current endeavours to eliminate lymphatic filariasis have been hailed as  a best buy in 
 global health ( ottesen , 2008 , e317 ) and  the most 
 effective pro - poor public health programme ( molyneux , 2003 , p. 1 ) . they are part of an international agenda to  rescue the bottom 
 billion through the control of neglected tropical diseases ( hotez et al . , 
 2009 , while there may be a degree of fundraising rhetoric in such 
 statements , there is no doubt that lymphatic filariasis presents a major public health 
 problem for large numbers of impoverished people . recent estimates suggest that around 120 
 million people living in tropical and sub - tropical environments are affected , with 
 approximately 40 million displaying clinical signs of infection such as hydrocele ( swollen 
 scrotum ) , lymphoedema / elephantiasis and a further 80 million people experiencing 
 sub - clinical signs of infection ( taylor et al . , 2010 ) . strategies to eliminate lymphatic filariasis currently rely heavily on the mass 
 distribution of drugs , free of charge , to all adults and children aged five or more living 
 in endemic areas . the drugs being distributed are albendazole , in combination with either 
 diethylcarbamazine citrate ( dec ) or ivermectin ; and recent reports suggest that more than 
 570 million individuals , residing in 51 countries where lymphatic filariasis is endemic , 
 have received these drugs ( taylor et al . , 2010 ) . first , it is important to break the cycle of transmission between mosquitoes and human 
 beings . anopheles , culex , aedes and 
 mansonia mosquitoes are all capable of transmitting parasitic worms 
 ( wuchereria bancrofti in africa ) that cause the disease , lymphatic 
 filariasis , in humans . the mass distribution of drugs provides an opportunity to interrupt 
 transmission , because the tablets have the effect of reducing the circulation of 
 microfilariae ( the larvae of the parasitic worms circulating in the blood of infected 
 individuals ) . second , elimination of the disease is thought to be achievable with the drugs mentioned 
 above if a large enough proportion of the population swallow the tablets being distributed . the necessary rates of drug take - up have been variously estimated at 6580% over four to six 
 years ( mohammed et al . , 2006 ) and 
 7090% over six or more years ( michael et al . , 2004 ) . in areas where the prevalence of microfilariae is greater than 
 10% , 2004 ) have 
 suggested that coverage levels of 90% or more may be necessary . whatever the requisite 
 coverage levels , multiple rounds of treatment are essential because the drugs currently 
 being used do not kill the adult worms . instead , they reduce the circulation of 
 microfilariae until the worms naturally die off , and it can take six years for this to occur 
 ( michael et al . , 2004 ; bockarie 
 & deb , 2010 ) . additional reasons for promoting mda include the fact that two pharmaceutical companies , 
 glakosmithkline and merck , have agreed to donate the relevant drugs until lymphatic 
 filariasis has been eliminated from the globe ( who , 2012 ) . the drugs , it is argued , can usually be distributed through existing national 
 health mechanisms to volunteers in the targeted communities . they are also considered to be 
 safe enough to be used without testing for infection , making it ethical , as well as cheap , 
 to treat everyone . in sum easy - to - do 
 and inexpensive health intervention ( molyneux , 2003 , p. 13 ) , a view that underpins the world health organization 's global programme 
 to eliminate lymphatic filariasis . by 2008 elimination of the disease was anticipated to be a real possibility by 2020 (  end in sight 
 for elephantiasis , bbc , 8th october 2008 , http://news.bbc.co.uk/1/hi/health/7659222.stm ) . continuing optimism is reflected in 
 statements such as those by the who department of control of neglected tropical diseases in 
 2011 , suggesting the campaign is  halfway towards eliminating lymphatic filariasis ( http://www.who.int/neglected_diseases/integrated_media/integrated_media_urogenital_lf_2011/en/index.html ) , 
 and by those associated with the january 2012 joint london declaration on neglected tropical 
 diseases ( ntds ) , in which partners pledged new levels of collaboration and announced a 
 co - ordinated push to accelerate progress toward the eradication of lymphatic filariasis and 
 the control or elimination of a range of other ntds ( http://www.dfid.gov.uk/documents/publications1/ntd%20event%20-%20table%20of%20commitments.pdf ) . the tanzanian national lymphatic filariasis elimination programme ( tnlfep ) is part of these 
 global operations to eliminate the disease . in 2009 , it was reported that it had covered 34 districts in six regions , with 9.2 
 million people having been treated over a period of eight years ( malecela et 
 al . , 2009a ) . efforts to eliminate 
 lymphatic filariasis from tanzania are also part of the national programme to control 
 neglected tropical diseases ( united republic of tanzania , 2009 ) . this programme was established in 2009 with a view to co - ordinating efforts 
 to control or eradicate a variety of tropical diseases including schistosomiasis , 
 soil - transmitted helminths , onchocerciasis , trachoma and lymphatic filariasis . it is 
 recognized in reports and official statements that an integrated and holistic approach to 
 lymphatic filariasis ( and other neglected tropical diseases ) is the ideal , and that mda 
 should be combined with other methods . however , it would be fair to say that , in practice , 
 the focus has primarily been on the distribution of donated drugs . in addition to the mass distribution of ivermectin and 
 albendazole , it is intended that there should be vector control ( involving the use of bed 
 nets and the reduction of breeding sites for mosquitoes ) ; lymphoedema management ; and 
 hydrocelectomies ( involving surgery for scrotal swelling caused by the parasitic worm , 
 wuchereria bancrofti ) . although the emphasis given to these latter 
 components may be different in other locations , such as zanzibar ( mohammed et 
 al . , 2006 ) and mafia ( malecela et 
 al . , 2009a ) , at locations studied in 
 this paper , vector control was receiving almost no attention , and lymphoedema management was 
 very limited . a variety of epidemiological and health policy research has been undertaken on lymphatic 
 filariasis in coastal tanzania ( see , for example , kolstrup et al . , 1981 ; meyrowitsch et al . , 1995 , 2004 ; 
 nielsen et al . , 2006 ; rwegoshora 
 et al . , 2007 ; simonsen 
 et al . , 2005 , 2010 ; malecela et al . much of this research documents the prevalence 
 of microfilariae as well as visible signs of infection such as swollen scrotums , legs and 
 feet . ( 2010 ) , for example , reported that in kirare , a 
 sentinel surveillance site located about 20 km from the regional capital of tanga , the 
 overall prevalence of microfilariae among individuals over the age of one was 24.5% , and it 
 was 53.3% for wuchereria 
 bancrofti - specific circulating antigen . they also noted that 4.1% adults 
 aged 20 years or more had elephantiasis of the leg and 32.8% adult men had hydrocele . these 
 data were collected in september 2004 , immediately before the tnlfep began the first round 
 of treatment . ( 2004 ) are correct , a daunting annual mda take - up rate 
 of at least 90% would be required to interrupt disease transmission . go on to document the effect of three rounds of mass 
 treatment with ivermectin and albendazole to adults and children aged five or more living in 
 kirare . the reported findings suggest the uptake of drugs was less than the target rate , and 
 that uptake declined over time . self - reported uptake fell from 82% in october 2004 to 79% in 
 february 2006 and 69.9% in may 2007 . beneficial biological effects for the population were 
 nevertheless observed . human infection with microfilariae declined , and however , the effects thereafter levelled off and transmission 
 still occurred after the third round of mda , albeit at a lower level . concerns were raised 
 about the length of time between rounds of treatment ( as they were longer than the 
 recommended period of one year ) as well as the fact that mass treatment had limited 
 influence on adult worm burden . the article concludes by highlighting the  waning effect of 
 mda and the need for careful monitoring and evaluation . this includes the need to make more 
 accurate assessments of the number of people receiving and actually swallowing tablets . with 
 respect to the latter point , the authors query the high rates of drug uptake recorded in 
 official reports . this , in turn , raises the additional issue of whether or not the uptake of 
 drugs in kirare represents the norm , or whether proximity to tanga town ( the location of the 
 regional referral hospital and medical headquarters ) combined with the regular visits of 
 tanga - based researchers , facilitated higher than average treatment coverage for the region . it is likely that this is the case as it would have been extremely difficult to have 
 collected blood samples without a significant proportion of participants understanding the 
 purpose of the research and the rationale for mass treatment . anthropologists are well - placed to assist with endeavours to assess the social and 
 biological consequences of mass treatment for the control of neglected tropical diseases 
 ( ntds ) such as lymphatic filariasis . to the authors ' knowledge , they have not , as yet , 
 explored local responses to mass treatment programmes seeking to eliminate lymphatic 
 filariasis . building on research undertaken in 
 north - western , northern and south - eastern uganda on two other neglected tropical diseases , 
 schistosomiasis and soil - transmitted helminths ( parker et al . , 2008 , 2012 ; 
 parker & allen , 2011 ) , it addresses the 
 following questions : is current enthusiasm for the elimination of lymphatic filariasis on 
 the global stage shared by those on the receiving end of these programmes ? is it appropriate 
 to assume that adults will be willing , if not grateful , to swallow tablets if they are 
 provided free of charge , in the interests of maintaining or preserving their own health ? how 
 does the social context in which mass distribution occurs influence the uptake of drugs ? the article is based on research undertaken in northern coastal tanzania from july to 
