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HEALTH POLICY AND PLANNING; 16(4): 362–371 © Oxford University Press 2001

Self-treatment by Kenyan and Ugandan schoolchildren and the

need for school-based education
P WENZEL GEISSLER,1,2 LOTTE MEINERT,1,2 RUTH PRINCE,1,2,3 CATHERINE NOKES,3
JENS AAGAARD-HANSEN,2 JESSICA JITTA4 AND JOHN H OUMA5
1Institut for Anthropology, University of Copenhagen, Copenhagen, Denmark, 2Danish Bilharziasis Laboratory,

Copenhagen, Denmark, 3Partnership for Child Development, University of Oxford, Oxford, UK, 4Child Health and
Development Centre, Kampala, Uganda and 5Division of Vector Borne Diseases, Ministry of Health, Nairobi, Kenya

Studies on Kenyan and Ugandan primary schoolchildren’s knowledge of medicines and self-treatment prac-
tices show that children aged between 10 and 18 years have a broad knowledge of herbal and biomedical
remedies and that they use them frequently, often without adults’ involvement. They use pharmaceuticals,
including prescription-only drugs, but lack knowledge about indications and dosages.

There is a gap between the children’s life worlds and the school health education as it is presently designed
and taught in Kenya and Uganda. It limits itself to disease prevention and health promotion, and does not
teach treatment or medicine-use. Self-treatment based on insufficient knowledge poses a threat to children’s
health and to the health of the wider community. Therefore, education on the critical and appropriate use of
medicines needs to be developed and tested for possible use in Kenya, Uganda and other countries in which
home-treatment is common. The proposed education on medicines should go beyond providing information
on accurate dosage and indication: it should create critical awareness with regard to medicine-use, enabling
children to use them appropriately and cautiously. Kenyan and Ugandan primary schoolchildren are active
agents within pluralistic medical fields. By taking the children seriously as competent health care agents, the
dangers of self-treatment could be reduced, and the potential of children could be guided to fruitful use.
Educational interventions cannot solve the problems of self-treatment, which are related to the wider social
and economic context, but they could contribute to increased awareness as a necessary condition for change.

Introduction
Primary schoolchildren’s knowledge of medicines and self-
treatment of common ailments were investigated between
1996 and 1998 among the Luo of western Kenya and among
the Iteso of eastern Uganda (for details on the study areas and
populations as well as detailed findings, see Meinert 1998,
2001; Geissler et al. 2000). These studies have shown that chil-
dren of primary school age possess knowledge of both herbal
remedies and ‘hospital’ medicines1 and that they use medi-
cines to treat themselves as well as their younger siblings.
Among the hospital medicines, aspirin, paracetamol and
chloroquine and their generics were well-known and widely
used, but also other antimalarials – notably Fansidar® and
generics – and antibiotics like Flagyl® and Septrin® were
acquired and used independently by primary schoolchildren
in both Kenya and Uganda. The children seemed to use these
drugs too frequently – many children resorting to antimalari-
als more or less every month – and often inappropriately.
Very few of them knew the correct dosage of chloroquine for
the treatment of malaria, or the difference between anti-
malarials, antipyretics and analgesics. Brand names, which
often transported confusing messages, were usually the only
source of information on the indication of different drugs
(Geissler et al. 2000).2 Antimalarials were thus commonly
taken for symptoms of common cold, different drugs with the
same effect were combined, and hardly ever was a full course
of the appropriate drug taken by a child.
Both the children’s knowledge of hospital medicines and
their reported use of these increased with age throughout
primary school. Likewise, the proportion of treatments with
hospital medicines as compared to herbal remedies increased
with age, and around the age of 16 years, the children seemed
to have acquired the medicine-use patterns of adults
(Geissler et al. 2000). The Kenyan children dealt with more
than two-thirds of all minor illness episodes without consult-
ing adults, and they provided more than one-third of all treat-
ments themselves, without an adult’s aid. With growing age,
the proportion of adult-assisted treatments fell, and around
the age of 16 years, few children consulted adults if they felt
ill (Geissler et al. 2000). In the Ugandan study, most of the
children contacted an adult at some point in the treatment
seeking process and often they obtained the money to buy
medicines from an adult caretaker, but they were often left
to administer the medicines themselves (Meinert 1998, 2001).
This difference between the Kenyan and the Ugandan
children may be due to the availability of money to children,
which probably is greater in Kenya. Along the Kenyan shore
of Lake Victoria, boys from the age of 10 onwards earn cash
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Self-treatment and health education of schoolchildren
through fishing, and redistributive mechanisms among the
children make small amounts of money widely available to
children (Geissler et al. 2000). The hospital medicines that
the children bought were cheap (e.g. aspirin or chloroquine
were sold for the equivalent of less than £0.01 per tablet at the
time of the study). Older children often took care of younger
children’s illnesses and administered medicines to them
(Meinert 2001).
