mogensen, h - finding a path through the health unit-1

Finding a Path through theHealth Unit: Practical Experienceof Ugandan Patients1

Hanne O. Mogensen

Finding ones way through a health facility is not necessarily an easy task forUgandan patients. Our understanding of how people succeed in doing so, andof the obstacles they encounter on their way, is incomplete if we focus only onthe cognitive level of the clinical encounter. Much research in public healthand medical anthropology implicitly works with the notion that agency islocated in the mind and that cognitive understanding is a precondition forpractice. Based on material from eastern Uganda, this article explores thepractical experience of Ugandan patients and their relatives and reflects uponthe ways in which this notion of agency has often caused us to confuse thespectators point of view with the actors point of view. Thus, as Pierre Bour-dieu has argued, we are made to look for answers to questions that practicenever asks because it has no need to ask them.

Key Words: clinical encounters; primary health care; Uganda; practice theory; health-seeking

behavior

No, he did not tell me the name of the sickness, but he is not supposed toeither. He is supposed to ask: What is the child suffering from? and then Iam the one to tell what he is suffering from. The musawo [health worker]does not tell you anything. He just writes what medicine to take.

Mother of a young child interviewed upon leaving a governmenthealth facility in eastern Uganda.

HANNE O. MOGENSEN has carried out research on medical anthropology and internationalhealth in Zambia, Uganda, and Vietnam, focusing on child health, reproductive health, andAIDS. She works at the Institute of Anthropology, University of Copenhagen, FrederiksholmsKanal 4, DK-1220 Copenhagen K Denmark. Phone: 45 35 32 34 54; Fax: 45 35 32 34 65;E-mail: [email protected]

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Medical Anthropology, 24:209236, 2005

Copyright # Taylor & Francis Inc.ISSN: 0145-9740 print/1545-5882 online

DOI: 10.1080/01459740500182659

The Ugandan mother cited above was less interested in the expla-nation of her childs sickness than in the writing of the healthworker. She is not alone in expressing this preference for aspectsof the consultation other than the verbal exchanges. The consul-tation room in a Ugandan health facility is sometimes referred toas where they write the paper, and people say that when she[the health worker] starts writing we know she has understood.When people choose a government health facility rather than aprivate drug seller it is, among other things, because there at leastthey do the writing. Understanding what is implied by statementslike these requires us to recognize that meaning emerges from prac-tices such as writing, whether the content of that writing is compre-hensible and useful or not. The attention paid by Ugandan patientsto the act of writing suggests that we should consider not only theirtheoretical but also their practical knowledge (Bourdieu 1990) whentrying to understand how they find their way through the healthcare system and how they evaluate the health care options availableto them. In this article I explore the practical experience of Ugandanpatients in order to reflect on the role of cognitive understanding inhealth care-seeking behavior.

THE STUDY

I have been doing research among the JopAdhola in the TororoDistrict of eastern Uganda since 1996. My first long-term fieldworkfocused on mothers interpretations of their childrens symptoms,their possibilities for action, and their health care choices. Sincethen I have returned to the area on a regular basis, carrying outstudies on various health-related issues. Over the years I have beenliving with two different families, and I have used their homes as astarting point for interacting with people in the neighboringvillages. While the members of one family have dispersed and dis-appeared from the area (largely due to AIDS), I have developedlong-term relationships with members of the other family, someof whom live in the rural areas, some in the provincial town, andsome in the capital. I have spent much time accompanying peoplein their health care-seeking behavior and listening to their evalua-tions of what has been offered them. I have accompanied themon regular visits to public health units, at times suggested and paidfor by me. I have spent hours and days waiting in line with them or

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searching for places to buy the drugs prescribed at the health unit. Ihave also accompanied them to diviners as they attempted to learnwhy the luck of an individual or a family had disappeared and sick-ness and misfortune had started to ravage their lives. I have fol-lowed their concerns, uncertainties, and ongoing evaluations asthey searched for explanations, for paths to follow, and for actionsto take.

My research is associated with a larger health research trainingproject (TORCH), which, since 1994, has carried out interdisciplin-ary research in the districts of Tororo and Busia in southeasternUganda concerning the interface between the community and thehealth care system. One of the collaborative studies that emergedfrom this project was a quality-of-care study carried out in 1996,which I draw upon in this article. Part of our study involvedobserving the structure of the public facilities (buildings and equip-ment), the technical practices of the health workers, and the clinicalencounter. We also explored quality of care from the point of viewof planners, providers, and patients through focus group discus-sions and open-ended interviews. In addition, we conductedsemi-structured interviews with 160 people as they left the healthunit. Some of these people were themselves patients, but most wererelatives (usually mothers) of children (Nshakira et al. 1996). I con-ducted a large number of the exit interviews together with myresearch assistant, and since I knew some of the health workersand patients I later did follow-up interviews with them.

What I learned from the exit interviews was in many ways sur-prising. People expressed a lack of interest in explanations, a senseof being in control during the consultation, and satisfaction with theservice they had received, which seemed to be in contrast with themany complaints normally uttered about the public health care sys-tem. Exit interviews, of course, provide a particular kind of infor-mation, and they need to be interpreted with caution. Therespondents were people in need who had just received help andwho were being asked to evaluate that help while still present atthe health facility. It can be expected that, in the midst of suffering,one is grateful that action has at least been taken, whereas later onemay reflect on the shortcomings of that action. Furthermore, peopleleaving the health facility can be expected to feel more intimidatedthan people interviewed at a distance in time and space. The point,however, of referring to these exit interviews is not to take peoplesstatements at face value but, rather, to follow up on reflections

Practical Experience of Ugandan Patients 211

sparked by them. The answers provided by these patients and theirrelatives helped me to see aspects of peoples health care-seekingbehavior that I had previously overlooked.