 september 2007 and july to august 2011 . in 2007 , ten weeks of fieldwork were undertaken in 
 the adjoining villages of mwembeni and jaira in pangani district , the small town of kigombe 
 in muheza district and several other villages close to the town in this district . follow - up 
 research occurred four years later over a period of five weeks . they were assisted by a group of four locally recruited researchers in 2007 
 and five locally recruited researchers in 2011 , all of whom were either secondary - school 
 leavers or graduates who had been unable to find employment . research in mwembeni and jaira villages in 2007 involved participant observation in a wide 
 range of settings , including visits to homesteads , attending local healing ceremonies , 
 talking to villagers cultivating maize and cassava , and visiting local dispensaries and the 
 district hospital . in addition , 30 open - ended , unstructured interviews were undertaken with 
 local healers , health care providers and village elders ; and village meetings were held at 
 various points during fieldwork to discuss the rationale for the research and to feed back 
 provisional findings . to complement this work , a 20% random sample of households was 
 generated from the 2004 ministry of health registers documenting the uptake of drugs for 
 lymphatic filariasis . semi - structured interviews were then undertaken with one adult from 
 each selected household . seventy - three semi - structured interviews were undertaken with 
 adults in mwembeni village and 35 semi - structured interviews were undertaken with adults in 
 jaira village . in july august 2011 , a further 118 semi - structured interviews were undertaken with randomly 
 selected adults in mwembeni . in contrast to 2007 , it was not possible to use the ministry of 
 health registers as a way of systematically identifying households in mwembeni as the 
 records were no longer based on census data detailing the names of all residents living in 
 the villages . instead , the registers were simply a list of names of people who had received 
 treatment . a sample of households was thus derived by visiting every other household in each 
 of the sub - divisions of the village . in addition , participant observation and fifteen 
 open - ended , unstructured interviews were undertaken as well as an open meeting in the 
 village to discuss key issues emerging from the research . in muheza district , for 
 administrative purposes the area is divided into kigombe east ( and its sub - villages ) and 
 kigombe west ( and its sub - villages ) . the peri - urban area of kigombe east runs along the edge 
 of the sea . in addition , there are numerous villages , spread out over many kilometres , 
 located to the north - east along the coast road running towards tanga town . the peri - urban 
 area of kigombe west spreads inland from the coast road and includes more distant rural 
 villages such as mchangani and ndonde . with the exception of the peri - urban area of kigombe 
 west ( for which there was a household list produced by an american anthropologist , suzi 
 krehbiel , who had lived in the area in 2006 ) , local registers were unavailable or 
 incomplete . it was thus necessary to derive a sample of households by visiting every second 
 home with a view to interviewing a similar proportion of people to that achieved in mwembeni 
 and jaira . a total of 146 semi - structured interviews were undertaken in kigombe west 
 ( including the sub - villages of mchangani and ndonde ) and kigombe east ( including the 
 sub - villages of sinawe , gawani and the village of kitongoji ) in 2007 and 144 semi - structured 
 interviews in 2011 . the methods employed were the same as those described for mwembeni and 
 jaira in pangani district , including a similar number of unstructured interviews . research was also undertaken in 2007 in two villages located close to the district capital , 
 muheza town : magila and bwembwera . here , 30 households were randomly selected in magila and 
 51 households were randomly selected in bwembwera . according to the lists of households kept 
 by the village chairmen , this represented more than 20% of the estimated number of 
 households . semi - structured interviews were then undertaken with one adult from each 
 selected household . all semi - structured interviews undertaken in pangani and muheza districts elicited 
 information about whether or not the adult being interviewed accepted free drugs for the 
 treatment and prevention of lymphatic filariasis . information and ideas emerging from 
 participant observation fieldwork and open - ended , unstructured interviews were subsequently 
 used to interpret these quantitative data . swahili is the dominant local language in this 
 part of tanzania , as well as being the national language . migrants into the region all spoke 
 swahili , even when they also spoke their own languages ( such as makonde ) . the vast majority 
 of semi - structured and unstructured interviews , as well as village meetings , were thus 
 undertaken in swahili . finally , an endeavour was made to elicit the perspectives of village - based drug 
 distributors and district officials involved in the mass drug administration programme for 
 the control of lymphatic filariasis . official records monitoring the uptake of drugs by 
 staff from the ministry of health were looked at wherever possible , and these were discussed 
 with the relevant staff in english . mwembeni village is about 8 km from pangani town and lies on the main road that links 
 muheza town to the coast . it is one of three villages that form part of madanga ward , and 
 one of eight villages that form part of madanga division . according to census data 
 published in 2006 , 1126 people live in mwembeni . the village is divided into four 
 sub - divisions : mzia , mwembeni , makuyuni and nunda . it is socially diverse , with christians 
 ( protestant and catholic ) and muslims ( sunni and shia ) living side - by - side . the christians 
 are predominantly makonde , and the muslims are predominantly zigua and zaramo . there is 
 inter - marriage between these groups , although tensions exist between muslim groups 
 ( focused in particular on rival imams ) as well as between muslim and 
 christian groups . it is not unusual for muslims to talk about the makonde as migrants or 
  refugees from mozambique , in spite of the fact that they have lived in the village for 
 two and even three generations . many of their homes are located at some distance from the 
 village centres , in some cases in remote places . mwembeni village has one primary school 
 and one small madrasa ( islamic school ) . it also has several mosques and 
 churches ( both of the most basic variety ) . a small number of people have access to piped 
 water from a tap every other day , and there are ten households with access to electricity , 
 two of whom have a satellite dish . broadly similar characteristics apply to jaira village , 
 which lies a few kilometres north of mwembeni . according to ministry of health data 
 collected in 2004 , the majority of adults in jaira and mwembeni own or rent plots of land that they 
 cultivate . others are employed on a temporary basis as farm labourers . a diverse array of 
 crops coconut , orange , mango and banana trees 
 are grown too , though most people do not have access to all these types of fruit trees . a 
 small number of people fish for prawns in the river , and these are mainly sold in pangani 
 town . it is important to note that very few people have regular , salaried work . historically , the large - scale production of sisal at nearby estates was an important 
 source of regular employment , and explains the presence of so many makonde . however , 
 decline in the global demand for sisal has led to a decline in production and the laying 
 off of staff . as part of the surveys on drug uptake discussed below , adults living in 
 mwembeni and jaira were asked what they considered to be the most serious problems facing 
 them : 58% mentioned unemployment and kigombe is a small town that lies on the coastal road linking the town of tanga to the 
 town of pangani . although it is geographically much closer to pangani , it is actually part 
 of muheza district . access to 
 the sea provides fishing opportunities to those with access to nets and boats , but the 
 majority of people rely upon the cultivation of cassava , maize and rice to survive , just 
 as they do in mwembeni . fifty - three per cent of surveyed adults highlighted unemployment 
 as the most serious problem they faced compared with 31% who mentioned inadequate health 
 facilities . there are several schools in kigombe , including a madrasa , 
 and there are also several mosques and a government dispensary . the population is mostly 
 muslim , but in common with mwembeni , there is a christian minority , generally living a 
 little further inland at the edges of the sisal fields . also like mwembeni , there are 
 divisions among the muslims , but of a more intense nature . radical islam has a presence 
 ( with some openly sympathetic to al qaida in 2007 ) . there are also divisions between more 
 orthodox sunni muslims and muslims who are members of the sudanese ansar sect . in contrast 
 to mwembeni , kigombe is characterized by the amplified call to prayer from rival mosques 
 at night time . other divisions relate to political activism , with the local chairman being 
 a member of civic united front ( cuf ) , a political party opposing the government . before addressing the specific issue of drug uptake for the treatment and prevention of 
 lymphatic filariasis , it is helpful to note that the study populations were found to draw 
 upon a broad range of ideas to understand illness and misfortune . interpersonal and 
 spiritual aspects of well - being are often used to interrogate biomedical understandings , 
 with many kinds of illness being discussed in relation to the swahili word 
 uchawi . witchcraft , but it does not necessarily have the same connotations as the english word . the majority of people interviewed in depth talked about uchawi as being 
 a constant threat , and many were surprisingly open about the specific individuals who they 
 suspected were most likely to use it . even in the semi - structured interviews , which were 