These findings indicate that the studied East African children
are handling medicines more independently than their Euro-
pean counterparts (Trakas and Sanz 1992; Bush et al. 1996).
They are competent agents in a pluralistic medical field and
they move actively between different medical traditions,
including local herbal and hospital medicines. The aim of this
paper is to examine how school-age children’s medical com-
petence could be taken into account in the design and prac-
tice of health education programmes in Kenya, Uganda and
other countries with similar socioeconomic conditions and lay
treatment practices.
Background
Children in Kenya and Uganda account for more than half of
the total population and school-aged children for more than
one-third of it (GOK 1996; Grauballe and Balslev 1998,
p. 12). Most children in the rural areas grow up in extended
families; their social life is situated in a group of siblings and
around the family’s home. From an early age children par-
ticipate in productive activities, such as caring for smaller
siblings, fetching water and firewood, herding cattle or
weeding the gardens.
Kenya has universal primary school education up to Standard
8, which is officially free, though in reality the costs of
uniforms, books and materials and various ‘activity fees’ put
significant financial pressure on the children’s caretakers.
School facilities in the rural areas vary between rough but
functional buildings and classes that are held under trees for
lack of any shelter. According to Kenyan government
statistics, school enrolment in the studied area is above 90%
(MOE 1998). This figure might be exaggerated and school
attendance is often irregular, but most children do attend
primary school at some point. Many leave school before
completion of Standard 8 because they lack funds, because
their labour is needed in the household, or because they lose
interest in school. In Uganda in 1997, the government
launched the Universal Primary Education programme,
which offers free education for four children from each family
(UNICEF/GOU 1997). Due to this policy, the number of
pupils in primary schools has more than doubled, which has
caused problems in terms of infrastructure and teaching
capacity. School attendance is irregular in rural areas, for the
same reasons as in Kenya, and drop-out rates are high.
The health situation in Kenya and Uganda is relatively poor,
as indicated by the estimated infant mortality rates (IMR) of
59 and 91 respectively, and a life expectancy at birth of 47 and
43 years respectively (CIA 1999). The major diseases
responsible for the high mortality and morbidity rates are
malaria, acute respiratory infections, diarrhoea, measles,
363
intestinal worms and HIV/AIDS (for Kenya see, for example,
MOH 1992; for Uganda see, for example, Barton and Wamai
1994). With the exception of AIDS, these diseases are pre-
ventable or curable, in principle at least. Morbidity is high
among school-aged children, and malaria and intestinal infec-
tions cause suffering, school absenteeism, poor learning
capacity and working capability (for Kenya see Brooker et al.
1999).
The Ugandan government health system is slowly being
rebuilt after decades of decay due to political instability and
a declining economy. In Kenya, several decades of economic
decline have resulted in ineffective government health ser-
vices in most rural areas. Private health care facilities of
varying quality – licensed as well as illegal private clinics,
drugstores and small shops selling pharmaceuticals – are the
main source of medical assistance outside the home and the
family (Whyte 1991; Snow et al. 1992). Most health care and
treatment of sickness, however, take place in the domestic
sphere. For instance, a recent study from Uganda shows that
about three-quarters of all treatments taken are home-treat-
ments (Adome et al. 1996). While herbal medicines are
widely trusted in Kenya and Uganda, hospital medicines play
an important role in home-treatment. Common drugs (both
prescription only and OTC) reach the remotest village
through extensive marketing and sales networks, and can be
bought in the smallest kiosk as well as in many homesteads
(Whyte 1997; Geissler et al. 2000; Maende and Prince 2000).
Children, medicine and society
The active participation of African children in the treatment
of illness and their use of medicines contradicts the ‘ethno-
centric, medicocentric and adult-centric’ (Van der Geest
1999) notion that children and medicines are two domains
that should be kept apart. In this view, children are vulner-
able and should be protected by adults; medicines are
powerful and at times dangerous and should be controlled
by experts.
Both the constitution of the weak and passive child, who has
to be taken care of by adults and taught in schools (e.g. Aries
1962), and the construction of ‘medicine’ as a domain of
expert knowledge (e.g. Foucault 1975) have co-evolved in a
historical process linked to overall European modernization
during the nineteenth and twentieth centuries. Central to
this process was the development of the nation-state and a
system of governance based on efficient taxation and the
creation of institutions taking care of the welfare – and to
some extent controlling – the citizens. The institutions of
school and hospital epitomize this process of modernization.
State influence was extended to the most personal dimen-
sions of social life: care for one’s children and one’s body. In
schools, children’s development and access to knowledge
was increasingly disciplined and canonized, and in a parallel
process, care for the body and its health became organized
in academic medical discourse and monopolized in the hand
of experts, based in hospitals. The construction and separ-
ation of the domains of children and medicines result thus
from specific historical processes and societal conditions;
they are not universal.
