Antiretroviral therapy in Zambia: Colours, ‘spoiling’, ‘talk’ and the meaning of antiretrovirals☆
Introduction
This article describes a study conducted in Zambia in 2004 during the roll-out of antiretroviral (ARV) therapy for HIV/AIDS. We examined patients' and practitioners' attitudes to the material characteristics of pharmaceuticals, ‘spoiling’ (concern about treatment strength, sometimes manifested in the experience of side effects) and rumours (‘talk’). We hypothesised that earlier biomedical interventions, colour symbolism and everyday experiences of the political and economic factors that hinder people's search for effective treatment could influence perception and use of ARVs.
We asked people living with HIV (PLWH) and practitioners (biomedical and traditional) to describe their reactions to the recent provision of ARVs and their ‘perceptible qualities’ (Etkin, Ross, & Muazzamu, 1990, 922). We also asked about dosage and life-long medication and explored informants' knowledge of alternative therapies and their experience and management of side effects. Informants were asked to compare the appearance and side effects of ARVs with those of other pharmaceuticals used for common infectious or chronic diseases (namely medication for malaria, tuberculosis, diabetes, epilepsy, herpes zoster and other STIs). We also asked about ‘talk’ they may have heard about ARVs.
Many studies discuss the clinical, delivery, access and educational dimensions of ARVs in Zambia (Dhaliwal et al., 2002, Dieleman et al., 2007, Stringer et al., 2006, Whyte et al., 2004). Others discuss ARVs in resource-poor settings (Farmer et al., 2001, Rabkin et al., 2002, Whyte et al., 2002). None, however, use Zambians' previous experiences with biomedical interventions to understand responses to today's roll-out or explore the significance of material characteristics, experiences of side effects and risks or the effects of the political economy of healthcare on concerns about ARVs. Our approach builds on studies of the introduction and interpretation of pharmaceuticals and their ‘social lives’ (Whyte et al., 2002) and studies of ‘meaning responses’ that can influence treatment outcomes (Moerman & Jonas, 2002). We also examine how the ARV roll-out in Zambia reflects wider contexts, situating medical experiences within the realm of social, political and economic relations and global inequities (Comaroff and Comaroff, 1999, Fairhead et al., 2006, White, 2000).
Section snippets
Background
Zambia carries one of the highest burdens of HIV/AIDS in the world. At the time of the study, the national prevalence for adults was 16%, rising to 23% in urban areas (UNAIDS/WHO, 2004). After nearly two decades in which most Zambians saw a diagnosis of HIV as a death sentence, the government is now rapidly introducing ARVs, assisted by US funding – the President's Emergency Plan for AIDS Relief in Africa (PEPFAR). This has given hope to PLWH, transforming HIV into a more manageable disease.
Methodology
We conducted the study at four sites in Lusaka (UTH, Chelstone clinic, Kamanga compound, Msisi compound) and in two rural districts (Choma in southern Zambia and Samfya in northern Zambia). We chose health facilities representing rural and urban contexts where PLWH and healthworkers had different levels of access to and knowledge of ARVs – UTH was the first government hospital piloting ARVs, Chelstone one of the four pilots for the ARV roll-out and Choma District Hospital one of the pilot
Materiality of medicines
Material characteristics have received some attention in studies of pharmaceutical use in the developing world (Bledsoe and Goubaud, 1985, Etkin et al., 1990, van der Geest and Whyte, 1991, Nichter and Vuckovic, 1994, Whyte et al., 2002, 5). Previous historical work has noted that colour can be important to African evaluations of a medicine's efficacy (Vaughan, 1991), though few have pursued this insight (for exceptions, see Bledsoe and Goubaud, 1985, Etkin et al., 1990). In contrast,
‘Spoiling’
The ‘spoiling’ and side effects questions used in the study revealed a number of key perceptions about toxicity or efficacy.3 The two dressers felt that ARVS were very strong and that this strength was appropriate – equivalent to the strength of the disease. Concerns about potential toxicity,
‘Talk’
The healers in the study observed that having faith in the medicine was important for curing the disease. Lack of faith in medicine – especially novel pharmaceuticals – and suspicion of the purposes of treatment also emerged from the interviews. One informant, an elderly healer in rural Samfya, engaged in a common (though not universal) African analysis of the HIV/AIDS epidemic – that it and its remedies were designed by whites to kill Africans.