 inevitably less probing , large numbers of people stated that uchawi 
 presented a problem . notions about interpersonal and spiritual causes of affliction are also connected with 
 beliefs about and experiences of spirit possession . those local healers with high status 
 were all found to be members of swahili possession cults . in common with giles ( 1987 , 1999 ) , 
 it became apparent that , unlike most possession cults in other parts of africa , these 
 cults are closely connected with local hierarchies , and are expensive to join . possession 
 is viewed as something dangerous and frightening , but paradoxically , also carries high 
 status and the possession cults operate as a parallel means of interpreting the spirit 
 world to that of islam . indeed some of the practices observed were strikingly un - islamic 
 ( such as the ritual drinking of sheep blood ) . to the authors ' knowledge it is also important to note that considerable 
 emphasis was placed on the training of healers at public sances . for example , more than a 
 dozen healers were present at a ritual that went on for several days at one of the 
 villages of kigombe and half a day was allocated to discussions between healers attending 
 the ritual and those who had become new members of the cult and would in the future be 
 acting themselves as healers . emphasis was placed on the appropriate relationships they 
 should have with their patients , implicitly contrasting them with the kinds of treatment 
 expected at clinics . their treatments involved a combination of local remedies , concocted 
 from locally available substances , with spiritual and moral interpretations of affliction . the findings of respected healers carried weight , and were not necessarily complementary 
 with biomedical interpretations and treatments , including those for lymphatic 
 filariasis . by july 2007 , three rounds of treatment had been distributed , free of charge , over a 
 four - year period for lymphatic filariasis . these took place in 2004 , 2006 and 2007 . in 
 both districts , registers were distributed by staff from the ministry of health to 
 village - based drug distributors prior to the first round of treatment in 2004 . this 
 enabled a detailed record to be made of the names and ages of people living in each 
 household with a view to keeping a year - on - year record of the proportion of adults and 
 children receiving drugs for the treatment and prevention of lymphatic filariasis . in mwembeni village , distributors were found to have kept meticulous records of the 
 number of adults and children aged five and above who took the drugs for lymphatic 
 filariasis . according to these registers , 59% of adults and children eligible for 
 treatment received the drugs in 2004 ; whereas 46% of them received treatment in 2006 and 
 34% received treatment in 2007 . in short , data derived by selecting a 20% random sample of households and 
 then interviewing one adult from each selected household also indicated a decline . that 
 is , 71% of adults interviewed in mwembeni said that they received treatment in 2004 ; 
 whereas 49% received treatment in 2006 and 35% received treatment in 2007 . table 1.uptake of drugs for the treatment and prevention of lymphatic filariasis among 
 adults in pangani district , tanga region , 20042007200420062007drug uptake among adults and children in village 
 registersmwembeni village 
 202 ( 59%)402 ( 46%)306 ( 34%)jaira village 
 263 ( 55%)164 ( 43%)160 ( 42%)self - reported drug uptake among interviewed adultsmwembeni village , n=7553 ( 71%)37 ( 49%)26 ( 35%)jaira village , n=3419 ( 56%)17 ( 50%)13 ( 38%)ain mwembeni village , the total number of people listed in the drug distributors 
 registers that were eligible for treatment was 345 in 2004 , 869 in 2006 and 901 in 
 2007 . the fact that fewer people appeared to be eligible for treatment in 2004 can 
 almost certainly be attributed to the fact that some of the registers had been 
 lost.bin jaira village , the total number of people listed in the drug distributors 
 registers that were eligible for treatment was 475 in 2004 , 386 in 2006 and 386 in 
 2007 . the fact that fewer people appeared to be eligible for treatment in 2006 and 
 2007 , compared with 2004 , is probably attributable to the fact that some of the 
 registers had been lost . uptake of drugs for the treatment and prevention of lymphatic filariasis among 
 adults in pangani district , tanga region , 20042007 in mwembeni village , the total number of people listed in the drug distributors 
 registers that were eligible for treatment was 345 in 2004 , 869 in 2006 and 901 in 
 2007 . the fact that fewer people appeared to be eligible for treatment in 2004 can 
 almost certainly be attributed to the fact that some of the registers had been 
 lost . in jaira village , the total number of people listed in the drug distributors 
 registers that were eligible for treatment was 475 in 2004 , 386 in 2006 and 386 in 
 2007 . the fact that fewer people appeared to be eligible for treatment in 2006 and 
 2007 , compared with 2004 , is probably attributable to the fact that some of the 
 registers had been lost . the table also shows that very similar findings were recorded in neighbouring jaira 
 village . the jaira registers suggested that 55% received treatment in 2004 ; 43% received 
 treatment in 2006 and 42% received treatment in 2007 . in common with mwembeni , a 20% 
 random sample of households was taken from the 2004 ministry of health drug distribution 
 registers . one adult was interviewed from each selected household , and data emerging from 
 these interviews also conveyed a decline in the uptake of drugs . that is , 56% adults 
 received treatment in 2004 , 50% received treatment in 2006 and 38% received treatment in 
 2007 . ministry of health registers documenting the uptake of drugs in kigombe and surrounding 
 villages could not be located . however , data collected in the course of undertaking 
 semi - structured interviews suggested a downward trend . table 2 shows that 47% of those interviewed in kigombe said they received 
 treatment in 2004 , 45% received treatment in 2006 and 22% received treatment in 2007 . a 
 different picture emerged in the northern part of muheza district . in the village of 
 bwembwera , interviews indicated that 47% received treatment in 2004 , 69% received 
 treatment in 2006 and 65% received treatment in 2007 ; whereas in magila , 40% received 
 treatment in 2004 , 43% received treatment in 2006 and 70% received treatment in 2007 . 
 table 2.self-reported drug uptake for the treatment and prevention of lymphatic filariasis 
 among adults in muheza district , tanga region , 20042007village200420062007kigombe 
 , n=14668 ( 47%)66 ( 45%)32 ( 22%)bwembwera , n=5124 ( 47%)35 ( 69%)33 ( 65%)magila , n=3012 ( 40%)13 ( 43%)21 ( 70%)akigombe includes kigombe east and kigombe west . kigombe east includes the 
 sub - villages of sinawe , gawani and jitingeni and kigombe west includes the 
 sub - villages of ndone and mchangani . self - reported drug uptake for the treatment and prevention of lymphatic filariasis 
 among adults in muheza district , tanga region , 20042007 kigombe includes kigombe east and kigombe west . kigombe east includes the 
 sub - villages of sinawe , gawani and jitingeni and kigombe west includes the 
 sub - villages of ndone and mchangani . in july  august 2011 , 118 semi - structured interviews were undertaken with a random sample 
 of adults in mwembeni , pangani district , to assess the proportion of adults that had 
 received ivermectin and albendazole for the treatment and prevention of lymphatic 
 filariasis since 2007 . as indicated in table 3 , 
 the self - reported uptake of drugs was below 50% for the period 2008 to 2010 . taking a sample of randomly 
 selected households near the trading centre , seventeen adults were interviewed , with 70% 
 of them stating they had received the tablets . follow - up research was also undertaken in 
 kigombe town and surrounding villages during this time . one hundred and forty - four 
 semi - structured interviews were undertaken and table 
 3 shows that the self - reported uptake of drugs remained below 50% from 2008 to 
 2010 . table 3.self-reported drug uptake for the treatment and prevention of lymphatic filariasis 
 among adults in mwembeni , pangani district , and kigombe , muheza district , 
 20082010village200820092010mwembeni , n=11826 ( 22%)45 ( 38%)56 ( 48%)kigombe , n=14445 ( 31%)57 ( 40%)49 ( 34% ) 
  self - reported drug uptake for the treatment and prevention of lymphatic filariasis 
 among adults in mwembeni , pangani district , and kigombe , muheza district , 
 20082010 official statistics submitted to the ministry of health from pangani district differ from 
 the information recorded in the ministry of health village drug distribution registers . 
 that is , the overall uptake of drugs for lymphatic filariasis among adults and children 
 more than five years old was reported to be 67.6% in 2004 , 78% in 2006 , 76.5% in 2007 and 
 75.2% in 2010 . aware of the possibility that these aggregate figures may reflect much 
 higher levels of drug uptake in other parts of the district , a decision was made in 2007 
 to go through all the available official village - based , drug distribution registers for 
 pangani district in order to double - check the accuracy of the official figures . in 
 addition to the registers for mwembeni and jaira , registers were found for six of the 33 
 villages that constitute pangani district . these villages were : barabani , chakaloboko , 
 mahakamani , boza , kimanga and msaraza bushiri . not all registers for these villages were 
 found to be complete for all three recorded rounds of drug distribution , but according to 
 the registers available , drug uptake fell short of the sustained high coverage levels that 
 are required to eliminate lymphatic filariasis . to be more specific , the uptake of drugs 
 among the 4755 adults and children listed in the available registers as eligible for 
 treatment in 2004 ranged from 49% in one village to 93% in another village , and the 
 average uptake for all eight villages was 65% . however , the uptake of drugs declined in 
 all villages except one in 2006 . that is , uptake ranged from 81% to 35% , and the average 
 uptake among the 7823 adults and children listed as being eligible for treatment was 46% . 
