In this chapter I explore the relationship between texts and literacy practices within the Hout Bay Day Hospital. I argue that texts are always located within particular social contexts and that understanding literacy involves studying both the texts and the practices surrounding the texts. It is not my intention to provide an inventory of the numerous texts encountered in the clinic, but rather to provide a narrative of texts and literacy practices and the manner in which they are discursively constructed within the various domains of the clinic. It became necessary to extract and analyze certain texts and literacy practices in order that their embeddedness in the institution and fabric of the social life of the patients could be explored. In a social literacy approach, texts and literacy practices are inextricably intertwined. In my findings they were however not always linked. There were numerous texts around, but they were often isolated and removed from practice. They literally formed the "walls of the institution" but little else.
Baynham and Street's definitions of literacy practices emphasize the ideological and culturally contested nature of literacy practices :
Investigating literacy as practice is not just what people do with literacy, but also what they make of what they do, the values they place on it, and the ideologies that surround it (Baynham 1995: 1).
Thus even though interactions with most texts were not visible, their presence and the manner in which they were often displayed represents an implicit ideological position.
I propose to examine the ideologies and discursive formations around these texts by posing the following questions:
· What do the texts represent in this space?
· How are they received by patients?
The fact that there is very little interaction with texts in the sense that there is minimal visible reading and writing opens up the space for variations of literacy practices. I argue that patients use certain genres of communication which are not standardized medical discourse but rather their own local vernacular practices.
In popular discourse the day hospital refers to the people who run the hospital, those who attend it, and to the building that symbolizes its presence. The day hospital positions the subject, whether patient or staff, and locates them in a socially constructed space. 1
The Day Hospital is situated on the ascent of the hill in close proximity to the Hout Bay harbour. In contrast to the nearby mosque, library and school, it is a small unimposing single storied building. The genre of architecture blends in well with the surrounding residential area. There is no signpost indicating the location of the day hospital, yet there is a signpost for the library, Apostolic and Catholic church. I later ask a patient and staff member if they are aware of any sign giving directions to the hospital and whether I may have overlooked it.
Their responses are :
Patient: Well, we all know where it is.
Nurse: Most patients know where we are and most patients have no cars.
Both these statements would endorse the view that the hospital requires no signposting. I focus on the lack of outside signage as I feel it has symbolic significance. There is a causal connection between the community's location on the social and economic margins of the greater Hout Bay area and the clinic as health care provider. Both are situated on the socio-economic margins in terms of geographical location and in terms of the organization and hierarchical structuring of the public health care system.
The minibus taxi rank is situated further down the hill. There are people milling about and a few taxis are parked at the taxi rank. Schoolchildren are walking up and down the hill, a phenomenon to which I was to become accustomed. No matter what the time of day there were schoolchildren on the streets and I was often to meet them at the hospital. Furthermore there is always a steady flow of men, women with babies, and older people walking up and down the hill. The neighbourhood assumes a rhythm of its own. Some men are sitting on the pavements talking and some are standing in the street or in the small parking lot and driveway of the hospital talking and smoking. Women are talking over fences and hanging up washing. Children are riding bicycles or skate boarding up and down the street. One's senses are bombarded by the smells of the nearby fishing factories,(depending on the wind) the hooting of cars and minibus taxis as they speed up and down the hill, dogs barking, children crying and the sound at noon of the muezzin calling the faithful to prayer. These sounds often filter through into the day hospital. The muezzin's noontime call to prayer reverberates throughout the entire hospital, all other sounds are for a brief period, drowned out.
The Day Hospital, where all services and supplies are provided free of charge, is easily accessible to most people living in the community. It is a social nexus for many people residing within the community. Patients frequently refer to the day hospital as part of their "family and home". Likewise, within the community, similar sentiments are voiced. Thus it would appear as if the Day Hospital has been incorporated as part of their social world. The assumed division between a medical institution and the outside world or community has become blurred. I am not however suggesting a pristine community untouched by outside influences. Apart from the youth, most residents rarely venture forth outside of the community. People go to a nearby suburb Wynberg to "Coloured Affairs" to collect their pension or disability grants or to outlying hospitals for maternity and other medical care.
