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The concept of medical pluralism implies that in any one community, patients and their carers may resort to different kinds of therapies, even where these have mutually incompatible explanations for the disorder. Pluralism is defined by the Oxford English Dictionary as ‘‘a theory or system that recognizes more than one ultimate principle,’’ with monism as its opposite. It is a term that appealed to anthropologists debating issues of cultural relativism and rationality in the 1970s and early 1980s. Where the medical profession strove for a monopoly of health care, medical anthropologists pointed out the existence of pluralism. The notion gained currency, historically, among those medical anthropologists who found the positivist paradigm of naturalistic versus personalistic medical systems inadequate.
However, since its inception the notion medical pluralism has been criticized for being grounded in an overly simplistic concept of culture; for conceptualizing health care from the professional’s, rather than patient’s, perspective; for engendering an overly behaviorist account of health seeking; for generating a false consciousness of choice; for underplaying the importance of financial, structural, and other political economic considerations; for insufficiently attending to issues of power, authority, and policy, or working with naive notions of them; and for implicitly reproducing a monolithic concept of (bio-) medicine. In summary, the concept is unsatisfactory as it is not grounded in social theory. It is currently an important research topic on the agendas of applied health research, while medical anthropologists are searching for new ways of conceptualizing the social phenomena discussed under this umbrella term and some have conceived of the field of health care as a medical landscape.
Historically, medical anthropology drew much of its raison d’etre from the notion of medical pluralism. The notion of pluralism went against the medical profession’s conceived monopoly and sense of exclusive competence over its work and its aim to generate a general public belief in its competence and authoritative expertise that set up the criteria of medical qualification (Freidson, 1970). Where the medical profession aimed at a monopoly, medical anthropologists pointed out pluralism. Charles Leslie (1973), above all, is remembered for coining the term while discussing the professionalization of the medical systems in South Asia. Although he used the term system, which many have (mis-) understood as invoking clear-cut boundaries of a homogeneous culture, a careful reading of the ambiguities that Indian medical revivalism entailed, highlights that he was well aware of the hybrid origins, inter and intracultural dynamics, and often disruptive histories of the medical system in question (Leslie, 1976a). He emphasized that the constructed histories of revivalism were a means whereby the expanding middle classes created new social spaces for medical practitioners.
Consequently, medical pluralism as a term suggested that a cosmopolitan, Western, modern, scientific biomedicine did not have the monopoly over health care, as had been taken for granted in medical circles, but that it was competing with a plurality of professionalized traditional medical systems. Leslie’s (1976b) seminal publication on Asian Medical Systems focused on the Great Traditions of Ayurveda, Yunani Tibb (Greek medicine, as introduced to India by the Muslim conquerors from the thirteenth century onwards), Chinese medicine, Kanpo, and the like, without neglecting to mention urban popular and rural folk medicines (he spoke of ‘‘bone-setters, surgeons, midwives, snake-bite curers, shamans’’). Leslie drew on Redfield’s (1956) distinction between Great and Little Traditions, with the aim of emphasizing that the Mediterranean, South Asian, and Chinese medical traditions were each relatively independent, while sharing general features of social organization and theory. This distinction, put crudely, implied that the text-based Great Traditions appealed to cognitive faculties, in particular to rationality and logic, and attended to the moral issues of sin, rebirth, and soul, while the Little Traditions of folk religion and superstitious practice attended to and manipulated affect, emotions, and feelings, and were concerned with the regulation of everyday misfortune and worship. This distinction had earlier been criticized by Stanley Tambiah (1970: 367–77). However, as Bruce Kapferer (1983: 44–45) clarified, it was not invalid since it reflected the bourgeois viewpoint. As a construction of the middle class, it was part of a cultural language of domination. This attitude was intrinsic to the construction of the professionalized traditional medical systems.