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364 P Wenzel Geissler et al.
As mentioned above, the idea of a ‘childhood’ free of
responsibility and distinct from adult life cannot, without
qualification, be applied to East African children, whose lives
are not separated from the every-day life of older members of
their domestic groups. Children participate in most produc-
tive activities; they take care of siblings, the elderly and the
sick, and they participate in the treatment of illness.
Likewise, the split between professional and lay medical
knowledge that is created by the historical constitution of bio-
medicine differs from the medical ideas and practices in many
African communities. Some specialized healers here possess
knowledge to treat rare and serious illnesses, but most
medical knowledge is distributed over the community, and
everybody knows some treatments for the illnesses from
which they or their family members commonly suffer (Whyte
1991; Pearce 1993; Sindiga et al. 1995). In the Kenyan study
area, we showed that mothers without any claims to be
healers had the same consensual core of medical (plant)
knowledge as a large sample of healers in the wider study dis-
trict (Johns et al. 1990; Geissler et al. 2001). This community
knowledge of healing is not regarded as inferior to that of the
specialist healers, but belongs to a continuum of accepted
ways of counteracting illness. Everybody in the household
can have a share in this knowledge and thereby participate in
the domestic medical practices.
Despite its historically specific origin, the ‘modern’ ideology
separating children and medicines guides the official policy of
most countries today. Governments set age limits for the
acquisition of over-the-counter drugs and aim to monopolize
the prescription of medicines in the hands of professionals
(Lee and Herzstein 1986). This policy is guided by the prin-
ciple that it is professionals who should control treatment and
provide medicines to the parents, who should then negotiate
the treatment with the child. In this way, the health system
should bar children from all independent contact with medi-
cines and concentrate medical power in the hands of adults.
Home and self-treatment
Restrictive drug legislation and the limitation of medical
knowledge to experts may be appropriate where illness is a
relatively rare event, and where governments efficiently
provide and control treatment. It becomes problematic where
serious illness is an almost daily experience and the health
care system is unable to provide even basic services, as is the
case in many parts of Kenya, Uganda and other economically
deprived countries.
Home- and self-treatment is a central part of local medical
culture in these societies, where people are used to taking
treatment into their own hands (Whyte 1988; Van der Geest
and Whyte 1989; Adome et al. 1996). Most common illnesses
are dealt with by lay people on their own; only when an illness
is prolonged or serious do people seek expert advice, be it a
local healer or a biomedical professional. Moreover, lay
medical practice in the studied communities seems not to be
dichotomized into ‘preventive’ and ‘curative’ practice, as it is
in biomedical thought. Biomedical illness concepts see illness
as occurring due to specific, defined causes, which can be
prevented, and it aims – at times successfully – at a definite
cure to get rid of illness. While in this understanding curative
practices should be left to the experts, prevention is the duty
of lay people. In contrast, in the understanding of many rural
Luo, illness is always present in the body and must accord-
ingly be controlled continuously. People’s medical practice
thus consists of continuous activity using all available materia
medica, which is part of every-day life and which does not
separate treatment from prevention (Geissler 1998; see also
Pearce 1993). This kind of practice involves medicine use, but
in contrast to biomedical treatment, in many cases it does not
aim at a final ‘victory’ over the illness – its ‘eradication’ – but
rather at keeping it at bay or ‘dispersing’ it (see Parkin 1996).
Similar features of medical culture have been found in
Uganda (Whyte 1997; Meinert 1998). A consequence of these
views on illness and treatment is that hospital medicines,
which in a biomedical understanding are intended to ‘cure’ a
specific, diagnosed sickness, are used frequently, and often in
low doses, as a response to minor signs of the potential of
illness. Consequently, hospital medicines are used too fre-
quently, unspecifically, in low doses, and by everybody in the
family.
Both because this kind of independent family-based medici-
nal treatment is rooted in the local medical practices, and
because the formal health system is often unable to provide
satisfactory medical care, home- and self-treatment are
common in societies such as those studied in Kenya and
Uganda. Research on community drug use in the developing
world shows that legislation alone cannot efficiently control
medicine use, and that people everywhere integrate hospital
medicines into their established patterns of home care (Haak
and Hardon 1988; Adome et al. 1996). Restrictive legislation
can affect treatment patterns, but the improvement of treat-
ment practices cannot be sustained unless satisfactory treat-
ment facilities and education accompanies the legislation. If
the state cannot provide health care and people have to help
themselves, a rigid legislation is rather likely to hide existing
health care practices from the public eye and thereby pose a
risk for people’s health.
The cited studies on children’s medicine use in Kenya and
Uganda indicate that attempts to protect children from medi-
cine use fail their purpose when the three assumptions of
western policies regarding medicines and children are not
given:
(1) Children here are not passive creatures constantly super-
vised by adults, but are responsible community members.
