The cane or the wife
Kizito Andrew lived with his jolly wife in a relatively large four-room house with a spacious compound and a poultry house where they reared chickens for sale. When the first author, Rehema, initially visited the couple in 2016, they were very welcoming. Kizito spoke enthusiastically about his twenty years as a civil servant back in the 1970s and 1980s. He was cheerful and good-humoured, despite having suffered terrible losses in his life. He told how six of his children died during the civil war in Uganda, between 1980 and 1986, leaving the couple with only three. Of these, one is ‘spoiled’ in his view, as he takes drugs and roams the streets of Kampala without any gainful employment. But another is successful; she lives and works in the UK. It was this daughter who bought the cane to which Kizito was so devoted.
In 2006, on the way to a burial, Kizito was involved in a motor vehicle accident. He was the only survivor, sustaining major injuries including a broken leg and arm. Since then, Kizito has been unable to walk without the support of his cane. At least, that is what he claims. While discussing how useful the cane has been in his daily life, Kizito said: ‘Without this stick, I can’t do anything! I can’t take myself to bed, and I cannot even go to the toilet!’ His wife was eager to share her side of the story about the cane. She thought Kizito had become overly dependent on the cane, and she felt that he needed to start walking unaided: ‘I have tried to convince him to leave that stick and try walking without it but he refused.’ Kizito was not willing to relinquish his cane: ‘I told her that I would rather lose her than lose my stick. This stick is much more important than her!’ Although this sounded a little comical – and, in fact, Kizito said it while smiling – it illustrated how much the stick meant to Kizito and how unwilling he was to let it go. Kizito further explained that elderly men such as himself should always have a stick anyway.
Now that I have a condition that dictates that I should walk with a stick, why should I not use it when I have it? Besides, in our times elderly men of my age would always have a stick. It is a good thing to have; it shows that you are elderly and responsible in society.
Practically, the cane that Kizito referred to in Luganda as omuggo, a stick, meant a lot to him. He valued its utility; it supported his ability in everyday activities and thus his autonomy. Beyond its practical purposes, however, it had at least two other kinds of value: it signified the love and care of his daughter in the UK, who had bought it for him; and it marked his status as an elderly man, deserving of the respect that senior men were given in the old days.
While Kizito was extremely attached to his cane, we shall see that others who received assistive devices did not use them. The relationship that people develop or fail to develop with the devices plays a crucial role in the process of use, embodiment and ultimately the actual impact of the device in the life of an individual user. It is not simply a matter of choosing a technical solution that supports mobility or overcomes environmental barriers. There are symbolic implications that should be understood in relation to the social and cultural context of the elderly person (Lupton and Seymour Reference Lupton and Seymour2000). In this article, we want to consider in detail the different kinds of significance at play: what older people’s relations to assistive devices reveal about their autonomy in daily life; the social significance of their source; and how the devices carry meaning, for themselves and for others, about what kind of person they are. We shall discuss these themes under the rubrics of utility, provenance and presentation.
Studying elders and technology in Wakiso
The study combined quantitative and qualitative methods, beginning with a survey and moving on to in-depth studies of selected elderly people.Footnote 1 It was conducted in two of Wakiso District’s sub-counties: Makindye-Ssabagabo (semi-urban) and Wakiso (rural). Both are densely populated, increasing the chances of getting the necessary sample for the study.
The first author collected data, using the village health teams (VHTs) as the first point of contact. VHTs helped to identify elderly people with impairments in their respective villages and in the communities around them. Mandated to provide basic health education to communities and to dispense medication to children for specific diseases such as malaria and respiratory infections, VHTs are familiar with residents in their villages. Rehema gave a form to each of the VHTs and requested them to write names, contacts and locations as well as brief directions to the home for each of the elderly people with a mobility impairmentFootnote 2 whom they knew in their village(s). It was made clear to them that it should not matter how serious they considered the impairment to be; whomever they thought was an elderly person with what they considered to be a mobility impairment was listed.
In total, 560 names were listed from eighteen parishes in the two sub-counties.Footnote 3 From this list, a sample of 337 elderly was selected; they all had physical or mobility impairments, were estimated to be aged sixty years and above, and could be located easily given the level of detail provided. Three research assistants were engaged and were trained to assist in surveying these 337 elderly people. The key question for the survey was: how do elderly people with disabilities use assistive technologies in manoeuvring their day-to-day life? This question required us first to establish what kind of assistive technologies were used and for what kinds of disabilities. The survey also helped highlight other issues, such as: living arrangements of elderly people, including their socio-economic situations; extent of mobility disabilities; major causes of disabilities among the elderly; and sources of assistive devices.
