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Medical Anthropology, 24:209236, 2005

Copyright # Taylor & Francis Inc.


ISSN: 0145-9740 print/1545-5882 online
DOI: 10.1080/01459740500182659

Finding a Path through the


Health Unit: Practical Experience
of Ugandan Patients1
Hanne O. Mogensen
Finding ones way through a health facility is not necessarily an easy task for
Ugandan patients. Our understanding of how people succeed in doing so, and
of the obstacles they encounter on their way, is incomplete if we focus only on
the cognitive level of the clinical encounter. Much research in public health
and medical anthropology implicitly works with the notion that agency is
located in the mind and that cognitive understanding is a precondition for
practice. Based on material from eastern Uganda, this article explores the
practical experience of Ugandan patients and their relatives and reflects upon
the ways in which this notion of agency has often caused us to confuse the
spectators point of view with the actors point of view. Thus, as Pierre Bourdieu has argued, we are made to look for answers to questions that practice
never 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 to
either. He is supposed to ask: What is the child suffering from? and then I
am 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 government
health facility in eastern Uganda.

HANNE O. MOGENSEN has carried out research on medical anthropology and international
health in Zambia, Uganda, and Vietnam, focusing on child health, reproductive health, and
AIDS. She works at the Institute of Anthropology, University of Copenhagen, Frederiksholms
Kanal 4, DK-1220 Copenhagen K Denmark. Phone: 45 35 32 34 54; Fax: 45 35 32 34 65;
E-mail: Hanne.Mogensen@anthro.ku.dk

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The Ugandan mother cited above was less interested in the explanation of her childs sickness than in the writing of the health
worker. She is not alone in expressing this preference for aspects
of the consultation other than the verbal exchanges. The consultation room in a Ugandan health facility is sometimes referred to
as 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 a
private drug seller it is, among other things, because there at least
they do the writing. Understanding what is implied by statements
like these requires us to recognize that meaning emerges from practices such as writing, whether the content of that writing is comprehensible and useful or not. The attention paid by Ugandan patients
to the act of writing suggests that we should consider not only their
theoretical but also their practical knowledge (Bourdieu 1990) when
trying to understand how they find their way through the health
care system and how they evaluate the health care options available
to them. In this article I explore the practical experience of Ugandan
patients in order to reflect on the role of cognitive understanding in
health care-seeking behavior.

THE STUDY
I have been doing research among the JopAdhola in the Tororo
District of eastern Uganda since 1996. My first long-term fieldwork
focused on mothers interpretations of their childrens symptoms,
their possibilities for action, and their health care choices. Since
then I have returned to the area on a regular basis, carrying out
studies on various health-related issues. Over the years I have been
living with two different families, and I have used their homes as a
starting point for interacting with people in the neighboring
villages. While the members of one family have dispersed and disappeared from the area (largely due to AIDS), I have developed
long-term relationships with members of the other family, some
of whom live in the rural areas, some in the provincial town, and
some in the capital. I have spent much time accompanying people
in their health care-seeking behavior and listening to their evaluations of what has been offered them. I have accompanied them
on regular visits to public health units, at times suggested and paid
for 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. I
have also accompanied them to diviners as they attempted to learn
why the luck of an individual or a family had disappeared and sickness and misfortune had started to ravage their lives. I have followed their concerns, uncertainties, and ongoing evaluations as
they searched for explanations, for paths to follow, and for actions
to take.
My research is associated with a larger health research training
project (TORCH), which, since 1994, has carried out interdisciplinary research in the districts of Tororo and Busia in southeastern
Uganda concerning the interface between the community and the
health care system. One of the collaborative studies that emerged
from this project was a quality-of-care study carried out in 1996,
which I draw upon in this article. Part of our study involved
observing the structure of the public facilities (buildings and equipment), the technical practices of the health workers, and the clinical
encounter. We also explored quality of care from the point of view
of planners, providers, and patients through focus group discussions and open-ended interviews. In addition, we conducted
semi-structured interviews with 160 people as they left the health
unit. Some of these people were themselves patients, but most were
relatives (usually mothers) of children (Nshakira et al. 1996). I conducted a large number of the exit interviews together with my
research assistant, and since I knew some of the health workers
and patients I later did follow-up interviews with them.
What I learned from the exit interviews was in many ways surprising. People expressed a lack of interest in explanations, a sense
of being in control during the consultation, and satisfaction with the
service they had received, which seemed to be in contrast with the
many complaints normally uttered about the public health care system. Exit interviews, of course, provide a particular kind of information, and they need to be interpreted with caution. The
respondents were people in need who had just received help and
who were being asked to evaluate that help while still present at
the health facility. It can be expected that, in the midst of suffering,
one is grateful that action has at least been taken, whereas later one
may reflect on the shortcomings of that action. Furthermore, people
leaving the health facility can be expected to feel more intimidated
than people interviewed at a distance in time and space. The point,
however, of referring to these exit interviews is not to take peoples
statements at face value but, rather, to follow up on reflections

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sparked by them. The answers provided by these patients and their


relatives helped me to see aspects of peoples health care-seeking
behavior that I had previously overlooked.