In drawing up rudimentary kinship systems, I have often been able to record at least four generations of kin still residing in the Hout Bay area, this further reinforces the notion that family structures are stable in that there is little movement in and out of the area.
The hospital is set back from the road and entry is made difficult by a narrow entrance and a winding driveway that is only able to accommodate one motor vehicle at a time. The manoeuvring of cars in and out of the small parking area which doubles up as a back yard and general meeting area is part of the daily routine of the hospital. The hospital cleaner has assumed the role of informing staff and visitors when to move their cars in order to allow other cars to enter. A security guard sits on a chair in the front parking lot and occasionally propels himself around in one of the wheelchairs. I find this rather odd and am surprised that no- one has reprimanded him for this action. This further conforms to the notion of how people have informalised the hospital space.
One enters the hospital from two possible entrances, there is no sign demarcating the entrance or the exit. The door is permanently open to the general public and is only locked at the end of the day with the closing of the hospital. The entrance and exit assume symbolic meaning because in numerous ways they embody the dynamics of the social practices present in the day hospital.
The boundaries represented by entrance and exit are not clearly demarcated, nor are they permanent entities but loosely constructed. The physical and structuring devices of the entrances and exit (doors, locks and signs) have been informalized by both staff and patients in their often free movement entering and exiting the hospital and in their refashioning of the practice of queues and appointments.
The procedure at the reception desk which requires patients to register and fill in forms, the queue structure and the signage in the reception and other clinic areas, is all part of the induction process into the medical institution. One cannot be seen by the doctor without following these formal procedures. Yet as I argue throughout, the formal frequently becomes informalized by patients. The everyday process of entrance and exit, becomes part of an alternative cultural response to the formal practices of the institution. Patients as well as staff, operate within this system of flux.
The medical institution and the social world of patients are not two distinct fixed entities but have periods of contradiction and intersection. The everyday life practices of the patients have been integrated into the daily functioning and ordering of the hospital. Patients "hang about" and meet friends, children run in and out, all these alter the sense of structured order typical of medical institutions. The patients do not always conform to the medical institution's demands for discipline. The medical staff repeatedly instruct patients to lower their voices, to stay in the designated areas and to wait for their turn and name to be called out.
A nurse yells above the din of voices:
If you don't keep quiet you won't hear your name being called and you will have to come back again tomorrow. So please try and be quiet.
She further elaborates :
Patients often wander outside and then it becomes difficult and time consuming. We have to send someone to look for them outside. As a result of this, they often miss their turn.
This procedure has been recently modified. Patients are now given their own medical folders and sit on the benches outside the doctor's office with their files.
A further indication of the often informal entrance into the hospital is the continuous movement of patients, children, friends and dogs in and out of both the entrance and exit. There is a constant stream of movement between entrance and exit as people drop by to greet staff, attempt to locate a friend, or relay a message. Some patients often merely come to "hang out" expressed colloquially by Piet and Brandon :
I meet two young men, sitting outside the dispensary with a ghetto blaster and a large dog. They are sitting separately from the other patients. Piet has a scar over his right cheek. I ask him if he is ill and whether he is here to see the doctor.
Piet: I am here waiting for my girlfriend. I will meet my girlfriend here, she has to collect her pump for her asthma.
I ask his friend Brandon, if he is also waiting for medication.
Brandon: No, I am at school.
Ethnographer: Aren't you supposed to be at school?
Brandon: It is now our break time.
I realize that he is playing truant and that there are no other schoolchildren around.
I discover later, that there is a problem in dispensing medication in his girlfriend's absence. I overhear the nurse saying : "It is illegal, your girlfriend must come and get her own medicine".
