Susan Reynolds Whyte

Treating AIDS: Dilemmas of unequal access in Uganda

The price of antiretroviral (ARV) medicines in Uganda has fallen dramatically in recent years and more people are under treatment. By mid-2003 it was estimated that 10 000 people were taking ARVs. Drawing on participant observation, qualitative interviews, work with key informants and document reviews, we seek to map out the channels through which ARVs are being made available to people and to describe and assess the social implications of the present system of distribution. Four channels of access to ARV medicines were common in mid-2003: (i) Medicines were provided free in structured research and treatment programmes funded by donors, but only to those who lived in a defined catchment area and met inclusion criteria. (ii) Gazetted treatment centres provided drugs on a fee-for-service basis; these urban-based institutions account for the largest number of drugs dispensed. (iii) Private practitioners, mainly based in Kampala, provided discrete treatment for those who could afford it. (iv) Finally, medicines were ‘facilitated’ along informal networks, supplying friends and relatives on a less regular basis, sometimes for free, sometimes for cash. However, access to ARVs remains highly uneven. We argue that cheaper drugs make possible different kinds of access, different qualities of care, and a growing awareness of inequity. Because the price of drugs has fallen drastically, middle-class families now have the possibility of buying them. But this requires tough prioritising and many cannot follow the regimen regularly. Health workers must consider whether patients will be able to purchase the drugs or not. In a kind of popular social pharmacy, people assess who can and should and does get access to ARVs. Further research should examine the whole range of ARV access channels in different countries and the associated patterns of social differentiation and exclusions.

Pharmaceuticals as folk medicine: transformations in the social relations of health care in Uganda

The deterioration of government health services in Uganda since 1971 has been accompanied by a process of privatization which has made pharmaceuticals readily available outside of biomedical institutions. On the basis of material from eastern Uganda, the article analyses this development in terms of the ‘sector model’ of health care systems, with special attention to the relations between the professional and folk sectors. Folk practitioners of pharmaceutical medicine include a broad range of specialists, from government trained paramedicals in private practice to vendors bringing medicine to local markets. Like other folk specialists, they respect the customers opinion, provide treatment by proxy and adjust their services to the customers ability to pay. Although there are negative aspects of this development, from the local point of view there are also positive ones, which deserve the consideration of health planners.

Penicillin, battery acid and sacrifice: Cures and causes in Nyole medicine

The existence of therapeutic alternatives, a very widespread feature of medical systems, is to be distinguished from medical pluralism, which characterizes situations where orthodoxy and power accrue to one group of medical professionals. Local African medical systems are dynamic and inclusive and this is the basis for the ready incorporation of Western biomedical elements. Analysis of the medical perceptions, treatments and practitioners of the Nyole of Eastern Uganda reveals that new divination techniques and exotic sorcery medicines have been absorbed as well. Some of the recent changes in Nyole medicine may be indicative of a growing medical individualism. Explanations and treatments directed toward the social and ritual situation of the sufferer still bear the greatest ideological weight.

Chronicity and control: framing 'noncommunicable diseases' in Africa.

This paper proposes a way of framing the study of ‘noncommunicable diseases’ within the more general area of chronic conditions. Focusing on Africa, it takes as points of departure the situation in Uganda, and the approach to health issues developed by a group of European and African colleagues over the years. It suggests a pragmatic analysis that places peoples perceptions and practices within a field of possibilities shaped by policy, health care systems, and life conditions. In this field, the dimensions of chronicity and control are the distinctive analytical issues. They lead on to consideration of patterns of sociality related to chronic conditions and their treatment.

The availability of drugs: what does it mean in Ugandan primary care

Availability of drugs is often considered the most important element in quality of health care in rural African settings. Using material collected through mainly qualitative methods, this article examines drug availability in six primary health care units in southeastern Uganda. Emphasis is on the differing perspectives of three categories of actors: health planners/managers; health workers; and users of health services. The main concern is the availability of chloroquine and penicillin, especially injectable forms, and the needles and syringes for administering them. Health sector reforms have changed the conditions for managing, supplying, and using drugs through decentralization, user fees, and privatization. Patients were dissatisfied when they were not able to obtain all drugs prescribed at the health unit. Government health units both compete with, and use, local commercial sources of drugs. They need to attract patients and, with user fees, they are more able to supplement the drug kit supplies provided through the Ministry of Health. There is a need to revise policy in light of the new situation. Dialogue and realism are needed in order to create policies that respect both good medical treatment standards and the concerns of front line workers and their patients. The exercise of rethinking the meaning of drug availability in primary health care calls for methodologies examining the changing context of health care and the positions of different categories of actors, at national and district setting, to appreciate gaps existing between drug policy and practice.