THE SETTING
The districts of Tororo and Busia border Kenya to the east and Lake
Victoria to the south. They are densely populated, and even rural
areas at times seem semi-urban. Agriculture is the major economic
activity and millet the staple food. Tororo town is a busy trading
center on the railway line between Kampala and Nairobi, and Busia
is an equally busy border town further to the south. Several other
smaller trading centers are found in the rural areas.2
Morbidity is generally high, particularly so when it comes to
small children. The national under-five-mortality rate is 152 per
1,000 live births (MOH 2002:1), and, with a birth rate of almost eight
children per woman, most women have lost at least one child.
About 40 percent of patients brought to outpatient departments
in government health centers in Tororo District are children under
five (16). Diseases most commonly diagnosed are malaria (40 percent of new cases at government units), respiratory infections
(20 percent), diarrhea and worms (13 percent). This part of the
country, like the rest of Uganda, is severely affected by the AIDS
epidemic. At the time of the study on which the present discussion
is based, the health care system had only symptomatic treatment to
offer to AIDS patients; therefore, AIDS was usually not referred to
in the clinical interaction. This situation is presently changing due
to the increasing availability of antiretroviral treatment (Whyte
et al. 2004).3
Prior to the 1970s Uganda was said to have one of the best public
health care systems in Sub-Saharan Africa (Odoi Adome et al.
1996:9). However, the political turmoil and civil strife of the 1970s
and 1980s resulted in serious neglect and much deterioration
(Dodge 1987). The health administration was weakened and functioned only sporadically, salaries were irregular and failed to keep
pace with inflation. All of this contributed to low morale among
health workers. An elaborate system of informal payments
developed alongside the public health care system (Whyte 1992).4
After Museveni came to power in 1986 the government health system 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 public


sector that focused on liberalization and decentralization (Jeppsson
and Okuonzi 2000). However, in 2000 there was, according to
Jeppsson and Okuonzi, no indication that this reform had resulted
in improvements (285). Morbidity and mortality remain high, and
service delivery is still suffering from many shortcomings. Salaries
continue to be meager and are often delayed, and the morale of
health workers remains low, as does public satisfaction with the
health care system. User fees were introduced in the early 1990s
as part of the structural adjustment program. The actual cost recovery was, as elsewhere in Africa, limited (Hansen 1995), but it did
seem to considerably reduce incidences of informal payment. Still,
complaints about fees were incessant, and fees were officially abolished in 2001 as a result of one of Musevenis election campaign
promises.5
In Tororo District 44 percent of the population lives within a fivekilometer radius of a government facility; however, these facilities
differ considerably in size and service provision. They range from
subdispensaries in roadside mud huts run by nurse aides to hospitals with both in- and out-patient departments and medical doctors.
While lab facilities, X-ray machines, and operating theaters are
appreciated, large units are also perceived as intimidating and
people often refer to the difficulties of finding out what to do and
where to go in these larger facilities.
In the 1980s private clinics, medicine vendors, and drug shops
started appearing everywhere in urban as well as in rural areas,
and today, as Whyte (1992:165) states, they exist in intimate articulation with the state system and donor-supported programs. In a
number of publications she deals with the explosive growth of private biomedical care and its co-existence and creative co-operation
with the state system (e.g., Whyte 1991, 1992, 1997). Many government health workers divide their time between their jobs in the
public sector and their private clinics or drugstores. Many of these
drugstores and clinics are run by people with very little or no training, though the actual owner may be a nurse or a medical doctor.
Musawo means health worker in all local languages, and it is
used to refer to all kinds of health workers (nurse aides, midwives,
nurses, medical assistants, and medical doctors). Often patients are
not aware of the distinction between the different levels of health
workers. Dwaliro means health facility in all local languages,
whether one is referring to a small dispensary or a hospital. I use

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these terms to remain in keeping with the interviewees, who did


not usually indicate the size of the health unit or the rank of the
health worker.
In the course of a sickness episode people move back and forth
between self-medicating with herbs and pharmaceuticals; visiting
local herbalists, diviners, and other kinds of specialists; visiting
public health facilities of difference sizes; and visiting private
clinics and pharmacies in the trading centers. With regard to small
children, who are frequently sick on and off for extended periods,
health care-seeking behavior is an ongoing process. One may seek
treatment for diarrhea at the health unit one day and then interpret
diarrhea as part of a larger constellation of symptoms that one
chooses to discuss with the diviner the next day. No sharp distinction is made between symptoms treated with biomedicine and
symptoms treated in other ways, and the public health care system
continues, in spite of its turbulent history and many shortcomings,
to play an important role in the ongoing process of seeking health
care. Alternative health care optionsbiomedical and otherare
available within reasonable distance and for a realistic cost. But a
visit to a government facility continues to be a central step in the
health-seeking process.

EXPLAINING ILLNESS
One of the respondents in the exit interviews was a 19-year-old
woman, the mother of a seven-month-old girl. She was shy and
gave only brief answers. When asked what had brought her to
the 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 four
days 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 bring
her back tomorrow. She had understood everything, she said, and
she had had nothing further to ask. When asked what treatment she
had received for her child, she showed us some tablets while carefully explaining that she had been given two tablets of chloroquine
to be broken in half and given to her daughter once a day, and 20
tablets 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 was
supposed to have another the following day. On the medical form
it was written that the girl suffered from respiratory infection and
clinical malaria and that folic acid had also been prescribed. The
mother did not know this and did not recall being informed she
should buy these medicines herself. She had paid 200 Ush6 for, as
she expressed it, the paper and the tablets.
Until then, the interview resembled most of the other exit interviews, but it suddenly took an unexpected turn. The penultimate
question, as usual, concerned the respondents satisfaction with
the service she had received. Most people answered that they were
satisfied and had received what they came for. This woman gave a
different answer: I havent seen anything good, she said and
looked down. The last question in the exit interview was an open
one about whether the respondent had anything to add, and she
did: The baby was born the 12th of July. After four months I
menstruated for three months, but now I have stopped menstruating, 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 she
fears her child is suffering from theri.
Theri is an ailment said to cause a child to whither away if the
mother becomes pregnant again while still breast-feeding. Are
you worried about this pregnancy? I asked, and for the first time
I got an elaborate reply: I fear that is why the child is like that and
gets sick all the time. I couldnt tell the musawo. But then he sent me
to you so I decided to tell you. Theri is of great concern to mothers
who fail to space their children and who struggle to keep them
alive. It is usually not brought up at the health facility, but the
woman decided to tell us about her fear, in all likelihood because
we were not representatives of the health care system.