After the survey, the authors selected a subsample of thirty elderly people for further in-depth interviews that were conducted by the first author. They were chosen to cater for variations in factors such as gender, duration of the impairment, type of device used and urban/rural location. Each of the thirty respondents was visited at least twice in their homes – three or four times for some. All respondents were thought to be in the age range of sixty to ninety-five years, although many were not very sure of how old they were. In their homes, their living conditions were observed, and they were interviewed about their life history: how they acquired the impairments and how their lives had changed since then. We discussed how and from where they acquired assistive technologies, how they used them in carrying out their daily activities, and their significance. All the thirty interviews were conducted by the first author in Luganda, the language spoken in this part of the country. All names used in this article to identify the study participants are pseudonyms. Most of the findings discussed here are from the qualitative part of the study, but some material from the quantitative survey is included to give an overview of the issues.
Consent was sought from participants, although the process was not without challenges. Elderly people often agreed to be interviewed; in fact, many would freely start sharing about their lives after a mere greeting. But many were not comfortable with being asked to sign or place their thumb print on consent forms. They hesitated for various reasons; a little over half (53 per cent) had spent less than five years in school and many could hardly write their names. A few were weak and did not want to be bothered with having to write, while others were hesitant, since land transactions often involve signing documents and because of the land-grabbing that had become rampant, especially in the central part of Uganda during this time. Elderly people had earlier been said to be the major victims of this. In addition to the elderly people themselves, consent sometimes had to be sought from neighbours in cases where they were regarded as the carers. It was not uncommon for a neighbour to come and ask Rehema what she was discussing with the older person. She often had to explain the purpose of her visit to the satisfaction of the neighbour. This was especially common for elderly people who lived alone, as will be explained further in the next section of this article. Other ethical dilemmas experienced were related to balancing Rehema’s role as a researcher with empathy for those who were sick and needed support to seek healthcare or means of survival. Whenever she could, Rehema provided some support for food or other material needs, especially for those households that she visited frequently.
Elderly life in Wakiso
Wakiso District has both urban and rural settings. It surrounds Kampala, the capital city, and is densely populated with approximately 2 million people, according to the National Housing and Population Census. While only 2.3 per cent of Wakiso’s population is estimated to be older than sixty years, which is lower than the 5 per cent national average, more than half (51.9 per cent) of them have a disability (UBOS 2017b). In Wakiso, as in the country as a whole, the lives of these older disabled people are affected by economic and social changes. Their adult children are increasingly engaged in formal employment or working away from home. While agriculture has been the main economic activity for rural households for a long time, since the 1990s there has been economic diversification, enhanced industrialization, and more labour movement from agriculture to the service sector (Byiers et al. Reference Byiers2015). With the introduction of universal primary education, enrolment in formal education has increased significantly, from 6.2 million in 2002 to 8 million in 2014 (UBOS 2014; 2017a). Moreover, there are several initiatives that promote education for girls and therefore they are less likely to stay at home to look after the sick and the elderly. These positive developments oblige the elderly to be more mobile and to be able to support themselves in their daily chores more than they were in the past.
Residential facilities for older people are almost non-existent in the study community and therefore elderly people live in their homes either alone or with other people. Most homes have many people, in line with patterns of African extended families (Ankrah Reference Ankrah1993). Sometimes even neighbours were relatives, or at least were treated as such. Some of the homes that Rehema visited housed up to twelve persons, although there were also a few elderly persons leading a solitary life. Moreover, mobility disabilities made elderly persons depend greatly on others: grandchildren and other relatives or sometimes hired helpers. Many children of older people have migrated, either for work or for marriage. In a few cases, one or more adult, currently unmarried, children were staying with their parents. In some cases, a spouse of the older person with a disability was providing care; therefore, there were instances where carers of older persons with disabilities were also elderly (see Van Eeuwijk Reference Van Eeuwijk, Hoffman and Pype2016). In Buganda, elderly women are not supposed to remarry once they lose their husbands. In contrast, widowers are encouraged to remarry as soon as possible; if not, it is thought that their lives will deteriorate faster.
Similar to Bunyole in eastern Uganda (Whyte and Whyte Reference Whyte and Whyte2004), it was normal for elderly persons to live with grandchildren. Earlier, it was a common practice in Buganda for parents to send their children to their grandparents, especially during school holidays. Although this practice still exists, it is becoming increasingly rare due to the increased time that children spend at school. With the reduced fertility rate, parents are reluctant to surrender their few children to go and spend time with their grandparents. This is coupled with the busy schedules of modern-day parents and the increased commercialization of life.