Studies on medical pluralism emphasized how social change had affected local medical care. They granted other medical practices internal logic and coherence, spoke of medical theories, and by highlighting how related practitioners’ and patients’ concepts were, they emphasized their cultural embeddedness (see, for instance, articles and books listed in Lock and Nichter, 2002). Some highlighted what they called syncretic ideas and practices, others fluidity between medical fields with overlapping jurisdiction. Rhodes (1980), for instance, outlined how a parent took his ill daughter to see several practitioners who mostly worked within incommensurable frameworks of medical learning. Nevertheless, patient and parent were able to combine the different strands of expert advice into a meaningful whole. Many authors emphasized the complementary rather than competitive nature of different medical systems, and highlighted how each of these was perceived to be useful for a different kind of disorder (e.g., Ohnuki-Tierney, 1984). Other authors highlighted the similarities in treatments provided by different professionals and one study, in particular, showed that practitioners advertising themselves as either Ayurvedic or Western medical in approach prescribed much the same treatments (Waxler, 1984). Since the Ayurvedic practitioners borrowed from Western medicine, but not viceversa, the latter was interpreted as structurally superior. While studies on medical pluralism had initially praised the systemic aspects of other medicines, with the postmodern turn authors working on the theme pointed out partial knowledges, and David Parkin’s (1995) latticed knowledge, used in discussion of Islamic medicine, stressed precisely such interdependency and fragmentation intrinsic to any medical system.
In summary, the concept of medical pluralism countered the medical profession’s claim to a monopoly. Within medical anthropology, it went against the paradigm that beliefs in medical practice were either personalistic or naturalistic (Foster and Anderson, 1978). It highlighted that medical systems often have both personalistic and naturalistic aspects, and that people transgress boundaries between medical systems and are able to use and make sense of different medical systems.
Critique Of The Notion Of A Medical System
Many authors writing in the 1970s and 1980s had in common that their points of reference were medical systems and that they wrote from a bird’s eye view about the respective medical professionals and their medical learning. However, others (e.g., Nichter, 1980) pleaded for an understanding of pluralism from the perspective of the health-care consumer. He maintained that the medical pluralism patients experienced was through their perceived choice of commodities on sale, such as drugs and their colors, taste, and packaging, or stethoscopes and scissors whose country of manufacture was considered relevant. At about the same time, medical anthropologists working in Africa, in particular, called into question the medical-systems approach (Last, 1981; Bibeau, 1982). Their critique made evident that the medical pluralism John Janzen (1978) had described in Lower Zaire was written from the perspective of a medical doctor working at a local hospital. Robert Pool (1994) later reinforced it by pointing out that the excessive interest of anthropologists in causal explanation was a conundrum to the local people. A focus on the patients’ perspective treatment choices could explain in terms of social pragmatism (Whyte, 1997) and social efficacy (Whyte et al., 2003). It also became apparent that many healers and herbalists were marginal figures who often did not speak the language of their clientele and derived their medical powers precisely from being associated with the Other, the exotic or the wild (Parkin, 1968; Whyte, 1988; Rekdal, 1999). Healers thus emerged as brokers who straddled boundaries, a theme we will return to at the end of this research paper.
For those working in public health, this means that more attention must be paid to the patients’ perspective, not by swamping patients with questionnaires but by participating in their lives and focusing on the daily problems they face. One easily projects superstition into people, when observation of social practice highlights that they make practice based decisions; their choices are often limited, their decisions therefore often situational and temporary. It is important to gain an understanding for people’s cultural logic without, however, locking other people into a cultural paradigm; they are far more versatile and pragmatic.
Rational Behaviors Of Seeking For Health Or Treatment Choices Based On Taste?
The study of the health-seeking behavior of the patient and his or her therapy managing group is one of the core themes of the studies on medical pluralism (e.g., Fabrega and Manning, 1979), emphasizing the importance of the perceived severity of the condition, the way in which it is classified and the range of treatment choices on offer. Research often centered on the individual and often operationalized accounts of decision-making processes, frequently within cognitivist frameworks. For example, early studies had identified hierarchies of resort, which outlined the nowadays somewhat obsolete acculturative (and counter-acculturative) sequences, from medical doctor to priest to local exorcist (and the not exactly symmetrically reverse from local exorcist to priest to medical doctor and back to priest and local exorcist, if the condition is terminal), which remained important for pointing out that choices depended not merely on the perceived speed of recovery achieved by treatment but on its sociomoral functions (Romanucci-Schwartz, 1969: 205). A decade later, Arthur Kleinman (1980) systematized what Romanucci-Schwartz and others had variously mentioned in passing, namely that most health care takes place within the so-called popular sector through the application of home remedies. He suggested that we speak of health systems, rather than medical systems, and differentiated between three sectors: The popular, folk medical, and professional medical sectors. Furthermore, his concept of explanatory models was often used for explaining choices of health care, although it initially had been developed in an attempt to assess (and improve!) the doctor–patient relationship, a well-known problem in medical sociology. In general, however, research on health-seeking behavior and explanatory models focused too much on the individual and the microsocial aspect and left aside the exploration of sociological issues. Thus, what Pierre Bourdieu in his book Distinction (1984) called taste and habitus, which highlighted that patterns of consumption are guided by the aesthetics particular to a social group has direct importance for explaining the health-seeking behavior and choices of treatment that medical anthropologists study. From the therapeutic itineraries that Samuelson (2004) studied in rural Burkina Faso for instance, it became evident that local healers (and a retired public health engineer) had a relatively strong position in the local medical field due to their social and cultural capital, while the government health center, which was by comparison higher in economic capital, and to a certain extent also higher in symbolic capital, remained marginal to the health field.