Local Idioms of Distress


There is much at stake in peoples lives that is never expressed during the consultation at the health facility. The above woman was
one of the only ones who used the exit interview to remind us of
this by referring to one of the local explanations of illness. I spent
much of the early phases of my fieldwork getting hold of local disease terminology or what I later, inspired by Nichter (1981), started
referring to as idioms of distress; that is, a range of idioms drawing
attention to various aspects of peoples illness experience.

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In my first language lesson I learned that measles is called koyo in


Dhopadhola and that malaria is called musujja, and I soon noticed
that the terms koyo and measles are mutually interchangeable, as
are the terms musujja and malaria. Whether people speak English
or not, they may use either koyo or measles, and sometimes they
jump from one to the other within the same sentence. But it also
soon became obvious that koyo does not in any way cover biomedically defined measles.
The mother of a seven-year-old boy in the home where I stayed
complained that he had had musujja every night for several weeks. I
asked if she thought it could be malaria, and she replied, Yes, it is
musujja. I suggested that we go to the hospital together to have
him checked. Next morning, the childobviously very excited
about a trip in the carwaited outside my house. His mother, he
said, was in the field uprooting groundnuts. I later explained to
her that she needed to accompany her son. Her reply was that
she did not think she could find time for it. Some weeks later she
explained: There was no reason to take my son to the hospital.
He only had musujja. During the day he was playing, it was only
at night he was feeling sick, and it was never koyo, it was never very
serious. At the hospital they would have laughed at me coming
with a child that plays every day. This case, together with numerous others, taught me that koyo, though normally translated into
English as measles, refers to a wide range of symptoms that are considered to have become so serious that they are life-threatening.
While less severe they are referred to as musujja. Koyo is tied to a
complex of believes about bad winds and juogi (see below), but
for the purpose of the present discussion I merely wish to point
to it as an example of an idiom of distress through which people
express a concern that goes beyond that associated with the
immediate symptoms.
Another idiom of distress is false teeth, which refers to a condition
that is said to be caused by the appearance of false teeth in the
gums of infants below the age of teething. It is characterized by
long-term or recurrent diarrhea, vomiting, and refusal to breastfeed. The condition is fatal unless the teeth are removed. It
may suffice to rub the gums with a herb, but in some cases two
to four incipient canine teeth are extracted from the babys gums
with homemade tools (such as a sharpened bicycle spoke) or even
a fingernail. There is general agreement that false teeth is a recent
phenomenon that first appeared during the years of political

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instability and civil war. An expert is needed for the removal of the
teeth, but false teeth is one of the few childrens diseases that young
mothers 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 better or worse, can influence human life and that covers phenomena
otherwise referred to in the literature as ancestors, symbolic pollution, witchcraft, and sorcery. Dealing with juok usually requires
joint action by family members, while the overall responsibility lies
with the head of the family, usually the father-in-law (or husband)
of a mother of small children (see Mogensen 2002 for further discussions of juok). These are but a few of the ways in which people
in the area express their experiences of illness.
The interest in local explanations of illness, often referred to as
the meaning-centered approach, has a long history in medical
anthropology. Among others, Good (1977, 1994) and Kleinman
(1980) have inspired many scholars to study how local interpretations of illness give us insight into peoples experience, their concerns and fears, the context within which they interpret their
health problems, the ways in which they tie their suffering to larger
social issues, and how they attribute meaning to suffering by
explaining not just the how but also the why of sickness
(cf. Evans-Pritchard 1937). So why are these idioms of distress
never brought up during consultations in health facilities in eastern
Uganda? Why could the young woman not tell the musawo about
theri? Do people fear that health workers do not have the time or
interest to listen to their experience of distress? Are people afraid
of being laughed at because they know that health workers do
not have the same understanding of sickness as they do? Do they
feel that two incompatible traditions of knowledge are being
brought into play? My attempt to answer these questions takes
me 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 about
the patient and (if the patient was a child) the caretaker. We then
went on to questions about what had brought them to the health
unit, what kind of sickness they had thought they were dealing
with before coming to the unit, what they had told the health
worker, and what the health worker had explained to them.

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The answer to the question about what had brought them to the
health unit was usually a list of symptomsat times a very long
list. The most frequent symptoms mentioned were diarrhea and
vomiting (of many different kinds and colors), fever, cough, and
chest pain. When asked by the researcher what they had told the
health worker and what s=he had explained to them, the same list
of symptoms was given in response to each query. People did not
expect that they would receive a diagnosis or that they would be
told 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, but
I do not know why it is disturbing the child if that is what you are asking
me about now.
. The musawo did not tell anything. He confirmed that it was fever and
chest pain and wrote those symptoms and the treatment on the paper.

