(1996; 157 pages)
3.1 The prevalence of injection use: a literature review
The data currently available on how injections are administered and their medical consequences, their distribution and the meanings that individuals attach to them are largely based upon impressionistic and fragmentary observations. More specific information on injection use can be found in more recent - but still sparse - studies, most of which have been conducted in health care institutions. Sciortino (1992, 1993) reports that in some health centres in the Javanese countryside 80 to 90% of all medical consultations end with an injection being given. Ofori-Adjei & Arhinful (1994) calculate that an injection is included in 80% of all malaria treatments given in Ghanaian health centres. More than a decade earlier Barnett et al. (1980) concluded that 96% of all Ghanaians attending a health care institution received at least one injection as part of their treatment. Senah (1990) estimates that between 80 and 90% of the clients of one informal 'dispenser' in the Ghanaian village where he was conducting research received an injection. A start has been made on conducting more systematic research into injection practices with the recent publication by Bloem & Wolffers (1993) which includes contributions on Ecuador, Indonesia, Thailand and Uganda.
The popularity of injections has been reported in many different countries9. In Asia, for example, this preference is mentioned in India (Alexander & Shwaswamy 1971, Bhatia et al. 1975, Nichter 1980, Greenhalgh 1987, Burghart 1988), Thailand (Cunningham 1970, Reeler 1993, Reeler & Hematorn 1994), Vietnam (Ladinski et al.), Indonesia (MSH 1988, Sciortino 1992, 1993), and Taiwan (Kleinman 1980). From Latin America and the Caribbean reports come from the Dominican Republic (Ugalde & Homedes 1988), Colombia (Browner 1985), Guatemala (Woods 1977, Cosminsky 1994), Nicaragua (Wolters 1993), El Salvador (Ferguson 1988). Other reports indicate the popularity of injections on the African continent: for example in Ghana (Barnett et al. 1980, Waddington & Enyimayew 1989, Senah 1994), Ivory Coast (Alland 1970), Gabon (Soeter & Aus 1989), Nigeria (Alubo 1985), Sierra Leone (Bledsoe & Goubaud 1988), Burkina Faso (Vincent-Ballereau et al. 1989), Cameroon (Van der Geest 1982b), Mozambique (Schapira & Moltesen 1984), Uganda (Whyte 1982, Birungi 1994a/b, Birungi & Whyte 1993), Morocco (Greenwood 1981), Tunisia (Bouraoui & Douik 1981), Ethiopia (Slikkerveer 1982). As early as 1968, Tayler et al. reported on injection use in Turkey.
9An earlier bibliographic exploration by van der Geest (1982a) gives still more references on the phenomenon of injection popularity.
The medical community has repeatedly reacted with concern to these reports (Michel 1985, Wyatt 1984, 1992, Nwokolo & Parry 1989). Injection use is thought by them to be often unnecessary and putting the patient at unacceptable risk of contracting malaria, Hepatitis B (Gopal Rao 1987), and other viral infections including the deadly Ebola-virus and possibly HIV10. According to Wyatt (1984), injections can increase the risk of paralysis when a child is infected with the polio-virus to an incidence of 25% (provocation poliomyelitis). Furthermore, the hygienic conditions under which these injections are administered are, in many cases, quite alarming resulting in many iatrogenic gluteal abscesses (cf. Berkley 1991; Guyer et al.1979; Soeters & Aus 1989; Wolffers & Bloem 1993; Wyatt 1993). Health economists and planners also point out that the cost of frequently administering injections places an intolerable strain upon the resources of local health care systems (cf. Guyer et al.1979, Hogerzeil et al.1989, Melrose 1982, Waddington & Enyimayew 1989).
10The magnitude of the risk of transmitting HIV through needle-stick injuries is subject to debate. Wyatt (1986) suggested that, although the risk of transmission of HIV by accidental needle-stick injections may be very small, the risk with multiple use and reuse of unsterile syringes and needles may be closer to that of intravenous drug users. In Zaire a possible correlation between a history of injections and HIV-positive babies with seronegative mothers has been reported by Mann et al. (1986). A similar study, conducted in Kigali (Rwanda), however, found no difference between the two groups of children in respect of the number of medical injections received (Lepage et al. 1986). Hrdy (1987) points out that while needle-stick injuries can transmit HIV, this mode of transmission is relatively uncommon. Injectionists utilize intramuscular injection which involves little exposure to blood, and their injections are often fairly widespread in time, which makes transmission of the rather unstable HIV even less likely.
Anthropologists find injection use an interesting phenomenon in that it is a spectacular example of the willing acceptance of Western medical technology by non-western cultures. The anthropologist's interest centres on the question: what makes injections so popular (cf. Reeler 1990) or, what do injections do which makes them so appealing? For analytical purposes this central question must be further sub-divided as follows: what meanings are given to injections; what role do they play in medical practices; how do they influence the world of social relations?