(2) Knowledge of medicines is not an expert’s domain, but is
common property and everybody participates in healing.
(3) The state does not have the capacity to provide health
care or control the trade in medicines.
Due to the ideology of childhood and of medical expertise as
described above, knowledge about the proper use of medi-
cines is withheld from children and other lay people, while
access to medicines, including potent hospital medicines, is
easy. Where the barrier between children and medicines is
broken down in practice, the described ideology, meant to
protect children from harm, endangers their health.
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Self-treatment and health education of schoolchildren
Risks of self-treatment
Self-treatment of illness entails a number of health risks.
Pharmaceuticals can have toxic effects when they are taken in
too high doses or too frequently. Chloroquine and analgesics
were the hospital medicines most commonly taken by chil-
dren in the studies cited above. Chloroquine can lead to acute
intoxication and is a frequent cause of death in Kenya (Maitai
et al. 1981); analgesics like aspirin can cause stomach bleed-
ings (Dengler and Roberts 1996), and paracetamol can
damage liver and kidneys (Whelton 1995). Beyond these
individual side-effects, frequent use of antimalarials and
antibiotics, and underdosing of these drugs, can contribute to
the development of drug resistance and thus harm the wider
community (Brinkmann and Brinkmann 1991; McCombie
1997). Self-medication without knowledge of these risks and
of the proper indication and dosage is therefore likely to have
iatrogenic effects.
Herbal remedies are not without dangers either. There is a
risk that plant products contain toxins, which can be
dangerous in themselves or may interact with hospital
medicines. Furthermore, experimentation with herbs and
traditional healers might delay the patient’s visit to a bio-
medical practitioner or a government health facility
(Adome et al. 1996).
The potential of children as agents of health
Despite these risks of self-treatment, the children’s use of
medicines and their appropriation of herbal remedies and
hospital medicines reveals also children’s potential as agents
of health. Many common infectious diseases could, if not be
prevented, easily be treated in a better way than is presently
the case. Given the state’s inability to provide health care,
children might be able to take a greater share in improving
community health.
The children’s knowledge of medicines, which grows with
their age, shows that they provide a good target group for
educational interventions on treatment and drugs. In the
process of rapid and radical changes of the medical system, as
occur for example in Kenya and Uganda, children are
exposed to a multitude of medical traditions ranging from the
grandmothers they live with to the advertisements of drug
companies on local markets. They learn quickly, and most of
them attend school and could therefore be easily reached by
relevant health education.
Medical knowledge and health education
The hierarchy of medical power described above, which
stretches from professional experts to lay adults to children,
reflects an unequal distribution of medical knowledge
between these groups. Professional expert knowledge guides
the active use of powerful medicines for treatment, while for
lay people – in particular for children – a passive knowledge
of how to prevent illness and compliance to the doctor’s
advice is regarded as sufficient. This distribution of roles in
the medical field – curative practice as expert competence,
prevention and compliance as lay duties – has shaped health
365
education in most contemporary school curricula. It usually
focuses on disease prevention – mainly by avoiding doing
certain things – rather than on active coping with illness.
Treatment and curing of illness and use of medicines are only
taught to medical professionals as part of their ‘medical edu-
cation’, while ‘health education’ gives advice on how to
remain healthy.
In Kenya, school health education is part of the subject
‘Home Science’, which comprises a wide range of topics, for
example, cooking, sewing, child-care and gardening (Kenya
Institute of Education 1992). In the schools studied, it was
given low priority by teachers, parents and children. Its
stated aim is to ‘help the individual realise and solve family
problems, as well as adapt more easily to the changing living
conditions in the home, community and society as a whole’
and ‘to give . . . basic skills, knowledge and attitudes which
can be applied in day-to-day living, and to improve the
quality of life of an individual and the society’ (Kenya Insti-
tute of Education 1992, p. 71). The general objective of
health education in this framework is to enable children ‘to
observe health practices and take precautionary measures . . .
in relation to personal hygiene, kitchen hygiene, sanitation,
water, poisonous substances and health hazards’ (Kenya
Institute of Education 1992, our emphasis). The focus of
health education is thus on prevention. Apart from first aid,
it does not contain any advice on curative practice. Neither
herbal nor pharmaceutical remedies are part of the syllabus
(Kenya Institute of Education 1992). If reference to treat-
ment is made in school books, this is always linked to a pro-
fessional health care provider, as in the advice: ‘Get
treatment from the hospital’ (Kenya Institute of Education
1993a,b).