Even more noteworthy than this lack of interest in a diagnosis is


the consistency with which the respondents expressed the belief
that they, the patients, and not the health workers, were the ones
who should define the problem:
. I was not told the sickness of the child. He asked me and I told him the
problem.
. They did not tell us what sickness it is. We were the ones who
explained, 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 am
the one to tell what he is suffering from. The musawo does not tell you
anything. He just writes what medicine to take.
. Now, what do you expect the musawo to tell me? I am the one who
knows what I am suffering from. I am the one who told him and he is
the one who gave me tablets.

Anthropologists have often pointed out that the biomedical


health care system builds upon the assumption that health workers
can decode the untrustworthy story of illness experience and
identify authentic disease as biological pathology (Kleinman
1995:32). In our study, however, it seems that it was not the health
workers 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 patients
experience to biomedical diagnoses and that people would be likely

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219

to have their ideas about sickness adjusted as a result of this. But


our assumption was not confirmed. The patients did not attempt
to 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 do
something about them. Furthermore, they saw themselves as the
ones who knew what their sickness was. They did not expect the
musawo to come up with any surprising discoveries or new knowledge; what they hoped for was treatment. While the respondents
were no doubt intimidated by the overall situation and thus may
have hesitated to complain, their answers still call for us to reflect
on the role of cognitive understanding in clinical interaction.

THE QUEST FOR COGNITIVE UNDERSTANDING


Medical anthropologists have often been concerned with the study
of local disease explanations. Peoples attempts to attribute meaning to sickness have been approached through notions such as
ethno-semantic disease classifications (Frake 1961), semantic networks (Good 1977), explanatory models (Kleinman 1980), and
culture-bound syndromes (Crandon 1983). In most of this work,
the focus has been on peoples interpretations rather than the ways
in which these are situated within the social context and practices of
everyday life. Discussions about narratives (Good 1994), local moral
worlds (Kleinman 1995), and embodiment (Csordas 1994) are but a
few examples of more recent attempts to approach the experience
of suffering as intersubjective and to view meaning as emerging
in practice. In much public health research it is, however, still
assumed that cultural explanations and beliefs are preconditions
for peoples behavior, and anthropology is seen as the discipline
that can provide cultural translations of local disease explanations.
In 1997 Medical Anthropology Quarterly published a special issue on
Knowledge and Practice in International Health. In the introduction Stanley Yoder critically discusses the use of anthropologists as
experts who identify local beliefs about illness and as advisors who
tell 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 also
implicit in our exit interviews (which contained many questions
about communication and explanations), may likewise be said to

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derive from the scientific paradigm permeating public health discourses on health behaviora paradigm that views agency as
located in the mind and cognitive understanding as a precondition
for practice (Yoder 1997). It may even be argued that the meaning
centered approach in medical anthropology, with its focus on
explanations and interpretations of sickness, is implicitly operating
within the same scientific paradigm.
In spite of Yoders call for studies on knowledge-in-action rather
than studies on beliefs as explanations of behavior, his insightful
introduction is followed by articles that discuss how illness beliefs
can be used as predictors of behavior, how they frame decisionmaking processes, and how health messages can be made culturally
sensitive (e.g., Lane 1997; Vecchiato 1997; Whiteford 1997; Weller
et al. 1997). The articles in this issue, like many other attempts to
situate anthropology within public health (e.g. Hahn 1999), illustrate
the difficulties we have, once involved in interdisciplinary and
applied work, in carrying our theoretical awareness of the complex
relationship between knowledge and practice into our analysis.
Though clearly our exit interviews fell into the same trap, I suggest that, if we take peoples implicit rejection of our line of questioning seriously, then these interviews provide useful insights into what
it is we miss when we get caught up in this paradigm. The respondents remind us that patients in eastern Uganda do not expect to
inform the health worker about anything other than their symptoms
and that the health worker is not expected to come up with a diagnosis or any elaborate explanation of their disease. Cognitive understanding is not the focal point of the interaction between health
worker and patient. What is noteworthy, however, is not only the
lack of interest in verbal communication and cognitive understanding but also the assertiveness with which the respondents expressed
this view and emphasized their own role in defining their problems.
What we learn from these exit interviews is, of course, not what
actually happened during the consultation but, rather, what the
patient remembered happened. We do know, from observation,
that health workers rarely initiated any communication beyond
asking What is the problem? or What is the sickness of the
child? However, the patients view that they were the ones defining the problem and that the health workers did not communicate
anything new may not correspond to the health workers experience of the interaction. As Burghart (1996) points out, inspired by
Heidegger, the dialogue begins not with the speaker but with the

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221

listener, and the addressee may not understand that she has not
understood the addressers message. Thus a move from symptom
to diagnosis may have taken place more commonly than the
patients recalled, and explanations may have been given without
the patients taking note of them. Still, what we learn from their
accounts is that they see their role in defining the problem and making the health worker prescribe medicine as being more important
than an exchange of knowledge between patient and health worker.
Their assertiveness on this point stood in remarkable contrast to
the subdued behavior we observed during the clinical encounters,
and this suggested that people were operating according to a logic
that had not been apparent to us. We may succeed in rendering this
logic visible by turning to Bourdieu (1990) and other theorists concerned with the logic of practice.