 in 2007 , there were further declines in the majority of villages . uptake ranged from 81% 
 in one village to 7% in another village and the average uptake was 34% among the 6436 
 adults and children listed as being eligible for treatment . the average figure for 2004 was thus very similar to that in the officially submitted 
 report , but the high drug uptake reported in 2006 and 2007 in the official records 
 submitted to the ministry of health did not correspond with the drug uptake data recorded 
 in the village registers . while it is possible that the uptake of drugs is higher in other 
 parts of pangani district , this is an unlikely scenario . many of the villages for whom 
 drug distribution registers could not be found were located south of pangani town . this 
 part of the district is often inaccessible to district staff as it involves crossing the 
 pangani river by a ferry that is prone to mechanical breakdowns . technical difficulties 
 aside , budgetary constraints at district headquarters restrict the frequency with which 
 staff can visit villages and facilitate the distribution of drugs  not least because many 
 of the villages are located a considerable distance south of the river . as a result , it was much harder to elicit comparable data about the uptake of drugs in muheza 
 district . in 2007 and 2011 , considerable efforts were made to talk to district officials 
 in muheza as well as associated officials at a ward , village and sub - village level , but no 
 ministry of health registers could be located in 2007 , and only a small number could be 
 located in 2011 . in addition , it was difficult to make much sense of the information 
 presented in the registers that could be located as they only provided a list of the names 
 of people that had received treatment in 2010 . in other words , in common with the 
 registers located in mwembeni in 2011 , it was not possible to use the information to 
 assess the proportion of people in any one village that had received treatment . nevertheless , summary statistics compiled at a district level ( and subsequently presented 
 as part of a regional report submitted to the ministry of health in dar es salaam in 
 2009 ) , recorded an uptake of drugs in the district of 81% in 2006 , 76% in 2007 and 81% in 
 2008 . the neglected tropical diseases co - ordinator for muheza district also reported 
 coverage of 83% in 2009 and 83% in 2010  whilst acknowledging that the uptake of drugs 
 was less in kigombe as official returns suggested an uptake of 69% in 2009 and 65% in 2010 
 ( personal communication , august 2011 ) . while these figures are lower than the 100% uptake 
 reported to the research team by a district official in muheza in july 2007 , they are 
 still much higher than those recorded in the course of interviewing randomly selected 
 adults at selected villages in muheza district . discrepancies between the figures derived from semi - structured interviews , the official 
 district figures , and the figures in the village - based registers raise important questions 
 about the relative merits of the methods employed to elicit information on drug uptake . 
 with respect to data arising from semi - structured interviews , is it really possible for 
 large numbers of adults to accurately remember whether or not they have received a 
 particular combination of drugs over an extended period of time ? is it possible that some 
 informants muddle up the years that they received them and the years that they did not ? is 
 it appropriate to assume that informants receiving drugs during mda actually swallowed 
 them ? whatever is done to alleviate anxieties and ensure that those being interviewed 
 recount events as accurately as possible , is it possible for informants to try and 
 second - guess the correct answer to be polite or to just make the researchers leave them 
 alone ? identical questions emerged whilst undertaking research on social responses to mda for 
 the treatment of schistosomiasis and soil - transmitted helminths in northern and 
 south - eastern uganda ( parker et al . , 2008 , 2012 ; parker & allen , 
 2011 ) . here it was found that those interviewed 
 clearly recalled treatment , partly because praziquantel tablets , which are used to treat 
 schistosomiasis , are unusually large , pungent and unpalatable . in addition , the free 
 distribution of biomedical drugs to treat adults is a rarity and not something easily 
 forgotten . indeed , it is widely commented on and the issue is less whether or not people 
 remember , and more whether or not they are willing to say what happened to the drugs once 
 they had received them . in some cases it became clear that instead of swallowing them 
 immediately , they had kept all or some of their dose for future use if they felt ill , or 
 to give to relatives and friends . the situation was found to be slightly different with respect to mda for lymphatic 
 filariasis in coastal tanzania , not least because the drug , ivermectin , is small , easy to 
 swallow and does not have an unpleasant smell . nevertheless , few people struggled to recall whether or not they had received 
 free treatment  partly because it was so unusual to offer free medicines to adults and 
 partly because it was considered to be very strange indeed to ask all adults to swallow 
 medication , irrespective of whether or not they felt ill . in fact , the vast majority of 
 people interviewed were remarkably forthcoming about their reasons for accepting or 
 rejecting treatment and , more often than not , they asked pertinent questions about the 
 rationale for the control programme that shed further light on why , for example , some 
 people accepted treatment in the early years of the programme and subsequently declined 
 treatment ; while others declined treatment but subsequently accepted treatment for one or 
 two years , before deciding to reject treatment again . in general , data recording the uptake of drugs from semi - structured interviews undertaken 
 at randomly selected households are , in most cases , likely to more accurately convey the 
 proportion of adults that received the tablets than the data embedded in the official 
 ministry of health registers by village - based drug distributors . first , villages can be quite dispersed and drug distributors were sometimes 
 found to be unaware of all people living in the village . second , social divisions within a 
 village can often affect the kind of people recorded . in mwembeni , for example , the 
 long - standing differences between muslims and christians were found to have influenced the 
 number of people registered . refugees , or even  not real people. third , short - cuts are often taken in the 
 time - consuming job of handing out tablets . close discussion with the distributors and 
 people receiving drugs revealed that the protocol of observing consumption was often not 
 followed . in several instances , it was found to have been largely set aside , in a similar 
 manner to the practice noted above with respect to praziquantel distribution in uganda . as 
 a result , it is not known if those who are recorded as having taken the drugs have 
 actually swallowed them . thus , drug uptake data in the village - based distribution 
 registers may overestimate , rather than underestimate , actual consumption . this is not to suggest that the data in the ministry of health registers are always 
 inaccurate . on the contrary , some drug distributors went to great lengths to carefully 
 record the names , ages and sex of the people they gave drugs to . however , the consistency 
 of registration between distributors was found to vary ; and it was often impossible to 
 judge the quality of the recorded data without checking them . in most cases , they 
 provided , at best , a partial picture of the proportion of people in a specific 
 geographical area that had received treatment . a more worrying issue is that the summary statistics compiled at a district level on drug 
 uptake suggest much higher levels of drug uptake than data eliciting drug uptake among 
 adults in the course of interviews . while the latter data only refer to adults , it is 
 likely that they provide a useful proxy of the extent to which mda programmes reach adults 
 and children at the selected study sites . the reasons are straightforward : mass treatment 
 occurs through village drug distributors , rather than school teachers ; and if adults are 
 willing to receive ( and possibly consume ) tablets for themselves , then they are almost 
 always willing to receive tablets for their children . similarly , if they reject medication 
 for themselves , then they are likely to reject treatment for their children . it is also 
 worth noting that in those instances in 2004 and 2005 when village drug distributors 
 recorded the numbers of people living in a village on a household - by - household basis in 
 the ministry of health registers and whether or not each person had received drugs , there 
 was a similar discrepancy  with drug uptake being much lower in the registers than the 
 aggregate figures recorded at a district level . senior district officials , when asked to 
 comment on the discrepancies , were quick to set aside the higher figures . one of them 
 disarmingly observed :  people are just sitting down and cooking the numbers. he went on 
 to express frustration with the treatment programme by saying  this programme has no 
 legs. this was a literal reference to the shortage of fuel and other resources enabling 
 staff to spend the requisite time in villages explaining the rationale for mass treatment . he was , in short , not surprised by the lower drug uptake figures emerging from field - based 
 research . this view was shared by others working at district headquarters . in short , there 
 is no doubt that the uptake of drugs is low at the selected study sites ( and rates of 
 take - up in other highly endemic coastal villages in pangani and muheze districts are 
 likely to be similar ) . the low uptake of drugs can not be attributed to a lack of awareness of the signs and 
 symptoms of lymphatic filariasis . while there is no swahili word for the disease , two of the 
 major clinically recognized signs of infection , swollen scrotums and swollen limbs , are 
 perceived locally as separate afflictions , with the former being referred to as 
 mabusha and the latter as matende . both are feared , even 
 if they are not considered as life - threatening as malaria or hiv / aids . adults participating 
 in the surveys on drug uptake were asked what they thought were the major illnesses 
 affecting local people . it was mentioned by 
 64% of those interviewed at study sites in pangani and 78% of those interviewed at study 
 sites in muheza , whereas hiv / aids was mentioned by 29% of adults in pangani district and 19% 
 of adults in muheza district . mabusha was mentioned by 27% and 24% in 
 pangani and muheza districts respectively and matende by 12% and 15%  
 although  muscle or leg pain was also mentioned by 26% and 20% of adults respectively in 
 these two districts . in more open - ended discussions , mabusha , in particular , was spoken about 
 as a constant threat for men . for example , a 27-year - old man from jaira village explained that 
 mabusha is a torturing disease :  [ it ] makes you sad , unhappy , everyday 
 ( all such quotes in the article have been translated from swahili ) . another man , aged 31 , 
 and also from jaira said ,  i feel so ashamed , especially with those i respect  . i have 
 access to women but they always say :  i do n't want you , because you will give me the 
 infection. others , including a 52-year - old man from kigombe , complained that  people talk 
 about you when you are not there . it makes you fearful and anxious  no woman will want you 
 if you have mabusha  unless they are a witch and they want your money  . in some cases , the distress , misery and desperation was so intense that men tried to 
 operate on themselves . in 2007 , for example , a 40-year - old man from mwembeni told us that he 
 had operated on himself twice to try and drain the fluid from his scrotum . tragically , he 
 died in 2008 , reportedly whilst trying to perform the operation on himself for a third time . attitudes to matende tended to be more stoical , but the worst cases 
 observed were shocking , with afflicted individuals , mostly women , being hidden away out of 
 site . given that mabusha and matende are widely recognized to 
 cause sickness and suffering , one might assume that the provision of free treatment would be 
 welcomed . the rest of this section demonstrates that there is no single explanation for the 
 low uptake of drugs . rather , a combination of social , economic and political reasons explain 
 the low uptake of drugs at the different study sites . these include : fear of treatment 
 ( attributable , in part , to a lack of trust in international aid and a questioning of the 
 motives behind the distribution ) ; divergence between biomedical and local understandings of 
 lymphatic filariasis ; insufficient and inadequate communication about the rationale for mass 
 treatment ; and too great a reliance upon too few volunteers to distribute drugs within 
 villages . mass drug administration for mabusha and matende 
 generated anxiety and scepticism among the majority of adults , with informants questioning 
 the motives behind the free distribution of drugs by the tanzanian government and 
 international agencies . a young man from jaira , for example , said :  there is something 
 strange going on . if the government want to help us , they should distribute malaria drugs 
 for free , not matende and mabusha. similarly , a 
 40-year - old man from mwembeni commented that ,  there is no sign [ on the drug ] that it is 
 for mabusha or matende  you have to trust in the 
 government to swallow the tablets  trust matters a lot . if you do n't trust them , you 
 ca n't swallow the drug  the programme does n't come with enough knowledge. meanwhile , in 
 kigombe , a man in his 50s justified not taking the tablets in the following way :  in this 
 village we cry for water  they haven't brought water for free , but they 've brought drugs 
 for free . why ? these free drugs have to be for an experiment  that is why i reject them. 