In Uganda, since 1985 health education has been an indepen-
dent part of the science syllabus and forms a remarkably large
part of the primary school curriculum. The National Curricu-
lum Development Centre, together with an Interministerial
Expert Panel on School Health Education, the Ministry of
Health, the Ministry of Education and UNICEF, made a
revision of the health education syllabus in 1988
(UNICEF/GOU, undated). A School Health Education Pro-
gramme was launched in which one teacher from each
primary school was given training in health education and
new materials were produced and distributed. Upon evalu-
ation, health education was made an examinable part of the
science syllabus in order to signal the importance of the
subject and make sure that the content was actually taught.
The School Health Education Programme ambitiously aims
at teaching schoolchildren knowledge, skills and attitudes in
a way that will stimulate them to change their behaviour and
also pass their knowledge on to parents and other children
(GOU 1990). To what extent these goals have been achieved
is unclear as no evaluation of the effects of health education
has been undertaken so far. The assumption that school-
children can promote better health practices in the family by
communicating school health messages to their parents is
problematic in the context of steep hierarchical family struc-
tures. Children are, however, able to communicate changes in
more subtle ways, through their own practices and through
communication to other children.
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366 P Wenzel Geissler et al.
The Ugandan primary school, health education syllabus is
oriented towards health promotion and disease prevention. It
does not include curative knowledge, although it gives more
concrete, applicable information on care for sick people than
the Kenyan syllabus. Health education covers hygiene,
sanitation, family life, HIV/AIDS and STDs, reproduction,
nutrition, immunization, the body, alcohol, smoking, drugs,
first aid, caring for sick or disabled people, and the causes and
symptoms of various diseases (MOE 1988). The module on
drugs describes ‘traditional medicine’, ‘manufactured’/
‘modern medicine’ and ‘drugs of dependency’, and encour-
ages teachers and children to consider useful, harmful and
harmless effects of different medicines within these groups
(MOE 1988). It is emphasized that pharmaceuticals should be
obtained from official sources and not from ‘the market’; the
issue of ‘spoiled drugs’ (expiry and storage) and the risk of
drug poisoning are pointed out. Compliance with regimens
and drug resistance are mentioned (GOU et al. 1988).
Although there are some significant differences between the
Kenyan and Ugandan school health education programmes,
the overall approach in both countries is in agreement with
the ‘modern’ ideas about children and medicines as separate
domains. Children are attributed a role in the prevention of
illness, but not given knowledge to engage actively in the
treatment of illness (see Lutwama and Bennett 1969). This is
in accord with the concept of ‘primary health care’ based on
the idea that prevention should have priority before cure
(WHO 1978). However, it is also rooted in the much older tra-
dition of tropical public health, which formed an integral part
of the colonial enterprise and – particularly in Africa – was
built on the idea of local people being passive, ignorant recip-
ients of western curative services or disease control (Vaughan
1991). Formal schooling in Africa also originated in colonial
times, and has equally been shaped by colonial ideology and
‘western’ ideas of childhood and education (Serpell 1993).
Due to this post-colonial legacy, health education in Africa
today is still largely providing ‘dos and don’ts’, i.e. instruc-
tions on how to promote general health and prevent the
threat of illness. These often cannot be followed under the
given economic conditions. Very little knowledge is conveyed
to children on how to cope with bodily afflictions in their daily
lives and to handle the potent medicines that are readily avail-
able to them.
Presently, teaching in health education in Uganda and Kenya,
as in most other subjects, consists of conventional, teacher-
centred practices conveying pre-formulated health messages
as are provided by syllabus and text books, which the children
copy from the blackboard or repeat after the teacher. It does
not involve discussion, active understanding of the principles
of health, or practical exercises. This teaching style does not
help children transform their knowledge into changed health
practices. Furthermore, the content of teaching is often unre-
alistic. For example, the advice to avoid contact with lake
water in a warm region where this is the only water source, or
the advice to boil all drinking water when firewood for
cooking is scarce, seem misplaced.
In both Kenya and Uganda the teachers tend to give more
importance to the ‘main’ subjects like English or mathematics.
Children and parents are less interested in a subject that is
supposed to teach them domestic skills, i.e. ‘work’, which
they have enough of before and after school. Children
come to school, or are sent by parents, to learn ‘modern’
skills such as reading, writing and calculating; skills that
they hope will eventually take them to salaried employment
and urban lifestyles (see Serpell 1993 for examples of what
he terms the ‘extractive’ model of schooling). The topics
dealt with in home science and health education are often
traditionally both gendered and generationalized, but this is
not tackled in health education. Moreover, the health
education aims at practical tasks, and therefore is not effec-
tively taught in the conventional style of learning described
above.
The aims, content and style of the existing health education
contrast with the practice of the children as described in the
studies cited above. While the children are very active in the
treatment of illness, the teaching in school confines their role
to preventive measures. By neglecting the children’s true situ-
ation, school health education is likely to fail in its stated goals
to provide basic life skills for the improvement of their daily
life.