Sometimes, it took a few visits for Rehema to get clarity on how the carer or other household members were related to the elderly person. All younger children were referred to as grandchildren (abazukulu), while adults were referred to as children (abaana), sons or daughters, even when these were hired housekeepers or helpers. Several times, neighbours also gave support to the elderly persons, and if a neighbour lived very close to the home of the elderly person, you could easily mistake them for members of the family. Neighbours and other community members provided critical physical, material and emotional support to the elderly, as part of the moral community obligation. Many neighbours would freely enter the house and help the elderly people in all kinds of chores, especially those who lived alone. Sometimes, when Rehema visited elderly people, someone in the neighbourhood would peep in with keen interest, and a few times someone would boldly come and enquire if she (Rehema) needed help with something, as a polite way of asking, ‘What have you come to do?’
Material wealth and physical location are important in attracting relatives; elderly persons with good resources in terms of food and other everyday provisions attracted relatives and other people to help with household chores, who got meals and accommodation in exchange. Being close to Kampala city and urban settings attracted people to stay with elderly relatives for easy access to services such as schools and workplaces. In turn, these people provided care and contributed to the meals if they were earning a living somewhere else. Thus, they lived in a kind of reciprocal relationship. This further highlights the importance of community and kinship solidarity, and the obligation to care (Kasente et al. Reference Kasente, Asingwire, Banugire and Kyomuhendo2002). Such support is built on the principle of reciprocity, and those with problems expect support from kin.
Carers, whether grandchildren or hired help, performed physical caring roles such as cooking, laundry and cleaning. Generally, women, even the elderly, were responsible for this work; sometimes they delegated these tasks, but they did the supervision. The men, on the other hand, regardless of age, were seen as responsible for financial requirements. In practice, however, both men and women often depended on their sons or daughters for provision.
Receiving help with household chores was not always attributed to disability or immobility. Being elderly in itself was perceived as a social status that entitled one to such support. Elderly people noted that the absence of grandchildren to help with chores was undesirable and was often a sign of ‘bad old age’. As we show in the next sections of this article, some elderly people would rather not use an assistive device if they had someone at home to help them run certain errands. In this case, therefore, immobility was not such a problem; rather, it was part of their social identity as elderly. When it came to personal activities such as going to the toilet and bathing, however, individuals preferred to manage themselves and got support only in extreme cases when they were completely unable to do things themselves, due to sickness or disability (see Van der Geest Reference Van der Geest, Makoni and Stroeken2002a).
Elderly people in Buganda are generally expected to visit the sick, attend church services, or even preside over functions in the community. Yet, for many of the study participants, movement outside their homes was very limited due to mobility impairments. Elderly people often spoke about their regrets at not being able to go to church or take part in Holy Communion. Being an elderly person in the village, you would be expected to attend funerals, whether for other people in the village or for relatives farther away. Elderly people would update Rehema on people who had died, distressed and embarrassed about their inability to attend their funerals.
Some elderly people were still engaged in income-generating activities, either directly or through their carers if their mobility was greatly compromised. Such activities included subsistence agriculture from which they could sell some of the foodstuffs, as well as petty trade around the home. But usually, the income from these activities was not enough for the household. Although they often mentioned their former occupations with some satisfaction, most elderly people do not have any stable sources of income at present. The majority depend on support from their adult children or other relatives. Those providing financial and other material support often take key decisions regarding the lives of the elderly, including when and where to go for medical care when sick. In recognition of the increasing need to provide financial support to the elderly, the Ugandan government is implementing social assistance grants for empowerment (the SAGE grant) in selected districts, which means that some older persons aged sixty-five and above receive an equivalent of US$8 per month (Akullo Reference Akullo2017). At the time of data collection, the SAGE programme had not yet been implemented in Wakiso District; therefore, none of our respondents had benefited from it. While this money is significant to the elderly, it is not sufficient to cover their care needs. This implies that families are still primarily responsible for supporting and taking care of older persons, providing the safety net that includes financial, physical and emotional support.
Unquestionably, mobility was important among elderly people, to sustain their social relevance and sometimes to be able to earn a living – and, most importantly, to perform their personal care activities. Participation in religious activities such as religious gatherings was part of this social relevance. In fact, Zoanni (Reference Zoanni2019) suggests that Christianity in Uganda is an important element in categorizing disability and shaping disability experiences. With the onset of disability in old age, however, whether due to disease or accident, their mobility was compromised and often this marked the end of economic activities and active participation in income generation for the men; for the women, immobility disrupted their engagement in the activities of daily living and implied that they needed more support for household chores. For some of the elderly people, debility – a broader term that describes multiple frailties and chronic illness associated with old age (Livingston Reference Livingston2005) – would be more apt to describe their condition. Both disability and debility implied that elderly persons had challenges and often were unable to perform socially expected tasks. In such conditions, they needed more care than other aged parents. To provide the much needed care, and to facilitate their mobility within and outside the home, sons, daughters and sometimes care institutions often provided mobility devices such as wheelchairs, crutches and walking sticks.