THE SETTING

The districts of Tororo and Busia border Kenya to the east and LakeVictoria to the south. They are densely populated, and even ruralareas at times seem semi-urban. Agriculture is the major economicactivity and millet the staple food. Tororo town is a busy tradingcenter on the railway line between Kampala and Nairobi, and Busiais an equally busy border town further to the south. Several othersmaller trading centers are found in the rural areas.2

Morbidity is generally high, particularly so when it comes tosmall children. The national under-five-mortality rate is 152 per1,000 live births (MOH 2002:1), and, with a birth rate of almost eightchildren per woman, most women have lost at least one child.About 40 percent of patients brought to outpatient departmentsin government health centers in Tororo District are children underfive (16). Diseases most commonly diagnosed are malaria (40 per-cent of new cases at government units), respiratory infections(20 percent), diarrhea and worms (13 percent). This part of thecountry, like the rest of Uganda, is severely affected by the AIDSepidemic. At the time of the study on which the present discussionis based, the health care system had only symptomatic treatment tooffer to AIDS patients; therefore, AIDS was usually not referred toin the clinical interaction. This situation is presently changing dueto the increasing availability of antiretroviral treatment (Whyteet al. 2004).3

Prior to the 1970s Uganda was said to have one of the best publichealth care systems in Sub-Saharan Africa (Odoi Adome et al.1996:9). However, the political turmoil and civil strife of the 1970sand 1980s resulted in serious neglect and much deterioration(Dodge 1987). The health administration was weakened and func-tioned only sporadically, salaries were irregular and failed to keeppace with inflation. All of this contributed to low morale amonghealth workers. An elaborate system of informal paymentsdeveloped alongside the public health care system (Whyte 1992).4

After Museveni came to power in 1986 the government health sys-tem began to revive. The country embarked upon health-sector

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reform in the early 1990s as part of an overall reform of the publicsector that focused on liberalization and decentralization (Jeppssonand Okuonzi 2000). However, in 2000 there was, according toJeppsson and Okuonzi, no indication that this reform had resultedin improvements (285). Morbidity and mortality remain high, andservice delivery is still suffering from many shortcomings. Salariescontinue to be meager and are often delayed, and the morale ofhealth workers remains low, as does public satisfaction with thehealth care system. User fees were introduced in the early 1990sas part of the structural adjustment program. The actual cost recov-ery was, as elsewhere in Africa, limited (Hansen 1995), but it didseem to considerably reduce incidences of informal payment. Still,complaints about fees were incessant, and fees were officially abo-lished in 2001 as a result of one of Musevenis election campaignpromises.5

In Tororo District 44 percent of the population lives within a five-kilometer radius of a government facility; however, these facilitiesdiffer considerably in size and service provision. They range fromsubdispensaries in roadside mud huts run by nurse aides to hospi-tals with both in- and out-patient departments and medical doctors.While lab facilities, X-ray machines, and operating theaters areappreciated, large units are also perceived as intimidating andpeople often refer to the difficulties of finding out what to do andwhere to go in these larger facilities.

In the 1980s private clinics, medicine vendors, and drug shopsstarted appearing everywhere in urban as well as in rural areas,and today, as Whyte (1992:165) states, they exist in intimate articu-lation with the state system and donor-supported programs. In anumber of publications she deals with the explosive growth of priv-ate biomedical care and its co-existence and creative co-operationwith the state system (e.g., Whyte 1991, 1992, 1997). Many govern-ment health workers divide their time between their jobs in thepublic sector and their private clinics or drugstores. Many of thesedrugstores and clinics are run by people with very little or no train-ing, though the actual owner may be a nurse or a medical doctor.Musawo means health worker in all local languages, and it isused to refer to all kinds of health workers (nurse aides, midwives,nurses, medical assistants, and medical doctors). Often patients arenot aware of the distinction between the different levels of healthworkers. Dwaliro means health facility in all local languages,whether one is referring to a small dispensary or a hospital. I use


these terms to remain in keeping with the interviewees, who didnot usually indicate the size of the health unit or the rank of thehealth worker.

In the course of a sickness episode people move back and forthbetween self-medicating with herbs and pharmaceuticals; visitinglocal herbalists, diviners, and other kinds of specialists; visitingpublic health facilities of difference sizes; and visiting privateclinics and pharmacies in the trading centers. With regard to smallchildren, who are frequently sick on and off for extended periods,health care-seeking behavior is an ongoing process. One may seektreatment for diarrhea at the health unit one day and then interpretdiarrhea as part of a larger constellation of symptoms that onechooses to discuss with the diviner the next day. No sharp distinc-tion is made between symptoms treated with biomedicine andsymptoms treated in other ways, and the public health care systemcontinues, in spite of its turbulent history and many shortcomings,to play an important role in the ongoing process of seeking healthcare. Alternative health care optionsbiomedical and otherareavailable within reasonable distance and for a realistic cost. But avisit to a government facility continues to be a central step in thehealth-seeking process.

EXPLAINING ILLNESS

One of the respondents in the exit interviews was a 19-year-oldwoman, the mother of a seven-month-old girl. She was shy andgave only brief answers. When asked what had brought her tothe health center, she explained that her daughter had diarrhea,cough, and a hot body: The heat has kept adding since yesterday;the diarrhea also started yesterday, but the cough started about fourdays ago. The musawo had asked nothing and explained nothing.The young woman had told him how the child was suffering.Then he touched the girls abdomen, felt her body temperature,and told the mother to give the child fresh cows milk and bringher back tomorrow. She had understood everything, she said, andshe had had nothing further to ask. When asked what treatment shehad received for her child, she showed us some tablets while care-fully explaining that she had been given two tablets of chloroquineto be broken in half and given to her daughter once a day, and 20tablets of septrin to be given two at a time, twice a day, for five

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days. The child had also received a chloroquine injection and wassupposed to have another the following day. On the medical formit was written that the girl suffered from respiratory infection andclinical malaria and that folic acid had also been prescribed. Themother did not know this and did not recall being informed sheshould buy these medicines herself. She had paid 200 Ush6 for, asshe expressed it, the paper and the tablets.

