Summary Use of official health services often remains low despite great efforts to improve quality of care. Are informal treatments responsible for keeping a number of patients away from standard care, and if so, why? Through a questionnaire survey with proportional cluster samples, we studied the case histories of 952 children in Bandiagara and Sikasso areas of Mali. Most children with reported uncomplicated malaria were first treated at home (87%) with modern medicines alone (40%), a mixture of modern and traditional treatments (33%), or traditional treatment alone (27%). For severe episodes (224 cases), a traditional treatment alone was used in 50% of the cases. Clinical recovery after uncomplicated malaria was above 98% with any type of treatment. For presumed severe malaria, the global mortality rate was 17%; it was not correlated with the type of treatment used (traditional or modern, at home or elsewhere). In the study areas, informal treatments divert a high proportion of patients away from official health services. Patients' experience that outcome after standard therapeutic itineraries is not better than after alternative care may help to explain low use of official health services. We need to study whether some traditional treatments available in remote villages should be considered real, recommendable first aid.

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There are an estimated 234,000 cases of measles and 13,851 measles-related deaths per year in Mali. In 1998 and 1999, 548,309 children aged 9-59 months were vaccinated against measles during mass campaigns in urban centers across Mali. After the first campaign, measles incidence decreased by 95% in districts encompassing vaccinated urban centers and by 41% in nonvaccinated districts. There was no shift in the proportion of cases by age group in vaccinated centers. Measles in vaccinated districts after the campaign was likely related to persistent transmission in age groups not targeted for vaccination and among children living in nonvaccinated districts. The second campaign (1999) did not change the incidence of measles in vaccinated compared with nonvaccinated centers. Urban mass measles vaccination probably did not affect overall measles transmission in Mali. Mass vaccination of all children in Mali, targeting a larger age group, will be necessary to reach measles control objectives.Measles kills 1500,000 children !5 years of age each year in Africa [1]. In Mali, routine measles vaccination for children 9 months of age began in 1986 with the Expanded Program on Immunization (EPI). EPI coverage between 1990 and 1999 for children !12 months of age ranged from 35.2% (1992) to 60.3% (1998) according to administrative data. A 1998 independent evaluation of the Malian EPI reported measles vaccine coverage of 23.8% for children !12 months of age. Measles is underreported in Mali because much of the population lacks access to health services and because of incomplete epidemiologic surveillance. The World Health Organization (WHO) therefore estimates that there are actually 230,850 cases and 13,850 measles deaths each year in Mali, assuming a birth cohort of 450,000, vaccine efficacy of 85%, routine coverage of 54%, and a case-fatality rate of 6% [2,3] and that 100% of non-immunized children will be infected.

Le nodule de Sœur Marie-Josèphe est une métastase ombilicale d'une tumeur le plus souvent intra-abdominale. C'est un signe clinique rare dont l'incidence est de 1-3% de toutes les néoplasies abdomino-pelviennes, avec un pronostic péjoratif du fait de son retard diagnostique. Nous rapportons quatre observations d'une métastase cutanée ombilicale révélatrice d'un adénocarcinome dont deux pancréatiques, un gastrique et un d'origine ovarienne. Le but de notre travail est de montrer à travers ces quatre cas cliniques, l'intérêt de l'imagerie (tomodensitométrie, échographie) et de la biopsie dans la démarche diagnostique. A travers ces quatre observations nous insistons aussi sur les difficultés diagnostiques et thérapeutiques que pose cette tumeur dans nos pays à ressources limitées.

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