Assistive devices for mobility
The assistive devices used by older people in our survey and discussed in our interviews were of two general types: ‘sticks’ and wheelchairs. The word ‘stick’, omuggo, referred both to homemade walking sticks and to manufactured metal canes. In the plural, emiggo, ‘sticks’, denoted crutches. Wheelchairs are known as akagali kabalema, ‘small bicycles/vehicles of the disabled’. Very few people reported any other devices. For example, only three had walking frames, mobility devices that are very common in the global North.
By far the commonest form of assistive device used by respondents in this study was the walking stick, omuggo; this was reported by 201 of the 337 respondents in the survey. These were sometimes made by local artisans, but most commonly they were do-it-yourself artefacts. Elderly people went themselves, or sent a child, to cut a piece of wood that they shaped into a walking stick. They were made of necessity for managing everyday activities such as gardening, cleaning, and moving about the home and neighbourhood. They were free and easy to replace by simply cutting another stick from the bush. Although they may not have featured prominently in the conversations of the elderly as treasured things, it was evident that they were very handy. In their homes, these walking sticks were used as routine bodily extensions during daily activities, with obvious practical significance. As many of these walking sticks were rough, elderly people sometimes tied pieces of cloth around them to protect against rubbing. These rags were used on both crutches and walking sticks.
The second most common mobility device was crutches, reported by thirty respondents. The crutches and walking sticks made by local artisans were similar to homemade devices in that they were often obtained by ‘self-prescription’ at the initiative of the person needing them. This was not always the case, however; sometimes neighbours or relatives contacted a local artisan and sometimes local health workers advised their elderly patients to have a stick or crutches made locally. The costs were relatively affordable and a few times the local artisans even offered the devices free of charge as a form of support to the elderly person. Like homemade devices, these locally produced sticks were valued for their utility. When they were provided at the initiative of family or friends, they also took on significance as indicators of empathy and care.
In contrast to wooden sticks and crutches, metal canes were manufactured elsewhere. As we shall see, they were rare and special – high-tech compared with the low-tech artisanal sticks. Some referred to commercially produced canes, such as the one Kizito’s daughter sent him from the UK, as omuggo omuzungu, meaning ‘European stick’.
The survey revealed fourteen people with manual wheelchairs, but sixteen more were discovered during the follow-up visits to the thirty elderly people who had earlier reported only walking sticks as their assistive technologies. Three of those were acquired by the respondents during the time of the study. (It is likely that if more than thirty people had been followed up, more unused wheelchairs would have been found.) The wheelchairs were of different types. Some were imported, but others were manufactured in Uganda.Footnote 4 Strikingly, out of the thirty wheelchairs, only one was being used for mobility; the others were either not being used at all or were used for other purposes. Mukisa placed his wheelchair in the sitting room where it served as an ordinary chair for anyone’s use. Nanyonjo used her old wheelchair as a place to collect her clothes; it could easily be moved between the bedroom and the sitting room, where she stayed for most of the day.
Utility
The primary significance of assistive devices is their practical utility in helping people to do what they need and want to do. This was certainly of fundamental importance for the elderly people with disabilities in Wakiso. Kizito would not have been so mobile and active without his stick. Elderly people needed to get in and out of bed, to use the bucket in the house or the outdoor latrine, and to move from the bedroom to the sitting room. For many, the absence of an assistive device would mean that the person would have to be lifted from one place to another, which in itself presented a burden to families without strong, younger arms to help.
Older people enjoyed interaction with their communities. Some elderly men used their sticks to participate in community meetings. For both men and women, it was vital to attend funerals, as noted earlier, especially in their neighbourhoods. Mobility devices were valued because they facilitated these activities. Moreover, they gave a desirable impression. The old people were proud to be seen as mobile, physically and socially active and able to care for themselves in daily life. The sticks allowed them to present themselves to others as relatively able. Elderly people considered how helpful a device was, given their living spaces and the activities they prioritized.
Sticks for specific purposes
Madarena Nakate looked strong and bright at the age of eighty years. She had a leg impairment that she attributed to an unknown illness that brought swelling and pain that could come and then sometimes disappear. Although Nakate was still independent and able to move, she needed a walking stick. In fact, she had three walking sticks for different purposes. One she bought from a health centre; it was metallic and silver in colour. Nakate kept this for special events such as when there were visitors at home, when she had to go to hospital or when she was attending a funeral. The other two sticks were homemade. The longest one helped her to go to the garden and walk around in muddy places, while the shorter stick was convenient for her daily activities around the home.
Assistive devices supported some degree of autonomy by enhancing movement and mitigating the consequences of disability. Like Nakate, many had several sticks that they used for specific tasks and situations. They had clearly worked out how to increase their ability in the different areas in which they manoeuvred. The unused wheelchairs were partly a reflection of this practical calculation, as will be seen in the example of Kirumira and the Good Samaritans described below. Wheelchairs were not suited to the uneven terrain and the kinds of work that needed to be done. They did not support autonomy as might be imagined. Older people used other devices to make them less dependent on others in everyday activities, and to appear less helpless in the eyes of others.