Until then, the interview resembled most of the other exit inter-views, but it suddenly took an unexpected turn. The penultimatequestion, as usual, concerned the respondents satisfaction withthe service she had received. Most people answered that they weresatisfied and had received what they came for. This woman gave adifferent answer: I havent seen anything good, she said andlooked down. The last question in the exit interview was an openone about whether the respondent had anything to add, and shedid: The baby was born the 12th of July. After four months Imenstruated for three months, but now I have stopped menstruat-ing, she said. She is trying to tell you that she is pregnant again,my assistant said to me in English. She is trying to tell you that shefears her child is suffering from theri.

Theri is an ailment said to cause a child to whither away if themother becomes pregnant again while still breast-feeding. Areyou worried about this pregnancy? I asked, and for the first timeI got an elaborate reply: I fear that is why the child is like that andgets sick all the time. I couldnt tell the musawo. But then he sent meto you so I decided to tell you. Theri is of great concern to motherswho fail to space their children and who struggle to keep themalive. It is usually not brought up at the health facility, but thewoman decided to tell us about her fear, in all likelihood becausewe were not representatives of the health care system.

Local Idioms of Distress

There is much at stake in peoples lives that is never expressed dur-ing the consultation at the health facility. The above woman wasone of the only ones who used the exit interview to remind us ofthis by referring to one of the local explanations of illness. I spentmuch of the early phases of my fieldwork getting hold of local dis-ease terminology or what I later, inspired by Nichter (1981), startedreferring to as idioms of distress; that is, a range of idioms drawingattention to various aspects of peoples illness experience.


In my first language lesson I learned that measles is called koyo inDhopadhola and that malaria is called musujja, and I soon noticedthat the terms koyo and measles are mutually interchangeable, asare the terms musujja and malaria. Whether people speak Englishor not, they may use either koyo or measles, and sometimes theyjump from one to the other within the same sentence. But it alsosoon became obvious that koyo does not in any way cover biomedi-cally defined measles.

The mother of a seven-year-old boy in the home where I stayedcomplained that he had had musujja every night for several weeks. Iasked if she thought it could be malaria, and she replied, Yes, it ismusujja. I suggested that we go to the hospital together to havehim checked. Next morning, the childobviously very excitedabout a trip in the carwaited outside my house. His mother, hesaid, was in the field uprooting groundnuts. I later explained toher that she needed to accompany her son. Her reply was thatshe did not think she could find time for it. Some weeks later sheexplained: There was no reason to take my son to the hospital.He only had musujja. During the day he was playing, it was onlyat night he was feeling sick, and it was never koyo, it was never veryserious. At the hospital they would have laughed at me comingwith a child that plays every day. This case, together with numer-ous others, taught me that koyo, though normally translated intoEnglish as measles, refers to a wide range of symptoms that are con-sidered to have become so serious that they are life-threatening.While less severe they are referred to as musujja. Koyo is tied to acomplex of believes about bad winds and juogi (see below), butfor the purpose of the present discussion I merely wish to pointto it as an example of an idiom of distress through which peopleexpress a concern that goes beyond that associated with theimmediate symptoms.

Another idiom of distress is false teeth, which refers to a conditionthat is said to be caused by the appearance of false teeth in thegums of infants below the age of teething. It is characterized bylong-term or recurrent diarrhea, vomiting, and refusal to breast-feed. The condition is fatal unless the teeth are removed. Itmay suffice to rub the gums with a herb, but in some cases twoto four incipient canine teeth are extracted from the babys gumswith homemade tools (such as a sharpened bicycle spoke) or evena fingernail. There is general agreement that false teeth is a recentphenomenon that first appeared during the years of political

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instability and civil war. An expert is needed for the removal of theteeth, but false teeth is one of the few childrens diseases that youngmothers are thought to be capable of diagnosing themselves(Mogensen 2000). This is not the case with regard to juok, or juogi.This is a complex notion that I summarize as a force that, for bet-ter or worse, can influence human life and that covers phenomenaotherwise referred to in the literature as ancestors, symbolic pol-lution, witchcraft, and sorcery. Dealing with juok usually requiresjoint action by family members, while the overall responsibility lieswith the head of the family, usually the father-in-law (or husband)of a mother of small children (see Mogensen 2002 for further dis-cussions of juok). These are but a few of the ways in which peoplein the area express their experiences of illness.

The interest in local explanations of illness, often referred to asthe meaning-centered approach, has a long history in medicalanthropology. Among others, Good (1977, 1994) and Kleinman(1980) have inspired many scholars to study how local interpreta-tions of illness give us insight into peoples experience, their con-cerns and fears, the context within which they interpret theirhealth problems, the ways in which they tie their suffering to largersocial issues, and how they attribute meaning to suffering byexplaining not just the how but also the why of sickness(cf. Evans-Pritchard 1937). So why are these idioms of distressnever brought up during consultations in health facilities in easternUganda? Why could the young woman not tell the musawo abouttheri? Do people fear that health workers do not have the time orinterest to listen to their experience of distress? Are people afraidof being laughed at because they know that health workers donot have the same understanding of sickness as they do? Do theyfeel that two incompatible traditions of knowledge are beingbrought into play? My attempt to answer these questions takesme to the exiting patients in the quality-of-care study.

The Absence of Explanations in the Health Unit

The exit interviews started out with biographical information aboutthe patient and (if the patient was a child) the caretaker. We thenwent on to questions about what had brought them to the healthunit, what kind of sickness they had thought they were dealingwith before coming to the unit, what they had told the healthworker, and what the health worker had explained to them.


The answer to the question about what had brought them to thehealth unit was usually a list of symptomsat times a very longlist. The most frequent symptoms mentioned were diarrhea andvomiting (of many different kinds and colors), fever, cough, andchest pain. When asked by the researcher what they had told thehealth worker and what s=he had explained to them, the same listof symptoms was given in response to each query. People did notexpect that they would receive a diagnosis or that they would betold anything different from what they already knew themselves.Some examples of answers that people gave will illustrate this:

. I do not know the sickness, but I can explain the symptoms.

. My child is suffering from fever, cough and chest pain as I told you, butI do not know why it is disturbing the child if that is what you are askingme about now.

. The musawo did not tell anything. He confirmed that it was fever andchest pain and wrote those symptoms and the treatment on the paper.