 these kinds of comments were typical in locations with low drug uptake and highlight the 
 fact that the rationale for distributing tablets for mabusha and 
 matende , free of charge , was poorly understood . acutely aware that 
 clinic - based biomedical practitioners tend to diagnose infections before administering 
 drugs , and confused why such an approach was deemed unnecessary by the tanzanian 
 government in this case , rumours circulated about the a very prevalent concern was the idea that the drugs had been designed to reduce 
 population growth . as one man in kigombe put it :  they are lying about this drug . it is 
 not for mabusha or matende  [ it is ] a family 
 controlling pill  . younger men discussing this issue tended to emphasize the idea that 
 the tablets reduced their sexual energy . for example , at a village meeting in mwembeni , a 
 young man summarized the views of others when he said ,  they are afraid  they say if you 
 are infected [ and you ] take the drug then your penis will never erect again. it was a 
 view echoed at a comparable group discussion at kigombe , where a man in his mid-30s 
 proclaimed that  [ people from the ] rich countries send us this drug to reduce our malehood 
 energy and to make us infertile , because the wazungu ( white people ) were 
 fed up giving us help every day. for others , the focus was more on the way the tablets 
 might be intended to prevent conception , a view that was probably supported by the 
 reluctance of some drug distributors to give the tablets to women who said they were 
 pregnant . for example , a man in his 60s living in mwembeni commenting on local views said , 
  they say if you take the drug , you will never give birth they believe the government 
 has failed to convince them to enter into family planning. women were particularly likely 
 to say something comparable . we know women in europe have two children and their intention is 
 to make africans like europeans . they think we ca n't manage so many children , that we 
 ca n't provide proper education , health care and home environment. concerns about infertility were also connected with the experiences of some of those who 
 had swallowed the drugs . a man in 
 his 30s from mwembeni , for example , described how he took the tablets in 2006 and 
 experienced a strong fever with rashes . he went on to say that he did not take the drug 
 again as he feared the side - effects . others expressed concern that the drugs exacerbated 
 existing symptoms , and even infected people with mabusha and 
 matende . a woman from kigombe , for example , said that she did not take 
 the drugs in 2004 as she was pregnant . seen people infected by those drugs in 2004  there were some who got 
 body pain and fever . if i took those drugs , i would be infected too  . in a similar vein , 
 an elderly woman from mwembeni said :  they were afraid that if they took the tablets the 
 busha would get bigger, and a man from kigombe said :  they are afraid 
 that if they take the drug they will get matende or 
 mabusha  . there were , in addition , stories that were even more 
 alarming . a young man from mwembeni , for example , said :  they fear the drugs will kill 
 them  . he was not the only one to mention this . he went on to explain that ,  most people 
 do not receive reliable information and knowledge about the drugs. these last remarks relate to prevalent doubts about drug efficacy . this is hardly 
 surprising as few , if any , people were aware that it was possible to be infected and 
 asymptomatic and almost all of those with mabusha and/or 
 matende complained that the drugs were not making much or any difference . for example , a man in his 60s from kigombe had lived with mabusha since 
 his mid-40s and took the treatment in 2004 , 2006 and 2007 , but declined free treatment in 
 subsequent distributions . he explained that ,  the drugs make no difference  the weight of 
 my testicles disturbs me. his experience was shared by a younger man who had accepted 
 treatment in 2004 , but subsequently refused it . some other people i know took the 
 drug and then got mabusha , so they did n't take it again either. these 
 perspectives were widely shared . a woman in her 30s with matende who had 
 also taken the drugs only once summed up attitudes when she said :  we are getting no 
 relief from the medicine the drugs are not working. widespread fears , anxieties and rumours emerge , in part , from villagers making their own 
 empirical observations about the side - effects associated with treatment and the limited 
 visible efficacy of the drugs . they also draw attention to the disjuncture between 
 biomedical understandings and responses to lymphatic filariasis and local understandings 
 and responses to mabusha and matende , which are 
 perceived locally as entirely separate afflictions . to quote a local healer 
 ( mganga ) from pangani : some people have both mabusha 
 and matende  but they do n't come simultaneously . the fact that 
 mabusha can be operated on and matende can not be 
 operated on , proves that they are different diseases  . the majority of people do not attribute a single cause to either mabusha 
 or matende . indeed , it is not unusual for three or four causes to be 
 mentioned , and for each to be accorded equal weight . this sub - section discusses local 
 understandings and responses to mabusha and matende . in 
 so doing , it becomes apparent that these locally recognized afflictions are understood in 
 a context where virtually everyone , including health care workers at government 
 dispensaries and health centres , draws upon a pluralistic approach to diagnosis and 
 treatment to understand sickness and misfortune . it is also worth noting that discussions about mabusha , and to a lesser 
 extent matende , can be infused with moral overtones , with spirit mediums 
 sometimes threatening those who are thought to be behaving badly by saying that they will 
  throw a busha. in madanga division , for example , there was a ceremony 
 associated with the local possession cult called mwaka koga , part of 
 which was held at a sacred well on the outskirts of a village . people gathered spoke to 
 the spirits in the well . at one point in the ceremony , the spirit medium said :  protect 
 us , cure us and treat us so that we can be healthy and have peace and happiness in our 
 lives  . there are some  who see those who come to us as barbaric , uncivilized and 
 ignorant ; and they see themselves as educated , civilized and more religious  they only 
 believe in one god  [ to them we say : ] give them bushas and 
 matende and never cure them , until they come here and beg for 
 forgiveness. the majority of adults are unaware of any relationship between mosquitoes and 
 mabusha . of the 335 adults interviewed whilst undertaking drug uptake 
 surveys in pangani and muheza districts in 2007 , just 11% attributed 
 mabusha solely to the bites of mosquitoes . while a small proportion of 
 informants attributed mabusha to the bites of mosquitoes and other 
 causes ( notably acts of witchcraft , sex , hernia , dimensions of diet , acts of god ) , the 
 vast majority of informants either did not mention mosquitoes as a possible cause or 
 remained unconvinced about their role in transmission . on one occasion , during a village 
 meeting , a female sub - village leader took issue with the biomedical explanation being 
 put forward by a health worker about the aetiology of mabusha and said : 
  we can fight to the death , but you will never get me to believe that it is not caused 
 by sex with a menstruating woman! the reference to sex is important here . it highlights the fact that 
 mabusha is widely talked about as a sexually transmitted disease . the blood is full of 
 vidudu ( micro - organisms )  god created menstruation to clean the 
 woman from vidudu  but these vidudu get into a man if 
 they have sex when she is bleeding [ and it leads to mabusha]. a muslim 
 elder added , the vidudu in the blood passes into the penis and it can 
 lead to mabusha. others agreed with this point , but emphasized that it 
 was only possible to get mabusha from a menstruating woman if the sex 
 occurred outside of marriage . thus , a woman from mwembeni said ,  if you steal someone 's 
 wife , who is protected by the healer , then you get mabusha with 
 vidonda ( severe rashes on the penis), and a man from kigombe said , 
  if you have sex with a prostitute that is menstruating , you can get 
 mabusha  you see , they will never tell you that they are menstruating 
 as they want the money. in addition to sexual intercourse , other explanations for mabusha 
 include one or more of the following : a lack of food , eating too many coconuts and/or 
 drinking immature coconut juice , being bitten by mosquitoes and acts of god . hernia , 
 too , is closely associated with the occurrence of mabusha . a 
 62-year - old male , for example , commented :  a hernia is a disease . inside the hernia oil or water from inside the 
 intestines pass down into the testicles and make a busha. similarly , a 
 local mganga said : it catches you at the waist  the muscles around 
 the waist can squeeze the hernia , and the fluid goes into the testicles, and a young 
 man , speaking at a village meeting , said : if you have a hernia , your testicles swell  
 but it does n't mean that it 's hydrocele [ although ] most people think that it 's not 
 possible to have a hernia and not have busha  . ideas about witchcraft also play a central role in local understandings of the 
 aetiology of mabusha . here , it is helpful to note that different kinds 
 of mabusha are recognized locally , with some kinds being more overtly 
 linked to acts of witchcraft than other kinds . two of the most widely recognized kinds 
 of mabusha are : busha la maji and busha la 
 mafuta . busha la maji is thought to be effectively treated 
 by surgery at hospital as the water can be drained away , whereas busha la 
 mafuta is not thought to be treatable in a hospital setting . as one 70-year - old 
 male said :   even if the fatty oil is scraped out , it just fills up again  . others 
 spoke of busha la mkoba and busha la uchawi . with 
 respect to busha la mkoba , it is interesting to note that the word 
 mkoba is swahili for woman 's handbag and that witches are sometimes 
 thought to carry the tools of their craft in their testicles . as one 
 mganga said :  mgangas who hide their tools in a 
 mkoba are not mgangas . they are witches , but they 
 exist. busha la uchawi translates as  bewitching 
 busha and a local mganga described it in this way :   
