
Level of endemicity Sub-district Settlement ‘ Reported
cases
High Pakro- Dego 1.Tabankro
2.Asaasiansa
3.Buokrom
4. Pakro
105*
Low IPokrom
2. Nsawam
3.Panpanso
1 .Okobeyeye
2.Ahodwo
3.Pokrom
24*
Non-endemic area 1. Aburi 1. Aburi —
Source: Author's construct, 2000 ‘ Reported cases between August, 1998 and 
March 2000.
Owing to time and resource constraints a sample of two hundred (200) 
household heads were randomly chosen for the exercise. Twenty-five (25) household 
heads were randomly drawn from each of the eight selected settlements. The 
dispersed nature of the houses necessitated the use of the simple random sampling 
technique. This is because no linear arrangements of houses were observed.
The total population of the selected communities according to the 1984 
Population census was ten thousand, seven hundred and thirty-five (10,735). Equal 
sample size of twenty-five (25) heads of household in each settlement was drawn for 
interview. This is shown in Table 2.2.
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able 2.2: Selected settlements and sample size for the study
Name of 
Settlement
Total 
Population (1984)
Sample size
Tabankro 425 25
Asaasiansa 120 25
Buokrom 498 25
Pakro 1425 25
Okobeyeye 101 25
Ahodwo 191 25
Pokrom 490 25
Aburi 7495 25
Total 10745 200
Source: Compilation based on 1984 Population Census
Apart from the questionnaires, which were administered to the heads of 
household, forty-seven (47) medically diagnosed Buruli ulcer patients who were 
receiving medical attention during the time of the study, were purposely sampled. 
This was done in order to throw more light on the effect the disease had had on 
them. This category of respondents includes some of the household heads.
2.3.4 Data analysis and presentation
Data analysis was mainly qualitative. Analytical techniques involved the use of 
simple descriptive statistics such as frequency distribution and percentages and 
inferences drawn from the direct field observations. The use of cross-tabulation 
techniques was also employed to show association between variables. These 
relationships include the spatial distribution of the disease and the physical 
environment. Tables and graphs were used in the data presentation. Furthermore, the 
spatial patterns of the disease were shown on a map.
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2.3.5 Data limitations
Everywhere people seek medical care outside the formal sector of the medical 
system, and the case is no exception in the Akwapim South District. Therefore, it is 
possible that there are people with infections have not yet shown up at any health 
facility for treatment, and consequently information on them may be lost. This means 
that, this group of people were not covered by the scope of the data. Thus, using 
medical records on reporting cases as a means of mapping and generalisations on the 
prevalence of Buruli ulcer in the district may give a wrong impression that may lead to 
wrong conclusions. Despite the outlined weakness, it is considered useful to make use 
of what is available in the study in order, to approximately determine the spatial 
patterns of Buruli ulcer in the Akwapim South District. This is because the geographical 
distribution of Buruli ulcer as established using the secondary data still gives an idea 
about where the incidence of the disease is serious. Similar studies using secondary 
data have been undertaken on the geographical distribution of cancer in the French 
Polynesia (Vinson, 1974).
Secondly, due to illiteracy of some of the respondents and poor geographic 
access of some villages, it became necessary to engage assistants at some cost to 
translate and interpret the research questions into the local language. The possibility of 
some bias being introduced into the responses cannot be ruled out. Illiteracy on the 
parts of some respondents may also have affected the understanding of some 
questions, particularly those on attitudes and perception. This may eventually mar the 
quality of the data obtained. In addition, some of the respondents were unwilling to 
divulge information. This was so with those who had active ulcers due perhaps to
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shyness. It is hoped that the existence of relevant variables in mapping out Buruli ulcer 
in the district may reduce distortions that may arise out of ignoring several unreported 
and unknown cases.
These limitations may affect the quality of work done. In the light of the above, 
criticisms are welcomed. Therefore, the researcher recommends further studies on 
the subject to improve upon what has been covered in this study.
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CHAPTER THREE 
3.0 The Magnitude and Spatial Patterns of Buruli Ulcer
3.1 Introduction
The chapter discusses the magnitude of the disease and the associated risk 
factors. It further discusses the geographical distribution of the disease and the socio­
demographic characteristics of the observed patients.
3.2 The Magnitude of The Problem
Compared to malaria, diari+ioeal diseases, and other endemic tropical diseases in 
the Akwapim South District, Buruli ulcer appears to be insignificant in terms of 
prevalence, incidence, and mortality. However, its high morbidity and debilitating and 
crippling effects on the afflicted makes it a disease of serious public health in the 
Akwapim South District.
According to the survey results of the 1999 National Case Search for Buruli 
ulcer in Ghana, ninety out of the one hundred and ten districts had recorded cases of 
the disease. This shows an appreciable increase in the reporting of cases over the 
period 1993-1997, when six out of the ten regions were known to have recorded 
incidence and prevalence of the disease. This information has already been shown in 
Table 1.1.
According to the survey results of the National Buruli ulcer Case Search in 
Ghana in 1999, all the administrative districts in the Eastern Region reported cases of 
the disease. The Akwapim South District ranked second in terms of incidence and 
prevalence to the Kwahu South District also in the Eastern Region (MOH, 1999).
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Some districts were more severely affected than others. This information is 
represented in Table 3.1.
Table 3.1: Reported Buruli ulcer cases per district in the Eastern Region, 1999.
District Males Females Total
Kwahu South 73 59 132
Akwapim South 66 63 129
Suhum-Kraboa Coaltar 41 28 69
Fanteakwa 15 21 36
Manya Krobo 17 10 27
West Akim 16 10 26
New Juaben 15 10 25
Birim South 9 7 16
Asuogyaman 8 6 14
East Akim 9 3 12
Birim North 7 3 10
Yilo Krobo 6 3 9
Akwapim North 6 1 7
Kwaebibirem 5 1 6
Source: Ministry of Health, Accra, 1999.
The incidence of Buruli ulcer caught the attention of the district medical 
authorities during the second half of 1998. The year recorded seventy-six 
accumulated cases from one out of the five sub-districts that constitute the 
administrative district. Sporadic cases were however, reported in other parts of the 
district except the Aburi sub-district. However, the extent of the scourge in the new 
areas is not as severe as it is in the original foci of the disease Pakro-Dego sub­
district, which accounts for 81% or one hundred and four (104) reported Buruli ulcer 
cases in the district.
Incidence is more prevalent in the remote and difficult to reach rural areas of 
the district, notably the Pakro-Dego sub-district. One hundred and twenty-nine Buruli 
ulcer cases involving all the communities had come before the district health
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authorities by the end of March 2000, with twenty-six deformities (Hospital statistics, 
Nsawam, 2000). Incidence is higher in some communities than others. According to 
Table 3.2, Tabankro, Pakro, Asaasiansa and Buokrom are the most severely affected 
settlements in the district. These settlements are all located in the river Densu basin. 
This trend has continued to the present. The least affected communities include 
Panpanso and Okobeyeye.
Table 3.2: Some ten communities with high cases of the Buruli ulcer in the 
Akwapim South District in 1999 __________
Community Number of reported cases
Tabankro 15
Pakro 9
Buokrom 6
Asaasiansa 6
Adesa 5
Adjimase Zongo 4
Asikabew 4
Okobeyeye 3
Panpanso 3
Okanta 3
Total 58
Source: Ministry of Health, Nsawam 1999
Available medical statistics on the incidence of the disease in the district 
revealed that at least five cases are reported monthly for treatment at the Buruli 
ulcer-dressing centre at Pakro. Using the provisional 2000 Population census total 
population of one hundred and twenty thousand, five hundred (120500), the 
incidence rate as of March 2000, was 1.1 per 1000 for the entire district. However, 
the rate differs from one area to another. It was 4.4 per 1000 for the highly endemic 
area and 0.03 per 1000 in the low endemic area.
The sex ratio of victims was sixty-one (61) males to sixty-eight (68) females. 
Most cases were children or teenagers. In all, a little over seventy-two percent
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(72.1%) or 93 cases were less than twenty years old. Out of this, 58.1% (75 cases) 
were below fifteen years. The distribution shows a rapid decrease with age in 
prevalence. In adults, women had a higher incidence than men. The same is true for 
the children and teenagers aged below twenty. The preceding information is 
illustrated in the Table 3.3.
Table 3.3: Age and gender distribution of reported Buruli ulcer cases in the
Age group Males
(Number)
% Females
(Number)
% Total %
0-4 2 3.3 11 16.2 13 10
0-5. 9 15 13 19.1 22 17.1
10-14. 9 31.7 21 30.9 40 31
15-19. 14 23.3 3 4.4 17 13.2
20-24 4 6.7 5 7.4 9 6.9
25-29 2 3.3 2 2.9 4 3.1
30-34 1 1.7 - 1 0.8
35-39 1 1.7 2 2.9 3 2.3
40-44 2 3.3 1 1.5 3 2.3
45-49 2 3.3 1 1.5 3 2.3
50-54 2 3.3 2 1.6
55-59 3 4.4 3 2.3
60+ 2 3.3 6 8.8 8 6.2
Total 61 100 68 100 129 100
Source: M nistry of Health, Nsawam, 1998-2000
There is the possibility that some people may be suffering from the disease 
but may not have reported for diagnosis at any of the health facilities in the district. 
Such cases are not reflected in Table 3.3. The problem of under-reporting or under­
diagnosis makes it very difficult to ascertain the exact magnitude of the scourge. The 
problem of under-reporting or late reporting has persisted in the communities due to 
the wrong public perception of the disease and its appropriate treatment. General 
awareness of the disease is low. This is because before the disease was first
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diagnosed, thirteen percent (13%) representing 26 of the public (heads of 
households) had heard of it while eighty-seven percent had not.
The chronic nature of ulcers associated with low rates of success of treatment 
has made people to believe that supernatural forces are responsible for the cause of 
the disease. Table 3.4 represents the public perception of the disease.
Table 3.4: Respondents’ perception on the cause of the Buruli ulcer
Response Frequency Percentage
No idea 95 38.3
Bacteria 18 7.3
From water 26 10.5
Witchcraft 66 26.7
Poor hygiene 19 7.7
Curse from gods 23 9.3
Total 247 100
Source: Fieldwork, May 2000
The information as represented in the table above involves both the afflicted 
and household heads. From Table 3.4, a little over twenty-six percent attributed the 
cause to witchcraft while a little over nine percent assigned the cause to a spell cast 
by gods. In all, thirty-six percent attributed the cause to supernatural forces. Thirty- 
eight per cent could not assign any possible cause of the disease. The responses 
given in the table indicate low level of awareness of the disease among the public 
and this will undoubtedly influence their health care seeking behaviour. As a result of 
these perceptions cases continue to receive attention from traditional healers, 
thinking that those healers can provide effective cure to their affliction. The wrong 
public perceptions on the cause of the disease reveal the shallow depth of 
knowledge of the disease among the public and this will continue to deter people 
from seeking health care from the appropriate source. Not until the erroneous 
impression among the public on the disease is corrected, incidence of the disease
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will persist and spread. When this happens the exact magnitude of the disease 
cannot be assessed hence under-reporting will continue to occur due to the fact there 
will not be adequate data on the disease.
3.3 Risk factors and transmission dynamics
A risk factor is a characteristic which, if present and active, clearly increases 
the probability of a particular disease in a group of persons who have the factor, 
compared to an otherwise similar group of persons who do not have (Jekel et. al., 
1996; Farmer et. al., 1996). Some risk factors are associated with several diseases, 
and some diseases are associated with several risk factors. Epidemiological studies 
can measure the relative contribution of each factor to the occurrence of diseases, 
and the corresponding potential reduction in disease from the elimination of each risk 
factor (Beaglehole et. al., 1993).
A number of risk factors are associated with the Buruli ulcer. Some of these 
are skin contamination and any penetrating injury. This is because mycobacterium 
ulcerans (the causative organism) cannot by itself penetrate the skin (Sciencenews, 
1999). The abiotic environment in the form of stagnant waters, slow moving waters, 
certain water insects on the roots of aquatic plants (Barker, 1972; WHO, 2000) serve 
as a habitat for the causative organism. Certain insects may also help the bacteria 
get under a person's skin due to the fact that certain water bugs living on plant roots 
in endemic areas of Benin and Ghana have tested positive for mycobacterium 
ulcerans (Lancet, 1999). However, this ought to be treated with caution for such a 
discovery could be accidental. Furthermore, mycobacterium ulcerans is believed to
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occur in soil or on vegetation, thereby infecting the skin through pricks or other 
penetrating injuries (Meyers et. al., 1974).
It was discovered in the study that penetrating injuries caused by pricking by 
vegetation, striking the foot against objects, cutlass wounds, that of water vessels, 
stagnant water bodies and restricted access to health facilities as well as the public 
perception on the disease were the main risk factors that are associated with the 
disease in the Akwapim South District. Contact with water cannot be left out of the list 
of possible risk factors in the Akwapim South District. This is because there is great 
water-contact through swimming and farming along watercourses and in swampy 
lands.