Felt needs of health education
When the discrepancy between the school’s preventive
syllabus and the children’s curative practice was brought
up in conversations with teachers in Kenya and Uganda,
two contrasting positions were evident. On one side was a
minority who adhered to an ideological position, maintain-
ing the separation of children and medicine. Some of these
denied that children were treating themselves at all, or
that they used hospital medicines; or they maintained that
‘. . . teaching them about these things will make them do it
even more . . .’ (primary school teacher, Kenya). On the
other side was the majority, who acknowledged the
situation as described and suggested that teachers, children
and other lay people need to be taught about the proper
use of medicines.
The latter group discussed which drugs should be taught
about, and whether the aim should be to provide correct
information for medicine use or if the children should be
discouraged from using potentially harmful drugs. These
discussions showed that an open and thorough debate
involving all stakeholders will be needed to attain a viable
consensus on the content of health education. Some
teachers suggested that issues such as drug dosages and
drug resistance could be explained to schoolchildren, and
that this could even be integrated into subjects not related
to health, like mathematics, in order to enhance the effect
of health education itself: “Dosages of medicines for differ-
ent body sizes provides a good example for teaching maths
. . .” (primary school teacher, Uganda). Another teacher
from this school gave an ingenious example of how to
explain the issue of drug resistance: “We can use the idea
of stubborn children, which is something we know very well
. . . If children are always beaten a little, but not enough to
make them behave well, they become stubborn. Malaria
parasites are like that. If you treat them with medicines a
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Self-treatment and health education of schoolchildren
bit here and a bit there, but you never put them down com-
pletely, they develop that stubbornness. They can transfer
this stubbornness to other parasites, just like stubborn
children can make other children become like them.”
Although this particular metaphor might raise ethical objec-
tions, the idea of using local metaphors or appropriate
analogies in health communication has proven to be work-
able (Nichter and Nichter 1989).
Among the health staff in and outside the MOH, with whom
we discussed the possibility of teaching children about medi-
cines, opinions were also split. Local health workers and
nurses often welcomed the idea; others raised valid concerns.
Their concerns focused on the dangers of:
(1) further undermining drug control legislation;
(2) enhancing an existing tendency for over-medication; and
(3) the unintended consequences of education on treatment,
creating ‘lots of little doctors’, as one of the interviewed
nurses put it.
These concerns will each have to be taken into account when
planning educational interventions:
(1) Close collaboration with the MOH, as well as with drug
authorities, is necessary to ensure complete agreement
between teaching and legislation.
(2) Teaching needs to focus on issues of overuse and over-
dosing as well as correct dosages; given the scarcity of
resources, children should have an interest in using
medicines as little and as efficiently as possible.
(3) This is an important warning, since Meinert’s research
shows how health education enhances the competence
and activity of children’s health action far beyond the
content of the educational messages themselves (Meinert
2001). Medical knowledge, however scanty, is a resource,
which people try to make maximal use of. This is illus-
trated by the omnipresence, in East Africa, of injection-
ists with no formal training apart from their employment
as hospital subordinates or medical research assistants.
Again, this tendency has to be balanced by an emphasis,
in the teaching, on the dangers of medicines. Unintended
effects of this kind must be monitored when educational
interventions on medicines are implemented.
Education on medicine-use
The prevention of disease should remain a paramount goal of
public health policies. But the discrepancy between children’s
practice and schools’ ideas about health illustrate that the
available health education is insufficient to enable children to
deal with the health and illness situation they face in their
everyday lives.
The preventive focus of current health education is based
on an idealistic conception of the local health situation,
neglecting problems rather than facing them (Meinert 1998).
This approach seems characteristic of official (especially
educational) discourses in Uganda and Kenya. The long dis-
cussion about sex education in Kenyan schools is an example
of this. Despite widespread teenage pregnancy and a growing
367
number of young victims of AIDS, some representatives of
churches and the government continue to refuse to include
contraception and safer sex in the primary school curriculum,
arguing that increased knowledge would incite the children to
engage in sex. Research has shown that this is not the case;
children who have received education on sex and AIDS
generally delay their sexual debut and/or practice safer sex
compared with children who have no sex education (WHO
1993).
In Uganda, AIDS has been given special attention in the
School Health Education Programme since recognition of the
epidemic. The Ugandan government’s openness about AIDS
and the health communication and education programmes
that have been implemented, together with other factors,
have been associated with a reduced incidence of HIV infec-
tion (Barton and Wamai 1994). The openness shown by the
Ugandan government in the field of sex education could
benefit broader health education as well. Moreover, the
experiences gained in Uganda could provide information and
inspiration for the current revision of the Kenyan school
curriculum.
An ethical educational policy, which takes seriously the aims
of schooling and health education as quoted above, must
leave behind the paternalistic legacy in educational and
public health thought. It should depart from the existing
situation and include children in the ‘acceptance of greater
responsibility for health by communities and individuals and
their active participation in attaining it’, as demanded by the
Alma Ata declaration (WHO 1978, p. 39).
