(1996; 157 pages)
3.4 Injections and human relations
Injections also influence human relations, although this influence appears, from the few accounts available, to be both complex and contradictory. While injections remain the reserve of the medical profession, they are being increasingly appropriated by lay people and absorbed into the self-care culture.
In societies where injections are still seen as being relatively 'hightech', they are administered exclusively by health workers (whether formal or informal). While other medicines, due to their free availability, allow individuals to solve their personal health problems without having to resort to a medical profession, medicines which require injection force the patient to call upon the services of a health worker in order to have the medicine administered. Under such circumstances they serve to confirm the inequality between the helper and the helped and become an instrument of social power.
Injection use indeed is one means by which health workers are able to give expression to their higher status. Sciortino considers this social 'by-product' of injection use as an important explanation for the enthusiasm with which workers in a Javanese health centre administered injections:
In fact, only health workers command sufficient power to decide whether an injection should be given or not. Other medicines can also be purchased over the pharmacy counter; injections are only available in the puskesmas or through the private practices of nurses and doctors. (Sciortino 1992:27)
However, the patients' ability to obtain injections may also be the result of their bargaining power vis-à-vis the provider. If the patients are empowered by purchasing power or a special social relationship with the provider, it will be easier for them to obtain a desired injection. Injections thus become the result of a social inequality which favours the patients to their perceived advantage (Reeler 1996).
Less educated health workers, and even unschooled employees of health centres, sometimes use injections more often than do doctors (Hardon 1993). Hardon attributes this finding to the status-elevating effect of injection use, as well as the financial rewards available to health workers for these services. Less educated health workers have less status and earn less; injection use is even more advantageous to them than it is to doctors. Van der Geest noted that this is the case in Burundi where cleaners and unschooled assistants in health centres appear to have gained command of the technique.
Social aspects of injections are also important in the informal sector. Senah (1990) noted that the clients of an illegal drug seller in a Ghanaian village considered this seller a 'good doctor' because he gave many injections. Cunningham (1970) writes that the 'injection doctors' in his Thailand research were so popular because the status gap between them and the general population was far less than between the official health workers and the general population. Comparable observations have been made by various other researchers.
Where patients themselves value personal contact with the help-giver, injections can become an effective means of communication. Nichter & Nordstrom (1989) point out that health care in Sri Lanka has become increasingly commoditized. One can buy medicines, just as any other product, on the market or in shops. However, if self-care does not effect a cure then one resorts to a specialist with 'power-of-hand'. The personal qualities of this specialist - expertise, dedication and care - are of fundamental importance in combating the complaint. In such cases, the relationship between the patient and the care-giver contributes towards the therapeutic effect. The importance of this personal relationship balances the trend towards impersonal commodification.
The use of injections offers an excellent means of expressing empathy: a personal involvement between patient and healer. To administer an injection is an action in which the health worker is able to demonstrate both concern and professional skill, whilst, at the same time, giving the patient faith in a successful recovery. While one oral medicine may be as good as any other, this is certainly not the case where injections are concerned. Giving an injection is an art. The informants in Birungi's (1994a) research in Uganda differentiated between injectors with a 'good' and those with a 'bad' hand. Injections from the former are painless and effective and cause no abscesses. A 'good' hand is, moreover, seen as a 'bringer of luck'. A similar remark is made by Wolters (1993) in her description of injection practices in a Nicaraguan town. Senah (1994) notes in his research in Ghana that if an injection draws blood, leads to pain and abscess or fails to effect cure, either the individual's constitution is blamed or the hand of the injection-giver is said to be bad: the injection or the medicine is rarely faulted.
There is evidence to suggest that injections are becoming increasingly the domain of lay practitioners. The status which health workers draw from injection use is also conferred upon members of the community or family who have gained a command of injection techniques and use them within a limited circle. They too harvest the social prestige which injections offer. A number of examples of self-care through injection have been discussed in the previous section. These indicate that injections appear to be losing their esoteric character and are, instead, taking their place alongside other commercial products offered for sale on the open market, although other considerations may also play a role here. Birungi (1994b) found that informants in Uganda had become fearful of injections administered in public institutions because the syringes and needles used there had to be shared with other, unknown, patients. They thought that to be injected in a public institution carried a high risk of infection with HIV and greatly preferred to be given injections at home or from someone well known to them from their village. Injection use can, therefore, have the dual effect of promoting appeals to specialists and increasing medical care within the family circle itself.