There are several important factors in the transmission of Mycobacterium 
ulcerans infection in the Akwapim South District. Fishing in water bodies that are 
either stagnant or flowing which eventually might predispose one to infection. This is 
because fishes caught might be contaminated with the causative organism but 
cannot be seen with the naked eye. Thus pricking by the fin of a fish or any other 
penetrating injury may lead to infection. Farming along water bodies or on swampy 
lands expose people to infection by the mycobacterium ulcerans. This is because 
such areas harbour the causative organism. According to Meyers et.al., (1974), it is 
believed mycobacterium ulcerans resides in soils. Therefore if any penetrating injury 
occurs on a contaminated skin infection may result.
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3.4 Geographical pattern of Buruli ulcer in the district
Geographical epidemiology is the description of spatial patterns of disease 
incidence (prevalence) and mortality (English, 1996). It is a descriptive epidemiology, 
which is more generally concerned with describing the occurrence of disease with 
respect to demographic characteristics, places, and time. Geographical studies have 
provided important clues to the aetiology of diseases. For instance, the geographical 
distribution of mortality from malignanat melanoma led Lancaster (1956) to conclude 
that, its major cause was excessive sunlight. Palm (1890) suspected that lack of 
sunshine was the major cause of rickets. His suspicion was confirmed having 
obtained data on the geographical variation in the prevalence of rickets in various 
countries.
Maps provide the most succinct summary of descriptive geographical 
phenomena since they display the spatial distribution of the characteristics of interest. 
On a map, the geographical distribution of disease is readily visible. For instance, the 
production of cancer maps for many countries (Boyle et. al., 1989) testifies to the 
appeal of this approach. Maps in the Chinese atlas of cancer show substantial 
regional variation in mortality for many sites (English, 1996).
Statistical tables, while able to present more data than maps, cannot easily 
convey these spatial patterns and so are less comprehensible or accessible means of 
representing geographical data. Minute patterns may be missed in tables since they 
cannot take spatial relationships between populations into account.
Although maps have the ability to portray spatial patterns of phenomena, they 
have limitations. Sutherland (1962) pointed out the principal deficiency of the
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geographical base-map in respect of Scotland. He showed that on the normal map 
correct weighting could not be given to the large urban populations, which occupy 
small areas, whilst small populations sparsely distributed over large areas could 
appear to be over-represented. The inherent deficiencies can be traced to the 
potential problems in the interpretation of geographical data. In other words, it is easy 
to forget that the instant visual impression of regions of high and low risk and of 
spatial patterns of disease frequency is based upon descriptive data which are subject 
to the problems of geographical interpretation. Furthermore, Barker (1981) noted that: 
'maps of disease compel speculation about aetiology, but only rarely has such 
speculation by itself led directly to the discovery of causes'. This means that disease 
maps can give clues to areas of occurrence of diseases. However, they (maps) 
cannot provide interpretation to the exhibited patterns unless they are probed into. 
Nevertheless, base-maps could relate disease rates to the local populations at risk as 
well as to geographical position and might prove to be a useful epidemiological tool 
(Brew, 1996).
For the purpose of this study, the administrative map of the Akwapim South 
District is the base-map upon which the prevalence of Buruli ulcer is plotted for the 
study and it is shown in Figure 2.1. The geographical distribution (prevalence) of the 
disease is established via district medical reports. Vigneron (1989) used a similar 
approach in the geographical studies of cancer in French Polynesia. In this study, only 
eight hundred and twenty-two (822) registered cancer cases could be used on a 
geographical basis. This is because places of residence for ninety-nine patients were 
missing. In a related development hospital registry data on cancer incidence in many
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developing countries (Parkin, 1988) have given valuable insight into high and low 
incidence areas in parts of the world where no population-based data exist. This 
approach is relevant and can therefore be extended to establish the geographical 
distribution of Buruli ulcer cases in the Akwapim South District. The disease shows 
clustering in one particular sub-district, Pakro while it is sporadic in the other sub­
districts but one. The spatial pattern of the disease is shown in Figure 3.1.
Of the total number of Buruli ulcer cases in the entire district, 81% can be 
found in the high endemic area (High number of cases). This corresponds to the 
Pakro-Dego sub-districts, which cover the north-western comer of the district. The 
disease is prevalent in twenty-six villages. The worst affected village is Tabankro. 
Others are Buokrom and Asaasiansa. In this area, infection is reported in all the 
settlements.
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FIG
. 3
.1 
DI
ST
RI
BU
TI
ON
 
OF
 
BU
RU
LI
 
UL
CE
R 
CA
SE
S 
RE
PO
RT
ED
 
BE
TW
EE
N 
AU
GU
ST
 
I99
8 
AN
D 
MA
RC
H 
20
00
 
IN
 
TH
E 
AK
W
AP
IM
 
SO
UT
H 
DI
ST
RI
CT
 
BY 
RE
SI
DE
NC
E
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The prevalence rate for the area is 4.14 per 1000. Retrospectively, linguistic 
evidence dates the incidence of the disease back to the early 1970s. The 
queenmother of Tabankro later during an interview confirmed this fact. Verbal 
responses from the public on the prevalence of the disease showed that it is 
common.
The second level (low endemic) area is characterized by sporadic prevalence. 
It encompasses three sub-districts namely Nsawam, Pokrom and Panpanso. Cases 
are few in numbers and scattered over the entire areas. This level thus represents 
the characteristic geographic pattern of scattered foci. It has a prevalence rate of 
0.03 per 1000 per two years. Verbal response from elders and the public was that it 
(Buruli ulcer) is not common there but in high endemic area, Pakro-Dego sub-district.
The third level is the non-endemic zone that has no evidence of the disease 
prevalence. The sub-district concerned is Aburi and the verbal responses on the 
prevalence of the disease showed that it is not known here, but common in the Pakro 
area.
3.5 Observed demographic patterns of Buruli ulcer patients
3.5.1 Sex
The gender distribution of Buruli ulcer patients residing in the Akwapim South 
District surveyed for the effects of the disease is shown in Figure 3.2. Apart from the 
non-endemic area where Buruli ulcer prevalence was zero, fifty-one percent of the 
patients in the high endemic area were females while forty-nine percent were males. 
There was not much difference in terms of prevalence of the disease between the
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two sexes. On the other hand, fifty-eight percent and forty-two percent of the patient 
respondents were females and males respectively in the low endemic area. Unlike 
the high endemic area where there was a slight female predominance over males, 
the opposite was the case in the low endemic area.
Figure 3.2: Sex Distribution of Buruli Ulcer Patients in the Two Endemic Areas
0  Male B  Female
High Endemic Low Endemic
Source: Fieldwork, May 2000
In all, prevalence was higher in females than males. This conforms to the 
overall picture in the district, which shows that forty-seven percent and fifty-three 
percent of reported cases in the district involved males and females respectively. 
Female predominance could be attributed to the domestic division of labour 
(behavioural roles) such as fetching firewood and other domestic chores, which 
exposes them to greater risk of infection through injuries in the discharge of their 
duties.
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The study revealed a high prevalence of the disease in children or teenagers 
aged below twenty. Figure 3.3 shows the age distribution of the observed Buruli ulcer 
patients.
Figure 3.3 Age Distribution of the Observed Patients in both Endemic
Areas
3.5.2 Age
[3 0-9 a  10-13 □  20-29 □  30-39 ■  40-49 [3 50+
High Endemic Low Endemic
Source: Fieldwork, May 2000
From Figure 3.3, seventy-seven percent (77%) of the observed patients in the 
high endemic area were aged below twenty (20) while the remaining twenty-three 
percent (23%) were over twenty (20) years. This shows a progressive fall in 
prevalence with age. This is in line with the overall prevalence of seventy-two per 
cent (72.1%) in the entire district. Although this group constitutes the dependent 
group, their plight has serious socio-economic effects on the children themselves and
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their parents. This is because they cannot help their families in economic ventures 
but their families will have to expend on their medical bills.
On the other hand, fifty percent (50%) of the patients were aged below twenty 
(20) years in the low endemic area while the remaining fifty percent (50%) were over 
twenty (20) years. The infection rate therefore balances between the two groups. 
This distribution therefore shows a balanced infection rate between the independent 
(productive) and the dependants age groups. Unlike the high endemic area where 
prevalence was high among the unproductive group, the opposite was the case in 
the low endemic area.
On the whole, seventy percent of the patients were below twenty (20) years. 
The foregoing discussion points to the fact that the disease predominantly affects 
young people. It is possible to suggest that young people are more susceptible to 
infection than their older counterparts. The high prevalence of the disease in children 
could be explained by the fact that they (children) over-expose their bodies 
particularly the limbs to penetrating injuries and rough play. The habit of not wearing 
clothes exposes them to hazards such as injury by any possible means, which will 
inevitably become a route for mycobacterium ulcerans the causative organism to 
enter the body. Furthermore, they have a higher conscious or unconscious trauma 
rate and less tough skin than adults do. Lastly, children were found not to be 
observing proper hygiene. It is therefore not surprising that infection was very 
common among children. In sum, since children or teenagers are most vulnerable to 
infection the impact of the disease may be greater on them than in adults.
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Figure 3.4 illustrates the various occupations as were declared by the patients. 
Figure 3.4 Occupation of the Observed Patients by Residence
3.5.3 Occupation
^  Pupil □Farming □  Trading □Masonry
High Endemic Low Endemic
Source: Fieldwork May, 2000
As can be seen from Figure 3.4, seventy-seven percent of the patients in the 
high endemic area were pupils, fourteen percent, six percent and three percent (3%), 
were engaged in farming, trading and masonry respectively. On the other hand, in 
the low endemic area fifty per cent (50%) were pupils, thirty-three percent (33%) 
were farmers while seventeen percent (17%) were traders. No cases were observed 
in the non-endemic area. The occupational distribution as shown in Figure 3.4 
indicates that the disease can impact severely on the socio-economic lives of its
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victims. It will adversely affect the education of the children owing to the fact that 
many of them would have to stop schooling or absent themselves from school 
sessions in order to seek treatment. Thus, their output both in school and home will 
be adversely affected.
3.5.4 Religious background of the patients
The following declarations were made with respect to religion. From Figure 
3.5, thirty-six percent of the patients from both areas claimed to be Christians, four 
percent were Muslims (Islam), fifteen percent were Pagans and forty-five percent 
(45%) did not belong to any religious denomination.
Figure 3.5 Religious Background of the Observed Patients by Residence
High Endemic Low Endemic
m Christianity B Islam
□ Paganism EH Non-Denom.
Source: Fieldwork, May 2000
Religion as discussed earlier influences public perception of health and
disease. This is because depending on one’s religious affiliation, one can give a 
different interpret to the cause of the disease. Whilst Christians for instance, do not
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believe that the devil is responsible for the plight of the people with respect to the 
affliction, others believe otherwise. It (religion) no doubt influences attitudes towards 
the disease and the appropriate therapeutic practices. Religion therefore has the 
potential for determining the type of medical system to consult for healing.
3.5.5 Marital status
In all, sixty-eight percent of the sampled patients were not married, thirteen 
percent (13%) were married with divorcees accounting for nine percent (9%), and ten 
percent (10%) had separated. The dominance of not married stems from the fact that 
a substantial part of that group was children. It can be concluded therefore that the 
children are unable to take good care of themselves.
3.5.6 Educational status
The relevance of the educational status of the patients reveals the impact of 
the disease on those who were still in school. It can also influence decision on when 
to patronize a health facility for medical attention. Figure 3.6 illustrates the 
educational status of the observed patients.
The overall profile on education of the observed patients as revealed by Figure
3.6 shows that fifteen percent had never been to school, another fifteen percent had 
completed different levels while seventy percent were still in school and were in 
different levels. The highest level attained was the Junior Secondary. By this 
statistics, it can be inferred that a greater proportion of the pupils had their education
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Figure 3.6 Educational Profile of the Observed Patients by Residence
M  Never Schooled ES Ever Schooled 
□  Still in School
Source: Fieldwork, May 2000
in jeopardy. The disease will adversely affect their performance. In addition, the 
statistics reveal low educational status of the respondents. This development has 
serious implications for the use of health care and public perception of the disease.
3.5.7 Ethnicity
Figure 3.7 below shows the ethnic background of patients for the two endemic
areas.
On the whole, seventeen percent of the patients were Gas, twenty-eight 
percent were Ewes, and forty percent were Akans (Akwapim). Eleven percent and 
four percent were Krobos and Dagartis respectively. However, differences exist in the 
composition of the population with respect to each of the two endemic areas.
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Figure 3.7 Ethnic Background of the Observed Patients by Residence
High Endemic Low Endemic
^Ga DEwes □  Akans IBKrobos ■ Dagartis
Source: Fieldwork, May 2000
In the high endemic area comprising the Pakro-Dego sub-district, seventeen 
percent of the patients were Gas, twenty-six percent were found to be Ewes and 
Akans accounted for thirty-seven percent. The rest were Krobos fourteen percent, 
and six percent were Dagartis. These statistics point to the fact that the population is 
fairly composed even though the area is for the Akwapims.
