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ABSTRACT
Access to anti-malarial drugs is increasingly governed by novel regulation technologies like rapid diagnostic tests (RDTs). However, high rates of non-adherence particularly to negative RDT results have been reported, threatening the cost-effectiveness of the two interrelated goals of improving diagnosis and reducing the over-prescription of expensive anti-malarial drugs. Below I set out to reconstruct prior treatment forms like presumptive treatment of malaria by paying particular attention to their institutional groundings. I show how novel regulation technologies affect existing institutions of care and argue that the institutional work of presumptive treatment goes beyond the diagnosis and treatment of a currently observed fever episode. Instead, in contexts of precarity, through what I will call “practices of preparedness,” presumptive treatment includes a variety of practices, performances, temporalities, and opportunities that allow individuals to prepare for future episodes of fever.
Acknowledgments
This research was a component of a larger project titled “Translating global health technologies: Standardization and organizational learning in health care provision in Uganda and Rwanda.” I am grateful to Rehema Bavuma, my Ugandan research assistant, and to the Law, Organization, Science & Technology (LOST) research group at Martin-Luther University in Halle who commented on an earlier version of the article. I also wish to thank the guest editors of this special issue who strongly helped structure the article.
Funding
This study was generously funded by the German Research Foundation (DFG).
Notes
1. As indicated in the training manual, there is also the possibility of RDTs showing an invalid result either due to user error or technical failures. The latter can be due to production errors, logistical constraints or climatic issues (e.g., exposure to increased heat and humidity). From my field experience and participant observation, it is more likely that invalid results occur because of user error. Particularly pricking and drawing the right amount of blood requires some skill. This is exacerbated as many patients in endemic areas suffer from anemia, making the collection of blood a difficult task (Sserunjogi, Scheutz, and Whyte Citation2003).
2. This kind of everyday perception of the disease strongly contrasts with Eurocentric representations of malaria as a “killer-disease” (e.g., “Malaria: a major global killer.” www.bbc.com/news/10520289).
3. When the program came to an end in 2014, it had only partially succeeded in achieving the goal of supplementing older therapies (Arrow et al. Citation2012). From my experience in Mukono district, Chloroquine and other drugs could still be purchased while prices for ACTs soared quickly.
4. The here quoted vignette was reported to me by one of my research assistants who mainly conducted interviews and participant observation on private drug shops in Mukono district between April and May 2014.
5. Determined by the logistic body of the Ministry of Health (National Medical Stores), 1000 RDTs should be standard for a period of two months for each facility. Since nationwide introduction in May 2012, however, facilities have only been supplied with 400 RDTs per supply cycle.
6. The effort people make to get access to free-of-charge drugs during times of well-being for me reflects a strong sense of responsibility for care. This is quite similar to expert clients who go the extra mile when caring for other HIV patients (Kyakuwa Citation2011).
7. Being able to rule out malaria as a cause of symptoms constitutes a novel epistemic realm whose acceptance or recognition requires new competencies from all actors. Nevertheless, convincing patients that they are not suffering from musujja/malaria is not part of any formal training. In most situations health workers are forced to improvise answers and options that are satisfactory to the patient without spoiling the reputation of the nurse. I treat this aspect as part of the relationship between science, technology, and the production of non-knowledge. In addition, the public health problem of “over-diagnosis of malaria” never seemed to be a major concern of patients, as many would store the acquired drugs as a first aid for a future fever episode.
8. In the field, I often came across complaints by patients that health workers were stealing drugs and selling these in their private drug shops; such stories were often picked up and used by local authorities to investigate particular cases.
9. There is reason to believe that health workers’ annoyance is less directed towards children and the difficulties in diagnosing them, but more to the perceived lack of care and contempt of the guardians to the service which health workers aim to provide. At the same time we can assume that sending children unaccompanied may be a form of maintaining and increasing access to drugs in the RDT era. The rationale is that the difficulties health workers have in determining the cause of symptoms in children increases the probability of obtaining drugs.
10. I would like to thank one of the reviewers for reminding me that this final point I make regarding therapy seeking in malaria is also captured in medical anthropological debates around the micropolitics of therapy seeking. For more on this topic within the Ugandan context, see also Mogensen (Citation2005) and Whyte et al. (Citation2004).
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René Umlauf
René Umlauf is currently a Postdoctoral Researcher at Martin-Luther University in Halle, Germany. In 2015, René finished his PhD (University of Bayreuth), in which he examined the socio-technical as well as epistemological implications of newly introduced diagnostic tests for malaria in Uganda. His main research interest focuses on the conceptualization of “ecologies of testing” and how these emerge and operate as part of Global Health programs.