 in the village , if you have a conflict with a man in the village , he will bewitch you there are some diseases that can not be cured by biomedicine , only by herbs . many local mgangas and other villagers talked about their ability to 
 make mabusha . a 35-year - old woman from kigombe , for example , said : if 
 you have a quarrel with a person , they can take revenge and punish you by making 
 mabusha  there is nothing you can do  no drugs can help. it is 
 important to note , however , that several mgangas did not concur with 
 the view that mgangas were capable of  throwing a 
 busha. as one mganga from madanga pointed out : 
  mgangas sometimes say they can  throw a busha , but 
 this is not the work of a mganga . the work of mgangas is to 
 cure , not to make sickness. whatever the role of mgangas , it became apparent that the majority of 
 informants linked the occurrence of some kinds of mabusha to acts of 
 witchcraft , with the type of mabusha influencing the type of treatment 
 sought . moreover , mgangas are usually consulted to determine the cause 
 of mabusha , and if it is deemed to be busha la mafuta , 
 then biomedical treatment is avoided . busha la maji is thought to be 
 treated by doctors and most mgangas recommend biomedical treatment , as 
 they do not think they can treat anything but the early signs of 
 mabusha such as fever . it is important to note , however , that some 
 informants did not differentiate between types of mabusha . for example , a 63-year - old christian 
 makonde in mwembeni remarked that :  it is a shameful disease and you ca n't live with it 
  you must be operated on as quickly as possible  no local mganga 
 operates on mabusha. similarly , a muslim man from kigombe observed 
 that ,  the best [ thing to do ] is to go to hospital for an operation it is difficult 
 for a mganga to treat mabusha because he has no 
 equipment and no knowledge of what to do. in general , it was found that there is considerable demand for surgical treatment . however , many men do not go down this route as it normally costs approximately 100,000 
 tanzanian shillings ( about  40.00 ) and few have the necessary income to pay for it . an 
 exception is when the operations have occasionally been offered free . in 2007 , for 
 example , names of individuals who stated that they had hydroceles and wanted an 
 operation but could not pay for it were collected at the field sites . two hundred operations were subsequently carried out on some of 
 these men as well as other individuals at a surgical camp in pangani district with 
 special funding in 2008 ( malecela , 2009a , p. 
 55 ; personal communication by email on october 19th 2007 ) . partly as a consequence , 
 scores of others needing operations made themselves known to the research team in 2011 
 ( roughly 1:10 men in mwembeni ) , although many stated that , even if the operations are 
 free , they would find it hard to be treated , because they could not afford not to work 
 for six months after the operation . to quote a 30-year - old man from mwembeni :  [ they 
 tell us ] you ca n't do masculine ( i.e. heavy ) jobs for six months , but how will our 
 children eat then ? what we do to earn a life is tough work if you rest for six months , 
 your children will die. others are afraid to be operated on . one man , reflecting on the fact that his friend 
 showed no inclination to get treatment from the hospital , said :  he has decided to tie a 
 tight rope around his testicles to try and prevent them from swelling. others are 
 afraid that they will die if they are operated on . this fear relates to anxiety as to 
 whether they have busha la maji or busha la mafuta as 
 the latter needs to be treated by a mganga and , more significantly , 
 treatment at a hospital is not only inappropriate , but can lead to death . to quote a 
 mganga from mwembeni :  some mabusha is caused by 
 uchawi  if you go to a hospital for an operation and it is caused by 
 uchawi , you will die immediately. in common with mabusha , villagers attributed matende 
 to a number of different causes . it was not unusual for several explanations to exist 
 side - by - side and for each one to be deemed of equal importance . matende , for example , was often said to be an inherited condition as 
 well as being caused by mgonzo fever and/or the bite of a mosquito . in 
 contrast to mabusha , the majority of adults at all study sites said 
 that they did not know what caused matende , but mgonzo 
 fever was widely recognized as an early sign of matende . it is very 
 different to the fevers associated with malaria , and one male informant described it in 
 the following way : when it 
 catches you , you will be seriously ill , to the extent that you urinate unconsciously , 
 shiver and speak nonsense . two or 
 three days later , the swelling goes down and the skin peels off . he or she might be ok 
 for a year [ but ] then they will experience the fever again , until it becomes 
 tende  it is best treated with a painkiller. similarly , a muslim 
 woman from kigombe east said :  homa mgonzo can lead to 
 matende . [ it ] is very strong  you feel very , very cold and shiver all 
 over  the fever goes into the body 's muscles and the effect of this is that it goes 
 into the legs and feet and leads to swelling . some people can get swellings in their 
 arms too. various causes are attributed to the occurrence of mgonzo , including 
 open wounds and sexual intercourse . the logic is clear : i cut my foot while i was 
 farming and , soon afterwards , i got mgonzo . it was not [ an ordinary ] 
 homa ( fever ) as the head does not hurt if you have 
 homa and my head was hurting  . some people also get 
 matende from mosquitoes , but i didn't, ( muslim woman from kigombe who 
 has had matende for many years ) ;  mgonzo is a strong 
 fever that leads to a swelling of the legs . i think i gave it to her through sexual 
 intercourse, ( christian makonde man from mwembeni ) . in contrast to mabusha , a sizeable number of informants mentioned 
 mosquitoes as the sole cause of matende ( for example , 37% in kigombe 
 west in 2007 ) . maybe the mosquito has poison inside it and this is why the legs 
 swell, ( a man in his 50s from kigombe east ) ;  there is a mosquito called culex when 
 that mosquito bites someone with matende and then bites you , you will 
 get matende, ( a man in his 80s from kigombe west ) . nevertheless , like any other affliction , such interpretations were a possible 
 explanation , often in combination with others . here people were jealous of her and they made uchawi 
 ( witchcraft ) to give her matende, ( 60-year - old man from mwembeni ) ; 
  when you have a conflict with someone , that person will go to a local 
 mganga and make matende by using spiritual force, 
 ( 34-year - old woman from kigombe ) ;  mchango  it is in your stomach , it 
 eats the food you take in . bad mchango causes 
 minyoo , busha and matende , together 
 with safura ( hookworm), ( 65-year - old man from kigombe ) ;  i got 
 matende by stepping over uchawi ( witchcraft), 
 ( 56-year - old woman from mwembeni ) . i think it is caused by a mosquito , but 
 many people think it is inherited.  if your father has it , then it can be passed on to 
 sons , daughters , grandchildren  like having twins.  if the parent has twins , then 
 anyone in the family can have them. my wife has matende in her right 
 leg and her mother suffers from it too . she inherited the condition. although it is less common with respect to matende to assert a 
 witchcraft explanation , the view is sometimes expressed that it is possible to 
 differentiate between the type of matende caused by a mosquito and the 
 type of matende caused by witchcraft . the following quotes are a good 
 examples of the range of perspectives frequently exchanged among groups of people 
 sitting together with an afflicted person and commenting on the problem :  there is no 
 treatment for normal matende , but witch matende can be treated by 
 mgangas ( local healers).  women can stop matende by 
 wearing several pairs of underwear to stop it spreading.  inside the 
 matende is oil if you go to the hospital , they can remove the oil and 
 the swelling will come down.  the normal matende can be cured , and the 
 swelling goes down , after treatment at the hospital . the other kind does not go down 
 with hospital treatment. it has been argued that social mobilization and advocacy is a key component of effective 
 mda for lymphatic filariasis in tanzania ( malecela et al . , 2008 , this is said to comprise everything 
 from radio spots to posters , film shows and the use of mobile megaphones . all this 
 activity is reported to occur in swahili and to have been incorporated into a set of 
 lymphatic filariasis control programme principles. while these activities may well have 
 occurred at some locations , it is also the case that they either have not occurred or they 
 have had a minimal effect at the field sites where this research occurred . as a result , 
 very few people understood the rationale for distributing drugs , free of charge , to adults 
 and children . staff employed at health centres , as well as village - based drug 
 distributors , were thus genuinely confused as to whether the drugs were designed to 
 prevent infection or treat existing infections . with few exceptions , they had no idea that 
 it was possible to be infected and asymptomatic and they were at a loss about how to 
 answer frequently posed questions . these included variations of the following , all of 
 which were posed at village meetings and/or during interviews in 2007 and 2011 : why should i take the tablets when i feel well ? why do the tablets need to be taken 
 by everyone once a year ? why should i take the tablets again as i took the tablets last year and i 
 still feel ill ? why should i take the drugs as i do not have mabusha 
 or matende ? i took the drugs last year as i have 
 mabusha , but the swelling did not go down . how can these drugs prevent mabusha when it is caused by 
 witches and spirits ? why is there an operation for mabusha , but not 
 matende ? why do some people get fevers and others swollen bodies 
 after swallowing the tablets ? why do drug distributors allocate the number of tablets 
 according to height rather than weight ? why are europeans manufacturing tablets for 
 mabusha and matende when they do not suffer from 
 these diseases ? why should i take the tablets when i feel well ? why do the tablets need to be taken 
 by everyone once a year ? why should i take the tablets again as i took the tablets last year and i 
 still feel ill ? why should i take the drugs as i do not have mabusha 