Piet appears to accept this situation without any resistance and leaves shortly afterwards. I ask him what he plans to do now. He replies: "don't worry, we will go and hang about and she can come and get her own asthma pump. It's not a problem".
Piet and Brandon were quite happy to pass the time sitting in the day hospital with no real purpose in mind. A visit to the day hospital was an outing which included bringing along the ghetto blaster and their dog, forming part of the daily routine of hanging about in the neighbourhood.
The day hospital is divided into two distinct sections, one falls under the Cape Provincial Administration (C.P.A., the medical section ) and the other falls under the Southern Peninsula Municipality which runs a Primary Health Care Clinic consisting of the Family Planning Clinic and the Mother and Baby Clinic. Other services include a monthly Psychiatric Clinic, weekly Dermatology and Dental Clinic and twice monthly Termination of Pregnancy clinic and counseling. Patients are then referred to a state hospital where abortions are performed. There are no visiting or district nursing services.
The clinic is designed so that one enters a large waiting room with a glassed-in reception area. Behind the reception desk is the receptionist's office filled with large filing cabinets containing the patients' folders and files. In contrast to the outside waiting room there is a sense of order and an air of importance.
The waiting room is large and starkly furnished with long rows of wooden benches all facing in the same direction. There are numerous posters on the walls. To the left and in the corner is a small window which opens into the dispensary where there are two wooden benches for people to sit on while they wait for their medications.
All medications are dispensed by a nursing Sister. There is a general sense of order and efficiency.
This space is reserved for medical treatments such as wound dressings, blood pressure and weight monitoring and breathing treatments. The powerful symbols of medicine and its technology create a sense of authority and presence. This is a well defined space where the boundaries are clearly demarcated between the formal medical domain and the outside world. The room is dominated by numerous medical artifacts; a large oxygen cylinder, instruments for measuring blood pressure, for examining eyes and ears, needles, syringes, bandages and numerous items used in the practices of writing, diagnosis and corporeal description.
My observations and interviews in the Family Planning and Mother and Child clinic took place in the space outside the nurse's consulting room. The area assigned to the initial entry into the Family Planning clinic is situated in the corner of the waiting room near one of the exits. This space is furnished with a large wooden table, on top of which is a box containing the patients' files and another into which patients place their family planning appointment cards.
I have provided a description of the spatial location and design of the different spaces within the clinic. This section introduces the various texts and corresponding literacy practices within four discursive domains; the Reception and Waiting room, the Dispensary, the Baby and Family Planning clinic and the Treatment room. I have not only focused on the family planning clinic as many of the women move between these other domains of the clinic often for related medical problems.
The term domain as used in sociolinguistics, refers to "spheres of activity" which are under the sway of "one language or variety"(quoted in Grillo 1989: 4). Barton (1994), uses the term to explore the position of literacy, as opposed to language. Different literacies are associated with different domains of life, such as home, school, work and church. There are different places in life where people act differently and use language differently. I work with Baynham's concept of domains of literacy ; "as social space in which literacy practices are embedded" (1995:68) as it provides an initial `structuring' of the social context of literacy practices in the clinic. Each domain does not necessarily have its own distinct literacy practices. Many literacy practices emanate from the domain of the home and penetrate other literacy domains. The home is the centre from which individuals venture out into other literacy domains. I argue that the "community" as an extension of the home is always present in the discursive domains of the clinic.
I attempted to link texts and literacy practices to specific domains of literacy to provide a more coherent understanding of the diverse practices encountered. However, identifying or linking domains with literacy practices has the potential of creating fixed and static entities allowing for little movement, interaction or overlap between domains. I take cognizance of this and hope to indicate through my data how certain literacy practices assume differing meanings and intent in the different domains.
In mapping who does what reading and writing in this domain and in the day hospital in general I come to the conclusion that most reading and writing is performed by nurses, doctors and the receptionist. Thus literacy depicted by the encoding and decoding of texts is performed by representatives of the medical institution, within the dominant medical discourse.