On the other hand, in the low endemic area constituted by the Panpanso, 
Pokrom and Nsawam sub-districts, seventeen percent of the patients declared 
themselves to be Gas, thirty-three percent were Ewes and fifty percent were Akans 
mainly Akwapims. The picture here contrasts sharply from the high endemic area. 
Over here, there is dominance by Akans. The distribution as outlined in Figure 3.7 
shows the extent of migration or the composition of the population. Although the 
area belongs to the Akwapims, the other ethnic groups together outnumbered the
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indigenes. Furthermore, the distribution indicates that Buruli ulcer affects people with 
diverse ethnic origin. This attests to the fact that the disease does not discriminate in 
affliction. The ethnic composition as discussed necessitated probing the history of 
travel of the patients in order to rule out the chance element in explaining the spatial 
pattern of the disease.
3.5.8 Travel history of patients
Before infection two percent of the patients had not lived within any of the 
endemic areas during the last four years, while ninety-eight percent had lived in both 
endemic areas. Figure 3.8 shows the travel history of the observed patients.
From Figure 3.8, three percent of the patients got infected outside the high 
endemic area. Nine percent declared to have lived in their locality (the high endemic 
area) for a year before infection and thirty-one percent declared to have stayed 
around for two years. Twenty percent of them had stayed there for three years, 
fourteen percent mentioned four years and twenty-three percent of them declared 
more than five years.
In the low endemic area, none of the patients declared to have lived outside 
the locality. According to the statistics for the low endemic area, forty-two percent 
lived there for only one year before infection. Those who had lived there for two years 
accounted for seventeen percent, another seventeen percent indicated four years 
while those who had stayed around for over five years accounted for twenty-five 
percent.
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Figure 3.8: Travel History of the Observed Patients by 
Residence
High Endemic Low Endemic
Residence
El<1 @1 0 2  E3 3 B 4  ® 5+
Source: Fieldwork May, 2000
On the whole, only two percent lived outside the district before infection while 
the remaining ninety-eight percent had lived around for between one and more than 
five years. The 2% involved a woman who was a native of Buokrom in the high 
endemic area but had lived elsewhere till she got infected. She had only come to 
Buokrom, to seek medical treatment from a fetish priestess, who unfortunately 
passed away in the course of attending to her (the patient). The ninety-eight percent 
(98%) who had lived continuously in both endemic areas points to the fact that they 
got the infection there. The periods indicated were long enough for the causative
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organism to cause the disease. Consequently, element of chance cannot be said to 
be influencing the pattern of the spatial spread.
The magnitude of the disease, its associated risk factors, the geographical 
distribution and the socio-economic dimensions of the observed patients have been 
discussed in this chapter.
3.6 Conclusion
Determining the exact magnitude of the disease requires accurate data on the 
incidence of the disease. Owing to the fact that some people continuously avoid 
medical treatment, it will be very difficult to know the exact magnitude of the disease 
in the district. This is because such unreported cases are not reflected in the records 
of the health administrators. This undoubtedly makes assessing the exact magnitude 
at any given time a very difficult task.
The next chapter focuses on the factors that could possibly explain the spatial 
patterns of the disease in the district.
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CHAPTER FOUR 
4.0 Factors Underlying Observed Spatial Patterns
4.1 Introduction
The previous chapter discussed the magnitude of the problem as well as some 
factors that militate against the ascertainment of the magnitude of Buruli ulcer in the 
study area. It again, touched on the geographical distribution of the disease and the 
socio-economic dimensions of the subjects. An attempt is made in this chapter to 
examine the underlying factors of the spatial spread of the disease.
4.2 Buruli ulcer and the natural environment
Independent studies by Snow (1854), Palm (1890), and Lancaster (1956), into 
the geographical distribution of diseases and mortality showed a link between spatial 
disease patterns and the natural environment. These studies confirm that the natural 
habitat influences the spatial variation of disease. The findings made by these people 
are relevant to this study. The physical factors that favour the survival of the 
causative organism prevail in the Akwapim South District, therefore physical 
environment can be said to have influence on the spatial distribution of the disease.
One striking characteristic of the spatial patterns of the disease in the district 
is the significance of natural drainage and altitude in the geography of the disease. 
Buruli ulcer has been found to be associated with riverine rural areas in Ghana and 
elsewhere (Mensah-Quainoo, 1997; van der Werf et. al., 1989 and Barker, 1972). 
Similar findings were made in this study.
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There was a high prevalence of the disease in the settlements along river 
Densu and its tributary, Ponponso. This area corresponds to the high endemic area. 
Some of the affected settlements are Asaasiansa, Pakro, Tabankro and Asikabew. 
These settlements are situated very close to water bodies. The high concentration of 
the disease in the basin of the Densu and its tributary, Ponponso suggests initial 
disease foci which later spread to other areas.
Beside the drainage factor, much of the topography in the high endemic area 
is below 150 metres (500 feet) above sea level. The low-lying nature of the terrain 
facilitates the growth and development of swamps along these watercourses 
particularly river Densu. Consequently, the water bodies overflow their banks during 
the rainy season. The often-resultant stagnant pool of water provides a conducive 
habitat for the causative organism. Oral evidence in the high endemic area indicates 
that there has been environmental change in the form of deforestation due to 
agriculture and exploitation of lumber. This also contributes to flooding.
There was a progressive fall in incidence of the disease in the low endemic 
area. Unlike the high endemic area, settlements such as Pokrom, Ahodwo and 
Obodan all in the low endemic zone are situated farther away from the basin of rivers 
Densu and Ponponso. In addition to the natural drainage, the zone is relatively higher 
in elevation than the high endemic area. Thus, there is an improvement in drainage 
quality. Again, most of the streams that serve this zone are ephemeral in nature. 
Consequently, waterlogged conditions are rare or absent.
Lastly, the non-endemic area occurs on the Akwapim ridge. The height of the 
area is higher than both the high and low endemic areas. Thus, there are no well-
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developed water bodies to create waterlogged conditions for the causative organism 
to survive. Some of the settlements on the ridge are Aburi, Ahwerase, and 
Obosomase.
From the discussion, poor drainage in the form of waterlogged conditions has 
been found to be associated with spatial variation in the prevalence of the disease in 
the district. It has in its small way helped in shaping the geography of the disease. In 
sum, it can be said that most of the Buruli ulcer cases in the district were located at 
low and on gentle slopes and occurs along watercourses.
Apart from the natural environment, the spatial patterns of the disease in the 
district cannot be understood without comprehending the secondary factors namely 
socio-economic and cultural factors. These artificial factors also help to interpret a 
health hazard. Probing into the differential living conditions rather than the 'natural' 
foci of disease (Shannon and Spurlock, 1976), can also bring out differences in the 
spatial spread of the disease. It may include socio-economic and cultural factors 
(lyun, 1983). Prominent among the secondary factors is accessibility to health care 
facilities in the district, and lifestyles that predispose the inhabitants to health 
hazards.
The inclusion of secondary factors is a way of avoiding the temptation to 
search for a single determinant of spatial morbidity patterns in the district. All sorts of 
possible influences may have accounted for the observed patterns, some of which 
can be measured, others can only be inferred.
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4.3 Utilization of health care services in relation to Buruli ulcer
4.3.1 Utilization and distance
A society's access to a health facility can determine its morbidity level. It was 
observed that restricted access to modem health facilities contributed to the 
incidence of the disease.
Physical distance was observed to have influence on the use of health 
facilities in the Buruli ulcer endemic settlements in the district. This has grave 
repecursions on the incidence of the disease. The study revealed the extent of the 
impact of physical distance on the use of health facilities in the high and low endemic 
areas. It was discovered that poor geographic access to health facilities had 
disadvantaged patients in the high endemic area. This is due to poor transportation 
system compounded by bad road network. Third class roads network the entire area 
most of which are rendered impassable during the rainy season. Besides the bad 
road network, some settlements such as Asaasiansa, Adjinase-Zongo all in the high 
endemic area are without road network. Consequently, inhabitants from distant areas 
in the high endemic areas really find it difficult to reach health facilities for 
consultation. Because vehicles hardly ply on these bad roads long distances are 
covered on foot. They are therefore compelled to live with whatever ailment they 
have irrespective of its degree of seriousness until their condition worsens. Based on 
this deterrent factor of physical distance, it is likely that treatment was not sought 
early hence the high incidence of the disease in the high endemic area. It is not 
surprising that there was a very high prevalence at Pakro, Asaasiansa, Asikabew, 
Buokrom and Tabankro all in the high endemic area.
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Poor transportation system has combined with the skewed distribution of 
health facilities in the district to put accessibility of health care beyond the reach of 
the populace in rural areas in the district. The over-concentration (60%) of these 
facilities in the urban areas poses grave consequences for health related matters 
particularly in the deprived rural areas. The distance decay factor, which also has 
socio-economic dimensions thus, becomes a well-recognized spatial phenomenon in 
the high endemic area.
From the foregoing discussion, it can be said that the high incidence of the 
disease in the high endemic area could be due to poor transportation system 
compounded by poor road network and skewed distribution of health facilities. 
Baseline studies conducted in the district in 1995 revealed that about 60% of the 
villages do not have access to health facilities. The situation in the high endemic area 
therefore makes it difficult for the communities to seek health care from both within 
and outside their locality.
Unlike the high endemic area, which is characterized by restricted access to 
health care due to poor transportation system and lack of health facilities, there was a 
sharp contrast in the low and the non-endemic areas. Although there are not enough 
health facilities in these areas, there is an improved transport system, which 
facilitates movement from one place to another. The improved transport system is 
made possible by the fact that all classes of road network serve both (low and non­
endemic) areas. Some of the settlements are Ahodwo, Pokrom, Nsawam and Aburi. 
With settlements such as Nsawam, Aburi and Pokrom being health centres 
inhabitants do not hesitate to seek medical care. In addition, improved transportation
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system, which is made possible by regular movement of vehicles, facilitates 
movement of people to reach health facilities located in the sub-district capitals like 
Pokrom, and Aburi as well as the district hospital at Nsawam. With this development, 
it is likely that Buruli ulcer cases received early medical attention hence low and non­
incidence in both areas respectively hence the lower prevalence rate.
In sum, it can be said that poor geographic access to health facilities due to 
poor transportation system has greatly contributed to the high prevalence of Buruli 
ulcer in the high endemic area. In the low and non-endemic areas improved 
transportation system has overcome the problem of physical distance hence high 
level of utilization of health facilities. The result is a low prevalence of the disease.
Poor geographic access to health facilities in the endemic areas has paved the 
way for diverse treatment options irrespective of the degree of seriousness of one’s 
sickness. This perhaps could be due to a matter of convenience.
Table 4.1: Utilization of health care facilities by level of endemicity.
Source 
of treatment
High
endemic
area
Low
endemic
area
Non­
endemic
area
Total
Freq­
uency
% Freq­
uency
% Freq­
uency
% Freq­
uency
%
Self­
medication
7 7 24 32 6 24 37 18.5
Orthodox 
medicine only
13 13 20 27 10 40 43 21.5
Traditional 
medicine only
24 24 14 19 5 20 43 21.5
Both 
(traditional 
and orthodox)
56 56 17 23 4 16 77 38.5
Total 100 100 75 100 25 100 200 100
Source: Fieldwork, May 2000
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The information in Table 4.1 was analysed based on the sample size from 
each of the endemic areas. As can be seen from the table, fifty-six percent of the 
household heads in the high endemic area relied heavily on both traditional and the 
orthodox medicine. Twenty-four percent depended on traditional medicine only, 
another thirteen percent mentioned the orthodox medicine as their only means of 
treatment whilst seven percent mentioned self-medication. On the other hand in the 
low endemic area, twenty-three percent declared that they combine both traditional 
and orthodox medicine, a significant proportion (thirty-two percent) relied on self­
medication, twenty-seven percent cited reliance on the orthodox medicine only while 
nineteen percent mentioned traditional medicine. In the non-endemic area sixteen 
percent of the respondents utilized both traditional and orthodox medicine, twenty- 
four percent relied on self- medication, forty percent mentioned the orthodox 
medicine and twenty percent declared to be relying on traditional medicine only.
The general picture of the treatment options open to the populace due to poor 
geographic access to health facilities showed that thirty-eight and a half percent used 
both medical systems (orthodox and traditional medicines). Eighteen and a half 
percent depended on self-medication and twenty-one and a half apiece opted for 
only orthodox and traditional medicine respectively.
From the responses given, the traditional and the orthodox medical systems 
play a complementary role in the health care of the populace. In other words, the two 
medical systems supplement each other as a matter of convenience. However, there 
was a strong preference for the traditional medical system. The complementary role 
played by these two medical systems is very significant in the high endemic area
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probably due to restricted access to modem health care facilities. Apart from the 
orthodox medicine, which can properly diagnose the onset of Buruli ulcer, the others 
are incapable of achieving that since their mode of diagnosis is purely speculative. By 
over relying on unorthodox medical system, which lacks precision in diagnosing the 
disease, it is possible that those sources of treatment from which household heads 
sought treatment for their children could not detect the disease. Consequently, the 
corresponding high prevalence in the high endemic area compared to lower 
prevalence in the low endemic area and none for the non-endemic area. In other 
words, low patronage of modem health care in the high endemic area is tantamount 
to initial self-denial of health services delivered by trained eyes in diagnosing the 
disease. Hence seeking assistance late. That is at the time when the situation of the 
victim might have already been worsened. The opposite was the case in the low and 
non-endemic areas since high patronage of modem health care might have exposed 
the disease at its initial stages of development for treatment hence low prevalence. 