Achieving self-sufficiency through assistive technology is of overriding importance in many settings. Assistive devices are specifically considered to improve mobility and social participation and to promote independence of the elderly (Biniok and Menke Reference Biniok and Menke2015). The use of technologies seems to be rapidly changing the ageing landscape, especially in countries with more developed infrastructure, healthcare and welfare. In the global North, the discourse on technology use among the elderly has shifted from simple mobility technologies to more complex ones such as the internet, telehealth, Skype, robots and social media (Miskelly Reference Miskelly2001). These support the elderly to ‘age in place’ without overdependence on others. However, some scholars have warned of the potential of ‘imprisoning’ and socially isolating the elderly in their own homes by heaping one technology after another on them, highlighting the potentially negative aspects of assistive technologies (Lupton and Seymour Reference Lupton and Seymour2000). Too much assistive technology might create not only autonomy, but also isolation.
There is little documented evidence of this being the case in African countries. In fact, some older disabled people clearly valued ‘dependence’ over self-sufficiency. For them, assistance from others was not necessarily negative; it indicated care and respect from intimate others. This lends itself to Scherz’s (Reference Scherz and Klaits2017) argument that, in Buganda, ethics of hierarchical interdependence occupy an important place in local understandings of moral personhood. As one respondent in Wakiso remarked about not using her wheelchair: ‘I have my grandchildren, I can send them anywhere, they bring me food right here, they bring me tea right here, now what else do I want? For me [at] this age I should just sit and eat’ (Bavuma et al. Reference Bavuma, Kyaddondo, Kiwuwa and Kajja2017). The meaning of grandchildren’s assistance was explicated in an analysis from Botswana. When the researcher suggested that an old blind lady could learn to move independently with a cane, the family protested that if she moved around alone it would look as if the family were neglecting her. ‘Botswana grandparents … appreciate being active and able to walk around in the village, to visit friends and beer-parties and participate in funerals and village meetings. But too much activity is seen as a sign of lack of help and respect from the children and grandchildren’ (Ingstad et al. Reference Ingstad, Brunborg and Bruun1996). Livingston (Reference Livingston2005) observes how, in Botswana, canes historically symbolized the power of elderhood and the aggregation of dependants rather than the loss of independence. In Kinshasa, as in other African settings, the immobility of elders due to bodily frailty conflates with the broader pattern that those with power and authority send others to run their errands: ‘immobility is a sign of power, honour and privilege – not the absence of these’ (Pype Reference Pype, Willems and Mano2016). A respected old person should not have to do everything herself. Thus, utility is not simply a matter of being able to perform activities; there are cultural meanings of self-sufficiency that shape the significance of mobility technologies.
The balance between autonomy and dependence has been a theme in social studies of ageing in many parts of the world (Buch Reference Buch and Lamb2017; Lamb Reference Lamb, Lynch and Danely2013; Whyte Reference Whyte and Lamb2017). Investigations into the significance of assistive devices show that there is a fine balance between these two poles. People may want to be self-sufficient in some respects – to get around in their own house with the help of a stick. At the same time, they enjoy dependence on their grandchildren who run errands for them so that they do not have to try to deal with an unwieldy wheelchair on muddy or bumpy ground.
Provenance
The significance of an assistive device was heavily shaped by its source. The artefacts seemed to maintain a link with their origin, in most cases a connection that was valued. This argument is in line with the notion of the inalienable character of certain gifts that allows them to carry some of the identity of the giver (Weiner Reference Weiner1992). In this, they resembled the media objects held by elders in Kinshasa (Pype Reference Pype, Willems and Mano2016; Reference Pype2018), both those such as broken radios no longer in use, and those including mobile phones that are important for keeping in touch with adult children.
As such, ICT objects are material proof of these elderly people’s strong ties. This kind of connectivity, established through links to others who can provide you with goods and money, is fundamental in a precarious society, where economic survival, for both young and old, depends on active and strong social networks. While the elderly have fewer opportunities than the young to expand their social networks, memories about distant and less distant social networks become very important (Pype Reference Pype2018).
Non-governmental organizations (NGOs) provided assistive technologies, especially wheelchairs. Many were given as a form of charity by NGOs from the global North; some of these were faith-based organizations that provided support to people whom they considered to be vulnerable, including the elderly and people with disabilities. The wheelchairs provided by NGOs were appreciated as gifts; often, even when they were not used, they were kept safe in the house and featured in the stories of disability experiences. They were part of the widespread pattern of NGO activity in Uganda in which people and communities tried to connect to donors and projects. They instantiated the generosity of a patron with possibly abundant resources.