 or matende ? i took the drugs last year as i have 
 mabusha , but the swelling did not go down . how can these drugs prevent mabusha when it is caused by 
 witches and spirits ? why is there an operation for mabusha , but not 
 matende ? why do some people get fevers and others swollen bodies 
 after swallowing the tablets ? why do drug distributors allocate the number of tablets 
 according to height rather than weight ? why are europeans manufacturing tablets for 
 mabusha and matende when they do not suffer from 
 these diseases ? at all sites there was an eagerness to engage in debate and discussion about these 
 issues , and innumerable complaints that the drugs were being given out by local 
 distributors who could not explain how they worked or exactly what they were for . as one 
 young woman from kigombe put it :  there is no information about why you should take the 
 drugs , what the drugs are for and other necessary information to convince people to take 
 the drugs. with so many unanswered questions , it is hardly surprising that people 
 questioned the merits of mass treatment . what appears to be an unwillingness or an incapacity to engage with local concerns of 
 these kinds , and specifically to address matters such as pluralistic approaches to 
 aetiology and treatment in health education materials and training of distributors , is by 
 no means unique to staff working for the national programme to control neglected tropical 
 diseases in tanzania ( see , for example , research on the control of schistosomiasis and 
 soil - transmitted helminths in uganda by parker et al . ( 2008 ) and parker & allen ( 2011 ) , and research on malaria by hausmann muela 
 et al . in tanzania ( 1998 , 
 2002 ) ) . it does , however , have unfortunate 
 consequences as it ends up confirming , rather than refuting , existing outlooks and fuels 
 anxieties about the merits of swallowing drugs provided by international donors and 
 distributed through government channels . that said , it would be a great mistake to assume 
 that more extensive and sophisticated communication will be sufficient to improve drug 
 uptake . the current system of rolling out free drugs relies upon voluntary labour to run 
 the programme and this , too , is problematic . village health workers , otherwise known as the  community 's own resource persons ( corps ) 
 take responsibility for distributing drugs for the treatment of mabusha 
 and matende ( malecela et al . , 2009b ) . that is , health 
 workers at a national level train health workers at a regional level ; regional staff train 
 staff working at a district level ; and district staff train those working at a ward and 
 village level ( malecela et al . , 2008 ) . village drug distributors are not paid for the time they spend handing out 
 drugs within their villages , but they receive a small  sitting allowance for attending 
 training sessions . while positive statements have been made about the effectiveness and 
 efficiency of the cascade system ( malecela et al . , 2008 , 2009b ) , observations 
 and discussions with health workers and other villagers suggest that the current system 
 does not always run smoothly . in particular , it overlooks the fact that some villages cover significant geographical 
 areas and there are often significant constraints preventing distributors from taking the 
 time to contact those living on the outer reaches of their village . to walk from home to 
 home , persuading individuals with whom there is little social connection , requires a big 
 commitment . this is expected to occur in addition to a normal day 's work , and may need to 
 be done repeatedly , because many individuals may be absent , perhaps fishing or farming or 
 visiting relatives . crucially , the reliance upon a small number of adults to distribute 
 drugs within each village also assumes that a sense of goodwill and concern extends to all 
 residents equally . in many places , this is not the case . in mwembeni , for example , the makonde are , in social and political terms , much more 
 marginal than their muslim neighbours . they are often referred to as 
 kafir . as a result , many of them are not even recorded in the village 
 register . in addition , it became apparent that by 2010 a parallel system of drug 
 distribution had emerged . that is , two muslims were taking responsibility for distributing 
 drugs throughout the village . christian makonde living reasonably close to the centre of 
 the village were told to come to a central location to collect drugs , but those living far from the centre were not informed of the treatment . a 55-year - old makonde man , 
 living on the outskirts of the village , summed up the situation when he revealed that he 
 had never heard about the free provision of drugs as :  the only information we get is when 
 we have to contribute something  the other news is not delivered. by contrast , many of 
 the friends , neighbours and relatives of the drug distributors were being given drugs in 
 their own houses . somewhat similar issues were also noted in kigombe , where divisions 
 between political parties , between muslim factions and between muslims and christians all 
 affected distribution activities . as in mwembeni moreover , in 2007 , one of the 
 imams was reported to have openly opposed distribution activities to 
 his followers , and the distributors lacked the authority or knowledge to challenge him . such diverse ( and often very locally specific ) divisions in what are perceived externally 
 as homogeneous communities obviously affect drug distribution . indeed , close scrutiny of a 
 programme like tanzania 's national lymphatic filariasis elimination programme makes 
 manifest social hierarchies and fissures . they become particularly clear in ethnographic 
 research , though they may be hard to enumerate . although efforts were made to see if it 
 was possible to discern consistent patterns of treatment exclusion in the data that were 
 collected during semi - structured interviews on drug uptake , this did not prove 
 particularly insightful . political affiliation , for example , was too sensitive an issue to 
 be asked in all interviews , and it was sometimes difficult to assess the accuracy of 
 answers when they were forthcoming . systematic effects of the manifest conflicts and 
 tensions in the muslim population were similarly hard to gauge and quantify . however , with 
 respect to drug distributers coverage of resident christians , it was possible to make a 
 basic assessment in mwembeni . here , there were some christians living near the primary 
 school , not far from the village centre , or who had children at the school . it was those residing at the periphery of the village that were 
 omitted . also , a general bias towards offering tablets to muslims in preference to 
 christians was discernible in the self - reported uptake data : between 2004 and 2007 , 53% of 
 muslim adults reported taking the tablets in mwembeni , and 48% of christians . ethnographic 
 research on this and other issues revealed that there were marked differences of attitude 
 and commitment among drug distributors . observations and discussions strongly indicated 
 that it was the most marginal that end up being excluded from the offer of treatment . it remains to be explained why self - reported drug uptake is higher in some places than 
 others . it relates to levels of engagement with 
 the target populations and resulting increased capacity of people to make informed 
 choices . it has already been observed that the proximity of the official sentinel site 
 near tanga town at kirare and the visits of medical staff and researchers explain a 
 relatively high self - reported uptake rate , even if it is less than is necessary for 
 long - term control or elimination of the disease . similar rates were noted in this study , 
 in bwembwera and magila in muheza district and at the small trading centre of jaira in 
 pangani district . the case of jaira was discussed with district medical staff based at the hospital in 
 pangani town in 2011 . the district medical officer commented that the improvement in 
 self - reported drug take - up ( from a low of 40% in 2007 to around 70% in 2010 ) must have 
 been to do with the direct involvement of his staff . some of his staff had been to jaira 
 at the time of distribution and had responded personally to the questions and concerns of 
 the population . it was not possible to do so elsewhere due to lack of transport and lack 
 of qualified personnel who might be deployed . with respect to bwembwera and magila , the take - up rates of 68% in 2006 and 65% in 2007 in 
 bwembwera , and 70% in 2007 in magila , probably reflect their proximity to muheza town and 
 to muheza hospital . it was found that in these locations knowledge about lymphatic 
 filariasis and the rationale for mass treatment had been more adequately communicated than 
 in locations near the coast . in addition , it was reported by informants that surgery had 
 been made available to those men seeking it through an established system of referral , 
 rather than the kind of ad hoc surgery camp that was run in pangani in 
 2008 . district medical staff additionally noted that higher rates of drug uptake near to 
 muheza town reflected the better training and larger number of drug distributors than was 
 the case in more remote locations . they were well aware of the difference in levels of 
 engagement within the district , and explained that they just did not have the resources to 
 run a more effective operation at a distance from their base . the research presented in this article is based upon fieldwork undertaken in northern 
 coastal tanzania . it demonstrates that the uptake of drugs at selected study sites in 
 pangani and muheza districts falls short of the sustained high coverage levels required to 
 eliminate lymphatic filariasis , and the prospect of eliminating the disease by 2020 with 
 current strategies is remote . in broad terms , the findings presented in this article add to 
 the worrying conclusions of simonsen et al . ( 2010 ) , who report that drug uptake at the nearby and closely studied 
 sentinel surveillance site at kirare , while higher than those reported at the study sites in 
 this paper , is insufficient ; and that mda is having declining effects on disease control . in 
 combination with research undertaken by michael et al . ( 2010 ) , results 
 presented here highlight the pressing need to fine - tune mass treatment programmes according 
 to ecological , biological and social factors operating at a local level . 