High patronage of orthodox medicine could therefore account for the low prevalence 
of Buruli ulcer in the low endemic area owing to the fact that it might have been 
detected at the onset. For it is possible that early detection and treatment would 
reduce the grave consequences the disease has on its victims.
Comparatively, there was improved geographic access to health facilities at 
Okobeyeye, Aburi, Pokrom and Sakyirom all in the low and non-endemic areas 
hence a strong preference for orthodox medicine as reflected in the responses given.
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Table 4.2: Respondents' preference for either orthodox or traditional medicine 
by household.
Source 
of treatment
Highly 
endemic area
Low 
endemic area
Non­
Endemic area Total
Freq­
uency %
Freq­
uency %
Freq­
uency %
Freq­
uency %
Traditional
medicine 41 41 13 17 54 27
Orthodox
medicine 15 15 4 6 4 16 23 12
Not
applicable 44 44 58 77 21 84 123 61
Total 100 100 75 100 25 100 200 100
Source: Fieldwork, May 2000
Of the fifty-six percent respondents who combined traditional and orthodox 
medicine in the high endemic area, only 15% opted for orthodox medicine. This 
fraction however, rarely used the orthodox medicine for the following reasons: no 
health facility 13%, 46% indicated long distance travel to reach a health facility, and 
41% said they cannot afford it. Furthermore, respondents from the low and non­
endemic areas accounted for 6% and 16 % respectively for orthodox medicine. Like 
their counterparts in the high endemic villages, patronage was low due to user fees 
charged at health centres. Comparatively, patronage was quite higher in the low 
endemic zone than the high endemic zone. This presupposes that those who 
frequent modem health facility stood the chance of benefiting from the early detection 
of the disease for themselves and their dependants. Thus, cases detected early were 
likely to have received early treatment hence low prevalence in these areas than the 
high endemic zone.
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A story by a Buruli ulcer patient underscores the problem of physical access to 
health facilities and the kind of initial treatment sought due to poor transportation 
system. The patient, a twelve-year-old boy at Tabankro in the high endemic area 
disclosed that owing to the poor transportation system in the area, he at times found 
it difficult to go for treatment at the health centre at Pakro. Therefore, his family 
initially relied on traditional medicine as a means of overcoming the physical barrier. 
Owing to the poor transportation system, he used to be carried on the back of his 
father in order to be able to reach Pakro for treatment. Later, he had to go to Pakro 
on foot anytime that he was to receive medical care. Consequently there were times 
he could not show up at the health centre simply because the ulcer became so 
painful, that he could not walk.
4.3.2 Ability to pay for health care
It was observed that income was a factor that greatly influenced the use of 
health facilities in the study area. This compels people to postpone seeking early 
treatment or resort to alternative medical sources for treatment, which sometimes fail 
them. In this study, seventy percent (70%) of the Buruli ulcer patients were children 
aged below twenty and for that matter depended on their parents and guardians for 
health care. The remaining thirty percent (30%) were adult patients. The inability to 
pay for modem health care, according to the children, compelled their parents to 
delay seeking early medical care and resorted to traditional medicine. This therefore 
caused the delay in seeking medical assistance among the patients. Table 4.3 shows 
the period patients waited until they sought treatment at a health facility.
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Table 4.3: Responses on the time gap between infection and first visit to a
lealth facility
Period High endemic area Low endemic area Total
(months) Frequency % Frequency % Frequency %
1-3. 3 9 5 42 8 17
4-6. 11 31 3 25 14 30
7-12. 15 43 1 8 16 34
Do not 
remember 6 17 3 25 9 19
Total 35 100 12 100 47 100
Source: Fieldwork, May 2000
From Table 4.3, nine percent of the patients in the high endemic area received 
medical care between one and three months after infection. Thirty-one percent 
waited for between four and six months, forty-three percent had to wait for between 
seven and twelve months while seventeen percent did not remember when they had 
it.
In the low endemic area, forty-two percent of the patients waited for between 
one and three months before medical personnel were consulted. Twenty-five percent 
did report after four to six months of affliction, eight percent did so between seven 
and twelve months after affliction while twenty-five percent could not remember the 
time lapse between onset of the disease and the time of seeking medical care at a 
health facility.
On the whole, seventeen percent waited for between one and three months 
after affliction, thirty percent said between four and six months, thirty-four percent 
mentioned between seven and twelve months whilst nineteen percent could not
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indicate when they did so. The indication here is that treatment was being sought 
elsewhere thinking that the ulcers were ordinary sores, which could easily be treated 
with warm water. The time lapse between the onset of the disease and when modem 
medical care was sought suggests that treatment was not sought early enough in 
order to check the disease from advancing among the patients. Postponing seeking 
medical care in this way could be seen to have compounded the plight of the afflicted 
particularly those in the high endemic zone.
Only nine percent of the patients in the high endemic area sought medical 
care during the first three months of infection compared to forty-two percent in the 
low endemic area. Again, the high prevalence of the disease in the high endemic 
area lies in the fact that the majority (74%) of the patients in the most endemic area 
sought medical care late. Behind the delay was their inability to pay their medical bills 
particularly the young patients whose health needs were determined by their parents.
The underlying factor of their financial woes was that their main source of 
income, agriculture was and continues to be saddled with marketing problems.
4.3.3 Educational status and the utilization of health care facilities
Education revealed its influence on the use of health care facilities, the public 
perception on the cause of disease and the appropriate treatment options. Generally, 
the low educational level of the respondents was observed to be associated with low 
utilization of health care facilities. It was also associated with erroneous impression 
with respect to the cause of the disease. The level of utilization of health care 
facilities will determine the degree of contact with trained health personnel whose
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services could moderate the incidence of the disease. Public perception that the 
disease is incurable by orthodox medicine to a large extent determined the type of 
medical system that was consulted when the disease started. Therefore, if people do 
not patronise such health care facilities, they deny themselves of scientific diagnosis 
thereby compounding their health problems.
Low patronage of health care services was found to have compounded the 
incidence of Buruli ulcer in the endemic areas in the district, particularly in the Pakro- 
Dego area, which corresponds to the high endemic area. Table 4.4 illustrates the 
educational profile of the household heads.
Table 4.4: Educational status of household heads
Response High
endemic
area
Low
endemic
area
Non­
endemic
area
Total
Freq­
uency
% Freq­
uency
% Freq­
uency
% Freq­
uency
%
No education 19 19 15 20 3 13 37 18.5
Primary/
Middle
64 64 46 61 6 24 116 58
J.S.S 5 5 4 5 3 12 12 6
O'Level 6 6 9 12 4 16 19 9.5
Post­
secondary
4 4 1 2 3 12 8 4
A'Level 1 1 - - 3 12 4 2
Tertiary 1 1 - - 3 12 4 2
Total 100 100 75 100 25 100 200 100
Source: Fieldwork, May 2000
The table above was analyzed in terms of the sample size per unit area. From 
the table, nineteen percent of the respondents in the high endemic area had no 
formal education, sixty-four percent had Primary and the defunct Middle school 
certificate background, and five percent had completed Junior Secondary. Six 
percent and one percent declared to have completed the General Certificate of
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Education Ordinary and Advanced levels respectively. While four percent had 
completed Post-secondary and were practicing as teachers and only one percent 
(1%) had completed the University.
For the low endemic area, twenty percent (20%) had no formal education. The 
majority (61%) had Primary and Middle school background and five percent had 
completed the Junior Secondary (Basic Education Certificate Examination). Another 
twelve percent and two percent had completed Ordinary level and Post-secondary 
respectively. Lastly, respondents in the non-endemic area seem to have a better 
educational background as outlined as follows. When compared to the high and low 
endemic areas, it has a low rate for those with no formal education. It was thirteen 
percent for those with no formal education and twenty-four percent for those with 
Primary and Middle school background. Twelve percent had completed Junior 
Secondary, sixteen percent and twelve percent were General Certificate of Education 
at the Ordinary level and Advanced level holders respectively. Twelve percent apiece 
declared to have completed various Tertiary institutions and Post-secondary.
These responses indicate low educational background of the respondents in 
both the high and low endemic areas and a high literacy rate in the non-endemic 
area. However, this does not change the overall low level of education unfolded in 
this study. This has some implications on the use of health facilities by themselves 
and their awards.
Consequently, such a weak educational background impacted negatively on 
the use of health care facilities as put forward by Grossmann (1975). This therefore 
caused the disease to persist and grew in some areas especially in the high endemic
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area. For people with such educational background many a time are ignorant about 
health problems. This state of affairs is a deviation from the fact that the better 
educated are more aware of health problems. Table 4.5 reflects the responses given 
with regards to the use of health care facilities and their educational background 
(see the table below).
The educational background of the household heads as discussed have 
influenced the use of health services on either themselves or their dependents who 
were afflicted by the Buruli ulcer. Because the minors’ demand for health care is 
decided by their parents or guardians.
able 4.5: Utilization of health services by education per household heads.
Educational level Rarely Very often Tota
Frequency % Frequency % Frequency %
No education 35 25 4 21 39 19.5
Primary/
Middle
93 68 4 21 97 48.5
J.S.S. 5 4 5 2.5
Ordinary level 3 2 2 10.5 5 2.5
Post-secondary 2 1 5 26 7 3.5
Advanced level - - 2 10.5 2 1
Tertiary - - 2 10.5 2 1
Not applicable - - - - 43 21.5
Total 138 100 19 100 200 100
Source: Fieldwork, May 2000
As can be seen from Table 4.5 above, sixty-nine percent (138 persons) of the 
household heads rarely used health care services whilst thirty-one percent (19heads 
of households) used it regularly. Among those who rarely used health facilities, 
twenty-five percent had no education, sixty-eight per cent had Primary or Middle 
education, and those with Basic education certificate background accounted for four 
percent. The rest (Ordinary level and Post-secondary) constituted 3%.
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Among the 31% (19 persons) household heads that patronised the formal 
medical care very often, 21% had no education and another 21% either ended at the 
Primary level or were the defunct Middle School leavers. The rest, from GCE 
Ordinary to tertiary levels constituted fifty-eight percent. These statistics shown in 
Table 4.5 indicates that the level of utilization of health care services is very low 
among respondents with little education (notably those with no education, Primary, 
Middle and the Basic education level). The educational status of guardians influence 
decisions on the use of medical facilities for dependants when ill. It is clear that the 
household heads with little education outnumbered the better educated. The reverse 
is the case among those with relatively higher education, and this in a way confirms 
Grossman (1975) assertion on the relationship between education and the use of 
health services.
It is not surprising that the high endemic area has a high prevalence due to 
low usage of health care services. This is because the bulk of those with little or no 
education came from the high endemic area, which until the discovery of the disease 
had not benefited from any health education with respect to the disease. Although 
the level of education is low in the low endemic area, the health education on the 
disease has made a positive impact on the villagers. It could be that they became 
enlightened on the disease or health workers who were going round the villages 
identified cases for treatment.
Besides educational status accounting for the low utilization of health care 
services, it also influences their perceptions on the cause of the disease and 
consequently, the source of treatment to consult.
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The public has different perceptions about the causes of the disease. The root 
of these perceptions could be attributed to the cultural background of the populace. 
This has influenced their choice of medical system when struck by the disease. 
These perceptions according to the study have a link with the educational 
background of the populace as well as the patients. Table 4.6 illustrates the 
perceptions of both the heads of households and the patients.
Table 4.6:Cause of the disease according to the educational background of
household heads patients
Level of 
education/ 
cause of 
the disease
No idea Bacteria Contami­
nated
water
Witch­
craft
Poor
hygiene
Curse 
by gods
Freq­
uency
%
None 27 - 8 10 1 6 52 21
Primary/
Middle
68 13 47 7 11 146 59
J.S.S. 4 6 6 2 7 2 27 11
Ordinary
level
- 5 - 3 2 10 4
Post­
secondary
- 8 - - 8 3
Advanced
level
- 1 - - 2 - 3 1
Tertiary - 1 - - 2 - 3 1
Total 99 21 21 27 59 20 247 100
Source: Fieldwork, May, 2000
Table 4.6 shows the causes of the disease according to the educational status 
of the respondents. Out of the twenty-one percent who had no formal education, fifty- 
two percent could not tell the cause of the disease. Fifteen percent attributed its 
cause to contaminated water. This sounds quite plausible since they might have got 
to know it through the health education embarked upon soon after the disease 
attracted attention in the district. The rest of the distribution is as follows: nineteen 
percent, represented by ten respondents perceived it (Buruli ulcer) to be the work of
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witches. This could be due to its low success rate of treatment. Two percent and 
twelve percent respectively attributed it to poor hygiene and a spell cast by gods. 