The authors therefore propose that health education on the
use and misuse of medicines should be added to existing
health education from primary school onwards, especially in
developing countries where self-treatment is common and
sources of information are scarce. This should take school-
children’s knowledge and use of herbal and hospital medi-
cines as its point of departure and adjust its teaching to the
medical reality the children live in. It should include the
potential and risks of traditional herbal remedies as well as
information on the appropriate use of common pharmaceuti-
cals. The initiative should, of course, be based on careful
studies of medicine use in specific local settings. Teacher
training programmes and education materials should be
developed in collaboration with teachers, children and health
workers, in order to represent the interests of all stakehold-
ers involved. Similar suggestions have been made for the UK
(Dengler and Roberts 1996), and a need for this kind of teach-
ing has been shown by various studies (Trakas and Sanz 1992;
Bush et al. 1996; King et al. 1996), but no appropriate edu-
cational measures have been taken yet.
The minimum goal of school-based education about medi-
cines should be to create awareness among schoolchildren
about the risks and potential of any treatment and the power
of medicines, be they herbal or hospital medicines. With
regard to herbal remedies, it ought to encourage the children
to learn about medicines from older family members and to
value their skills, while at the same time stressing the import-
ance of using herbal medicines as cautiously and responsibly
05 Geissler (JB/D) 9/11/01 1:10 pm Page 368
368 P Wenzel Geissler et al.
as any other medicine. Similarly, children should learn about
the consequences of misusing the most widely used commer-
cial pharmaceuticals and about the correct dosages and indi-
cation of some of these drugs. Drugs used for the treatment
of malaria – antimalarials, analgesics and antipyretics – will
be particularly important here.
Given the wide distribution of pharmaceuticals with a
variety of brand names, it would be useful to teach children
the differences between these medicines and the distinction
between generic and proprietary drugs. The fundamental
difference between drugs against symptoms, like analgesics,
and those against the disease itself, like antimalarials, ought
to be taught. What should be learned, and at what age, will
have to be discussed for different medicines, and will vary
greatly between different target populations. While for
analgesics appropriate use can be taught easily, antibiotics
entail greater risks. The content of education about medi-
cines will thus need a balance between the established drug
use patterns of the children and their communities, and the
risks as assessed by medical professionals, teachers and the
children’s caretakers. Public discussion about the aims and
content of health education is required to achieve such a
balance.
Education about medicines needs to be integrated into the
existing education and health policies through collaboration
with different agencies and agents. The authors are presently
setting up an intervention study in Kenya, in which education
on the management of fevers and malaria, including the
appropriate use of medicines, will be implemented and evalu-
ated in a controlled trial in a number of primary schools. The
preparations for this intervention study will be undertaken
after consultations with children, parents and teachers in the
respective areas. They will involve representatives of two div-
isions of the MOH, namely the Division of Health Education
(DHE) and the Division of Vector Borne Diseases (DVBD).
Both divisions are represented in the National Malaria
Control Programme (NMCP), which coordinates the efforts
of different ministries and NGOs in malaria control through
its Malaria Control Unit (MCU). The DHE is currently
involved in the development of new ‘information, education
and communications strategies for the promotion of health by
community members’. The DVBD has been the national
centre for the control of malaria and other infectious diseases
for most of the past century and has expertise in all aspects of
malaria control. Within the Ministry of Education and
Human Resource Development (MOE), the School Health
and Nutrition Section (SHN) is responsible for health and
nutrition in Kenyan schools, including curriculum develop-
ment on these issues. Also linked to the MOH is the Kenya
Institute of Education (KIE), which provides expertise for
curriculum and schoolbook development and edits the stan-
dard textbooks used in primary schools.
Representatives of these government bodies on the national
and the local level and the National Drug Authority need to
be consulted and their expertise and opinion sought in the
planning of the intervention. In addition, a variety of UN
organizations and NGOs are working within health education
and malaria control in western Kenya and possess experience
and knowledge that is valuable for an innovative educational
intervention. The example of this broad institutional frame-
work illustrates the need for a consultative process involving
different stakeholders in the preparation and implementation
of school-based education on medicines.
Education about medicines in primary schools could con-
tribute to an improved drug use and activate children as
agents of medical care and of a changing health discourse.
The ‘child-to-child’ programme has explored some ways of
involving children in community health with some successes
(Haws 1988). Approaches based on children communicating
preventive health messages to parents and other adults some-
times face difficulties, because of children’s lack of influence
on household decisions (Meinert 1998). The children’s
activity in the curative field might provide new grounds for
child-centred initiatives on community health. Concrete,
applicable skills for the treatment of acute illness may be
more readily acknowledged and used by adults than long-
term, labour intensive preventive measures like latrine-build-
ing.