Even more noteworthy than this lack of interest in a diagnosis isthe consistency with which the respondents expressed the beliefthat they, the patients, and not the health workers, were the oneswho should define the problem:

. I was not told the sickness of the child. He asked me and I told him theproblem.

. They did not tell us what sickness it is. We were the ones whoexplained, like I explained to you.

. He did not say any name of a sickness, but he is not supposed to either.He is supposed to ask: What is the child suffering from? and then I amthe one to tell what he is suffering from. The musawo does not tell youanything. He just writes what medicine to take.

. Now, what do you expect the musawo to tell me? I am the one whoknows what I am suffering from. I am the one who told him and he isthe one who gave me tablets.

Anthropologists have often pointed out that the biomedicalhealth care system builds upon the assumption that health workerscan decode the untrustworthy story of illness experience andidentify authentic disease as biological pathology (Kleinman1995:32). In our study, however, it seems that it was not the healthworkers but, rather, the researchers who expected this to take place.It may be argued that we, through our line of questioning,implicitly assumed that there would be a move from patientsexperience to biomedical diagnoses and that people would be likely

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to have their ideas about sickness adjusted as a result of this. Butour assumption was not confirmed. The patients did not attemptto express their experience of suffering during the consultation:they just mentioned those symptoms that, for the last week or so,had bothered them to the extent that they thought they should dosomething about them. Furthermore, they saw themselves as theones who knew what their sickness was. They did not expect themusawo to come up with any surprising discoveries or new knowl-edge; what they hoped for was treatment. While the respondentswere no doubt intimidated by the overall situation and thus mayhave hesitated to complain, their answers still call for us to reflecton the role of cognitive understanding in clinical interaction.

THE QUEST FOR COGNITIVE UNDERSTANDING

Medical anthropologists have often been concerned with the studyof local disease explanations. Peoples attempts to attribute mean-ing to sickness have been approached through notions such asethno-semantic disease classifications (Frake 1961), semantic net-works (Good 1977), explanatory models (Kleinman 1980), andculture-bound syndromes (Crandon 1983). In most of this work,the focus has been on peoples interpretations rather than the waysin which these are situated within the social context and practices ofeveryday life. Discussions about narratives (Good 1994), local moralworlds (Kleinman 1995), and embodiment (Csordas 1994) are but afew examples of more recent attempts to approach the experienceof suffering as intersubjective and to view meaning as emergingin practice. In much public health research it is, however, stillassumed that cultural explanations and beliefs are preconditionsfor peoples behavior, and anthropology is seen as the disciplinethat can provide cultural translations of local disease explanations.In 1997 Medical Anthropology Quarterly published a special issue onKnowledge and Practice in International Health. In the introduc-tion Stanley Yoder critically discusses the use of anthropologists asexperts who identify local beliefs about illness and as advisors whotell us how to make health messages culturally appropriate and,thereby, assist us in turning belief into knowledge (Yoder 1997).The focus on knowledge and understanding, which was alsoimplicit in our exit interviews (which contained many questionsabout communication and explanations), may likewise be said to


derive from the scientific paradigm permeating public health dis-courses on health behaviora paradigm that views agency aslocated in the mind and cognitive understanding as a preconditionfor practice (Yoder 1997). It may even be argued that the meaningcentered approach in medical anthropology, with its focus onexplanations and interpretations of sickness, is implicitly operatingwithin the same scientific paradigm.

In spite of Yoders call for studies on knowledge-in-action ratherthan studies on beliefs as explanations of behavior, his insightfulintroduction is followed by articles that discuss how illness beliefscan be used as predictors of behavior, how they frame decision-making processes, and how health messages can be made culturallysensitive (e.g., Lane 1997; Vecchiato 1997; Whiteford 1997; Welleret al. 1997). The articles in this issue, like many other attempts tosituate anthropology within public health (e.g. Hahn 1999), illustratethe difficulties we have, once involved in interdisciplinary andapplied work, in carrying our theoretical awareness of the complexrelationship between knowledge and practice into our analysis.

Though clearly our exit interviews fell into the same trap, I sug-gest that, if we take peoples implicit rejection of our line of question-ing seriously, then these interviews provide useful insights into whatit is we miss when we get caught up in this paradigm. The respon-dents remind us that patients in eastern Uganda do not expect toinform the health worker about anything other than their symptomsand that the health worker is not expected to come up with a diag-nosis or any elaborate explanation of their disease. Cognitive under-standing is not the focal point of the interaction between healthworker and patient. What is noteworthy, however, is not only thelack of interest in verbal communication and cognitive understand-ing but also the assertiveness with which the respondents expressedthis view and emphasized their own role in defining their problems.

What we learn from these exit interviews is, of course, not whatactually happened during the consultation but, rather, what thepatient remembered happened. We do know, from observation,that health workers rarely initiated any communication beyondasking What is the problem? or What is the sickness of thechild? However, the patients view that they were the ones defin-ing the problem and that the health workers did not communicateanything new may not correspond to the health workers experi-ence of the interaction. As Burghart (1996) points out, inspired byHeidegger, the dialogue begins not with the speaker but with the

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listener, and the addressee may not understand that she has notunderstood the addressers message. Thus a move from symptomto diagnosis may have taken place more commonly than thepatients recalled, and explanations may have been given withoutthe patients taking note of them. Still, what we learn from theiraccounts is that they see their role in defining the problem and mak-ing the health worker prescribe medicine as being more importantthan an exchange of knowledge between patient and health worker.

Their assertiveness on this point stood in remarkable contrast tothe subdued behavior we observed during the clinical encounters,and this suggested that people were operating according to a logicthat had not been apparent to us. We may succeed in rendering thislogic visible by turning to Bourdieu (1990) and other theorists con-cerned with the logic of practice.

THE LOGIC OF PRACTICE

A common response of people asked to evaluate a visit to a healthunit was to state: I got medicine so I am satisfied. But it is notonly the desire for tablets that makes people come to the healthunit. Tablets can be bought on the market or in the many drugshops, sometimes for less than the cost of user fees associated withthe health unit. There are other reasons for choosing the publichealth facilities. Whereas exiting patients showed little interest inverbal communication, they repeatedly pointed out the importanceof the examination and the writing on the paper.