The reception area and waiting room form the nexus of bureaucratic practices and literacy practices, yet very little reading and writing is performed by patients. This is the official face of the institution. It is here that the patient is constructed bureaucratically and `read' and recorded into the medical institution. The performance at the reception desk, the bureaucratic transactions of registering, filling in forms, being seen in the correct order and according to disease stratification "emergency's first" and signage, all replicate in miniature Goffman's (1961) description of the total institution.1 These induction procedures are similar to Goffman's descriptions though more integrated into the patient's everyday life structures.
The official intent is to separate and remove all forms of writing from the patient as part of the process of induction into the medical institution. All writing is performed by the receptionist and by the medical staff. These normalizing textual procedures are the first attempts to register the patient as an institutional text within the record-keeping circuits of the institution. These normalizing procedures consist of being assigned a number, a place in the queue structure, and a disease typology.
I identify different genres of visually displayed texts in the forms of signage and notices, official texts, posters and other miscellaneous visual displays. The entire reception area is surrounded by handwritten notices and signs, authority is designated by these official signs. In entering this space, patients are confronted with a display of signs situating them physically inside a particular world of signs.
In contrast to the outside space where the only signage is a small printed sign stating Hout Bay Day Hospital, the signage in the inside space is prescriptive. This is evident in displays of notices ranging from:
· Please bring your appointment card when you attend this hospital. It is important to take care of the card. Keep in a plastic packet in a safe place or in your ID book. If you lose your card write your name and folder number on a piece of paper and place in box. A fine of 50c will be requested from patients who lose their cards. Thank you. Sister in charge.
· Attention please : Please sit in the waiting room until your name is called by the staff
· Patients who do not respond when called will be required to wait until remaining patients have been seen by Doctor. Thank you Sister- In -Charge.
· Please use the bins.
In spite of the prescriptive tone of these notices, patients have negotiated a situation whereby the rules and regulations are not strictly enforced. I observe that the rules are frequently waived as many of the older patients who have forgotten or misplaced their appointment cards and who are known to the receptionist are seen by the doctor.
Thus, many of the older patients who are unable to remember their folder number are still able to by-pass the need for formal schooled literacy.
The entire reception area is glassed-in with the exception of a small area through which the receptionist is able to place her head and converse with patients. The manner in which she is physically positioned behind a glass window surrounded by signage and official texts provides a form of structural distancing.
The central figure in this domain is "Sister Pam". She is not a nursing Sister, but is called Sister, due to her religious affiliations and hierarchical positioning in the hospital. She is surrounded by bureaucratic and official discourse and text. All writing is performed by the receptionist who becomes the literacy mediator between the patient as bureaucratically constructed and the institution. In addition she is the official gatekeeper having direct access to the artifacts of medical literacy ranging from the folders, files, forms and clinic cards to communicative technology, the fax and phones. Yet her position is also one of local literacy mediator. She is a familiar and respected figure in the community, yet her position as literacy mediator and as official gatekeeper is constructed by relations of power. As representative of the dominant institution and gateway to their resources, Sr. Pam, as literacy mediator, has a particularly authoritative voice. She decides whether patients who have not followed the correct procedures can still be seen. This can be seen in an incident with a woman I had interviewed. She arrived late, yet requested to see the doctor urgently as her infant was ill. She appealed to Sr. Pam who subsequently directed her request to the nurse- in -charge. The child was subsequently seen by the doctor.
Interwoven with power relations are the processes of literacy mediation. Sr. Pam performs the task of what Schiffrin (1994) has referred to as the "writing for the other". Schiffrin1 shows how experts in formal codes and modes of communication do the reading and writing for clients and relates this process to a particular "self \ other alignment" which defines communicative roles. The formal institution makes use of standardized modes and codes of communication such as forms, files and other medical documents. The clerk or nurse is expert at translating the local or vernacular discourse into formal register or bureaucratic discourse. The clerk is familiar with the bureaucratic codes used and performs the function of writing for the other, other being the patient. This writing for the "other" is not merely a convenience as claimed by Sr. Pam, but is linked to the process of induction into the medical institution and lends to the general order, discipline and structuring of the clinic. Thus practices of induction such as temporal scheduling, spatial organization and body surveillance by the medical institution are exercises in, and displays of the power of institutional literacy, with which the patient must conform. The following instructions are displays of institutional literacy with which the patient must comply.