Good Samaritans
Kirumira, seventy-five years old (he estimated), was born with a leg impairment. Both his limbs were weak and he could walk only on his knees. Kirumira grew up with his parents and has never married nor had any children. At the time of the study, he stayed in a well-built house that belonged to his brother, who lived in Kampala at the time of the research.
When he was twenty, Kirumira was taken to a rehabilitation centre in Jinja District, where the government offered skills training for children with disabilities at no or reduced cost. Kirumira said that he was taken there by some bazungu (white people), who sponsored and paid for all his expenses in the rehabilitation centre and bought all the materials that he was to use during his training. He does not know how these bazungu were directed to his home or how they got to know about him or his parents. While in the rehabilitation centre, he learned agriculture. Indeed, during the study, he had a very lively garden near his home, where he grew beans, maize, sugar cane, plantains/bananas and many other vegetables and fruits by and for himself.
During our conversation, Kirumira proudly pulled out a wheelchair covered in dust even when he was not asked. He told how the ‘Good Samaritans’ had been a blessing in his life from his childhood until that moment. The wheelchair was labelled ‘Wheelchair Foundation’. It had evidently hardly been used from the time he had received it. Kirumira said that he tried to use it for a few days after it was donated to him, but he failed because of the physical terrain surrounding his home and the general environment. The wheelchair tyres were too smooth to manoeuvre around Kirumira’s surroundings. Moreover, his daily routine involved making a fire to prepare his meals, going to the garden and, on some days, washing his clothes. These activities required bending, which would not be possible when seated in a wheelchair. Probably he could have used it to move around his compound during his leisure time, but perhaps there was not much of that; Kirumira was always busy doing his household chores. Yet despite its apparent uselessness, Kirumira had kept the wheelchair for years.
The meaning and value of the wheelchair for Kirumira derived from its provenance: the ‘Good Samaritans’ who had been his patrons. It indexed his connection to these charitable persons and organizations and signified the importance of trying to maintain relations to such patrons, even though the logic of project cycles and sponsorship is time-limited. In a similar way, Whyte describes how a young woman kept a wheelchair given to her by a donor project, despite the fact that it was useless, because she thought the project might return to check on it and perhaps provide something more (Whyte Reference Whyte2020: 136).
Most assistive devices did not derive from organizations, however. They were given to older people by relatives, especially their adult children. Mauss (Reference Mauss, Halls and New York1990) notes that gifts have potential to create new relationships or to consolidate already established social ties. The relations between parents and children are among the strongest and most long-lasting, and they are characterized by reciprocity over the life course, as Van der Geest (Reference Van der Geest2002b) showed through his research on ageing in Ghana. He argued that people who took good care of their children could expect to receive good care from their children in return. Assistive technologies in this case were seen as reciprocating the care that the parents had provided to the children. It seems as though the children felt the need to ‘pay back’ the love and care that they received from their parents. The phrase from Kiwanuka (below) – that his daughter remembered how he took care of them when they were young – supports this notion.
Kizito, who claimed to value his cane over his wife, moved with the assistance of a cane given to him by his daughter in the UK. The cane was a link to his daughter, and he used it constantly. Perhaps it even compensated a bit for her absence and helped him to cherish and remember her. Miller and Parrott (Reference Miller and Parrott2009) have discussed the idea of memorialization of social relationships through the keeping of goods, as did Pype (Reference Pype2018) in considering why old people in Kinshasa kept and even displayed broken radios and televisions.
Children give many things to their ageing parents, but the gift of a mobility device is special in that it shows sympathy for their frailty and instantiates the wish to restore their mobility and functionality. Perhaps it is especially significant when provided by an absent child. Not present to help in everyday situations, the giver is there vicariously, assisting by proxy. The nature of the gift reveals something of the moral obligations felt by the donor. There is a parallel here with the gift of a mobile phone, as Pype (Reference Pype, Willems and Mano2016) suggested in her study of elders and mobile phone use in Kinshasa. For the adult children who live far away from their ageing parents, providing a handset and phone credit was part of a strategy of caring. For the parents themselves, the phone was a way of maintaining contact with their children – not, Pype asserts, a way of showing off or of staging themselves as modern or cosmopolitan. By contrast, we argue that the ‘smartness’ of manufactured canes was important in the way in which Wakiso elders presented themselves to others.
Presentation
At the onset of a disability, sons and daughters often provided an assistive device, either on the recommendation of a health worker or at their own discretion. Children living outside the country sometimes sent ‘nice’ canes of various sizes and forms, and ‘nicely made’ (industrially produced) walking sticks; these differed from the ordinary ones that were made at home. Often elderly people would immediately show the cane that was sent by their son or daughter who lived or worked abroad. They were proud of those sticks and often mentioned them at any opportunity during the conversations.