Examinationthough it is often very limitedis expected andappreciated. It is noticed when the health worker touches the bodyor puts the pen (i.e., the thermometer) under the armpit, looks foranemia by examining the eyes, or checks for dehydration by pinchingthe skin to see how quickly it smoothes itself out. People know whatthey are suffering from, but examination, machines, and instruments(thermometers, stethoscopes, microscopes) help the health workersidentify the physical entity, which the medicine, in turn, is supposedto work on. In private drug shops you can buy the medicine, activelyparticipate in the decision about what and how much to buy, and evenbe treated in a friendly manner. But the problem, people add, is thatthere they do not do the examination.

The result of the examination is written on the paper, the Medi-cal Form Five. This piece of paper is looked upon as a powerful


element of the treatment, almost as important as the medicine itself.There is rarely any attempt to read what is written (which is diffi-cult even if you are literate). The writing on the paper is thought ofas a secret internal code that is used to pass on a message from onemusawo to another (e.g., from the consulting health worker to thedispenser or pharmacist), and people do not expect to understandit. The paper is a powerful symbol of the knowledge of the healthworker: He had already written on the paper, so there was nothingto ask about, one person said upon leaving the health unit,thereby, like van der Geest et al. (1996:158161), suggesting that fill-ing out a prescription is a social act that demonstrates the concerns,skills, and authority of the prescriber.

It is not so much the paper (papila) as it is the act of writing (ndiko)that represents the significance of the prescription. The medicalform is carefully kept until the drugs have been received or bought.Some people keep them even longer and may use them again if thesame symptoms return. Sometimes it is wrapped around theremains of the money and the small brown envelopes containingthe medicine. Usually, however, it is soon lost, as are most materialthings. Similar observations were made by M. Whyte and Higenyi(1997), who investigated records kept by mourning societies in theTororo District. These records contain information about whoshowed up at what funeral, who contributed, what they contributed,and how much they contributed. Even though these records play amajor role during the burial, when the mourning period was overthey would often simply deteriorate and=or be used for otherpurposes. Funeral writings, according to Whyte and Higenyi, are,with the exception of the inscription on a cement grave, not aboutproducing data; rather, the written record is simply a by-productof the process and is, in itself, of little interest to people. Writing isused not because it is useful but because the act of writing has mean-ing. At both the health unit and the mourning society it is the act asmuch as the facts on the paper that is of significance to people.

I suggest that the lack of request for an explanation, the impor-tance of the examination, and the writing on the paper all pointto an emphasis on doing rather than on talking during the clinicalencounter. When focusing on explanations and diagnoses, as wedid with our line of questioning in the exit interviews and as iscommonly done in medical anthropology and public health, wemay be confusing the spectators point of view with the actorspoint of view and, in Bourdieus (1990:82) words, be looking for

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answers to spectators questions that practice never asks because ithas no need to ask them. People do need information about healthand sickness, but while in the midst of suffering the questions theyask themselves are different from those they ask at other momentsin their life. The questions they ask are practical rather than theor-etical, and the type of explanation that the patient remembered hav-ing been given during the clinical encounter always concernedwhere to go and what to do.

For the patients, the purpose of the visit to the health unit is tomake the health workers engage in examining and writing, withthe hope that this will result in injections and tablets. However, thisis not a simple process: one has to have a feel for the game, knowhow to pass the ball to the other players (i.e., to find the paththrough the health unit). One has to know how to position oneselfin the field, both socially and temporally. As Bourdieu (1990:81)says, our actions are not only unfolding in time, they are also play-ing strategically with time and especially with tempo. Practiceunfolds in time, Bourdieu (1990:81) emphasizes,

and it has all the correlative properties, such as irreversibility, that synchro-nization destroys. Its temporal structure, that is, its rhythm, its tempo, andabove all its directionality, is constitutive of its meaning. As with music,any manipulation of this structure, even a simple change in tempo, eitheracceleration or slowing down, subjects it to a destructuration that is irre-ducible to a simple change in an axis of reference. In short, because it isentirely immersed in the current of time, practice is inseparable from tem-porality, not only because it is played out in time, but also because it playsstrategically with time and especially with tempo (1990:81).

The same actwhether it is giving, reciprocating, offering onesservice, paying a visit, throwing a ball, or drawing attention to asymptomcan have completely different meanings at differenttimes. Practice therefore requires an active and creative relationshipto the world, and much ingenuity is needed to select appropriateresponses from practical repertoires (80ff). Thus it should not besurprising that maneuvering in the time and space of a Ugandanhealth unit presents a significant challenge to most patients.

Time and Space of the Health Unit

A woman who had moved into the house where I stayed in the vil-lage had been to the out-patient department of the hospital with her


6-month-old son. She had been told he had pneumonia and shouldbe admitted, but she decided to take him back home. I encouragedher to have him admitted and offered to pay the cost, assuming thiswas her main concern. She continued to be reluctant to go, spent theday under a tree having her hair done, and got her mother anduncles wives involved in a fight over whether she should savethe money for other purposes and not waste her time at the hospi-tal. Finally, by the end of the day, she left. Months later, when shehad become my confidante, she told me that it was neither themoney nor the waste of time that had made her reluctant to go tothe hospital. She feared going there because:

All the other people there just talk to each other and laugh and they look atyou and think you are strange. And also, even if you had given me moneyfor the fees and the medicine, then everybody could see that I was poor.When they see that you do not even come with your own flask for porridgeand just a sheet, but not a blanket, then they just think that you are poorand ignorant and do not understand anything, and they will treat you assomebody primitive. But after you had visited me in the hospital itimproved a bit, and the nurses became very polite to me. They thought thatsince a muzungu [white person] visited me I must be somehow rich andeducated.