Given these responses, it can be said that only a handful of respondents with no 
education at all, were able to give plausible explanation to the cause of the disease. 
Respondents with Primary and Middle school educational background together 
constituted fifty-nine (146 persons). Forty-six percent had no idea about the cause, 
four percent attributed it to bacteria; eleven percent pointed to contaminated water 
while twenty-eight percent assigned the cause to a spell cast on them by gods. It can 
be inferred from these responses that their level of education on the disease is low. 
Other responses given were poor hygiene (8%) and curse from gods (7%). Judging 
from the responses given there was not much variation between those without formal 
education and those with little education with respect to the cause of the disease.
The perception of those with higher educational background is plausible to 
explain the cause of the disease. This contrasts sharply from their counterparts with 
little or no education. Those constituting this group (higher educational background) 
had educational levels from the General Certificate of Education Ordinary and 
Advanced through Post-secondary to the Tertiary. There is no doubt that the better 
educated have a more accurate idea about the causes of the disease. They can 
therefore protect themselves against infection by observing good hygiene unlike 
some of those with low education ones who think otherwise.
When put in geographic context, the responses illustrated in Table 4.7 show 
spatial trends and could be used to account for spatial patterns of the disease in the
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Akwapim South District. Table 4.7 below illustrates the responses for each endemic
area.
Table 4.7:Cause of the disease by zone
Reason High endemic 
area
Low 
endemic area
Non­
endemic area
Total
Freq­
uency
% Freq­
uency
% Freq­
uency
% Freq­
uency
%
No idea 50 37 26 30 4 16 99 40
Bacteria 12 10 7 8 6 24 21 8.5
Contami­
nated
water
15 11.1 13 15 5 20 27 10.9
Witchcraft 37 27 22 25 3 12 59 23.8
Poor
hygiene
10 7 10 12 6 24 20 8
Curse 11 8 9 10 1 4 21 8
Total 135 100 87 100 25 100 247 100
Source: Fieldwork, May 2000
Perception about the disease in no doubt determines the type of medical 
system to consult. This in the end may worsen the plight of the afflicted, if the source 
of treatment fails. From Table 4.7, seventy-two percent of the respondents in the high 
endemic area could not provide plausible cause of the disease compared to twenty- 
eight percent (28%) who could do so. The former group are likely to associate the 
chronic nature of ulcers to unscientific causes thereby seeing orthodox medicine as 
ineffective. Given the fact that the disease had prevailed in some communities such 
as Tabankro for over two decades but has not benefited from any education 
regarding the disease, prevalence overthere was high.
Although respondents in the low endemic area who assigned unscientific 
causes to the disease was quite high (65%), the prevalence rate was low. This could 
be attributed to the moderating effect of the vigorous public education that was 
embarked upon soon after the disease became medically known in the area. It is
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likely the awareness created compelled people to seek medical attention at the least 
symptoms of the disease. However, the high level of ignorance displayed suggests 
that not everybody did benefit. The few, who did might have advised their folks to 
report any traces of the disease at the nearest health facility or health post. It was a 
different scenario altogether in the non-endemic area. Here knowledge about the 
cause of the disease, shown in Table 4.7, was very high. This is represented by the 
responses given. Sixty-four percent (64%) of the respondents were very much aware 
of the clues to the cause of the disease. With this high degree of awareness there is 
no way that, they would allow themselves to be taken unawares by the disease 
hence low prevalence in the low endemic area.
4.4 Lifestyles and Buruli ulcer
According to Meade et. al.,(1988), humans create many habitat conditions that 
could be hazardous. Implicitly implied by this assertion is that a habitat may become 
a health hazard to the society concerned. Besides creating habitat conditions to suit 
disease agents, one’s behaviour exposes one to hazards and protects them from 
others. Newly created habitats and exposure to hazards could be extended to include 
disease pathways associated with all sorts of insanitary conditions. Certain human 
behaviours as was observed are a predisposition to infection in the study area.
4.4.1 Sources of drinking water and scarcity of water and poor hygiene
Majority of the Buruli ulcer endemic communities in the district depends on 
unprotected surface water sources such as streams and ponds. Underground water
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(wells) and boreholes are another source of drinking water. It is only at Nsawam and 
on the Akwapim ridge where pipebome water is available. However, supply is not 
regular on the ridge. Table 4.8 illustrates the sources of drinking water as indicated 
by the Buruli ulcer patients in the two endemic areas
Table 4.8: Responses on the source of drinking water indicated by the Buruli
ulcer patients.
Source of 
drinking water
High 
endemic area
Low 
endemic area Total
frequency % frequency % Frequency %
Borehole 1 3 2 17 3 6
Well - - 5 41 5 11
Pond 15 43 2 17 17 36
Stream/ Rivers 19 54 3 25 22 47
Total 35 100 12 100 47 100
Source: Fieldwork, May 2000
A majority (47%) of the patients depended on streams while thirty-six percent 
mentioned ponds as their sources of drinking water. Another six percent and eleven 
percent depended on boreholes and wells respectively, which by all standards are 
well protected. This information represents the entire patients’ population.
According to Table 4.8, fifty-four percent of the patient respondents in the high 
endemic area depended on streams and rivers for drinking water, forty-three percent 
depended on ponds while three per cent mentioned boreholes. It is clear from these 
responses that the high endemic area lacks potable water. Consequently, they 
experience water shortages during dry seasons. This has serious implications for 
hygienic practices and on the incidence and the prevalence of the disease.
On the other hand, twenty-five percent of the patients in the low endemic area 
relied on streams, seventeen percent depended on ponds, forty-one percent 
depended on wells whilst seventeen percent mentioned borehole. The distribution as
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shown in the table indicates that the sources of drinking water are fairly balanced in 
the low endemic area. Thus when one source fails them, they can rely on the other.
In communities such as Tabankro, Adesa, Asaasiansa, Buokrom and 
Adjimase-Zongo all in the high endemic zone, the river Densu is their main source of 
drinking water. At Pakro, also in the high endemic area, the source of water is from 
boreholes and surface water. The situation is quite different in the low and non­
endemic areas, which comprise such settlements as Okobeyeye, Nsawam, Pokrom, 
and Ahodwo. Here, the inhabitants draw water mainly from wells, boreholes and 
particularly at Nsawam, it is pipebome and surface water. The outcome of the 
dependence on these water sources is that the high endemic area that depends 
heavily on surface water and ponds, at times experience acute water shortage during 
flooding of the water bodies and dry season. Inhabitants therefore have no 
alternative than to depend on ponds, some of which look muddy and are likely to be 
contaminated. Infection could therefore occur when such untreated waters are used 
for bathing.
Unhygienic practices are often associated with water scarcity. Children in 
particular hardly bath in order to keep their bodies clean and healthy. In an interview 
with an opinion leader at Buokrom, in the high endemic area it was mentioned that 
children in the community feel reluctant to have their bath before they go to school or 
after the day’s work. Not even persistent call from their parents or guardians to do so 
would be heeded to. Oral evidence also indicated that there is frequent outbreak of 
skin diseases during periods of water scarcity, and it is common among children. 
These remarks were made after explaining some of the underlying factors for the
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cause of the disease to him. It is no wonder that more children in the high endemic 
area are afflicted compared to the low endemic area, where high prevalence in adults 
could be attributed to the economic activity they are involved in.
Poor environmental sanitation was observed to be another underlying factor in 
the spatial variation of the disease. The dispersed nature of settlements in the high 
endemic area compounds the sanitation situation there. For instance, at Tabankro 
and Asaasiansa all in the high endemic area, the inhabitants dispose of household 
waste in their surroundings. This practise no doubt creates room for disease causing 
organisms of which the mycobacterium ulcerans is one. The scenario was different in 
the low and non-endemic areas, which are more urban and more accessible than the 
high endemic area. Sanitary inspectors therefore, find it difficult to reach settlements 
in the high endemic area to carry out inspection because most of the settlements 
apart from Pakro, are farming communities where the buildings are widely apart, and 
separated by thick bushes. In this way, filthy habitats are created for disease causing 
organism to thrive.
4.4.2 Human-water contact activities that predispose population to 
infection
Many human activities facilitate human-water contact in the endemic villages 
in the river Densu basin. Swimming is a very common activity practised by both 
young and old particularly in the high endemic area. However, this scenario changes 
farther away from the river Densu basin. A fact admitted to by both household heads 
and the afflicted. With the known risk factor of abrasion on a contaminated skin, one 
can easily get infected with the causative organism. In this survey, 44.7% of the
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patient respondents from the endemic villages indicated swimming as a common and 
easiest way of having their bath as against 55.3% who mentioned the use of a water 
vessel. It is through water contact that the causative organism can penetrate the skin. 
The fraction of patient respondents, who could remember a trauma at the site of 
lesion, forty-seven percent (47.3%) indicated injury while swimming, fourteen percent 
mentioned an injury knock at the site of the lesion but could not tell the cause and 
thirty-eight percent cited a prick by a thorn. The situation is different in the low and 
non-endemic areas, where such water bodies do not abound to permit swimming. 
About forty-six percent of the patient respondents indicated surface water (streams 
and river) as their main source of water supply, thirty-six percent cited ponds, a little 
over six percent (6.4%) cited borehole and the rest mentioned wells. Availability of 
surface water (rivers, streams and ponds) therefore enhances swimming. The 
essence of the discussion is that it explains the nature of human-water contact in the 
study area.
In addition to swimming, farming on swampy lands is also a very common 
activity in the endemic areas particularly in the high endemic area. By associating 
Buruli ulcer with swamps suggests that the agent thrives very well in such places. 
Farming on such lands increases human contact with the causative organism leading 
to infection. This fact was admitted to by forty-six percent (46%) of the respondents 
who were farmers, and for that matter relied on such water bodies to water their 
crops.
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High water contact activities thus suggests a high prevalence at Tabankro, 
Asaasiansa, Buokrom and Pakro all in the high endemic area and vice versa in the 
low and non-endemic areas.
4.4.3 The role of health workers
The geographical distribution of the disease in the district can also be 
understood by acknowledging the activities of health workers. The initial or the 
suspected case of the disease was spotted by the then District Chief Executive in the 
district, who was attending a funeral at Tabankro, in the high endemic area. He then 
drew the attention of the authorities of the District Health Management Team that 
came and confirmed the cases. The discovery by the District Chief Executive 
portrayed the inefficiency of general disease surveillance in the district at the time. 
Had the exercise been effective, incidence of the disease would have been detected 
long ago for early treatment. This further suggests that the depth of knowledge 
among health workers was low. It is possible that they had spotted cases of the 
disease but mistook it for an ordinary sore or chronic ulcer due to diabetes, as some 
people believe. The way by which the incidence of the disease came to the attention 
of the district health authorities suggests low awareness and the lack of capacity for 
detection. Given the favourable environmental conditions for the causative organism 
to survive, the disease persisted and spread in the high endemic area. This perhaps 
accounts for the high prevalence of the disease in the high endemic area prior to its 
diagnosis.
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Ever since the detection of the disease, The District Health authorities have 
not relented in their efforts at checking the further spread of the disease to other parts 
of the district. Vigorous health education was embarked upon in order to raise 
awareness in the communities of the disease and its symptoms. Volunteers from the 
communities were trained in order to be able to identify the onset of the disease for 
onward reporting to the district health authorities for action to be taken. It therefore 
follows that increase in knowledge about the disease in other parts of the district 
helped in keeping incidence and prevalence low. This is because with knowledge 
about the symptoms of the disease any sign of its occurrence would be reported 
immediately for medical assistance. This perhaps accounted for the low endemic and 
non-reporting cases of the disease in both areas. With the knowledge acquired, they 
would not hesitate to report any traces of the disease for cure.
It can be concluded from this discussion that the physical environment is a 
very important factor underlying the spatial variation of the disease. However, 
secondary factors such as the socio-economic, and cultural are also equally 
important. Laying emphasis alone on natural factors (environmental factors) such as 
climate, biotic and biological conditions that suggest "disease region" cannot give a 
clearer picture of the geography of Buruli ulcer in the district. This is because Buruli 
ulcer as a disease has socio-cultural dimensions, which need to be understood in 
order to come out with plausible explanation for its spatial spread. This could help to 
arrive at preventive measures to reduce its harsh effects.
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4.5 Conclusion
It can be said from the discussion that the spatial variations of the disease 
correspond to the pattern of the quality of the natural environment as well as human 
behaviour. That is the environment influences the geography of the disease. There 
was a high incidence of cases in the poorly drained and swampy lands in low-lying 
areas. In areas of low prevalence drainage is better and occurred on gentle slopes 
while in the non-endemic area, highland (the Akwapim ridge) and better drainage 
characterized it. This confirms the proposition that the quality of the natural 
environment influences the spatial patterns of the disease.
Secondly, the socio-economic status of household heads coupled with the 
skewed distribution of health facilities have restricted access to these health facilities 
in the endemic areas. The socio-economic background greatly influenced the health 
needs of children in the households. In addition, certain bad habits predispose the 
population to infection. In sum, these factors confirm the propositions that guide the 
study.