Education on medicines must provide knowledge for medi-
cine use as well as against it. It should raise awareness about
the ‘commodification’ and ‘pharmaceuticalization’ of health
(Whyte and Birungi, in press), and provide information on
the economic interests connected to the spread and market-
ing of pharmaceuticals. It should emphasize that medication
is not a solution to ill-health, and that only effective resource
distribution, improved infrastructure, active prevention and a
functioning health system will have a long-term effect on
health. In other words, it must not advocate a further ‘medi-
calization’ of social, economic and political problems, which
have their roots in poverty and unequal distribution of wealth
(Illich 1977; Scheper-Hughes 1992, pp. 195–212), but create
critical awareness alongside concrete information and skills.
The topic of pharmaceuticals not only provides an oppor-
tunity for education on illness and treatment, but also invites
teaching about the broader context of health and illness in
global economic and political relations. Education on medi-
cines does not provide a ‘magic bullet’ against the misuse of
medicines, and it will not improve children’s health practices
by itself. Changes in knowledge by themselves rarely lead
directly to improved practices (Yoder 1997). Economic and
other contextual factors limit changes in practice, and an
improved school curriculum will not change these. If, because
of poverty, a child is confronted with the choice between an
insufficient treatment, which nevertheless will alleviate her
suffering, and no treatment at all, she will choose the former,
even if she knows the right drug or dosage. However, in the
given situation of widespread use of hospital medicines by
children, the introduction of education on medicines in the
primary school curriculum will contribute to a gradual
improvement in health care practices and, eventually, in the
health of school-age children.
Endnotes
1 In this article we use the term ‘hospital medicine’ for indus-
trially produced and marketed materia medica (medicinal materials)
in contrast to local herbal medicines or religious healing rituals. This
05 Geissler (JB/D) 9/11/01 1:10 pm Page 369
Self-treatment and health education of schoolchildren
designation is the direct translation from the local terms among the
Luo – Yath osiptal – and Iteso – Ekeya lokadakis. Descriptions of
medicine-use in pluralistic medical systems often use ‘biomedicine’,
‘western medicine’, ‘cosmopolitan medicine’ or ‘pharmaceuticals’ to
designate medicines linked to the medical tradition that emerged in
Europe after the eighteenth century, and that today are commer-
cially produced and sold on global markets. There are some prob-
lems with all of these designations. The designation ‘western’
detracts in our view from the fact that people everywhere in the
world have appropriated these medicines into local practices;
‘cosmopolitan’ suggests a unity of medical practices and ideas
associated with these medicines, which cannot be assumed, as people
give varying meanings and use to medicines in different contexts;
‘pharmaceuticals’ implies that herbal medicines would work in a
non-pharmacological way, which they do not necessarily do; ‘bio-
medicines’ refers to the links that these medicines have to the-
‘biological’ thinking that dominates European medical and scientific
discourse and does not account for the fact that medicines may be
moved away from this epistemological context and into an other. All
these terms tend to unify heterogeneous ideas, practices and sub-
stances in an undue way, which is why we mainly use the emic term
‘hospital medicine’ here.
2 For example, Homanol (gen. panadol) and Homaquin (gen.
chloroquin) – both deriving their names from Kiswahili homa, which
often is translated as malaria – were indiscriminately used by Luo
children for common cold, which in western Kenya is often referred
to as homa.
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Acknowledgements research interests are childhood and health, especially in Eastern
Africa.
We want to thank the children of Bar-Awendo and Majengo
Primary Schools in Kenya and of Asinge, Kwapa and Apuwai Jessica Jitta is Director of the Child Health and Development Centre
Primary Schools in Uganda, as well as their parents and teachers for at Makerere University, Uganda. She is a medical doctor with a
their co-operation. We are indebted to the field assistants Philister specialization in paediatrics and is a Senior Lecturer at Makerere
Adhiambo and Collins Omondi in Kenya and Aja Michaeli, Pius University. She is Chair of the Committee on Health Research under
Emojong and Agnes Akuleut in Uganda. Professor Susan Reynolds the National Council for Science and Technology. Her research
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Self-treatment and health education of schoolchildren 371

interests include: nutrition, mothers’ perception and management of
children’s illnesses, and health care systems.
John H Ouma is the Head of the Division of Vector Borne Diseases,
Ministry of Health, Kenya. He was trained as a parasitologist at the
University of Nairobi and the Liverpool School of Tropical
sMedicine, and obtained his PhD with a study on helminth infections
in Kenya from the latter. He has conducted research on parasitic dis-
eases in East Africa for the past 20 years, and is actively involved in
health policy, including malaria control, in Kenya.
Correspondence: P Wenzel Geissler, Institut for Antropologi,
Fredriksholms Kanal 4, DK-1220 Copenhagen K, Denmark. Email:
wenzel.geissler@anthro.ku.dk