Positioned alongside the reception window is a box consisting of three compartments with a hand-written sign attached to it with the inscription:
· Pille
· Dressing
· Dr.
I describe below, from my fieldnotes, impressions and the hidden literacy practices observed.
Patients are instructed to place their cards into the appropriate compartment.
Patients follow the procedure of registering at the desk, producing their clinic cards and placing them in the appropriate box. Occasionally this procedure is not followed and Sister Pam organizes the cards accordingly. The only writing I see is the patient's signature on hospital forms or receipts. The patients who can read and write, also have their forms filled in because according to Sr. Pam: "It is much quicker. I don't have time because nothing is computerized, everything is done manually. So, I don't worry if they can write or not. I am too busy to wait for them to fill in the forms with each visit. Anyway, I know many of these patients, they have been coming for a long time.
Thus bureaucratic transactions are at times personal and most patients are well acquainted with Sr. Pam who has strong community ties. Her house is situated in close proximity to the hospital. According to the Sister in charge, Sr. Pam knows most of the patients by name as she is a key figure in the Baptist church and "zealous in her recruitment efforts".
All official texts such as patient's files, clinic cards, registration cards and receipts play an important part in the daily rituals of the hospital. It is not required or expected of patients to be able to engage with official texts in the form of standardized reading and writing capacities. Patients have learnt, through mobilizing their own vernacular literacies,1 which texts have currency, and which do not. Which texts are important vehicles for gaining access to health care entitlements and which are of lesser significance. This has become an acquired practice and part of what I term the culture of entitlement and the ability to work the system. Important texts are kept in safe places. I notice that one woman keeps her clinic cards in her brassiere and another patient keeps it in a suitcase under her bed filled with other important documents. Therefore in looking at the relationship between literacy practices and texts, the focus is on how patients use medical texts and literacies to negotiate and mediate their position within the clinic.
The relationship between literacy acquisition and socially embedded literacies is crucial to an understanding of literacy practices within the hospital domain. The literacies are embedded in the daily social practices of the patients and part of the logic of everyday hospital practice and procedure. Patients have acquired these discursive skills through practice and routine such as placing their cards in the appropriate box, returning on a certain day and taking medications at a specified time.
An example of separation from the medical texts is the patient's interactions with official texts. There is very little contact with the official texts represented by files, folders and recorded medical details. These documents are always written on by representatives of authority and never by the patient. These medicalized texts belong to the medical institution, and are part of the ordering, classifying and quantifying apparatus of the institution. They are emblems of power, becoming part of secret knowledge and integral to the functioning of the institution. They are the literacy practices that are hidden from the patients. This system of keeping the patient's files separate has recently changed. I note that patients now sit outside the doctor's consulting rooms with their medical folders in their hands. Some of them are flipping through their files and reading. I ask the nurse in charge what is happening as this is the first time that I have seen patients having access to their own medical files. She states that they should be familiar with their own medical history and many of the patients feel a sense of self importance. Furthermore this change has facilitated the waiting process and helps the medical staff get through the heavy patient load.
However, many of the elderly patients are not able to read and if they are a lot of what is written is in medicalised code and abbreviations that is very much part of medicalized discourse and in a language, English, which they are not necessarily fluent in.