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CHAPTER FIVE
5.0 Consequences Of Buruli Ulcer Infection and Strategies to Check its
Spread
5.1 Introduction
Buruli ulcer is an infection that has significant immediate and long-term socio­
economic effects on the people it afflicts. It has direct and indirect effects. It directly 
affects sufferers and impacts indirectly on their relatives, who provide medical care 
and attention while receiving treatment, if the patient is hospitalised. This chapter 
attempts to examine the effects of the disease on the patients, their relatives and 
health resources. In addition, it discusses the strategies adopted by the health 
personnel to check the spread of the disease. It therefore addresses the research 
objective of assessing the impact of the disease on the sufferers.
5.2 Effect on the human body (Physical effect)
Lesions can occur on any part of the body especially on parts, which are most 
of the time exposed to injuries. One could hypothesise on aetiological possibilities 
based on the distribution of the lesions. Among the children or teenagers aged 
below twenty (20), the disease occurred on all parts of the body. Ulcers were 
mostly singles and were more prevalent on the trunk and the lower limbs. On the 
other hand lesions were common on both upper and lower limbs in adults.
The distribution of the ulcers on the body suggests that differential exposure to 
the causative organism probably account for the difference in the location of lesions 
according to age. Differential exposure of the body to the causative organism through
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injuries to the body implies that infection can occur on different parts of body that are 
more prone to injury.
The physical effects thus come from the lesions on the human body. This is 
seen in the pain that is associated with the disease as well as the physical damage it 
can cause to the victims. In this study, twenty percent (20%) of the patients were 
found to have been disfigured in the limbs particularly in the lower limbs. This took 
the form of contracture of muscles in the body. A majority of these patients were 
children currently in school. It is likely that these affected children would drop out of 
school in view of the fact that they travel long distances to attend school. In addition 
to the physical defects that some of the patients had suffered, the pain from the 
ulcers was described as terrible. It is very difficult to sleep when one is in pain neither 
can one concentrate effectively on any activity. This undoubtedly could disturb 
sleeping. Insufficient hours of sleep would certainly affect the general health situation 
of the patients owing to the fact that sleep is a form of therapy.
Besides the physical effects the disease has on its victims, the patient suffers 
other consequences as unfolded in the remaining sections.
5.3 The stigma attached to Buruli ulcer
Besides the physical effects that are associated with the disease is the stigma 
attached to patients by society due to the unusual nature of the ulcers. This causes 
psychological stress in the patients, as they most often feel embarrassed. The 
subjects for this study did attest to this fact. Owing to the low success rate of 
treatment of the disease, thirty-three percent (33%) of them said members in their
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respective communities described them to be agents of the devil. All sorts of stories 
were told about their plight. It was believed that the ulcers served as dining tables for 
the wizards. This perhaps originates from the wrong notion that the disease is caused 
by some supernatural forces. This again underscores the need to intensify public 
education. The younger patients intimated that their playmates did tease them both in 
school and at home. According to them their playing mates did not want them (the 
patients) to come closer to them simply because of the bad odour from their ulcers. 
The adults were also not left out. Their difficulty lay in their inability to go to places 
where their colleagues met and played the games of draught and "oware”, a local 
game. This is because participants when winning a game compose songs to tease 
their opponents. The words of which can be centred on any theme such as Buruli 
ulcer. Thus, patients who cannot resist being teased under such conditions did not 
want to go to such places.
The psychological torture associated with the disease was further manifested 
at Asaasiansa, a settlement in the high endemic area. A patient was unwilling to 
grant a request for an interview. He preferred keeping his plight to his folks than to a 
stranger. He shifted his earlier position following persistent persuasion from a 
member of the community who was attending a bi-weekly meeting to discuss the 
welfare of members and their community. His earlier stand could be attributed to the 
fact that he might have overcome the initial mental trauma suffered. Thus there was 
no need to expose himself again to a fresh mental torture to someone whom he did 
not know. The attitude of a patient towards a teacher in class was another testimony 
that confirms the mental torture patients go through. A schoolteacher residing at
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Pakro but teaching at Otukwadwo confirmed this assertion with a story. According to 
him, he once posed a question to a Buruli ulcer infected schoolgirl in his class in 
order to test her understanding on a topic being discussed in class. While he was 
staring at her in anticipation of an answer to the question, the girl got annoyed that 
the teacher was staring at her due to her condition. Eventually, she did not answer 
the question. These two narratives reveal the extent of mental trauma patients 
undergo.
5.4 Effect on marriage
The disease can dwindle one’s marriage prospects in the event of any 
physical disfigurement. Although none of the subjects in the study could tell the exact 
impact of the disease on their marriage, a different scenario emerged. It involves how 
a disagreement ensued between a young man on one hand and his wife and mother- 
in-law on the other over the type of treatment to seek for their child. He got to know, 
on returning home from a journey that one of his children had been struck by Buruli 
ulcer. Instead of seeking medical care at the Pakro health post, his mother-in-law 
together with his wife had rather sent the sick child to a fetish priest for treatment. 
Their reason was that the kind of ulcer the child was suffering from was not an 
ordinary type due to its chronic nature. He did not like the action the in-law and the 
wife had taken. He intimated that getting the materials or the objects for the healing 
process for the priest to perform the necessary rites for healing was more expensive 
than what would have cost them at the health centre. None of his persuasions to 
seek medical care from credible source could yield positive results.
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Because of the misunderstanding that ensued, his wife out of anger left with 
the sick child to join her mother in another village outside the Akwapim South District. 
Consequently, he had threatened not to follow the wife. Thus he was staying alone at 
the time this study was being conducted. It was later on communicated to him that 
the child had been deformed in the left lower limb. If the strained relationship should 
continue, there is no doubt that the marriage would not survive.
It can be concluded that though the young man did not suffer from the 
disease, the incidence of the disease indirectly had caused a strained marital 
relationship. This shows the extent to which the incidence of the disease can throw 
families apart.
5.5 Effects on socio-economic activities
The disease apart from its physical and psychological effects has socio­
economic dimensions as well. This is because the physical effects of the disease on 
the victim will in no doubt disturb the social and the economic lives of the victims as 
well as the health resources that are used for treatment. The preceding section 
therefore examines the socio-economic effects of the disease on the patients.
5.5.1 Effect on education
Advanced ulcers require prolonged period of treatment and hospitalisation, 
where necessary. In this study, seventy percent (70%) of the patients were currently 
in school with active ulcers. The prolonged treatment period had disturbed their
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education in so many ways. The educational status of the respondents had already 
been shown in Figure 3.6
With reference to Figure 3.6, seventy percent (70%) of the patients were 
currently in school and were seeking treatment. This scenario could seriously 
jeopardise their education since treatment requires a long period of time.
From Figure 5.1, thirty-three percent (33%) of the respondents of school-going 
age repeated in class for a year. This could be attributed to the prolonged treatment 
they underwent. This therefore cost them dearly since they could not write terminal 
exams that provide a basis for assessing their promotion to the next class. The 
majority (67%) intimated that attendance at school was not regular.
Figure 5.1: Effects of the disease on the Education of 
the Observed Patients
80
70 67
v
Q .
u
? 50 
1  40
20
10
60
0
0
Repeated Irregular Attandance 
Effect
NA
Source: Fieldwork May, 2000
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This could be attributed to prolonged treatment along side schooling. Some of the 
patients indicated that there were at times that their ulcers became painful that they 
could not afford walking to school let alone to concentrate on what is being taught 
there. It was terrible for patients at Asaasiansa and Adesa where there are no 
schools. Consequently, children from there always walk to nearby villages to attend 
school. Therefore when a patient is in pain there is no way that the said child can 
make it to school.
Lastly, four and a half percent of the deformed patients declared that they 
might discontinue with their formal education owing to the physical defect they have 
suffered. None of them was able to tell the last time he or she was in school. It might 
be that they had stopped but did not want to disclose it.
The preceding discussion points out that the performance of these children is 
certainly not the best, a fact made known by them. Regular school attendance to a 
large extent guarantees a good performance. However, the disease keep them out of 
school for long periods of time will no doubt adversely affect their output in school. In 
short, the disease has had a negative impact on these school children.
5.5.2 Effects on economic activities
The destructive nature of the disease and the associated prolonged treatment 
period it requires have adversely affected the economic lives of the people. Patients 
have to suspend whatever economic activity they might be engaged in so as to seek 
medical care from whichever medical system they deemed appropriate. The situation 
as highlighted is not different from what was obtained from the study. Respondents in
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the productive age group declared that they have been affected in several ways. 
Although the sample size was small, it reveals the extent of the impact of the disease 
on those it affects.
The occupational distribution of the patients has already been shown in Figure 
3.4. The proportion of the patients in employment constituted thirty percent of the 
total population (the observed patients). On the whole, nineteen percent were
Figure 5.2 Economic Effects of Buruli Ulcer Infection
CPSF CAMC CPFN LAE I IMA
Effect
CPSF = Cannot Pay School Fees, CAMC = Cannot Afford Medical Care, CPFN = Cannot Provide Family 
Needs, LAEI = Lost Ability to Earn Income, NA = Non Application
Source: Fieldwork, May 2000
farmers. Nine percent were traders while two percent were bricklayers or masons. 
Given the physical effects the disease suffered, their income earning ability was 
severely affected. They could not work and this undoubtedly impacted negatively on 
themselves and their dependants. Having been rendered incapable of earning 
income as a result of the disease, they were thus denied the opportunity of enjoying
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some services to the disadvantage of the households they headed as shown in 
Figure 5.2.
From Figure 5.2, twenty-one percent declared that they could not pay their 
wards' school fees. The affected children were thus being denied their rights to 
education. Forty-three percent also intimated that they could not afford paying for 
health services for themselves and their families. It is therefore not surprising that the 
patients of school going age disclosed that their parents could not send them early 
enough for medical treatment hence allowing the disease to advance. Another 
twenty-one percent intimated that they could not provide basic family needs such as 
clothing and nutritious food for their households. No clothing on implies children 
walking bare-chested whilst no nutritious food for family members may cause 
malnourishment especially in children, and consequently prone to infection via a 
weakened immune system. Lastly, fourteen percent pointed out that they had been 
physically disabled and consequently, they had lost the ability to earn income. In 
sum, the disease has rendered them unemployed.
The adverse effects on their economic lives would certainly have grave 
consequences on their families particularly the young ones. The welfare of their 
dependants may suffer in this regard. Instead of being breadwinners, these 
unfortunate people are rather going to depend on their family members for survival.
It can therefore be concluded from the discussion that although the disease 
affected the patients directly, the setback they suffered to their income earning 
potential indirectly affected members of their household.
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Treating Buruli ulcer patients at no cost to the patient has put an enormous 
pressure on, the limited health resources in the district. The 1998 Yamoussoukro 
Declaration on Buruli ulcer mandates governments of the affected countries to 
provide free medication for sufferers. This will make cost recovery very difficult for 
health facilities owing to the fact that sometimes the much-needed medical supplies 
do not arrive on time to serve the purpose for which they are needed.
Notwithstanding his inability to provide data on the average cost of treating a 
patient, the District Director of Health Services intimated that cost of treatment has 
stretched the scarce health resources at their disposal. Consequently, his outfit is 
unable to run vital health programmes. This stems from the fact that patients do not 
pay for medical treatment thereby compelling them to divert resources for other 
programmes to furnish the dressing centre at Pakro with dressing materials. Cost 
recovery therefore becomes impossible.
The strain on the scarce medical resources is made worse by the 
uncooperative attitude of beneficiaries to contribute in order to sustain the Buruli 
ulcer-dressing centre at Pakro. The beneficiaries (the patients) are not comfortable 
with the laudable idea of voluntary contribution to sustain centre. It was disclosed by 
the health personnel at the Buruli ulcer dressing centre that anytime they ran out of 
dressing materials and patients were asked to supplement their efforts they refused 
or would temporarily discontinue treatment until the situation improves. Since the 
district health authorities want to keep the incidence rate low, they have no option
5.5.3 Impact on health resources
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than to provide the needed dressing materials for the patients to continue enjoying 
free medical treatment.
5.6 Strategies to check the spread of the disease
Efforts are being made by the district health authority to alleviate the Buruli 
ulcer scourge in the Akwapim South District. In this direction, so much has been done 
aimed at reducing its spread since the incidence of the disease caught attention.
Presently, there is a Buruli ulcer Surveillance Team in the district whose duties 
include disease identification for early treatment. Established two and half years ago, 
the team has helped in training community volunteers whose main task is to identify 
the disease at the nodular stage of development, and to advise potential sufferers to 
go to any health centre excision to be performed on them. Attacking the disease at 
the nodular stage of its development saves the patient from the harsh conditions, 
associated with the disease. It is also cost saving to the advantage of the health 
authorities.
The surveillance team also analyses and collates reports on the disease in 
order to establish at first hand areas where the problem is most serious. This 
facilitates rapid action to check its further spread.