Attitudes towards mental health problems in Tanzania

The anthropological part of the baseline evaluation was intended to gather iiiformation on current views of mental health problems and on the ways in which actual problems were being handled by those who encountered them. In line with this double intention, two studies, an attitude and a practice survey, were carried out. The perspective in both was that of ordinary Tanzanians, rather than that of the national health facilities. The two studies were done in the same locations and were designed to supplement one another. (The results of the practice survey are presented in the following chapter.) The attitude survey was meant to compile data on people’s ideas concerning six different mental health problems, which had been chosen as targets by the Tanzanian Mental Health Programme. These included alcoholism, epilepsy, depression, acute psychosis, chronic psychosis and mental retardation. We wished to investigate: 1) The extent to which people were familiar with these

Communication between HIV-infected children and their caregivers about HIV medicines: a cross-sectional study in Jinja district, Uganda

Knowledge of antiretroviral therapy (ART) among children with HIV depends on open communication with them about their health and medicines. Guidelines assign responsibility for communication to childrens home caregivers. Other research suggests that communication is poor and knowledge about ART is low among children on treatment in low‐income countries. This study sought to describe communication about medicine for HIV in quantitative terms from the perspectives of both children and caregivers. Thereafter, it established the factors associated with this communication and with childrens knowledge about their HIV medicines.

Recognition as care: a longitudinal study of Arabic immigrants’ experiences of diabetes training in Denmark

This longitudinal study provides critical insight into the social processes of municipal diabetes training for Arabic-speaking immigrants in Denmark focusing on participants’ experiences. Our study builds on observations of three diabetes courses and 36 interviews with participants at the start of, immediately following or 30–36 months after the courses. Lifestyle change and responsibility were dominant messages in the courses; over time and depending on their daily social context, participants selectively accepted and incorporated these messages. However, in retrospect, participants highlighted other meaningful benefits; these centred on reducing isolation and being met on their own terms regarding language and logistics. Most importantly, they remembered when treated with attention and respect by professionals and the mutual acknowledgement between participants. We use Axel Honneth’s notions of rights-based and solidarity-based recognition to analyse what was at stake in these experiences, and we engage Annemarie Mol’s concept of a logic of care to show how recognition unfolded practically during the training. We propose that participants’ wider social context and experiences of misrecognition situated the training experiences concerned with recognition. We also show exceptions. The sociality, which for some generated solidarity-based recognition, felt intimidating for others. We argue that the silent processes of recognition in the diabetes training carried significant meaning for participants, and that over time, many highlighted these as benefits rather than lifestyle change and responsibility.

Measuring risk, managing values: health technology and subjectivity in Denmark.

Based on fieldwork among Danes with a diagnosed risk of type 2 diabetes or cardiovascular disease, this paper investigates how the technological possibilities of diagnosing and monitoring invisible risks shape understandings of health and form subjectivity. It focuses on the experiences of being diagnosed with a risk condition in the form of high blood pressure or elevated blood glucose and the ensuing use of measuring devices. It argues that measurements of these conditions can be seen as ‘formative processes’ that produce and maintain a view of health as something that can best be known through the use of medical technology. The numerical values such measurements yield are seen as true indicators of health, and doing something about risk conditions is felt to be a personal imperative. The formative processes illustrated in this paper are motivational and thought provoking. The informants do not experience new symptoms after being diagnosed; rather they reflect upon their health in a new way and numbers become associated with personal responsibility and morality. However, because numbers influence subjective experiences, they can come to take up too much space in everyday life. Therefore, people have reservations about how often they should measure their values at home. The formative processes of being diagnosed with a risk condition are thus about subjectivity both in the sense of being subject to the demands of living with an illness and of being a subject who acts to keep life from being colonized by concerns about health.

Men, Women and Misfortune in Bunyole

This article deals with what may be called a problem in collective representations. It attempts to show how a model which is shared by all the members of a society may in fact be elaborated from the perspective of only one group within that collectivity. Collective representations contain a point of view and a set of interests associated with a particular social position. The argument is made in terms of Nyole ideas as to the causes of misfortune.