Visiting a health unit is part of everyday life for most people, but attimes it is also an overwhelming experience. I came across people inthe villages who had never had the courage to turn up at a healthfacility. It can be difficult to find out where to start, where the lineis, where to go next, who to ask, how to respond, how much to payfor what, where to get the medicine, and so on. Knowing some-bodyanybodywhether it is the gatekeeper or the anthropol-ogist, may help one move in the right direction. Being able topresent oneself as a respectable and knowledgeable person, i.e.somebody who is capable of doing all those things correctly, is ofgreat importance.

Some of the things you have to know as a patient (or relativeof a sick child) are how to show respect and to acknowledge theauthority of the health worker by greeting her=him politely, talkingsoftly, and listing the symptoms of the patient. You have to pay theright amount at the right time. In exchange for this you may gainaccess to the knowledge and skill of the health worker in the formof an examination and a paper upon which she=he has written.And, if lucky, you get drugs.

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But there are many more things you need to know. You need toknow the tempo of social interaction. People may be at the healthfacility for several hours before getting through registration, consul-tation, and dispensing, even though each of these may require onlya few minutes. When interacting with a health worker, people haveto provide short, precise answers to the questions asked. From thequality-of-care study we know that people generally say that theycame to the health unit to seek treatment for symptoms that startedone to seven days previously. The treatment provided is sympto-matic and is given for a three-to-five-day period. Improvement isexpected to occur within this period, and if it does not, then peoplestart considering what to do next. When patients were asked whattreatments they had been given before coming to the health unit,they referred to whatever treatment they had received within thelast week. Many of them, however, were likely to have had othertreatments within different tempos. This was particularly true ofchildren, who were frequently sick and whose caretakers werelikely to have already tended to the symptoms within a differenttime frame (e.g., by rubbing the gums to treat false teeth or slaugh-tering a chicken to treat juogi). However, it is not considered appro-priate or relevant to refer to this in the health unit, where actionsare played out in a different tempo than the one pertaining to falseteeth and juogi.

User fees also provide insight into the significance of tempo.During the years of instability, when informal payment was normalin all health facilities in Uganda, a visit to a health unit was alwaysaccompanied by the insecurity of not knowing what one would endup paying. There are many horrific stories about treatment havingbeen delayed until the last moment, or not given at all, due to thehealth workers attempts to get as much money as possible out ofthe family. Patients would be asked Did you bring you brother(i.e., a relative with money) or Did you bring me sugar or salt?(i.e., money). Often, however, the health workers would notdirectly state how much they wanted, and the exchange processwould stretch out in time. Informal payment was greatly reduced,though not fully removed, when user fees were introduced in the1990s. But the introduction of formal fees brought with it numerouscomplaints as people assumed (often correctly) that this would sim-ply add to the cost of health care. Thus we expected people to bedissatisfied with the fees they had paid, but this was not usuallythe case.


A partial explanation for this may be found in Bourdieus dis-cussion of the temporality of gift exchange. According to Bourdieu(1990:112), an exchange that involves money telescopes a trans-action into an instant, while an exchange that involves giftsstretches out in time (see Mauss 1966). The giving of money, likethe giving of other kinds of gifts, calls for a counter-gift, but ithas the potential to inhibit the development of prolonged socialrelations because once the debt is paid (i.e., the gift is returned)the tie is dissolved. While payment was informal, by setting theterms for the size of the counter-gift and the time of its paymenthealth workers created ties of dependency with their patients, andthis was not to the latters advantage. With the introduction of for-malized fees came a tempo that limited the possibilities of depen-dency and returned to the patients a sense of agency. Whenpeople in the quality-of-care study expressed dissatisfaction withthe payment of fees, they always did so when there was uncertaintyabout how much to pay or when they had not been given drugs.Complaints rarely concerned the actual amount (between 300 and1000 Ush) charged, and this may support the argument of Reeler(1996) and van der Geest (1992), who contend that formalized feeshave the potential to empower patients.

Hence, in the health unit, phenomena judged to be significant tothe sickness (e.g., cause, symptoms, treatment, and improvement)are telescoped into a time frame of about a week. The exchangebetween the patient and the health worker is particularly com-pressed and lasts no more than a few minutes. As has been dis-cussed, the formalization of fees helps to limit the healthworker=patient relationship to this moment in time. People knowthat by accepting this time frame they will gain access to the knowl-edge, competence, and experience of health workers as well as tothe writing, the examination, and the drugs. Some people are betterthan others at finding the right person to ask about where to go, atpresenting the sickness within the right time frame, and at present-ing themselves respectfully. Katehoire (1998) shows that educatedwomen are better at all of this, not necessarily because they are lit-erate or more knowledgeable about sickness than others, butbecause the confidence they derived from having been withinanother institutional setting (i.e., the school) has set them in goodstead for dealing with the space and time requirements ofthe health unit. It seems that it is the ability to conduct oneselfappropriately within the health unit, rather than the extent to which

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cognitive understanding or a verbal expression of suffering takesplace, that shapes peoples experience of the clinical encounter.7

A TEMPORALLY EMBEDDED PROCESS OFSOCIAL ENGAGEMENT

A dichotomy between knowledge and practice may seem to be thecorollary of my claim that practiceand not cognitive under-standingis what is at stake in clinical interaction, while illnessexplanations and expressions of experience occur through idiomsof distress that emerge in social interactions outside the health unit.The point, however, is not that people act a certain way in thehealth unit and then begin to reflect upon this once they leavebut, rather, that we cannot base our analysis on a dichotomybetween knowledge and action, reflection and practice.

The notion of social agency, which has come to play a prominentrole in recent anthropological discussions, is an attempt to getbeyond such dichotomies, to take as our starting point reflectiveand acting bodies, and to understand words not as representationsbut as thoughts in action (Hastrup 1995). Agency is understood as atemporally embedded process of social engagement through whichwe respond to the various contexts in which we live. We are allsocial agents situated within a range of different structural contextsto which we have to respond and that provide both constraints andpossibilities for action. These contexts are themselves temporal aswell as relational fields, according to Emirbayer and Mische(1998), or time-spaces, according to Hastrup (2004). We may say thatone such temporal-relational field is the health unit, a space that hascertain criteria for social interaction and for the use of time. We mayalso talk about other health care settings as particular temporal-relational fields (e.g., the space associated with a jathieth [diviner],the drug shops, or the domestic sphere). With this in mind, I onceagain return to the local idioms of distress presented earlier, or, rather,to the logic of the practice of health care in the domestic sphere.