In addition to the trained community volunteers identifying nodules, public 
education is ongoing in order to increase awareness among the public on the various 
stages of development of the disease. This is done to enhance the public's ability to 
identify the disease early for prompt medical attention. A dressing centre has been 
established at Pakro (the heart of the problem), to treat ulcers. The location of the
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settlement is strategic because it is there that the bulk of the cases (81%) have been 
reported from. Furthermore, two medical doctors have been trained in surgical 
removal of nodules. These pieces of evidence show that the District Health Authority 
has not relented in its efforts at alleviating the scourge of the Buruli ulcer in the 
Akwapim South District.
Programme of activities that have been embarked upon by the health authority 
are beset with problems. The District Director of Health Services enumerated 
inadequate dressing centres considering the growing incidence of the disease as a 
major problem they face. There is only one dressing centre thus, patients have to 
travel long distances on foot to reach it due to poor transportation system. Other 
problems narrated were inadequate resources to acquire dressing and surgical 
supplies for excision. Therefore, for the programme to be successful these problems 
ought to be ameliorated.
5.7 Conclusion
From the discussion in this chapter, incidence of the disease has adverse 
effects on the various socio-economic groups. The disease has directly affected the 
lives of the patients and indirectly the dependants of patients in the economically 
active group. The discussion shows the extent of the socio-economic impact the 
disease has on the population in the study area. This fulfils the research objective of 
ascertaining the effects of the disease on sufferers in the study area. The chapter 
also examined the activities of the district health authorities so as to keep incidence
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as low as possible. This fulfils another research objective of ascertaining the efforts 
made by the health authorities to check the spread of the disease.
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CHAPTER SIX 
6.0 Summary, Conclusion and Recommendations
6.1 Summary
The thesis has attempted to account for the incidence and prevalence of Burul 
ulcer in the Akwapim South District. The following observations based on the 
research objectives and the propositions were made.
The disease was more prevalent in all the administrative sub-districts but one, 
the Aburi sub-district located on the Akwapim ridge. However, it clustered neai 
swampy lands along the river Densu and its tributary Ponponso in the high endemic 
area as pertains in the study. Apart from the poor drainage, the topography in much 
of the area is low, below 75 metres (250 feet) above sea level. The natural 
environment has influenced the spatial distribution of the disease. The most endemic 
villages were in the Pakro-Dego sub-district. Incidence decreases farther away from 
the river Densu basin where drainage is better and marked by gentle sloping. The 
area concerned is characterised by sporadic cases of the disease. The most endemic 
areas were remote and difficult to reach rural areas. This observation therefore 
confirms the proposition that the natural environment influences the spatial spread of 
the disease in the district
It was further observed that incidence was highest in children and teenagers 
aged below twenty (20) years. They accounted for seventy percent (70%) of the 
subjects for the study. Prevalence therefore decreased with age. This compares 
favourably with the overall high prevalence in children and teenagers. On the other 
hand, incidence was higher in females than males in both endemic areas. This, like
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the age also conforms to the general sex pattern for the entire district. The high 
incidence of the disease among children there could be attributed to the fact that they 
do not on their own determine when to seek medication from appropriate sources. 
This fact supports the proposition that the socio-economic background of parents 
influence their level of utilization of health care for themselves and their dependents 
particularly the young ones. Thus their educational and income levels influence the 
decision on when and where to seek medical care.
Unlike some studies that observed seasonal variation in incidence between 
dry and wet season (Barker, 1972), no such phenomenon was observed. This is 
because apart from the cumulative cases that were recorded in the middle of 1998, 
the subsequent monthly medical records on the disease showed a uniform pattern. It 
would therefore be incorrect to conclude that what was recorded in 1998 was only for 
wet period.
The study also revealed that lesions occurred singly and on any part of the 
body. However, it was very common on the trunks of the children. Although this part 
of the body is supposed to be always clothed the children most of the time were seen 
not to be covering that part of their bodies. In adults, lesions occurred on the limbs, 
but largely on the lower limbs.
Another fact worth mentioning is the lack of potable water in the endemic 
communities. Their main sources of water were surface water (rivers and streams), 
underground water (wells and boreholes) and ponds. Frequent breakdown of 
boreholes and drying up of surface water during the dry season result in water 
scarcity in these villages. The villages are therefore compelled to fetch water from
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ponds, which by their very appearance suggests contamination. Communities such 
as Asaasiansa, Buokrom and Adjinase-Zongo that depend greatly on streams and 
rivers hardly have good drinking water during the rainy season owing to the fact 
these water bodies get flooded. There was direct contact with the water bodies 
through swimming, wading in surface water in order to fetch some for domestic 
purposes and for watering of crops along watercourses. Poor sanitation supports the 
proposition that it is a predisposition of the populace to infection.
Low literacy level, inability to pay for health care and poor geographic access 
were found to have restricted the use of health facilities among the heads of 
households and their subordinates. This had serious implications for children who 
could not decide on their own as to when to use a health facility. Consequently, the 
traditional and orthodox medicines play a complementary role in the health care 
needs of the people. However, the traditional medicine was the most preferred in 
areas disadvantaged by poor geographic access to health facilities.
Risk factors associated with the disease related to the natural environment. 
Others were injuries sustained through kicking the foot against objects and water 
contact through bathing without treating water.
6.2 Conclusion
The environment plays a crucial role in the spatial patterns of the disease in 
the district. The geographical distribution of the disease followed the quality and the 
pattern of the physical environment. The spatial distribution thus suggests a link of 
the prevalence of the disease and the quality of the natural environment. Similar
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observations were made in the Nile basin in Uganda (Barker, 1972) and along the 
river Densu in the Ga District of the Greater Accra Region of Ghana (Mensah- 
Quainoo, 1998).
Poverty is another environmental factor that determines financial and 
geographical access to health services. Restricted access to medical care was a 
major problem in the endemic villages in the district. This is attributed to difficult 
geographic access because of poor transportation system, no health facilities, and 
inability to pay for health care. The result is low utilization of such facilities where 
expert advice would have been given on health problems. In addition, bad habits 
such as poor hygiene predispose the populace to infection by mycobacterium 
ulcerans.
With increasing number of cases, high treatment cost and serious 
complications, a vaccine to immunize individuals against the disease is yet to be 
designed. The best and effective means of controlling the disease from advancing, is 
early detection and treatment at the nodular stage of development. Urgent attention 
should therefore be given to the disease in terms of control and research efforts 
aimed at early detection and treatment.
6.3 Recommendations
Buruli ulcer is emerging as a serious public health problem all over the world 
particularly in the humid tropics and the sub-tropics. Presently, the treatment choice 
is surgical but adequate surgical facilities are not available in most endemic areas 
particularly where dressing centres have been established. Because of limited
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access to health care and other socio-economic and cultural factors, most patients 
report late at health centres for medical attention. Consequently, complications often 
occur associated with high treatment costs. This is because some cases of Buruli 
ulcer require a prolonged hospitalisation. Treatment therefore becomes burdensome 
to both patients and their relatives. With increasing number of cases therefore, the 
burden prolonged treatment brings deepens. With no vaccine against, early detection 
and treatment for Buruli ulcer is crucial and could thus, be cheaper. However, this 
would require an effective control programme, expanded health education good 
surveillance system, and increased access to health services.
Both patients and non-patients still hold on to the claim that the disease is 
caused by supernatural forces. The root cause of this misconception stems from the 
low rate of success of treatment hence hospital treatment is irrelevant or even 
dangerous. This is an indication of sheer ignorance. The situation is not different from 
what prevails in the Akwapim South District. Preventive measures should look 
beyond environmental and biological factors to include people’s lifestyles and other 
co-factors as contributory factors of illness in much the same way as Buruli ulcer. The 
study therefore strongly suggests a more comprehensive Buruli ulcer surveillance 
system in the Akwapim South District.
The fact that not all incidence of Buruli ulcer has been reported in the district 
makes it difficult to measure the exact magnitude of the disease for effective 
planning. It is therefore necessary to have a surveillance system in place, which will 
undertake an ongoing, systematic collection, analysis and timely dissemination of 
public health data for planning purposes. Such a surveillance mechanism would help
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identify areas where the disease is, who it affects and to decide on how preventive 
measures should be directed. When this is accomplished, it would be possible to 
measure the exact magnitude of the burden associated with the disease for effective 
planning in order to minimise future incidence.
For a successful surveillance strategy, the superstitious beliefs some people 
have about the cause of the disease can deter them from seeking medical care at the 
formal health sector. This misconception stems from the fact that the disease cannot 
be effectively treated by western medicine. Consequently, treatment continues to be 
sought outside the formal medical sector. This undoubtedly may derail any 
surveillance effort due to the fact there is no collaboration between the medical 
systems. Thus, vital statistics needed for a surveillance system might be lost. It is 
when these factors are thoroughly dealt with that such a programme will be 
successful. Vigorous and sustained health education should be embarked upon so 
as to remove any ingrained cultural belief, which is a potential threat to a successful 
Buruli ulcer Surveillance.
It is further recommended that health workers must be given adequate training 
in order to be able to accurately recognise the onset of the disease for prompt action 
to be taken. With increased awareness among health workers, the incidence of the 
disease can be reduced. Because they can make accurate diagnosis that would 
possibly stop the disease from advancing. Apart from the training given to such 
health personnel, they must be motivated in order to stay and work in the rural areas 
where the disease is very common.
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Since health workers are not available in every village coupled with the fact 
that many people have limited access to health facilities, volunteers must be recruited 
from these villages to be trained on how to recognise the disease for onward 
reporting to trained health workers for confirmation. These volunteers will in no doubt 
play the role of health workers in areas that lack the services of such personnel.
Furthermore, any ulcer found among the populace must be treated with 
seriousness. They must be washed to ward off any suspecting organism, which is 
capable of causing the disease. It would be appropriate in this regard to report such 
cases to the health centres for prompt action to be taken.
The disease-causing organism it is believed thrives in water bodies. Since 
these organisms cannot be seen with the naked eyes, it is recommended that water 
must be treated using chemicals or simply by boiling it before bathing. Comparatively, 
the latter is cheaper than the former. Treating water before bathing can kill the 
causative organism if any, thereby making the water safe for use. In case of any 
puncture on the skin, there will be no organism to enter the body.
Health care facilities must be strengthened, and made both geographically and 
economically accessible, in order to provide treatment for all patients identified to be 
having the disease. If the remotest areas are opened up by way of improved 
transportation system more people in these remote villages will be able to visit health 
facilities for treatment. Besides improving the spatial accessibility, regular screening 
should be undertaken on rotational basis by the health workers in the district. Chiefs 
and opinion leaders must co-operate with the health personnel in this regard.
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The district administration must be seen as an active partner in this crusade. 
Part of the share of the District Assembly common fund must be channelled into 
improving the socio-economic well being of the populace. In this regard, the poverty 
alleviation programme must be vigorously pursued in the district. A successful 
poverty alleviation programme would improve the well-being of the populace. By that 
they can enjoy vital life enhancing services including health care. This will therefore 
improve their health status. This will save people including the afflicted who cannot 
make it on foot to the nearest health facility for treatment.
Owing to the poor system of transport in the remote areas of the district, more 
dressing centres must be established. Since the only one at Pakro offers free medical 
service, people travel from far away places to enjoy the facility. These facilities 
should as much as possible have simple surgical units that can perform incision 
without referring cases to the district hospital where such facilities are available. 
Further, dressing materials must always be made available to the Buruli ulcer- 
dressing centre to provide uninterrupted service to the patients. In addition, more 
health personnel should be trained in the treatment of the disease.
Education has the ability to remove public misconception on a subject. Certain 
cultural beliefs have been found to be hindering villagers in Buruli ulcer endemic 
areas from seeking medical care outside their locality. The removal of these cultural 
beliefs could be a fundamental key to the success of any Buruli ulcer surveillance 
strategy. Based on this, people through education would understand that the disease 
is curable by western medicine when detected early. Education can uproot the 
superstitious beliefs people have about the disease due to its chronic nature. It will
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enable them to know that the disease can be cured by orthodox medicine and it is 
not dangerous or irrelevant as some people share that view. Besides, the populace 
can be educated on the need to utilise a health facility where expert advice can be 
given on the disease.
Though public education has gone on, it seems it has not gone down well with 
the people as reflected in the response on the knowledge (57%) about the symptoms 
of the disease. Therefore, public education should be intensified in order to equip the 
people with skills in the accurate identification of the disease at the nodular stage for 
prompt treatment. This can take the form of colour posters displayed at popular 
points in the villages and video shows in the evenings interspersed with questions 
and answers session. This will go a long way to minimise the reliance on friends and 
local traditional healers for information about the disease and appropriate form of 
treatment.
It is further suggested that who receive medical care patients must supplement 
the efforts of the health personnel by contributing towards the provision of dressing 
materials at the dressing centre. Services are supposed to be free of charge, 
courtesy the 1998 Yamoussoukro Declaration on Buruli ulcer. However, where the 
co-operation of patients are needed, it must be done in such a way that it does not 
discourage the patients from coming to the Buruli ulcer dressing-centre.