THE LOGIC OF PRACTICE


A common response of people asked to evaluate a visit to a health
unit was to state: I got medicine so I am satisfied. But it is not
only the desire for tablets that makes people come to the health
unit. Tablets can be bought on the market or in the many drug
shops, sometimes for less than the cost of user fees associated with
the health unit. There are other reasons for choosing the public
health facilities. Whereas exiting patients showed little interest in
verbal communication, they repeatedly pointed out the importance
of the examination and the writing on the paper.
Examinationthough it is often very limitedis expected and
appreciated. It is noticed when the health worker touches the body
or puts the pen (i.e., the thermometer) under the armpit, looks for
anemia by examining the eyes, or checks for dehydration by pinching
the skin to see how quickly it smoothes itself out. People know what
they are suffering from, but examination, machines, and instruments
(thermometers, stethoscopes, microscopes) help the health workers
identify the physical entity, which the medicine, in turn, is supposed
to work on. In private drug shops you can buy the medicine, actively
participate in the decision about what and how much to buy, and even
be treated in a friendly manner. But the problem, people add, is that
there they do not do the examination.
The result of the examination is written on the paper, the Medical Form Five. This piece of paper is looked upon as a powerful

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element of the treatment, almost as important as the medicine itself.


There is rarely any attempt to read what is written (which is difficult even if you are literate). The writing on the paper is thought of
as a secret internal code that is used to pass on a message from one
musawo to another (e.g., from the consulting health worker to the
dispenser or pharmacist), and people do not expect to understand
it. The paper is a powerful symbol of the knowledge of the health
worker: He had already written on the paper, so there was nothing
to ask about, one person said upon leaving the health unit,
thereby, like van der Geest et al. (1996:158161), suggesting that filling 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 medical
form is carefully kept until the drugs have been received or bought.
Some people keep them even longer and may use them again if the
same symptoms return. Sometimes it is wrapped around the
remains of the money and the small brown envelopes containing
the medicine. Usually, however, it is soon lost, as are most material
things. Similar observations were made by M. Whyte and Higenyi
(1997), who investigated records kept by mourning societies in the
Tororo District. These records contain information about who
showed up at what funeral, who contributed, what they contributed,
and how much they contributed. Even though these records play a
major role during the burial, when the mourning period was over
they would often simply deteriorate and=or be used for other
purposes. Funeral writings, according to Whyte and Higenyi, are,
with the exception of the inscription on a cement grave, not about
producing data; rather, the written record is simply a by-product
of the process and is, in itself, of little interest to people. Writing is
used not because it is useful but because the act of writing has meaning. At both the health unit and the mourning society it is the act as
much as the facts on the paper that is of significance to people.
I suggest that the lack of request for an explanation, the importance of the examination, and the writing on the paper all point
to an emphasis on doing rather than on talking during the clinical
encounter. When focusing on explanations and diagnoses, as we
did with our line of questioning in the exit interviews and as is
commonly done in medical anthropology and public health, we
may be confusing the spectators point of view with the actors
point of view and, in Bourdieus (1990:82) words, be looking for

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answers to spectators questions that practice never asks because it


has no need to ask them. People do need information about health
and sickness, but while in the midst of suffering the questions they
ask themselves are different from those they ask at other moments
in their life. The questions they ask are practical rather than theoretical, and the type of explanation that the patient remembered having been given during the clinical encounter always concerned
where to go and what to do.
For the patients, the purpose of the visit to the health unit is to
make the health workers engage in examining and writing, with
the hope that this will result in injections and tablets. However, this
is not a simple process: one has to have a feel for the game, know
how to pass the ball to the other players (i.e., to find the path
through the health unit). One has to know how to position oneself
in the field, both socially and temporally. As Bourdieu (1990:81)
says, our actions are not only unfolding in time, they are also playing strategically with time and especially with tempo. Practice
unfolds in time, Bourdieu (1990:81) emphasizes,
and it has all the correlative properties, such as irreversibility, that synchronization destroys. Its temporal structure, that is, its rhythm, its tempo, and
above all its directionality, is constitutive of its meaning. As with music,
any manipulation of this structure, even a simple change in tempo, either
acceleration or slowing down, subjects it to a destructuration that is irreducible to a simple change in an axis of reference. In short, because it is
entirely immersed in the current of time, practice is inseparable from temporality, not only because it is played out in time, but also because it plays
strategically with time and especially with tempo (1990:81).

The same actwhether it is giving, reciprocating, offering ones


service, paying a visit, throwing a ball, or drawing attention to a
symptomcan have completely different meanings at different
times. Practice therefore requires an active and creative relationship
to the world, and much ingenuity is needed to select appropriate
responses from practical repertoires (80ff). Thus it should not be
surprising that maneuvering in the time and space of a Ugandan
health 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 village had been to the out-patient department of the hospital with her

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6-month-old son. She had been told he had pneumonia and should
be admitted, but she decided to take him back home. I encouraged
her to have him admitted and offered to pay the cost, assuming this
was her main concern. She continued to be reluctant to go, spent the
day under a tree having her hair done, and got her mother and
uncles wives involved in a fight over whether she should save
the money for other purposes and not waste her time at the hospital. Finally, by the end of the day, she left. Months later, when she
had become my confidante, she told me that it was neither the
money nor the waste of time that had made her reluctant to go to
the hospital. She feared going there because:
All the other people there just talk to each other and laugh and they look at
you and think you are strange. And also, even if you had given me money
for 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 porridge
and just a sheet, but not a blanket, then they just think that you are poor
and ignorant and do not understand anything, and they will treat you as
somebody primitive. But after you had visited me in the hospital it
improved a bit, and the nurses became very polite to me. They thought that
since a muzungu [white person] visited me I must be somehow rich and
educated.

