(1996; 157 pages)
3.2 Injection use: explaining their popularity
Often, the explanation for the popularity of Western medicines is sought in the dramatic cures by single shots of penicillin during mass campaigns to control yaws (Michel 1985, Nwokolo & Parry 1989). According to Wyatt (1984), the mass campaigns against yaws and kala-azar occurred in two waves, first with neosalvarsan in the nineteen-twenties and thirties and, after World War II, using a single injection of depot penicillin to cure horrible, disfiguring lesions in one or two weeks. This cure was described everywhere as quite extraordinary. For example, Reeler notes in her research in Thailand (1993) that older people still remember how a single shot could miraculously cure yaws or protect against dreaded diseases like smallpox11. The use of injections has therefore come to epitomize Western medicine itself: magical properties have been attributed to injections after their ability to bring about the miraculous cure of diseases had been demonstrated.
11However, according to Wyatt (1984), vaccination campaigns have not contributed to the popularity of injections, because the connection between an injection now and not getting a disease in the future is too tenuous.
Although no miracle cures can be observed in the majority of the cases of injection use today, still the belief in their effectiveness remains strong. An explanation based solely upon past miracles is therefore insufficient to explain injections' present popularity. Even the most obvious answer to their widespread, probably even universal, use in combating illness - their chemical action - is not an altogether totally adequate explanation of their popularity. Medicines whose chemical composition exerts no biochemical influence upon the illness, amulets worn around the neck or holy objects placed in or around a house, for example, are often used as part of the therapeutic process. Western science is also well acquainted with the 'placebo effect' where tablets containing no chemically active constituents have been shown to be just as effective as 'real' medicines.
For a more comprehensive interpretation of the action of medicines we must look to the 'total drug effect' (Helman 1994:194). The characteristics of the medicine itself (its colour, taste, form, name), of the patient (his or her personality, experience, social-cultural background), of medicine providers, and of the situation in which the transaction takes places, all play a role in the final result of the medicine's use. Yet another characteristic particular of medicines is that it is a substance, an object which is physically present. The very tangibility of a medicine fosters trust in the patient that something can be done with a complaint which at first appeared to be rather elusive.
This movement from the abstract complaint to concrete action can also be applied to the use of injections, although their widespread popularity is also to be explained by certain characteristics specific only to this example of Western medical technology. Birungi and Whyte (1993) write that, in Uganda, patients show a preference for injected medicines against oral medicines as they believe them to be more effective: they go directly into the blood-stream. Hence they remain longer in the body than would oral medicines which will eventually leave the body through the action of the digestive system. Moreover, the injected medicine goes directly to the source of the illness which they believe is centered in the blood12. One remark by a woman interviewed by Birungi (1994a) clearly illustrates this: "The illness is in the body so the injection attacks the illness directly". In other countries the idea that 'the injection goes straight into the blood' is also considered to be the greatest advantage of injection use (for example in Nicaragua, Wolters 1993; Indonesia, Sciortino 1993; Thailand, Reeler 1993). Injections enter deep in the body, to the root of the disease, according to supporters of injections in Borneo (Bloem & Naterop 1990). A study by Greenwood (1981) in Morocco suggests that the penetration of the needle during an injection produces the best effect against 'deep diseases'. A Thai respondent even quantified the effect of injections as compared with pills: "one ampoule equals ten pills!" (Reeler 1993:61).
12Similar ideas are reported by Cosminsky (1994:107). In Guatemala, injections are believed to go directly into the bloodstream "like alcohol". That is why they work faster and are more effective than pills which are perceived to go in one way and out the other, like food.
In his discussions with an Ayurvedic healer in Northern India, Burghart (1988) came across comparable explanations of the action of injections. This healer often administered penicillin injections. His preference for the injection was based upon the notion that, through this trajectory, the medicine enters the body both quickly and directly. The normal route, through the digestive system, would take much longer. More importantly, this healer believed that medicines must pass a number of 'control points' in the body which bring about a gradual decrease in the medicine's potency. This healer thought that an injection is able to bypass these control points bringing the healing substance directly to the trouble spot. The result is an extremely fast, although dangerous, intervention. It is for this reason that the Ayurvedic healer said he was not in favour of the use of injections for young children and the aged. Nevertheless, he did often give injections to these two age groups explaining that "people are often impatient" and they had often already tried another remedies without positive result. Under these circumstances he decided that a more powerful intervention was indeed necessary, and administered an injection.
The extra charm of the injection is that it fits easily into many local systems of thought on illness and health. One consequence of this tendency is that rather than this new technology serving as a vehicle for the introduction of new ideas, as one might expect, it may often, in fact, simply serve to confirm current traditional notions on illness and health. One striking example is the cultural reinterpretation13 given by the Ayurvedic healer to Burghart. The healer considered penicillin to be a medicine with both a hot and desiccating effect. An illness which is caused by a imbalance resulting in an excess of cold, a notion common to humoral etiology, cannot, therefore, be more quickly and powerfully combated than by a penicillin injection. This cultural adaptation of penicillin injections became cultural appropriation when the healer remarked to Burghart that penicillin is, in fact, an ancient Ayurvedic medicine. Another example of the importance of local ideas on balance is given by Sciortino (1992): some patients in Central Java ask for a 'double injection', one shot in the left and one in the right buttock, so as not to create an imbalance.