Pamphlets and posters are delivered by different organizations and are placed by the staff in various spaces, mainly in the space reserved for the Family Planning clinic. I notice various pamphlets distributed by the Association for Voluntary Sterilization of SA, and pamphlets on various STIs such as herpes, gonorrhea and syphilis. Outside the family planning clinic is a timetable with the days and times of the family planning and child health clinics and a poster with emergency telephone numbers such as Lifeline, Rape crisis, Nicro support center, Safeline and Childline. These emergency telephone numbers are a reflection of the increasing domestic violence occurring in the community .
The appointment cards, Baby clinic and Family Planning clinic cards are fixed texts, the texts that have the most currency. There is a sense of permanence and ordered logic in the manner in which they are interacted with. Patients remember to bring them, place them in the correct containers and follow the procedures by placing them in numerical order as part of the queue structure. There is a permanence and temporality to these cards, they position and structure identity and enable access to health care entitlements. The dates and times inscribed on the cards inform clients to return every two or three months for their contraceptive injection. This is an important event, as it safeguards their reproductive status.1
My initial understanding was that patients were not interacting with these texts. Few patients knew the name of their contraceptive injection nor voiced concern that they did not know. Yet most were able to read the name Depo- Provera off their clinic cards. As events began to unfold I realized that patients followed the registration procedures which required simple numeracy practices and returned timeously for their injections. This appeared to be a contradictory situation, on the one hand they interacted with these texts, in safekeeping their cards and by remembering when to return, yet on another level they did not interact by reading or memorizing the name of their contraceptive injection. I soon discovered that this was not necessarily a paradoxical situation, the medical domain had usurped this literacy practice by not informing or educating patients about the name, side effects and how the contraceptive works. Thus through the construction of expert medical knowledge certain literacy practices had been appropriated by the discourses of medicine and consequently patients were placed in a position of distance from their own bodies. Recordings in my fieldnotes begin to deal with this apparent contradiction.
The staff are busy preparing the space for the Family Planning clinic. In the corner of the waiting room is a table with a large box containing the patients' files and another into which patients place their appointment cards in numerical order. Everyone appears to have a good grasp of this system. There are two weighing scales, one for adults and one for babies. The cards are numerically ordered in piles. Procedures are clearly structured by means of rows, queues, cards and folders which not only simplify matters for the staff, but give the patients the security that they can rely on the system and will be seen in an ordered fashion. The nurse calls out their name, they are weighed and then proceed into the Sister's office where she records the patient's blood pressure and administers the contraceptive injection, Depo -Provera or Nur Isterate. There is little verbal communication between staff and patients. They are not informed of their blood pressure nor do they ask. One of the side effects of Depo -Provera is weight gain, yet none of the patients seem to comment on this phenomenon, with the exception of one patient who claims: "I don't worry if I gain weight. It's better to be safe.
Patients enter a visual system of posters displayed on the walls of all domains. There is no vacant or empty wall in the entire hospital, even the kitchen has posters on the wall. Posters are numerous, varied and with no real logic or order. They are often randomly placed as confirmed by the staff. These visual texts are not visibly interacted with, yet returning to my previous conceptualizations of literacy as explicitly or implicitly ideological, the display of posters on the walls can be viewed as a display of medical identity and hegemony. They construct the patient in a world of visual imagery which is varied and often imposing in the choices of visual display.
Most patients need not actively engage with any of these posters and in all my interviews most patients did not relate to any of these forms of visual display. Yet in spite of these overburdened significations, visual display did have an important part to play in the construction of the day hospital as a community and medical space and I will now explain how.
Posters form the walls of the institution as part of the institutional display and the manner in which the clinic is presented as a space for public health discourse and prescription. These spaces have become overburdened with meaning through the abundant visual displays. They have consequently lost their impact in terms of their educative function, but have provided and created a space which positions the patient and staff into a medical space of public health discourse.
Sister G recalls the time when all the posters were removed from the walls and how they were subsequently empty for two weeks. Patients did not notice these changes. When asked if they had noticed anything different they had said, No. However, Sister A states that :
During AIDS week when we put out new posters, we had some response. A few patients looked at the AIDS posters and asked some questions.