Within the context of discussing health-seeking behavior, as well as in some contexts of applied medical anthropology, the notions of medical pluralism and medical systems tended to be used in historically, sociologically, and politically less sensitive ways and intrinsic differentials in power and authority within the medical field and society at large tended to be overlooked. There were remarkable exceptions, such as the ethnography by Crandon-Malamud (1991), who highlighted how medical pluralism related to race and ethnicity as well as to hierarchical class structure. However, many studies on medical pluralism focused on health care without embedding it in problems of society at large. Brodwin (1996) criticized the concept heavily. He suggested ethnography around the notion of healing powers, which embrace ideas about clinical effectiveness, moral authority, political coercion, and collective identity. Thus, treatment choices in Haiti cannot be understood without awareness that biomedical institutions are backed by the authority of the Catholic church (Brodwin, 1996). Or, word meaning and usages of medical terminologies in China entail a particular type of authority (Hsu, 2000). Furthermore, governmental health policies incisively shape everyday practice of medical care in Indonesia (Ferzacca, 2002). The cultural, social, psychological, and economic aspects matter, no doubt, but so do issues of authority, politics, and power.
In summary, when studying the patients and their treatment itineraries, one cannot focus on the individual and its therapeutic managing group alone. Rather, an illness event is entangled in the social, economic, and also political dynamics at large.
The Marxist Critique Of Pluralism
The Oxford English Dictionary defines pluralism as ‘‘a theory or system that recognizes more than one ultimate principle’’ and presents it as an opposite to monism. In retrospect, it seems that pluralism was appealing to anthropologists who in the 1970s were caught up in debates over relativism and rationality. Many medical anthropologists instantly embraced it, although Marxist authors had long dismissed it, maintaining that the notion of pluralism created a false consciousness within late capitalist society; i.e., it lulled the people into believing there were choices when in fact there were none. In One-dimensional Man, Herbert Marcuse stated that ‘‘at the most advanced stage of capitalism, this society is a system of subdued pluralism, in which the competing institutions concur in solidifying the power of the whole over the individual’’ (Marcuse, 1964: 54). He claimed that ‘‘the contemporary form of pluralism would strengthen the potential for the containment of qualitative change’’ (i.e. it diverted them from getting prepared for the Revolution) (Marcuse, 1964: 64). When writing on the role of publicity in consumer society, John Berger intimated the same. And ‘The myth of medical pluralism’ (Han, 2002) perpetuates this Marxist stance in its critique of complementary and alternative medicines as creating a pretence of choice when, in fact, they reproduce the bourgeois philosophy and the same capitalist principles that shape biomedicine.
The term new medical pluralism concerned what, as Cant and Sharma (1999) emphasized, was a re-emergence of alternative, unconventional or what others have called heterodox medicines in Britain and the West at large. Based on a study of the interplay of the state, the medical profession and patients as consumers, they suggested the diversity the new medical pluralism referred to was far more structured than that observed in the rest of the world. They claimed an ‘‘ideal type pluralism’’ involved players on a level playing field and promised equity and choice (Cant and Sharma, 1999: 4), which, as is obvious from the above, never was an assumption among the anthropologists who first used the term; twentiethcentury government expenditure on health care has been spent almost exclusively on biomedicine, worldwide. Baer (2001) also stressed the hegemony of biomedicine in his study of alternative healing systems in America, but he repeatedly emphasized that its dominance was delegated rather than absolute. He traced its rise to that of the corporate class and its political allies who provided not only financial support but also, through a licensing system, legitimation. Both these studies on alternative medicines stressed the hegemony of the medical profession in the West, and neither attributed their reemergence to deprofessionalization. Rather, they both found that the ideology of holistic health care not only remedicalizes everyday life but also reifies capitalist values. It reinforces the ideology of the ever-productive citizen so fundamental to the political economy of health in any modern nation-state. And in an era of increasingly indebted governments, complementary and alternative medicines are now increasingly being evaluated for their cost-effectiveness. They have been incorporated primarily into government-sponsored sectors of primary care, in much the same realm, Cant and Sharma suggest, as traditional medicines have been in the southern hemisphere.
