The paper draws upon research material collected during a one year long ethnographic study on injection use and a WHO funded Injection Practices Research Project, which were both carried out during 1992/1993. The paper examines the changing trends in injection use and practices in the context of the Ugandan health system and in relation to popular views about risk and trust. Generally, people mistrust injections provided at government health institutions and prefer to gain access to injections as symbolic tokens of healing through personal contacts and private ownership of injecting equipment. It now appears that the use of this Western biomedical technology is widespread at all levels of the health care system; needles, syringes and injectables are readily available in homes for use by families and untrained providers. In other words, the injection technology has been domesticated and personalized. The Giddens (1990) framework [Giddens, A. (1990) Consequences of Modernity. Stanford University Press, California.] concerning modernity, trust and risk is applied to understand the motivations behind these processes. The basic argument is that the weakening of state institutions of health care has been accompanied by a loss of trust in the treatment offered there. In addition, the massive anti-AIDS education campaigns which have warned people against the dangers of sharing unsterilized needles, have reinforced existing mistrust in public health facilities and induced families to seek care from people they know and using injecting equipment over which they have personal control. The paper concludes that changing the current injection practices in Uganda will necessitate a change in the organization of public health institutions.
One of the most popular forms of therapeutic administration in Uganda is the injection (UEDMP, 1990; Glenthoj, 1991; Whyte, 1991; Birungi and Whyte, 1993; Kafuko et al., 1996). Injection use is abundant at all levels of the health care system, both public and private; among formal and non-formal providers, among trained and non-trained providers, in hospitals, health centers, private clinics and homes. On average 7 out of 10 treatments made by formally trained providers at established health facilities include an injection (Birungi et al., 1994). This is far above the national desired level of injection prescription of 15% which was stipulated by the Uganda Essential Drugs Management Programme (UEDMP, 1990). Over 95% of all the injections prescribed are chloroquine, procaine penicillin fortified (PPF) and crystalline penicillin. The high level of morbidity in the country which features malaria as the top cause of illness, followed by acute respiratory infections, encourages the overuse of injections1.
The use of injection therapy in Uganda has been under government jurisdiction. The Pharmacy and Drug Act of 1970 made it illegal for any person to own a syringe for injection (Uganda Government, 1970). It states “...no person shall have in his possession without lawful excuse, the proof wherein shall lie on him, any syringe designed for injection” (The Pharmacy and Drug Act, 1970, p. 1116). Although the recent National Drug Policy and Authority Statute 1993 (Uganda Government, 1993) does not explicitly state the law on injections, there are strong intentions from the National Drug Authority to restrict its use (Chairman NDA, personal communication). In effect, injection use is still formally restricted to biomedical experts.
However, perceptions of risk and trustworthiness have made lay people more autonomous in controlling their health care and have opened new dimensions in the use of injections (Birungi and Whyte, 1993). It now appears that this Western biomedical technology is becoming more and more dependent on local social relations and personal ownership of injecting equipment. Findings of a WHO study carried out in two regions of Uganda, show that 63 and 83% of the 360 households visited in Busoga, Eastern Uganda and in Ankole, Western Uganda, respectively, owned needles and syringes. In the same study, it was noted that there was growing mistrust of government health care as a source for injections. For instance in Busoga, in the 359 households where an injection was ever administered, 35% of them had received their last injections at government units, 36% were given in private clinics and the remaining 28% were received from informal providers and at home. In Ankole, it was noted that less than a quarter of the last injections had been given in a public institution. In 358 households where an injection was ever administered, 47% received their last injection at a private facility, 23% at a government facility and 30% were received from informal providers and at home.
This paper looks at the changing trends in injection use and practices in relation to perceptions of risk and trust. In order to understand people's motivations, the framework developed by Anthony Giddens (1990) concerning modernity, institutions and trust is applied. The basic argument is that the weakening of state institutions of health care has been accompanied by a loss of trust in the treatment offered there. In addition the massive anti-AIDS education campaigns which have warned against the dangers of sharing unsterilized needles, have reinforced existing mistrust of government health facilities and moved families to seek care from people they know and only using injection equipment over which they have personal control. The paper draws upon research material collected during a one year long ethnographic study on injection use in Busoga, Eastern Uganda and also on research materials collected during an Injection Practices study funded by WHO, which was carried out in 1992 in Western and Eastern Uganda.