Visiting a health unit is part of everyday life for most people, but at
times it is also an overwhelming experience. I came across people in
the villages who had never had the courage to turn up at a health
facility. It can be difficult to find out where to start, where the line
is, where to go next, who to ask, how to respond, how much to pay
for what, where to get the medicine, and so on. Knowing somebodyanybodywhether it is the gatekeeper or the anthropologist, may help one move in the right direction. Being able to
present oneself as a respectable and knowledgeable person, i.e.
somebody who is capable of doing all those things correctly, is of
great importance.
Some of the things you have to know as a patient (or relative
of a sick child) are how to show respect and to acknowledge the
authority of the health worker by greeting her=him politely, talking
softly, and listing the symptoms of the patient. You have to pay the
right amount at the right time. In exchange for this you may gain
access to the knowledge and skill of the health worker in the form
of an examination and a paper upon which she=he has written.
And, if lucky, you get drugs.

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225

But there are many more things you need to know. You need to
know the tempo of social interaction. People may be at the health
facility for several hours before getting through registration, consultation, and dispensing, even though each of these may require only
a few minutes. When interacting with a health worker, people have
to provide short, precise answers to the questions asked. From the
quality-of-care study we know that people generally say that they
came to the health unit to seek treatment for symptoms that started
one to seven days previously. The treatment provided is symptomatic and is given for a three-to-five-day period. Improvement is
expected to occur within this period, and if it does not, then people
start considering what to do next. When patients were asked what
treatments they had been given before coming to the health unit,
they referred to whatever treatment they had received within the
last week. Many of them, however, were likely to have had other
treatments within different tempos. This was particularly true of
children, who were frequently sick and whose caretakers were
likely to have already tended to the symptoms within a different
time frame (e.g., by rubbing the gums to treat false teeth or slaughtering a chicken to treat juogi). However, it is not considered appropriate or relevant to refer to this in the health unit, where actions
are played out in a different tempo than the one pertaining to false
teeth and juogi.
User fees also provide insight into the significance of tempo.
During the years of instability, when informal payment was normal
in all health facilities in Uganda, a visit to a health unit was always
accompanied by the insecurity of not knowing what one would end
up paying. There are many horrific stories about treatment having
been delayed until the last moment, or not given at all, due to the
health workers attempts to get as much money as possible out of
the 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 not
directly state how much they wanted, and the exchange process
would stretch out in time. Informal payment was greatly reduced,
though not fully removed, when user fees were introduced in the
1990s. But the introduction of formal fees brought with it numerous
complaints as people assumed (often correctly) that this would simply add to the cost of health care. Thus we expected people to be
dissatisfied with the fees they had paid, but this was not usually
the case.

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A partial explanation for this may be found in Bourdieus discussion of the temporality of gift exchange. According to Bourdieu
(1990:112), an exchange that involves money telescopes a transaction into an instant, while an exchange that involves gifts
stretches out in time (see Mauss 1966). The giving of money, like
the giving of other kinds of gifts, calls for a counter-gift, but it
has the potential to inhibit the development of prolonged social
relations because once the debt is paid (i.e., the gift is returned)
the tie is dissolved. While payment was informal, by setting the
terms for the size of the counter-gift and the time of its payment
health workers created ties of dependency with their patients, and
this was not to the latters advantage. With the introduction of formalized fees came a tempo that limited the possibilities of dependency and returned to the patients a sense of agency. When
people in the quality-of-care study expressed dissatisfaction with
the payment of fees, they always did so when there was uncertainty
about how much to pay or when they had not been given drugs.
Complaints rarely concerned the actual amount (between 300 and
1000 Ush) charged, and this may support the argument of Reeler
(1996) and van der Geest (1992), who contend that formalized fees
have the potential to empower patients.
Hence, in the health unit, phenomena judged to be significant to
the sickness (e.g., cause, symptoms, treatment, and improvement)
are telescoped into a time frame of about a week. The exchange
between the patient and the health worker is particularly compressed and lasts no more than a few minutes. As has been discussed, the formalization of fees helps to limit the health
worker=patient relationship to this moment in time. People know
that by accepting this time frame they will gain access to the knowledge, competence, and experience of health workers as well as to
the writing, the examination, and the drugs. Some people are better
than others at finding the right person to ask about where to go, at
presenting the sickness within the right time frame, and at presenting themselves respectfully. Katehoire (1998) shows that educated
women are better at all of this, not necessarily because they are literate or more knowledgeable about sickness than others, but
because the confidence they derived from having been within
another institutional setting (i.e., the school) has set them in good
stead for dealing with the space and time requirements of
the health unit. It seems that it is the ability to conduct oneself
appropriately within the health unit, rather than the extent to which

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227

cognitive understanding or a verbal expression of suffering takes


place, that shapes peoples experience of the clinical encounter.7
A TEMPORALLY EMBEDDED PROCESS OF
SOCIAL ENGAGEMENT
A dichotomy between knowledge and practice may seem to be the
corollary of my claim that practiceand not cognitive understandingis what is at stake in clinical interaction, while illness
explanations and expressions of experience occur through idioms
of distress that emerge in social interactions outside the health unit.
The point, however, is not that people act a certain way in the
health unit and then begin to reflect upon this once they leave
but, rather, that we cannot base our analysis on a dichotomy
between knowledge and action, reflection and practice.
The notion of social agency, which has come to play a prominent
role in recent anthropological discussions, is an attempt to get
beyond such dichotomies, to take as our starting point reflective
and acting bodies, and to understand words not as representations
but as thoughts in action (Hastrup 1995). Agency is understood as a
temporally embedded process of social engagement through which
we respond to the various contexts in which we live. We are all
social agents situated within a range of different structural contexts
to which we have to respond and that provide both constraints and
possibilities for action. These contexts are themselves temporal as
well as relational fields, according to Emirbayer and Mische
(1998), or time-spaces, according to Hastrup (2004). We may say that
one such temporal-relational field is the health unit, a space that has
certain criteria for social interaction and for the use of time. We may
also talk about other health care settings as particular temporalrelational fields (e.g., the space associated with a jathieth [diviner],
the drug shops, or the domestic sphere). With this in mind, I once
again 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 consisting
of 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