The water supply system for the communities ought to be improved upon in 
order to provide safe water for the communities. Frequent breakdown of boreholes 
should be accompanied by regular maintenance in order to ensure safe water for the 
populace. The district assembly, the government, non-governmental organisations
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and individuals must assist communities without boreholes to acquire such facilities. 
This to a large extent will provide potable water throughout the year.
People must also try as much as possible to wear clothes to cover parts of 
their bodies, which are most of the time, exposed to injuries so as to reduce likely 
points of entry for the organism into the skin. Parents must check the habit of children 
by not wearing clothes at home and in the bush, since they will be exposing 
themselves to the risk of sustaining preventable injuries.
People must observe good hygienic practices. This can ward off the agent for 
the disease from striking. Indiscriminate waste disposal in the surroundings 
particularly in the villages must be stopped. Sanitary inspectors should go round the 
communities to inspect the surroundings of households in the various communities. 
Anyone found to have gone contrary to the practice of good hygiene should quickly 
be sanctioned as it was some decades ago.
It is envisaged that if these recommendations would be followed incidence of 
the disease would be reduced.
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APPENDIX 
Appendix A
QUESTIONNAIRE FOR HOUSEHOLD HEADS
Section A: Personal information
1a. Age: (state).......................................................................
2a. Name of village:.................................  3a. Subdistrict:.....
4a. District...............................................................................
5a. Sex: (Tick) (i) Male [ ] (ii) Female [ ]
6a. Marital status
(i) Married[ ] (ii) Divorced[ ]
(iii) Single[ ] (iv) Separated[ ]
(v) Others, specify.............
7a. What is your educational background?
(i) None [ ] (ii) Primary [ ]
(iii) Middle[ ] (iv) J.S.S.[ ]
(v) Secondary[ ] (v) Others, specify............
8a. Which religious denomination do you belong?
(i) Christianity [ ] (ii) Muslim [ ]
(iii) Pagan[ ] (v) Non denomination [ ]
9a. What is your ethnic group?
(i.) Ga[ ] (ii) Ewe[ ]
(iii) Akan (iv) Krobof ]
(v) Dagarti[ ]; (vi) Others..............
10a. How long have you lived here?........................................
Section B: Utilisation of health care services
1b. Which of these medical systems do you utilize?
(i) Orthodox medicine[ ];
(ii) Traditional medicine[ ]
(iii) Do not rely on any of these sources[ ]
(iv) Self-medication [ ];
(v) Both traditional and orthodox medicine[ ]
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2b. If both medical systems are utilized, which one do you prefer most?
(L) Traditional medicine[ ] (ii) Orthodox medicine[ ]
3b. Give reasons for your choice of answer in Question 2b
i.........................................................................................................
4b. If traditional medicine is preferred to orthodox medicine, which of these 
practitioners do you seek treatment?
(i) Faith healers[ ];
(ii) Herbalists [ ];
(iii) TBAs [ ];
(iv) (iv) Fetishpriests/ Priestesses;
(v) Others, specify..........
5b. Give reasons for your choice of answer in question 4b
6b. How often do you seek medical care?
(i) Every month[ ] (ii) Once in every three months[ ];
(iii) Once in a year[ ] (iv ) Twice in a year[ ]
(v) Thrice in a year[ ] (vi) Very often[ ]
(vii) Daily[ ] (viii) Rarely[ ]
7b. If rarely, give reasons
(i) No health facilityf ]
(ii) (ii) No money to pay for the service[ ];
(iii) Have to walk over a considerable distance from home[ ]
Section C: Economic Activities
1c. What is your occupation? ...............................................................
2c. What factors negatively affect your income earning?
(i.) Ill- health[ ] (ii) Damage to produce[ ];
(iii) Marketing problem[ ] (iv) None of these[ ]
3c. How does unreliable income affect your consumption of services?
(i) Cannot pay for health services[ ]
(ii) No entertainment ]
(iii) Cannot pay children's school fees[ ]
(iv) Cannot afford basic family needs [ ];
(v) Not affected[ ]
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1d. How has domestic duties been shared among the family members?
(i.) Boys fetch water and weed the surroundings[ ]
(ii) Girls help their parent in selling to generate family income[ ]
(iii) Females fetch firewood[ ]
(iv) Males work on the family farm[ ]
(v) Both males and females work on the family farm[ ]
(vi) Such division does not exist[ ]
(vii) Cooking is done by the females[ ]
2d. Would you say such activities involve dangers (injuries)?
(i) Yes [ ] (ii) No [ ]
3d. If yes to the question above, which of these injuries do they sustain?
(i) Pricking by thorns [ ]
(ii) Cutlass wounds [ ]
(iii) Puncture on skin by stone(s) [ ]
(iv) Piercing by pointing instruments[ ]
4d. With regards to the dangers involved, which group is the most vulnerable?
(i) Childrenf ]; (ii) Women[ ]; (iii) Men[ ]
Section D: Behavioural roles (Division of labour in the family)
Section E: Source of water supply
1 e. Which source do you draw water?
(i) River/stream[ ] (ii) Pond [ ]
(iii) Borehole [ ] (iv) Well [ ]
2e. How do you draw water from the source?
(i) Wade in stream due to shallow river/stream mouth[ ]
(ii) Steps on rocks in river[ ]
3e. Which route leads to the water source?
(i) Footpath through the bush[ ];
(ii) Road[ ]
(iii) No clear -cut route[ ]
4e. What are some of the dangers encountered on the way to the site?
(i.) Snake bite[ ] (ii) Cut due to striking of toes against stones[ ] 
(iii) Thom prickf ] (v) Cut caused by water vessel[ ]
(vi) Others, specify...
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5e. How do you treat water before bathing?
(j) Boil it[ ]; (ii) Filter it[ ];
(iii) Chlorinating[ ]; (v) Do not treat it [ ]
6e. Why do you treat water before bathing?
(i.) To kill germs in order to avoid skin infection[ ]
(ii) With no clear motive because others do it[ ]
(iii) No treatment because I swim in stream/ rivers[ ]
7e. What is responsible for water shortage in this community?
(i) Water bodies dry up during the dry season[ ]
(ii) Frequent break down of boreholes [ ]
(iii) Do not experience water shortage[ ]
8e. How many times do you bath in a day?
(i.) Once[ ] (ii) Twice[ ] (iii) Thrice[ ] (iv) None[ ]
9e. Which is the commonest form of bathing to both children and adults? 
i.................................................. ii................................................
Section F: Perceptions and attitudes
1f. Have you ever heard of the disease, buruli ulcer before? 
(I) Yes [ ] (ii) No [ ]
2f. Where did you first hear of it?
(i) In the news bulletin[ ]
(ii) Read from the dailies[ ]
(iii) From a friend [ ]
(iv) Have not heard of it[ ]
(v) Other sources, specify...........................................
3f. If you have heard of it, how long ago?
(i) 1-3 months ago [ ]
(ii) 4-6 months ago [ ]
(iii) 7-12 months ago [ ]
(iv) Over one year [ ]
(v) Others, specify...........................................
4f. What do you think underlies the cause of the disease?
(i.) It is a curse from gods[ ];
(ii.) Its cause is due to natural factorsf ];
(iii) Poor hygiene[ ]
(iv) Witchcraft [ ]
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5f. If the family has experienced the disease, which medical system did yoi
utilise?
(i.) Western medicine[ ]
(ii) Traditional medicine[ ]
(iii Did not seek medical care[ ]
(iv) Self- medication[ ]
6f. How many cases have you had so far?
(i.)Once[]; (ii)Twc cases[ ]; (iii) Three cases[ ]; (iv) Over four cases[ ]
7f. If yes, would say m sdical treatment was sought early?
(i) Yes [ ] (ii) No [ ]
8f. Give reasons if no medical treatment was sought?
9f. What are your beliefs about the Buruli ulcer?
Section G: Access to facilities
1g. How would you rate road transport in this area? 
(i.) Excellent! ]
(ii) Very good[ ]
(iii) Good[ ]
(iv) Average[ ]
(v) Very poor[ ]
2g. How does bad transport network affect you? ....
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Appendix B
FIELD QUESTIONNAIRE FOR PRESENT BURULI ULCER PATIENTS 
Section: A: Personal information
1a .Name of village................................................................................
2a. Subdistrict.........................................................
3a. District.............................................................
4a. Gender: (i) Male [ ] (ii) Female [ ]
5a. Age (state):.......................................................
6a. What is your ethnic origin:..............................
7a. Religion:
(i) Christianity [ ] (ii) Muslim [ ]
(iv) Pagan[ ] (v) Non denomination.
8a. Marital status:
(i) Single [ ] (ii) Married [ ]
(iii) Divorced [ ] (iv) Others, specify......
9a. Level of education:
(i) None[ ] (ii) Primary [ ]
(iii) J.S.S./ Middle[ ] (iv) Secondary[ ]
(v) Others............
10a. I f  e v e r  schooled, did you complete? (i) Yes[ ] (ii) No [ ]
11a. If you did not, why?
(i) Did not have interest in schoolingf ]
(ii) Due to financial difficulties [ ]
(iii) Due to disease (Buruli ulcer)[ ]
(iv) Others, specify.................
(Students should answer questions 11 to14)
12a If you are still in school, is your attendance regular?
(i) Yes [ ] (ii) No [ ]
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13a. If No, why?
(i.) Because of the Buruli ulcer[ ];
(ii) No one to pay school fees [ ]
(iii) Others, specify.........................
14a. Has irregular attendance affected your performance? 
0 ) Yes[ ] (ii) No[ ]
15a. If Yes to question 13a above, in what way?
(i.) Verygood[ ] (ii) Good[ ]
(iii) Average[ ] (iv) Poor[ ]
16a. If poor, give reason(s) for that poor performance.......
Section B: Economic activities
1b. What is your main occupation?.....................................................
2b. How did or has the disease interfered in pursuing your activities?
i.....................................................................................................
Section C: Community specific question
1c. Source of drinking water (
(i) Pipebome [ ] (ii) Borehole [ ]
(iii) Well [ ] (iv) Stream/river [ ]
(v) Pond [ ]
2c. How do you draw water from the source?
(i) Wade in stream due to shallow river/stream mouth[ ]
(ii) Steps on rocks in river[ ]
3c. Which route leads to the water source?
(i.) Footpath through the bush[ ]
(ii.) Road[ ]
(iii.) (iii) No clear -cut routef ]
4c. What are some of the dangers encountered on the way to the site? 
(i.) Snake bite [ ]
(ii) Cut due to striking of toes against stones [ ]
(iii) Thom prick [ ]
(v) Cut caused by water vessel [ ]
(vi) Others, specify.................
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Section D: Individual specific questions
1d. What is the duration of the illness before you sought medical care?
2d. If you reported late what was the caused?
(i.) No money to pay for health care[ ]
(ii.) No health facility[ ]
(iii) Others (state)......................................................................
3d. Which is the commonest form of bathing to both children and adults?
(i.) Swimming [ ]
(ii.) Fetch water into bucket[ ]
(iii.) Others.........
4d. Did you have a trauma at the site of lesion?
(i) Yes[ ] (ii) No[ ]
5d. If yes, what was the cause of the trauma?
(i) Cannot remember [ ]
(ii) Pricking by thom[ ]
(iii) Puncture through injection [ ]
(iv) Others,
6d. How long have lived here?.........................................................
7d. Where did you get infected?...................................................
8d. What are your views about the cause of Buruli ulcer?
9d. Which form of medical treatment did you seek?
(i) Orthodox medicine[ ] (ii) Traditional medicinef ]
10d. Why did you seek treatment from the source as indicated in question 8d?
11 d. Do you often sustain penetrating injuries?
(i) Yes[ ] (ii) No[ ]
12d. Mention any two forms of injury you sustain.
i................................. ii..................................
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Appendix C 
QUESTIONNAIRE FOR HEALTH WORKERS
I. Name of institution...............................................................................
2 Subdistrict.............................................................................................
3. Sex: (i.) Male[ ] Female[ ]
4. Profession/Status:................................................................................
5. Do you have a Disease Surveillance Team in the district?
(i.) Yes[ ] (ii) No[ ]
6. If yes to question (5) above, how long has it been in existence?...
7. Could you define its scope of operation?...........................................
8. What has it been doing since its inception?.................................
9. When was the first case of the Buruli ulcer reported at your health
facility?..................................................................................................
10. Would you say it was detected early?
(i.) Yes[ ] (ii) No[ ]
I I .  If No, to the preceding question could you explain why?
i ................................................................................................................................................................................................
12. Do you often record cases of the disease?
(i) Yes[ ] (ii) No[ ]
13. If Yes, to the preceding question, how often?............................
13. Do patients pay for the cost of treatment?
(i) Yes [ ] (ii) No[ ]
14. Ever since it was reported what has your outfit been doing to alleviate
the situation?.................................................................
16. If you have a programme in place, how effective is it? ........................
17 . Do you encounter problems in the discharge of your activities?
(i)Yes[ ] (ii) No[ ]
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