Time and Space of the Domestic Sphere

During my fieldwork I became acquainted with a family consistingof the parents, their three sons, their four wives, and their children.One of the daughters-in-law, Achieng, a 20-year-old woman, had no


living children. She had given birth twice but lost both infants whenthey were five and six months old, respectively. Achieng had beenmarried to her husband for more than two years, but his familyhad not yet initiated bridewealth negotiations with her family. Shelived with his parents and brothers, but with no bridewealth paidand no living children her position in the family was precarious.In the event of conflicts within the family, she risked being thrownout. One day she came to see me to talk about her problems. She toldme that, when people had been quarreling at home, she had heardthem say that it is juogi that disturb her children. The juogi of the clanhad approached the father-in-law and asked him to build a shrinefor the ancestors of the clan. However, Achieng said, he takes itin a Christian manner, and refuses to take up this responsibility.According to him, her childrens deaths had nothing to do withjuogi; instead, he argued that Achieng was a careless mother whodid not seek treatment for her children in time. This was not the case,she insisted; she had sought treatment as early as she could. And tosubstantiate this claim, she gave me a long and detailed descriptionof how she had tried to save them.

The first one had diarrhea for three days and then died. Achiengtook her to the health center on the second day. She had to wait forher husband to return from town to give her money to go there, soshe could not go on the first day. Also, she did not think it was soserious on the first day, but the next day she started fearing it waskoyo. She got some tablets at the health center, and she also tried tomake the child drink a lot of milk and water, which of course shehad boiled. But still the girl died. The second child also died veryquickly. He was vomiting badly, so Achieng went to the health cen-ter in the morning to get medicine. By the end of the day there wasstill no change, so she went there again, but the health worker toldher that, since the medicine did not seem to work, she should gohome and find someone who could help her sort out this familymatter. The child died overnight. Achieng and her husband hadbeen to see a diviner, who had confirmed that, as long as the fatherof the husband did not agree to celebrate the juogi, the problemwould remain in the family. Since Achieng was now pregnant againhe had given them medicine to protect her unborn child untilsomething was done about the juogi.

While staying in the area, I sometimes heard neighbors mention-ing that the father-in-law did not like Achieng, which was why theyhave not married her yet (i.e., had not started the bridewealth

228 H. O. Mogensen

negotiations). Achieng, they said, was somewhat educated (fiveyears of primary school), and her father-in-law found her stubbornand impolite. Her husband had not been a respectful son either.He once stole something from someone, and his father had had topay a fine of several cows, which was another reason why he wasunwilling to pay bridewealth for Achieng.

The story of Achieng and her children, to which many moredetails could be added, illustrates how negotiations over diagnosesare a temporally embedded process of social engagement. Thefather-in-law continually refused to acknowledge the responsibilityof the ancestors (juogi) with regard to his grandchildrens sicknessand death, as he refused to acknowledge the wedding of his sonto his grandchildrens mother. He may be seen as attempting tomake time work for him by not allowing anything to happen. Hetried to put things off by sending his daughter-in-law to the healthcenter. She tried to speed up events by emphasizing her regular useof hospital medicine and its lack of results. In one situation hos-pital medicine may be used to speed things up or redirect them, inanother it may be used to put things off. Everything depends ontiming, occasion, and the social actors position in the field. A fatherwho has not yet paid bridewealth for the mother of his childrenmay neutralize time by providing drugs to cool the effects of sick-ness while he saves up enough money to be able to finish thejuogi. A mother who is desperately worried about her childrenmay ask for drugs over short intervals of time in order to communi-cate to her relatives the need for a tempo other than the one thatthey are employing. Or she may slow things down and take atten-tion away from her pregnancy and its effect on the child by seekinghospital medicine, like the woman fearing theri. People moveback and forth between different diagnoses because each calls fordifferent responses and responsibilities. Again, the same act canhave completely different meanings at different times, whether itis giving, reciprocating, swallowing a pill, treating false teeth or theri,building a shrine for juogi, or visiting a health center. It is a questionof timing and of occasion.

I suggest that the idioms of distress discussed above can provideus with insight into peoples attempts to make things happen in time-spaces outside of the health unit. Reducing these idioms to explana-tory models would be to confuse the spectators view with theparticipants view. They are not onlyand maybe not evenprimarilyused to express distress and to give meaning to suffering:


they are also used to act upon the world and upon suffering. In otherwords, I suggest that these idioms of distress have temporal struc-tures that play out against each other in relational fields. They linkthe past, present, and future in a certain way and may, therefore,be thought of as plots creating a whole out of a succession of events.These idioms of distress combine heterogeneous components, cir-cumstances, and agents in different ways and thereby merge a rangeof factors (e.g., infidelity, parents-in-law, poverty, pregnancy, cough,diarrhea, hunger, etc.) into a single story with a beginning, a middle,and an end (cf. Ricoeur 1991). In Mattinglys (1998) words, they areexamples of how emplotment takes place not only when we tell stor-ies about life but also when we act. Being a social agent involves try-ing to make certain things happen, trying to bring about desirableendings, trying to search for possibilities that lead in hopeful direc-tions (Mattingly 1994:813). Through these idioms of distress, I sug-gest, we get insight into how people make these efforts in easternUganda when their health is at stake.