13This term has been borrowed from Herskovitz (1948) and has been applied by Bledsoe & Goubaud (1985). It means that old, familiar cultural meanings are ascribed to new elements, for example Western pharmaceuticals.
In many humoral traditions, injections are classified as 'hot' in hot-cold divisions. Nichter (1980:228) notes that in South Kanara (India) injections are believed to be powerful and 'heating'. The most powerful injections are those manifesting the greatest burning sensation. On the other hand, this classification also implies risks for the receiver of the injection. For example, in Nicaragua, when a person is agitada ('in an agitated state'), the blood runs faster and the body is in a 'hot' state. Administering an injection could then produce a dangerous effect. In addition, after injecting, the pierced skin is agitado and should not be exposed to the sun (Wolters 1993).
The direct access to the blood-stream offered by injections is of special importance when blood is conferred a central role in the process of illness and recovery, a notion found in many cultures. If injections are so powerful in a curative sense, then clearly they can also be used as a prophylactic. Illness is often seen as a succession of phases, with each becoming more serious than the last, unless an intervention is made. Etkin et al.(1990) describe how, in Northern Nigeria, this idea leads to patients continuously switching medicines in keeping with the progression of the phases. This notion then is instrumental in preventing a more serious phase. Birungi (1994a) describes how her informants in Uganda were even concerned about a common cold believing that this could lead to a more serious and dangerous complaint such as malaria. On the basis of this notion, an injection may even be used for a common cold simply to prevent something worse.
Another explanation for the superiority of the injection's effectiveness is related to pain. In Nicaragua a painful injection is considered to be strong, because pain is associated with more healing power (Wolters 1993). In Sierra Leone, injections are seen as the most potent remedy apparently because the pain associated with them must indicate efficacy (Bledsoe & Goubaud 1988). However, the pain injections may generate is also a reason given for disliking or fearing them (Sciortino 1993).
Injections also perhaps owe much of their popularity merely to the fact that they come from 'far away'. Syringes and needles are examples of an alien technology that cannot be made or copied using local resources. Cassava powder, for example, can be made to look like penicillin (Whyte & Van der Geest 1994), but instruments of injection are 'hightech'. Through its 'alien origins', the injection appears to possess special qualities which only serve to further increase its symbolic power (Whyte 1988).
The image of the injection is so appealing to the imagination that it has become a symbol of western medical practices as a whole. Medical messages constantly reinforce the potency of injections as a force for good. Injections and the syringe have become the symbol of modern medicine (Wyatt 1992). Even outside medicine the latter has become a metaphor for everything that is fast and efficient. A syringe is equated with health in all sorts of propaganda. The injection is so dominant that it has lent its name to a whole array of, often informal, practitioners whose practices include, among other things, administering injections. Terms such as 'injectionist', 'injection doctor' and 'needleman' are used to describe healers who do much more than just give injections (Taylor et al. 1968, Cunningham 1970, MacLean 1974, Whyte 1982).
Yet, the preference for injections is not universal. Sachs & Tomson (1992) found no preference for injections in their drug utilization study in Sri Lanka although they give no reasons why. Herdt reports (personal communication) that injections are not popular in Papua New Guinea. He is of the opinion that injections are viewed as violation of the body. In the Philippines in community drug use studies, injections were also found to be used very rarely (Hardon 1991). In the Netherlands, as in many Western European countries, injections also do not appear to be popular. In contrast to many non-western countries, people in Western Europe cannot buy injecting equipment directly over the counter or acquire it through informal healers. They must resort to doctors who are perhaps rather less inclined to prescribe an injection than are their non-western colleagues14.
14As far as we are aware, no studies have been conducted into the cultural meaning of injections in European societies. It is plausible that great differences in the popularity of injections can be found within Europe, concomitant with variations in medical practices.
Various authors have indicated that the injection of children is particularly mistrusted, for example in Indonesia (Sciortino 1992, 1993), India (Nichter 1989), Dominica (Krumeich 1994), Burkina Faso (Vincent-Ballereau et al.1989). In each case the justification given was that injections were too powerful for small children. Hagenbeek (Indonesia 1994) notes that many of his informants objected to the injecting of young children. The injection is considered too strong, and the child may be paralyzed or even die from this treatment. These fears, however, also influence immunization: it is believed the vaccination makes the child sick. According to Sciortino (1993) negative experiences in vaccination and treatment have made mothers cautious about injections in small children. Not everywhere is it thought that children are less suitable for injectable therapy. Many people in Thailand believe that even babies benefit from injections, notes Reeler (1993).