(1996; 157 pages)
3.3 Injections and medical practice
A number of authors have pointed to the imperative character of medical technology. The reasoning behind this is that, where recovery to good health is concerned, no stone should be left unturned (Reiser 1978, Wolf & Bishop Berle 1981, Tymstra 1987, Koenig 1988). If a remedy for a particular illness exists then it would be irresponsible not to use it. The health 'market' varies from other markets in this respect. Patients demand injections and health centre staff often prefer them. In informal and clandestine medical practices, up to and including self-care, injections also enjoy a growing popularity.
Just as patients desire 'the best' for themselves - an injection, for example - health care staff also want to give them the best. Many publications make clear that doctors and nurses administer injections far more often than is medically justified. Health workers are convinced of the superiority of injections, and therefore frequently administer them. Injections work very fast, something particularly important when dealing with acute conditions. Another important reason is their desire to meet the perceived needs of the patient. When it occurs one could speak of reversed 'compliance': the doctors and nurses now obey the patient. Sciortino (1993) shows, however, that this situation could be the result of a misunderstanding between nursing staff and patient where the former simply assumes that the latter desires an injection. Many mothers in health centres in Java preferred their child not be injected, notes Sciortino, but dared not say so to the nursing staff.
According to many health workers, injections can also be instrumental in avoiding problems of non-compliance (Ofori-Adjei & Arhinful 1994, Sciortino 1993, Janszen & Laning 1993, Reeler 1993). When the health worker administers an injection, it is certain the patient has received therapy. This is certainly not the case when he or she prescribes pills to be taken later. Patients who are considered 'irresponsible', or those whom the doctor feels are too poorly educated to properly observe the instructions of a prescription are often given an injection simply to avoid these problems.
Financial considerations are a final important reason why many doctors and nursing staff show a preference for injections. Injections cost more than many other remedies and, as the prescribers will gain material advantage from the sale of the prescribed medicines, this serves as an extra stimulus to administer an injection (Kleinman 1980:287). Pharmacists have also discovered this profitable market. Injection administration in pharmacies has been reported from Ethiopia (Norberg 1974, Kloos 1988), Nigeria (Igun 1987), Somalia (Serkkola 1990), and from Ecuador (Janszen & Laning 1993). Pharmacies play a decisive role in the distribution of injectables and injection equipment to informal injection providers and the general public.
It is understandable that the ardent use of injections should spread far beyond the official circuit in which it belongs. Many community health workers and traditional midwives who have received instruction in modern medical practices fear they may not be taken seriously unless they too can offer injections. Some are, in fact, trained to administer injections although most have learnt the required techniques themselves and, in doing so, transgress the boundaries of what is formally permitted. The use of injections by traditional midwives is reported by Schwarz (1981) in his article on Colombia, by Wolters in Nicaragua (1993) and by Sukkary in Egypt (1981).
Nowhere is the attraction of injection use greater than among informal medicine sellers. Reports of these lay people both administering injections and selling syringes, needles and injectable medicines have been made by a number of authors, for example, the reports on Ugandan needle curers (Whyte 1982) and itinerant injectionists (Birungi 1994a/b), Ethiopia (Slikkerveer 1982, Buschkens & Slikkerveer 1982), Zaire (Janszen 1978), Nigeria (MacLean 1974), Guatemala (Woods 1977), Colombia (Press 1971), El Salvador (Ferguson 1988), Thailand (Cunningham 1970), and India (Gould 1965; Bhatia et al.1975). Often, these lay injectionists are not aware of the need to sterilize their needles, and have received little or no training at all in Western medical techniques. An example from Ecuador:
Injectionist Beatriz sees most of her patients on market day, when her little shop turns into a bar and clinic. Then she sees approximately 25-30 patients a day. According to her, patients trust her because she is friendlier and less formal than the doctors in the health centre. Patients confirm this. Her prices are much higher than elsewhere. She charges up to 7 U$ for a treatment, while most of her clientele only earn between U$ 0.10 and U$ 1.00 a day. Before starting her practice she followed a one month nursing course. She could not tell the names of the medicines she injected, but the researchers found a wide range of empty ampoules on the kitchen floor, ranging from oxytocin, to anti-histamines, vitamins and lincomycin. This last antibiotic she uses for rheumatic pains (adapted from Janszen & Laning 1993:52-54).
Even traditional healers are making increasing use of injections. Landy (1977) points out that traditional healers must make choices in order not to be supplanted by 'modern' Western medicine. They often take a very critical view of this 'imported' health care and, in response, cultivate particular practices not found in hospitals or health centres. Some specialize in problems for which Western medicine has no answer. Others have taken the opposing position and attempt to meet the increasing competition by appropriating the methods and practices of the dominant health culture, including the use of injections. Wolffers (1988) found that fifty percent of traditional practitioners in rural Sri Lanka used modern pharmaceuticals in their practice. Twenty years ago, Bhatia et al.(1975) established that of the 93 healers they had visited in three Indian states only 14% did not administer injections. Eighty-seven percent of the healers possessed needles and syringes. An earlier survey of traditional healers in Mysore State (India) showed that half of the patients received injections (Alexander & Shivaswamy 1971). In 1963, Halpern already reported that traditional healers in Laos had adopted injections into their practice. Ndonko (1991) reports that traditional healers in Cameroon also use injections. In Nicaragua, the injectors are often traditional birth attendants or curanderas (traditional healers) (Wolters 1993).
The unregulated sale of syringes and injectable medicines also leads to their use in self-care. Often it is difficult to make a distinction between informal health services and self-care. People inject their neighbours and their relatives without money changing hands for the service, reports Wolters (1993). The major determinant is confidence in the person who injects: "confidence derives from fame". Her informants stressed that it is necessary to have confidence in the injector, otherwise the injection will not 'drop' well.