False teeth, theri, and juogi suggest different tempos with smalleror larger intervals of time between the events judged to be signifi-cant and, hence, different suggestions as to who is responsible.They draw attention to the diarrhea of the previous weeks (whichotherwise would have been forgotten) or to the infidelity of the hus-band, the insufficiency of food, or the need for child spacing. Theysuggest not only what action should be taken but also by whom andhow fast. Koyo, for instance, draws attention to the need for quickaction. The interpretation of the fever of this morning must be pro-jected into a future, which becomes the present of today, hencespeeding things up and requiring the immediate involvement ofsomeone with money who can take the patient to the hospital. Juogi,on the other hand, connects childrens sickness with family eventsof long ago, which otherwise would have been forgotten but thatnow draw attention to irresponsible actions within the family.The tempo of juogi is different from that of koyo. In the end, the cer-emony for juogi may never be performed, or at least not as firstintended. But postponement involves an interval of time thatshould not be confused with an inert gap (cf. Bourdieu 1990:106).This is because postponement is time that potentially functions torework social relations and to negotiate the responsibilities of socialactors (like Achiengs father-in-law, who questioned her position inthe family by refusing to link her childrens death to family matters[i.e., juogi]).

230 H. O. Mogensen

De Certeau (1984:3536) makes a distinction between strategiesand tactics, suggesting that the former involve the creation of anautonomous space while the latter involve a clever utilization oftime within the space of others. I suggest that the search for healthcare must be seen as exactly that, as an attempt to utilize timewithin the limitations of the space in which health care is provided.This maneuverability of time is crucial for an understanding of theactions people takeor do not take. A child may be seriously sick,and, as an observer, you may wonder why the mother does not doanything. But she herself may feel that she has done a lot of things:informed her husband, been polite to her mother-in-law, given thechild syrup regularly; and saved tablets from her last visit to thehealth center and given the child two per week; rubbed the childsgums for false teeth; and=or requested her husband to stay awayfrom his lover while she is still breastfeeding.

The point is that the mother connects events in her life and theactions she has taken with a time-space other than the one favoredby the health worker. She is well aware that the time-space of thehealth unit is not the time-space of the domestic sphere. Interactionsat the health unit take place in a different tempo; hence koyo andjuogi make no sense within the clinical interaction. The reason shedoes not bring them up cannot be reduced to a simple fear thatthe health worker has a different theoretical understanding of sick-ness from hers. It is also a question of her being aware that acting inthe time-space of the health unit requires other ways of playingwith timeways that will result in a desirable response frompeople in that particular relational field. She does not simply sup-press her suffering or hide her own explanatory models; rather,she takes upon herself the complicated task of playing the gamerequired by the temporal-relational field of the health unit.

CONCLUSION

When patients leaving health units in eastern Uganda answer ourquestions, they do so not as spectators distanced from their suffer-ing but, rather, as participants commenting upon their sense oftheir ability to act appropriately within the time-space of the healthunit. The significant differences between the health unit and thedomestic sphere do not concern different traditions of knowledgeor the fact that one leaves room for communication and explanation


while the other does not. Local idioms of distress are not simplyexplanations of sickness that are unacceptable in the health unit:they are ways of acting in the world. The difference between thedomestic sphere and the health unit is that they are different rela-tional and temporal fields. And social actors have to obtain a feelfor the game required in each field (i.e., they have to learn howto act in each so as to evoke appropriate responses). In the momentof suffering, what matters is the possibility of acting upon this suf-fering by making others (health workers or relatives) re-act in cer-tain ways. And anthropology, with its ability to obtain insightinto social interaction and the practices of everyday life as it unfoldsin time, should therefore contribute to a furthering of our under-standing of the practical experiences of patients rather than merelyfunctioning as a translator of cultural beliefs about illness.

NOTES

1. My research was carried out in association with a research training project knownas Tororo Community Health (TORCH), which is financed by the Danish Inter-national Development Agencys Program for the Enhancement of ResearchCapacity (ENRECA). The institutional collaborators of TORCH are the ChildHealth and Development Centre, Makerere University; the Institute of Anthro-pology, University of Copenhagen; and the Department of Epidemiology andSocial Medicine, University of Aarhus, Denmark. The quality-of-care study wascarried out by members of the TORCH team, Nathan Nshakira being the principalinvestigator. I alone am responsible for the particular interpretation of the materialpresented here. My long-term fieldwork was financed by the Danish ResearchAcademy and the Danish Council for Development Research.

I am deeply grateful to Richard Odoi and his family as well as to Susan andMichael Whyte for their never-ceasing support and their interest in sharingideas. And I thank the late Frances Kamuge, my research assistant, from whosefriendship, vast experience with the Ugandan health care system, and brightintellect I benefited immensely. I also want to thank Anne Katehoire, LotteMeinert, Tine Tjrnhj-Thomsen, Marie Larsen Ryberg, and the students in myspring 2005 medical anthropology course for their comments on earlier versionsof this article.

2. The JopAdhola are one of four ethnic groups inhabiting the two districts. Theycall themselves a Luo-people, and their language (Dhopadhola) is closely relatedto the language of the Luo of Western Kenya. In Uganda a mosaic of Bantu groupsand the Teso surrounds the JopAdhola, of whom there are said to be about150,000. In the course of my fieldwork I obtained a rudimentary knowledge ofthe language, but I continued working with someone who could also assist withtranslations.

3. TORCH has initiated research to monitor this development, but little is as yetknown about the medical and social impact of antiretroviral treatment.

232 H. O. Mogensen

4. The supply of drugs was also a major problem until UNICEF instituted anessential drugs management program in 1981. Since the mid-1980s it has suppliedkits of medicine to all rural and urban outpatient facilities, many of whichhave, however, found their way into the fast-developing private market for healthcare.

5. I am not aware that research has as yet been carried out on the consequences ofthe abolishment of fees or on the extent to which official fees have been replacedby a return to informal payment. Preliminary observations indicate that manypeople are not even aware that fees have been abolished since many things stillhave to be paid for (notebooks for prescriptions, syringes, food when admitted,possibly informal fees, etc.).

6. At the time of the study one U.S. dollar corresponded to about 1,000 Ugandanshillings (Ush).

7. Small things could be done to assist people in negotiating the health unit (e.g.,clearly advertising fees, putting lines on the floor to direct people to the rightrooms in the right order, providing practical illustrations of how to take medicine,employing staff to guide people, etc.).

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mogensen, h - finding a path through the health unit-1

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