The cane from the Netherlands
After retiring from active public service as a university worker in 2006 at the age of sixty, Kiwanuka slipped and fell in his compound, fracturing his right leg. He was admitted to hospital and received orthopaedic care for about three months. On returning home, he was able to walk with a stick within and around his house. His daily routine involved taking a bath in the morning and eating the breakfast prepared by his wife while listening to the radio. Kiwanuka read newspapers occasionally if his son, who lived and worked in a nearby trading centre, was able to bring them. He then took a nap or walked around his compound until invited in for lunch by his wife.
During the first study visit to his house, he was very willing to share information about his life, his impairment and how he got it. He immediately went to his bedroom and brought out his three walking sticks. One was locally made, bought from a nearby artisan on the recommendation of his orthopaedic doctor. The other two were canes provided by Kiwanuka’s daughter, who lived and worked in the Netherlands. One of these was short and helped him to walk around within his house and outside in his compound; the second one was foldable and adjustable. Kiwanuka considered this foldable cane to be very special and used it sparingly so that it would not get damaged. It folded conveniently for travelling and he took it whenever he had to go to the hospital or for a visit (although he noted that he rarely visited anyone). It was also smart-looking and he used it when he received visitors at his home.
‘I am so blessed to have her [his daughter]; she understands me and remembers me all the time. She remembers how hard I worked to take care of them and educate them. She calls me and we talk. She is the one who sent me these sticks.’ It was very evident that Kiwanuka loved and treasured the canes that were sent to him by his daughter and his life’s narrative was always imprinted with his canes. When Rehema visited Kiwanuka’s home on subsequent occasions, he kept referring to the canes and was quick to ask her once more if she remembered the canes or if she wanted to see them again.
The canes such as Kizito’s and Kiwanuka’s, which people referred to as omuggo omuzungu, provided by employed sons and daughters, contrasted with homemade sticks in being relatively ‘high-tech’. Often, they were made of metal; some could be folded; and they were industrially produced in other countries. For many, these ‘European canes/sticks’ had higher prestige; they were ‘smart’.Footnote 5 Their prestige meant, however, that they were often kept for special occasions; they were too good for everyday use around the house and garden, as the case of Kiwanuka illustrated. In fact, it was common to find up to three walking sticks owned by one person, with the most ‘high-tech’ ones reserved for use when wanting to make a good impression. Anyone could immediately see that they came from a special source and often showed that the owner had a caring son or daughter working abroad. Thus, the ‘modernity’ of the cane represented its owner as cosmopolitan and smart, while at the same time it suggested a connection to an employed and devoted adult child.
This combination of appearance and provenance had the opposite effect on presentation in the case of wheelchairs. Even though wheelchairs too were ‘high-tech’ in that they were made elsewhere, those provided by hospitals on the recommendation of a health worker could not shake their connotation of ‘sickness’, perhaps because elderly people obtained those wheelchairs after a bout of illness had weakened them. Wheelchairs were often acquired from health facilities, often following a health worker’s recommendation or prescription as part of medical treatment.Footnote 6 Although they were frequently paid for by the children of the elderly person, the initiative came from health professionals.
The allocation of wheelchairs to elderly patients is therefore dependent not on the taste of the patients, their home setting or their personal needs, but on their condition judged and interpreted medically. The conceptual framework developed by Kamaraj and colleagues (Reference Kamaraj, Bray, Pearlman, Rispin, Borg and Kankipati2017) shows that the relationship between wheelchair provision and its outcomes is affected by environmental and personal factors. The environmental factors given include physical, cultural, social/financial and climate, while the personal factors mentioned include demographics, education, vocation, participation and functional ability. This, however, leaves out an important personal factor of preference and taste as well as the social perceptions and concerns of the people with whom the elderly person lives.
Wheelchairs were seen as a technology for the sick. Some elderly people said that the wheelchair was given to them while they were admitted to hospital, but now they do not consider themselves sick anymore. Many elderly people used the term obugonvu, weak, rather than sick, to refer to their condition (in Tanzania, the Kiswahili sina nguvu, ‘I have no strength’, is used by frail old people (Obrist Reference Obrist, Hoffman and Pype2016)). ‘Having a wheelchair signified a new identity of being completely disabled, with a changed body and therefore changed identity’ (Bavuma et al. Reference Bavuma, Kyaddondo, Kiwuwa and Kajja2017: 27), which elderly people tried to resist. Whatever utility value a wheelchair might have had was negated by its symbolic value. ‘I am not that sick,’ as several respondents asserted.