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living children. She had given birth twice but lost both infants when
they were five and six months old, respectively. Achieng had been
married to her husband for more than two years, but his family
had not yet initiated bridewealth negotiations with her family. She
lived with his parents and brothers, but with no bridewealth paid
and no living children her position in the family was precarious.
In the event of conflicts within the family, she risked being thrown
out. One day she came to see me to talk about her problems. She told
me that, when people had been quarreling at home, she had heard
them say that it is juogi that disturb her children. The juogi of the clan
had approached the father-in-law and asked him to build a shrine
for the ancestors of the clan. However, Achieng said, he takes it
in a Christian manner, and refuses to take up this responsibility.
According to him, her childrens deaths had nothing to do with
juogi; instead, he argued that Achieng was a careless mother who
did 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 to
substantiate this claim, she gave me a long and detailed description
of how she had tried to save them.
The first one had diarrhea for three days and then died. Achieng
took her to the health center on the second day. She had to wait for
her husband to return from town to give her money to go there, so
she could not go on the first day. Also, she did not think it was so
serious on the first day, but the next day she started fearing it was
koyo. She got some tablets at the health center, and she also tried to
make the child drink a lot of milk and water, which of course she
had boiled. But still the girl died. The second child also died very
quickly. He was vomiting badly, so Achieng went to the health center in the morning to get medicine. By the end of the day there was
still no change, so she went there again, but the health worker told
her that, since the medicine did not seem to work, she should go
home and find someone who could help her sort out this family
matter. The child died overnight. Achieng and her husband had
been to see a diviner, who had confirmed that, as long as the father
of the husband did not agree to celebrate the juogi, the problem
would remain in the family. Since Achieng was now pregnant again
he had given them medicine to protect her unborn child until
something was done about the juogi.
While staying in the area, I sometimes heard neighbors mentioning that the father-in-law did not like Achieng, which was why they
have not married her yet (i.e., had not started the bridewealth

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229

negotiations). Achieng, they said, was somewhat educated (five


years of primary school), and her father-in-law found her stubborn
and impolite. Her husband had not been a respectful son either.
He once stole something from someone, and his father had had to
pay a fine of several cows, which was another reason why he was
unwilling to pay bridewealth for Achieng.
The story of Achieng and her children, to which many more
details could be added, illustrates how negotiations over diagnoses
are a temporally embedded process of social engagement. The
father-in-law continually refused to acknowledge the responsibility
of the ancestors (juogi) with regard to his grandchildrens sickness
and death, as he refused to acknowledge the wedding of his son
to his grandchildrens mother. He may be seen as attempting to
make time work for him by not allowing anything to happen. He
tried to put things off by sending his daughter-in-law to the health
center. She tried to speed up events by emphasizing her regular use
of hospital medicine and its lack of results. In one situation hospital medicine may be used to speed things up or redirect them, in
another it may be used to put things off. Everything depends on
timing, occasion, and the social actors position in the field. A father
who has not yet paid bridewealth for the mother of his children
may neutralize time by providing drugs to cool the effects of sickness while he saves up enough money to be able to finish the
juogi. A mother who is desperately worried about her children
may ask for drugs over short intervals of time in order to communicate to her relatives the need for a tempo other than the one that
they are employing. Or she may slow things down and take attention away from her pregnancy and its effect on the child by seeking
hospital medicine, like the woman fearing theri. People move
back and forth between different diagnoses because each calls for
different responses and responsibilities. Again, the same act can
have completely different meanings at different times, whether it
is giving, reciprocating, swallowing a pill, treating false teeth or theri,
building a shrine for juogi, or visiting a health center. It is a question
of timing and of occasion.
I suggest that the idioms of distress discussed above can provide
us with insight into peoples attempts to make things happen in timespaces outside of the health unit. Reducing these idioms to explanatory models would be to confuse the spectators view with the
participants view. They are not onlyand maybe not even
primarilyused to express distress and to give meaning to suffering:

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they are also used to act upon the world and upon suffering. In other
words, I suggest that these idioms of distress have temporal structures that play out against each other in relational fields. They link
the 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, circumstances, and agents in different ways and thereby merge a range
of 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 are
examples of how emplotment takes place not only when we tell stories about life but also when we act. Being a social agent involves trying to make certain things happen, trying to bring about desirable
endings, trying to search for possibilities that lead in hopeful directions (Mattingly 1994:813). Through these idioms of distress, I suggest, we get insight into how people make these efforts in eastern
Uganda when their health is at stake.
False teeth, theri, and juogi suggest different tempos with smaller
or larger intervals of time between the events judged to be significant and, hence, different suggestions as to who is responsible.
They draw attention to the diarrhea of the previous weeks (which
otherwise would have been forgotten) or to the infidelity of the husband, the insufficiency of food, or the need for child spacing. They
suggest not only what action should be taken but also by whom and
how fast. Koyo, for instance, draws attention to the need for quick
action. The interpretation of the fever of this morning must be projected into a future, which becomes the present of today, hence
speeding things up and requiring the immediate involvement of
someone with money who can take the patient to the hospital. Juogi,
on the other hand, connects childrens sickness with family events
of long ago, which otherwise would have been forgotten but that
now draw attention to irresponsible actions within the family.
The tempo of juogi is different from that of koyo. In the end, the ceremony for juogi may never be performed, or at least not as first
intended. But postponement involves an interval of time that
should not be confused with an inert gap (cf. Bourdieu 1990:106).
This is because postponement is time that potentially functions to
rework social relations and to negotiate the responsibilities of social
actors (like Achiengs father-in-law, who questioned her position in
the family by refusing to link her childrens death to family matters
[i.e., juogi]).