To summarize, the notion of pluralism implies a political stance and is a cherished rhetorical phrase in late capitalist society. It does not provide a theoretically founded conceptual framework for the social scientist interested in the processes that generate and maintain difference.
Deconstructing The Monolithic Medicine
Since the 1990s, Foucault’s notion of biopower, the anthropology of the body and gender, the new reproductive technologies and kinship, and the politics of science and medicine, have gained momentum as themes for study within medical anthropology, while research on medical pluralism has been taken up with new fervor in other fields, such as public, international, or global health. Medical anthropology has certainly also seen a surge in critical studies of generally held medical assumptions. First, the notion of local biologies effectively did away with an early credo of some medical anthropologists that biomedicine ‘cures’ universally extant ‘diseases’, and other forms of therapeutics ‘heal’ culturally constructed ‘illnesses.’ Thus, a life cycle phenomenon, like the loss of fertility in aging women, is not only experienced differently in Japan and North America but has also culture-specific biologies (Lock, 1993). Or, rather than reducing medical practitioners to the humanitarian role of providing health services, their social agency and engagement in political movements has been described (Adams, 1998). Differences in medicine and ways in which the body is conceived, or, rather, enacted, in different medical disciplines have led to an ethnographically based critique of the biomedical profession as a monolithic institution (Mol, 2002). These studies did not set out to explore medical pluralism but are immensely important for current research on the theme because they have led to important redefinitions of what to some had been a unified state-supported hegemonic medicine with only one purpose. Medical anthropologists nowadays often speak of multiple medical realities.
Within the so-called risk society marked, in Ulrich Beck’s view, by the dismantling of nation-states and by international interdependencies, the social position of medical professionals has also been shaken, their authority questioned, and their role as gate keepers in the domain of health delivery restricted. Instead, the multinational pharmaceutical and food industry, with ever more aggressive advertising, can reach their clientele directly, who in turn are driven by an ideology of individual responsibility for personal health and security. Biomedicine’s unrivalled expansion and colonization of the southern and eastern worlds has been newly challenged. Flows of traditional medicines in ever more commercialized form are moving from the East into health markets of the West, and also of the South (Hsu and Hoeg, 2002). In the light of the neoliberal commercialization of health care and the increased mobility of patients, health professionals and technologies, Ho¨rbst and Wolf (2003: 4) coined the term medicoscapes (derived from the work of Appadurai, 1990). They highlight that health personnel and health organizations have increasingly become interdependent through electronic communication, multinational pharmaceutical corporations, the WHO, and development agencies. Gone are the times where one could speak of a mosaic of clearly bounded, different medical cultures.
Medical pluralism implies there are many systems other than Western medicine. However, Western medicine does not exist as a monolithic discipline. The biomedical worlds are hugely diverse, fragmented, and fluid in themselves, changing in orientation, organization, research, and care delivery in a changing world.
Independently, the landscape metaphor has been taken up in teaching and research in Britain. It has been suggested that studies of medical pluralism be reframed in terms of medical landscapes. The word landscape was in English initially used to refer to a painted landscape, which is a cultural artifact (Hirsch, 1995), and in anthropology, to the cultural artifact of an ethnography. Any landscape is by definition specific to the perspective either of the observer or of the people themselves. The anthropology of landscape implies that the researcher is acutely aware of his or her position and of perspective, with foreground and background. It furthermore entails, as Hirsch says, ‘‘a relationship between the ‘foreground’ and ‘background’ of social life’’ (Hirsch, 1995: 3), a relationship understood as a cultural process. Articles on the anthropology of landscape have highlighted how the place of everyday life in the foreground is put in relation to its background, a space of regenerative life pregnant with potentialities for social life. In Amazonia, for instance, the shaman is considered to travel from proximate place to distant space. Likewise, as West and Luedke (2006) suggest in their introduction to Borders and Healers, medical practitioners in southeastern Africa are people who cross borders and are brokers between different cultures, between the rural and urban, local and global, between places of daily life and spaces of potentialities. They appear to derive their therapeutic powers precisely from this movement and straddling of boundaries. Rather than invoking a clearly bounded culture concept with a culturally adept healer in its center, the notion of medical landscapes implies social processes, relatedness, and movements between foregrounds and backgrounds, and across boundaries. It thus promises to provide a theoretical framing for future studies on theme that until recently has remained central to medical anthropology, namely the study of medical pluralism.
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