‘Medicine that comes from out[side] of the
Conclusion
Our data reveal a small but salient use of colour symbolism when informants evaluate pharmaceuticals, indicating the need for further research into potential meaning responses that can influence treatment outcomes. Informants also clearly drew on previous encounters with pharmaceuticals when responding to ARVs, making strong parallels with TB drugs and their side effects and implying deeper connections to previously introduced pharmaceuticals and their side effects. Other factors such as
References (53)
- et al.
The reinterpretation of western pharmaceuticals among the Mende of Sierra Leone
Social Science & Medicine
(1985) - et al.
The indigenization of pharmaceuticals: therapeutic transitions in rural Hausaland
Social Science & Medicine
(1990) - et al.
Where techno-science meets poverty: medical research and the economy of blood in The Gambia, West Africa
Social Science & Medicine
(2006) AIDS talk and the constitution of cultural models
Social Science & Medicine
(1994)- et al.
Community-based approaches to HIV treatment in resource-poor settings
Lancet
(2001) White, red, and black: colour classification and illness management in northern Ghana
Social Science & Medicine
(1997)- et al.
Agenda for an anthropology of pharmaceutical practice
Social Science & Medicine
(1994) - et al.
ARV treatment in resource-poor settings: clinical research priorities
Lancet
(2002) Community education and referral: Supporting adherence to ART and prevention for people with HIV in Zambia
(July 2007)- et al.
Basic colour terms
(1969)
‘Kuyendela odwala TB’ – visiting TB patients: the widening role of home-based organizations in the management of tuberculosis patients in Lusaka, Zambia
International Journal of Tuberculosis and Lung Diseases
DHS EdData Survey
Universal church pastors deported
Times of Zambia
Occult economies and the violence of abstraction: notes from the South African postcolony
American Ethnologist
‘We are also dying like any other people, we are also people’: perceptions of the impact of HIV/AIDS on health workers in two districts in Zambia
Health Policy and Planning
Prisoners of freedom: Human rights and the African poor
Scenes from African urban life: Collected Copperbelt papers
40 Years of medicine on the Copperbelt
Horizon
Health providers' opinions on provider–client relations: results of a multi-country study to test ‘Health Workers for Change’
Health Policy and Planning
Hippocrates' Latin American legacy: Humoral medicine in the New World
HIV/AIDS in Zambia, Country AIDS Policy Analysis Project
‘Kachinja are coming!’ Encounters around a medical research project in a Kenyan village
Africa
The modernity of witchcraft: Politics and the occult in postcolonial Africa
Cited by (24)
'Experts', 'partners' and 'fools': Exploring agency in HIV treatment seeking among African migrants in London
2010, Social Science and MedicineCitation Excerpt :With such significant biomedical advances being made in recent years, non-consistent use of anti-retroviral therapy (ART), and use of other forms of non-biomedical treatment can be interpreted from within the health sector as a combination of ‘incompetent’ doctors and ‘failing’ (Green & Smith, 2004) and ‘desperate’ (Broom & Adams, 2009) patients. However, such understandings overlook the broader socio-cultural contexts within which such treatments are used (Schumaker & Bond, 2008; Wong & Ussher, 2008), and the ways in which the meanings and values people invest in different treatments and medications can influence treatment uptake and consistency (Del Casino, 2004; Helman, 2007; Persson et al., 2003; Reynolds, van der Geest, & Hardon, 2006). As van der Geest, Reynolds and Hardon (1996, 166) state, “rarely is noncompliance [with medications] the result of patients misunderstanding the doctor's information, but it is the result of patients having different ideas and, in particular, different interests.”
From end of life to chronic care: The provision of community home-based care for HIV and the adaptation to new health care demands in Zambia
2016, Primary Health Care Research and Development“Even the fowl has feelings”: access to HIV information and services among persons with disabilities in Ghana, Uganda, and Zambia
2020, Disability and Rehabilitation
- ☆
The Wellcome Trust funded the research on which this article is based – University Award Grant No. 056339, ‘Mining and medicine in Zambia’; International Collaborative Research Grant No. 073963, ‘The necessity of history: contextualising the introduction of antiretroviral treatment in Zambia’. We are grateful to the staff of ZAMBART and, especially to the medical researchers, Joseph Banda and Helen Ayles, for their help in Zambia during fieldwork in 2004. The research could not have been accomplished without the translation and insights of the following research assistants: Phales Mitimingi, Timothy Mgala, Florence Moyo and Titus Kafuma. Thanks also to Elizabeth Colson, Sandra Wallman and the anonymous reviewers from Social Science & Medicine for their helpful comments.