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231

De Certeau (1984:3536) makes a distinction between strategies


and tactics, suggesting that the former involve the creation of an
autonomous space while the latter involve a clever utilization of
time within the space of others. I suggest that the search for health
care must be seen as exactly that, as an attempt to utilize time
within the limitations of the space in which health care is provided.
This maneuverability of time is crucial for an understanding of the
actions people takeor do not take. A child may be seriously sick,
and, as an observer, you may wonder why the mother does not do
anything. But she herself may feel that she has done a lot of things:
informed her husband, been polite to her mother-in-law, given the
child syrup regularly; and saved tablets from her last visit to the
health center and given the child two per week; rubbed the childs
gums for false teeth; and=or requested her husband to stay away
from his lover while she is still breastfeeding.
The point is that the mother connects events in her life and the
actions she has taken with a time-space other than the one favored
by the health worker. She is well aware that the time-space of the
health unit is not the time-space of the domestic sphere. Interactions
at the health unit take place in a different tempo; hence koyo and
juogi make no sense within the clinical interaction. The reason she
does not bring them up cannot be reduced to a simple fear that
the health worker has a different theoretical understanding of sickness from hers. It is also a question of her being aware that acting in
the time-space of the health unit requires other ways of playing
with timeways that will result in a desirable response from
people in that particular relational field. She does not simply suppress her suffering or hide her own explanatory models; rather,
she takes upon herself the complicated task of playing the game
required by the temporal-relational field of the health unit.

CONCLUSION
When patients leaving health units in eastern Uganda answer our
questions, they do so not as spectators distanced from their suffering but, rather, as participants commenting upon their sense of
their ability to act appropriately within the time-space of the health
unit. The significant differences between the health unit and the
domestic sphere do not concern different traditions of knowledge
or the fact that one leaves room for communication and explanation

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while the other does not. Local idioms of distress are not simply
explanations of sickness that are unacceptable in the health unit:
they are ways of acting in the world. The difference between the
domestic sphere and the health unit is that they are different relational and temporal fields. And social actors have to obtain a feel
for the game required in each field (i.e., they have to learn how
to act in each so as to evoke appropriate responses). In the moment
of suffering, what matters is the possibility of acting upon this suffering by making others (health workers or relatives) re-act in certain ways. And anthropology, with its ability to obtain insight
into social interaction and the practices of everyday life as it unfolds
in time, should therefore contribute to a furthering of our understanding of the practical experiences of patients rather than merely
functioning as a translator of cultural beliefs about illness.
NOTES
1. My research was carried out in association with a research training project known
as Tororo Community Health (TORCH), which is financed by the Danish International Development Agencys Program for the Enhancement of Research
Capacity (ENRECA). The institutional collaborators of TORCH are the Child
Health and Development Centre, Makerere University; the Institute of Anthropology, University of Copenhagen; and the Department of Epidemiology and
Social Medicine, University of Aarhus, Denmark. The quality-of-care study was
carried out by members of the TORCH team, Nathan Nshakira being the principal
investigator. I alone am responsible for the particular interpretation of the material
presented here. My long-term fieldwork was financed by the Danish Research
Academy and the Danish Council for Development Research.
I am deeply grateful to Richard Odoi and his family as well as to Susan and
Michael Whyte for their never-ceasing support and their interest in sharing
ideas. And I thank the late Frances Kamuge, my research assistant, from whose
friendship, vast experience with the Ugandan health care system, and bright
intellect I benefited immensely. I also want to thank Anne Katehoire, Lotte
Meinert, Tine Tjrnhj-Thomsen, Marie Larsen Ryberg, and the students in my
spring 2005 medical anthropology course for their comments on earlier versions
of this article.
2. The JopAdhola are one of four ethnic groups inhabiting the two districts. They
call themselves a Luo-people, and their language (Dhopadhola) is closely related
to the language of the Luo of Western Kenya. In Uganda a mosaic of Bantu groups
and the Teso surrounds the JopAdhola, of whom there are said to be about
150,000. In the course of my fieldwork I obtained a rudimentary knowledge of
the language, but I continued working with someone who could also assist with
translations.
3. TORCH has initiated research to monitor this development, but little is as yet
known about the medical and social impact of antiretroviral treatment.

Practical Experience of Ugandan Patients

233

4. The supply of drugs was also a major problem until UNICEF instituted an
essential drugs management program in 1981. Since the mid-1980s it has supplied
kits of medicine to all rural and urban outpatient facilities, many of which
have, however, found their way into the fast-developing private market for health
care.
5. I am not aware that research has as yet been carried out on the consequences of
the abolishment of fees or on the extent to which official fees have been replaced
by a return to informal payment. Preliminary observations indicate that many
people are not even aware that fees have been abolished since many things still
have 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 Ugandan
shillings (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 right
rooms in the right order, providing practical illustrations of how to take medicine,
employing staff to guide people, etc.).

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