 the results also highlight the need for more adequate monitoring , recognizing that there are 
 risks involved in sustaining mda with partial coverage over time , including risks associated 
 with drug resistance ( mccarthy , 2005 ) . elsewhere in the country considerable success , for 
 example , has been reported in zanzibar ( mohammed et al . the prevalence of microfilariae has fallen from 17.8% and 7.2% to less 
 than 2% at two sentinel surveillance sites , following five annual rounds of mass treatment . where there are apparent successes of this kind , it would be helpful to know exactly why 
 they have occurred . the present trend in the ntd literature , driven by target - orientated 
 funding , is to assume they are inevitable . explanations for the reported achievements in 
 zanzibar include sustained high mda coverage of 7080% over a five - year period , linked to 
 the introduction of effective lymphoedema management programmes . it is probably also 
 significant that the prevalence of microfilariae was initially lower than that recorded at 
 kirare . it is not clear , however , whether these lower levels were due to other vector 
 control activities that may have been running in the vicinity for lymphatic filariasis 
 and/or malaria or whether they reflect the relative affluence and ease with which zanzibari 
 populations can access public health interventions and other forms of biomedical care 
 compared with populations in tanga region on the mainland . whatever the explanation(s ) , it 
 is dangerous to simply assume that the results can be readily replicated . there are specific 
 reasons why mda works in some places and fails in others ; and it is crucially important to 
 know what these reasons are . the mixed effects of mda for lymphatic filariasis have specific aspects but in other ways 
 are not unique . mass distribution of drugs for other neglected tropical diseases faces 
 comparable problems . in tanzania , hastings documented the uptake of ivermectin and 
 albendazole for the treatment and prevention of onchocerciasis in doma , morogoro region , in 
 2007 . working with a 20% sample involving 150 randomly selected adults , her research 
 suggested that uptake fell from 31% in 2004 to 29% in 2006 and 17% in 2007 ( hastings , 
 personal communication ) . wingate - saul documented the uptake of the drug praziquantel for the 
 treatment and prevention of infection with s. mansoni . working in fourteen 
 villages in ukerewe island , her research suggested that in 2007 drug uptake among adults 
 ranged from 18% to 74% , with the average uptake being 44% ( wingate - saul , 2008 ) . these rates are well below target levels , and it 
 is not clear what effect they are having on the prevalence of infection . meanwhile , a 
 disturbing indicator of how local fears and rumours can spiral out of control are the 
 violent riots that occurred in several locations during 2008 in response to mda for the 
 treatment and prevention of s. haematobium in schools . hastings had to be 
 rescued from her research location near morogoro by armed tanzanian police . some teachers 
 found distributing drugs were not so lucky and were beaten by angry mobs convinced that 
 tablet distribution had sinister motives , such as population control ( irin humanitarian news 
 and analysis , 2008 ; daily news online edition , 
 2008 ) . there are , of course , well documented accounts of social resistance to other top - down 
 biomedical disease control programmes such as vaccination programmes to control polio in 
 nigeria ( yahya , 2010 ; renne , 2011 ) and tetanus in cameroon ( feldman - savelsberg et 
 al . , 2000 ) ; as well as the provision of 
 condoms to prevent the transmission of hiv / aids in parts of indonesia ( butt , 2005 ) , botswana ( heald , 2000 ) and south africa ( niehaus & jonsson , 2005 ) . with respect to neglected tropical diseases , 
 there has also been some active resistance to treatment in uganda , if not on the scale of 
 the tanzanian riots . these have been described in relation to mda for schistosomiasis in 
 north - west uganda ( parker et al . , 2008 , 2012 ; how , then , should fears associated with the mass distribution of drugs for the treatment 
 and prevention of lymphatic filariasis be addressed ? it may be tempting for policymakers and 
 planners to feel that the most effective way to respond to the low uptake of drugs for 
 lymphatic filariasis is to continue to focus on narrow technical and logistical aspects of 
 drug delivery as there is little they can do to counter rumours that the government and 
 international agencies have hidden agendas that do not serve the interests of local people . however misplaced local fears and anxieties about free treatment 
 actually are , they are also ideas that are widely held and have emerged from experiences and 
 empirical observations . white ( 2000 ) , reflecting on 
 the persistence of vampire stories in africa , and geissler & pool ( 2006 ) , analysing rumours associated with medical 
 research projects in sub - saharan africa , have demonstrated the multiple ways in which 
 stories and rumours articulate local understandings of the workings of power and knowledge . given that it is politically and economically neglected people who are mostly infected with 
 neglected tropical diseases , it is hardly surprising that the targets of vertical mda 
 projects do not necessarily take the stated intentions of those running them at face value . there is a need for a 
 real engagement with such populations , necessitating different kinds of local - level 
 strategies . with respect to lymphatic filariasis a range of interventions are required , and social empowerment needs to be 
 part of the mix . new ways have to be found to explain the rationale for mass drug 
 administration ; that mabusha and matende are signs of the 
 same infection ; that it is possible to be asymptomatic and infected with parasitic worms ; 
 that the drugs being provided will not necessarily reduce the swelling of those suffering 
 from matende or mabusha ; that the purpose of combining the 
 drugs invermectin and albendazole is to prevent those who are infected but asymptomatic from 
 developing clinical signs of infection ; and that the drug albendazole also has the capacity 
 to treat those suffering from other worms , notably soil - transmitted helminths . there has to 
 be knowledge transfer for afflicted people to be able to make informed choices . as allotey et al . ( 2010 ) note , the current 
 emphasis on context - free , pathogen - focused ntd control is a return to magic bullet 
 medicine , and ignores the fact that vaccines and drugs do not cure neglect or poverty . perhaps the largest challenge of all is not how to win round the hearts and minds of those 
 being targeted for treatment , but rather how to create a space whereby those engaged in 
 developing policies at a global level feel able to acknowledge that the types of 
 difficulties discussed in this paper are significant and that raising them is helpful and 
 relevant for developing more effective strategies . considerable institutional pressures 
 mitigate against effective action , not least because intense competition for funding 
 discourages critical thinking and analysis ( allen & parker , 2011 , 2012 ) . there is a tendency 
 towards disingenuous dismissal of important information , both social and biological , and an 
 overemphasis on quickly achieving optimistic goals . it has led to some questionable claims 
 about what has already been achieved , and to some strongly worded responses to the kind of 
 research presented here . a global commitment to control or eliminate lymphatic filariasis and other neglected 
 tropical diseases is a hugely positive development , but that is all the more reason to avoid 
 treating fundraising rhetoric as facts , and to learn lessons from what has happened with 
 such large - scale vertical schemes in the past . as a 2010 editorial in the 
 lancet observed : currently , it is only an afterthought  without proper monitoring and accountability , 
 countries and donors  and taxpayers  have no idea whether or how their investments are 
 working, ( the lancet 
 2010 , p. 526 . ) with respect to mda , there is a need 
 for sober and rigorous assessment , which examines locally specific effects and subjects 
 reported results to appropriate critical scrutiny . even if claims about  making poverty 
 history and  alleviating the suffering of the bottom billion are set aside as overblown , 
 it is certainly possible that programmes have potential to assist some poor and marginal 
 populations . however , without heeding warnings and amending strategies , that window of 
 opportunity may be lost .
summarythis article documents understandings and responses to mass drug administration ( mda ) for 
 the treatment and prevention of lymphatic filariasis among adults and children in northern 
 coastal tanzania from 2004 to 2011 . 
 assessment of village - level distribution registers , 
 combined with self - reported drug uptake surveys of adults , participant observation and 
 interviews , revealed that at study sites in pangani and muheza districts the uptake of 
 drugs was persistently low . the majority of people living at these highly endemic 
 locations either did not receive or actively rejected free treatment . a combination of 
 social , economic and political reasons explain the low uptake of drugs . 
 these include a 
 fear of treatment ( attributable , in part , to a lack of trust in international aid and a 
 questioning of the motives behind the distribution ) ; divergence between biomedical and 
 local understandings of lymphatic filariasis ; and limited and ineffective communication 
 about the rationale for mass treatment . 
 other contributory factors are the reliance upon 
 volunteers for distribution within villages and , in some locations , strained relationships 
 between different groups of people within villages as well as between local leaders and 
 government officials . 
 the article also highlights a disjuncture between self - reported 
 uptake of drugs by adults at a village level and the higher uptake of drugs recorded in 
 official reports . 
 the latter informs claims that elimination will be a possibility by 
 2020 . 
 this gives voice to a broader problem : there is considerable pressure for those 
 implementing mda to report positive results . 
 the very real challenges of making mda work 
 are pushed to one side  adding to a rhetoric of success at the expense of engaging with 
 local realities . 
 it is vital to address the kind of issues raised in this article if 
 current attempts to eliminate lymphatic filariasis in mainland coastal tanzania are to 
 achieve their goal .