This was later confirmed by a patient during an interview.
I don't really notice these posters. But those ones about AIDS and such things are important and the young people should read those things as well.
Recently the situation has changed somewhat as primary health care initiatives becomes more entrenched. Throughout my fieldwork I was to notice a regular change of posters corresponding to government and health department initiatives such as World AIDS Day, World No Tobacco Day and Pregnancy Education week, plus various mission statements of the restructured health department using Alma Ata guidelines. These visual displays are manifestations of spaces of visual and material representation providing the capacity for creating and claiming this space as official hospital space signifying their sense of power.
Literacy practices in this discursive domain centre around the administration of medications. The most visible literacy practices are the nurses' instructions, both verbal and written. Instructions with regards to dosage and frequency are printed on plastic packets. The administration and instructions around medicines are brief and hurried. They are often provided in the form of a narrative such as; "this is the pill to make you strong", or, "this tablet is for the sugar sickness". The former refers to a multivitamin and the latter to diabetes. In other instances nurses provide instructions that are connected to time spacing, colour coding and identification according to somatic and locally shared meaning codes between staff and patients. Patients use certain genres of communication in their narratives, and in their identification of their medications and treatment. The communicative or linguistic codes such as; the pills for "sugar diabetes", the pills for "water", the pills for "high blood or "hoe blood druk" and medicine for "double pneumonia" are examples of local non- standard vernacular medical terminology used by patients and frequently by the nurses in their explanations. Nurses express the desire to provide an educative function when dispensing medications reflected by the following comment from the nurse in the dispensary. "It is here that I would like more time for education and teaching patients but there is no time. We are always pressed for time".
What is important in terms of my argument is that literacy as reading and writing, is not in the forefront of these transactions. Patients do not appear to read the instructions or names off the medicine labels. Many patients however were able to read the instructions off their medicine bottles and if asked were able to identify their various medications. It was often through practice and locally shared meaning codes that patients identified their medications and their corresponding illnesses, illustrated by the following statement:
I know this bottle is for the "hoes"1 and this bottle is an antibiotic which I keep in the fridge. You see, as every few months my child needs this medicine. You know, he was born like this, always with a runny nose and chest problems.
The concept that there is no visible reading and writing opens up the space for variations of literacy. Camitta (1993) in her study of adolescent writings produced outside of the school environment argues that vernacular discourse is derived from "folk or popular traditions" and a lack of conformity to the standard. By vernacular writing she refers to writing that is traditional and indigenous to the diverse cultural processes of communities as distinguished from the uniform standards of institutions.
I argue that the vernacular literacy practices employed by patients such as evidenced by two sisters from Kronendal farm (discussed below) are in response to dominant medical discourse and are closely allied to everyday life practices. I meet two elderly sisters from Kronendal farm, both had never been to school.
My sister is here to see the doctor for her "nerves". Ethnographer: Do you have an appointment to see the psychiatrist? Yes, the letter is with the doctor. Ethnographer: What does it say? She replies: I cannot read. But I know that I must bring my sister for her appointment to see the doctor because she is unable to talk. She understands everything but cannot talk. We talk our own "dom taal."1 I ask how she manages to take her medications. She responds by identifying medications through size, shape and colour and distinguishes the different time sequencing. This is based on establishing a relationship between the main social activities of her day; (eating and sleeping) and those which correspond with the spacing of her tablets: You see they did not give me the name of the medicines so I have my own system. You see I take the white one, the one for high blood; one- one and then half. The small yellow one is for the "water". I take it one and one, in the morning and as I sleep.
The taking of tablets is not necessarily centred around or dependent upon being able to read the labels or linked to clock time, but is structured around daily social practices. Thus the focus is on the taking of tablets according to daily social activities and through a form of visual literacy, (through colour coding, shape and size ) and not according to standard medical instructions such as decoding or deciphering the print on the medicine bottles.