There is a clear contrast between the significance of Kirumira’s wheelchair and that of others obtained from hospitals after a period of severe illness. Kirumira was disabled from birth and his wheelchair was connected to rehabilitation training funded by foreign patrons. He had received it in his youth, and although he was now elderly, it did not represent transition to weak old age. For a young man, a wheelchair facilitates access to education, employment and social participation. He can be seen as taking his place in society and overcoming the barriers he faces due to his impairment. But an elderly man who is using a wheelchair can be seen as becoming frail, unable to support himself anymore and nearing his death. The point that wheelchairs are ‘signifiers of disability’ that mark people with a discredited identity was clear in a study of technology and selfhood in Australia (Lupton and Seymour Reference Lupton and Seymour2000). Here, we are suggesting a refinement of that observation: a life course perspective on the adoption of a wheelchair in later life adds another layer to the presentation of the self as not only disabled but declining towards the final disability of death. Devlieger (Reference Devlieger2022) adopts a similar approach in showing how the moral careers of people with mobility disability in Kinshasa are linked to different kinds of assistive devices, which have significance for their identity.
Using or not using assistive technologies was not only a matter of utility or provenance, but also an issue of presentation. Elderly people were conscious of how the device affected their presentation of self to others – how others perceived their use of the assistive technology and treated them accordingly as competent and not helpless. Sticks and wheelchairs convey meanings to others in part because of cultural conceptions of the life course. Older men in Uganda carried sticks as signs of authority. Kizito mentioned that this was an old practice that earned men respect in their communities. Men were fonder of using sticks than women. Women preferred to manage as long as possible without a stick. For them, a stick seemed to mean inability whereas it was a symbol of their respected elder status for men.
The meanings of assistive devices for elderly people
As we have shown, the mere availability of assistive devices does not mean that they will be used. And simply registering use says little about what significance they have. Assistive devices themselves are part of a technology that includes the people using them and the significance they have. Others have argued that artefacts have symbolic value and social meaning in addition to their technical function. We have taken that assertion further by specifying those values and meanings in terms of utility/autonomy, provenance and presentation. Some of the elderly people in Wakiso District attributed meaning and value to their assistive devices according to these overlapping criteria. Their assistive technologies were mediators; they influenced and were influenced by social relations. Utility promotes greater autonomy; it makes disabled people less dependent on others. But, as we have seen, some degree of dependence is desired since assistance indicates care and respect. The provenance of a device imbues it with significance because a visible or sometimes invisible stamp of the donor sticks to the gift. The contrast between canes given by sons and daughters and wheelchairs provided by hospitals or NGOs illustrates the importance of provenance. The artefact stands for the giver and allows the older person to keep the relationship present. But when the origin is a hospital, the elderly person does not want to be reminded. Provenance is meaningful for the owner of the device, and it also presents an image to others. Those ‘modern’ canes have great sentimental value and give a better impression in certain social situations. Provenance and presentation overlap, in that the ‘European stick’ shows the care provided by a salaried child.
Unlike much of the research on disability, this article deals with elderly people. In some ways their situations differ from those of younger people, and their disabilities are often considered separately, as an unavoidable aspect of ageing. Yet considering assistive technology from their perspective is revealing. It illuminates the importance of seeing disability and technology in relation to life courses. A stick used by an old man underlines his respected status, while a wheelchair may suggest helplessness and decline towards death. Studying elderly people reminds us that social relations around technology may be very personal. The old people in central Uganda did not usually acquire assistive technology from state or NGO actors promoting development, as was the case for deaf people in northern Uganda (Beckmann Reference Beckmann2022) or disabled people in Ethiopia (De Silva Reference De Silva2022). Instead, they depended on devices made locally or purchased by their children; relations to intimate others were paramount. Those who had received wheelchairs from more socially remote sources such as humanitarian or medical organizations did not use them. Assistive technology was acquired and used primarily in the domestic and neighbourhood arena, where its multiple significance was played out in everyday life.
Rehema Namaganda is a PhD student of ageing and disability in Makerere University College of Health Sciences. She has a BA in Development Studies and an MA in Social Sector Planning and Management, both from Makerere University.
David Kyaddondo has a PhD from the University of Copenhagen and is a social worker and anthropologist with over twenty years of experience in teaching at Makerere University. He has undertaken research on healthcare arrangements, particularly for HIV and AIDS, youth strategies in changing economies and community mobilization of treatment resources.
Isaac Kajja is an orthopaedic surgeon in Mulago National Referral Hospital and the principal of Makerere University College of Health Sciences. He is a member of the Higher Degrees Research and Ethics Committee of the College of Health Sciences.
Steven Kiwuwa is a lecturer at the Child Health and Development Centre, Makerere University, with a specialization in clinical epidemiology and biostatistics. He has over eight years’ experience in disease control, epidemiology research and graduate training at university level and over twenty years’ experience in service delivery at all levels of the healthcare system.