Alongside the opening to the dispensary is a host of handwritten instructions pertaining to the overuse of medications and as of March 1999 cough medicines will no longer be available.
Outside the dispensary and doctor's consulting room is a large notice board dedicated to AIDS related issues with a sign indicating the current number of AIDS patients. This number is changed on a monthly basis. The abundance and almost exclusive preponderance of AIDS related and safe sex posters is linked to the emerging health care crisis around AIDS / HIV and STIs. The spread of AIDS and STIs has been identified as the most pressing issue in the day hospital.
Currently the most overriding concern to staff in the day hospital is the increasing incidence of HIV\AIDS in the community, mainly localized to the nearby Imizamo Yethu informal settlement. On returning to the Day hospital in 1997, I was frequently alerted to the HIV \AIDS crisis and how it was "getting totally out of hand".2 So much so, that I was asked to help and provide counseling to newly diagnosed HIV patients as the nurses did not have sufficient time to fully explain to patients the implications of their disease process, nor did they have time to provide adequate counseling.
Health care workers and other community and health care professionals in the Hout Bay area have identified HIV\ AIDS as an important health care crises. An AIDS sub-committee was formed in February, 1997 as part of the Hout Bay Health Forum in direct response to this epidemic. The initial meeting of health officials and community leaders was convened by the head nurse of the Day Hospital. Their immediate goals were to provide long term AIDs education, involving health facilities, community workers, service organizations, churches, schools, youth groups, factories, and life skills programmes at the schools, to provide free distribution of condoms, and the early detection and treatment of HIV. In addition, the need for Xhosa- speaking staff at the various health facilities was identified.
Committee members are diverse and include the local high school principal, social workers, doctors, nurses and health care workers from both Hout Bay clinics, traditional healers (Sangomas), pharmacists and other related medical personnel and ministers from the various churches.
A small black book, labeled the HIV Book, is kept in a locked drawer in the dispensary. HIV statistics have been recorded by the nursing staff on a monthly basis since 1995. The most common symptoms that HIV positive patients have presented with are other STIs such as gonorrhea and syphilis, and diarrhea and skin lesions. Gender distribution of the disease is fairly equal. For example, out of a total of 17 for November, 1997, 7 were women and 10 were men, the age distribution for women was 20-28 and 21-38 for men. Racial breakdown reveals two Coloured men and two Coloured women from the harbour community, the remainder are African men and women from Imizamo Yethu informal settlement.
The texts on the walls are directed at the medical staff and are infused with medical discourse. The medical texts, symbols and artifacts claim this space as interventionist medical space. Patients are not required to interact with texts and are positioned in a relationship of dependence with the medical staff. Medical texts centre around the prevention of the spread of infectious diseases, AIDS, tuberculosis and hepatitis and what procedures to follow.
Medical literacy and intervention is experienced at its most intense level in this particular domain. Patients sit passively while their wounds are dressed, vital signs are recorded and their diseases are encoded and quantified into a form of operational medical literacy. The patient is read into the institutional memory as an assemblage of symptoms, signs and behaviors. Expert medical knowledge and technologies through their display of institutional power over patients' bodies have taken away the patients' need for their own literacy practices, whether schooled or local. Patients thus suspend their own literacy practices as expert knowledge is constructed and applied.
In conclusion, I return to my original understanding of literacy that it is not about reading and writing as isolated technical skill, but rather about social practice embedded in relations of power, agency, identity and the material and social realities of patients as experienced and lived.
The encoding and decoding of texts is not the central issue. Patients have, through practice and through their own local interpretations of the various medical texts, decided what it is that they need to know and when they need to utilize their reading and writing skills. These discursive skills have been acquired both through informal practice and in literacy instruction at school. What is more important to the patients is not how to read and write as reflected in their role in filling in forms and their response to reading labels on medicines bottles, or appointment cards, rather it is how patients use their own socially embedded literacies to mediate and gain access to health care entitlements and treatment and the discursive resources that they employ in order to do so.
