M. S. Subedi/ Healer Chaice in Medically... 129
and the curative measures that they have created in their efforts to eradicate the diseases or at least to mitigate its consequences. Recently there has been a surge in publications, which address the importance of incorporating the 'body' in theories about the world of ' social reality'. In a given individual or social HEALER CHOICE IN MEDICALLY network, people's understandings of how their body functions PLURALISTIC CULTURAL SETTINGS: AN influence health practices, symptom evaluation, and taking OVERVIEW OF NEPALI MEDICAL remedial actions. Help may be sought from a number of sources in the patient's social network, including friends, family, PLURALISM traditional healers, and the professionals (Christakis et al. 1994; Subedi 200Ia). This is connected with a growth of medical Madhusudan Sharma Subedi' anthropology and its interest in exploring the interface between natural processes, which affect the bodies we 'are living in' and Introduction socio-cultural processes in terms of which 'people understand and cope with the health of their bodies'. Our survival as Cross-cultural comparison of medical setting around the individual human beings depends on natural processes world led to the formulation of general models of the maintaining the health our bodies. These processes involve an relationships between the various medical traditions within of interaction between natural processes internal to the body single settings. The study of human confrontation with disease organism and processes involved in the physical interaction of and illness, and of the adaptive arrangements made by human our bodies with a natural environment. Like for any other species groups for dealing with ever-present danger has come to be a these processes are subject to 'natural law'. However, in contrast special branch of anthropology called medical anthropology. It is to other species, humans are not endowed with a genetically one of the youngest and most dynamic of the various branches of transmitted repertoire of behaviors, which allow a viable anthropology. It concerns with a wide variety of health related interaction in a natural environment. The genetically transmitted issues, including the etiology of the disease, the preventive repertoires have been softened and weakened to such an extent measures that humans as members of socio-cultural systems that human beings neither orient themselves in their world nor have constructed or devised to prevent the onset of the diseases, communicate with each other without acquiring a great deal of knowledge through learning (Elias, 1991). In Geertz's words, "man is an animal suspended in webs of significance he himself Mr. Subedi is an anthropologist and has been associated with Central has spun (1973:5)." These webs are clarified through elaborate Department of Sociology/Anthropology in the capacity of Part-time symbolic exposition. Lecturer. Without growing up in a context of cultural webs to
The information used in this paper were collected in the year July interpret the interaction between the embodied self and its December 1999 for my M. Phil. thesis in Social Anthropology. University natural and social environment, the human an imal is of Bergen. Norway. and January -March 2002 for personal research. I am impossibility. In other words, humans are situated in an grateful (0 Norwegian Agency for International Development and environment that entails both a natural dimension and a Cooperation (NORAD) for financial support. I would like (0 thank Prof. culturally cwmstructed one. This "social environment" is an Gunnar Haaland. University of Bergen for his comment on earlier draft of this paper. intrinsic system of interaction between nature and culture, which
meanings
the
embedded
traditions
found
observed
behavior,
Methods
epidemiology,
susceptibility,
explanation
behavior.
different
may
essential
care
determining
services
environments.
starting
consciousness
in
Fundamental
one's
bodily
breakthrough
aI.,
particular
with
only
material
is
130
answers
created
Nepal,
1997:39).
traditions
be
Occasional
meaning,
experience
it
embodied
How
In
death.
The
point
In
on
related
remains
healing
of
to
necessary
Examinations
constraints
health-care
and
in.
I
order
cultural
to under
this
their
knowledge understand
cope
impact
of
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do
have
Specifically,
the concern
as
For
is
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of
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context
and factors
Papers
well
illness
to
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that
bodily
self
following
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my
em reasonable seems
nature
death
with
frame
reviewed
of or
to
understand
interact
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specific
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as
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people
description
in
it
referral
services.
everywhere,
a
affect
of
medically
the
and
afflictions?
what
place
how
implies
causality
the
makes
affecting
multiple
as
which
health
of
etiologies
little
I
human
questions:
most
have
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we
understanding
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with
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Nepali
them
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culturally
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decision
the
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emotion
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types
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health
pluralism
the imposes
humans
as
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of
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fit
ability
research
health
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it,
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pluralism
on
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of
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health
body
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people
we human
health
\
to social
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it
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is of
I
et
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argument wanted
of
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information,
with
demography.
simultaneously
leaders
traditions
understand
acupuncture
both formally
informal
posts,
with collection
informal
and view
categories
systematic
intended
the
different practices
available
and
conversations
various
explain
health.
natural
local
help
different
male
of
doctor's
to
in
Several
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both
depending
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to
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here
medical
as
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and
patterns
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study
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environments?
Kathmandu well
and
and
the
therapy),
research
I
political
relation
healers
practiced informally
this
is
and
often
do healers
are
are and
how
sorts
female)
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private
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handle
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traditions?
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why
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I
within
of
behaviors
people
other
followed
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on
with
followed
M.
diverse
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and
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I
of
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healers
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methods
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describe
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relate
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Valley?
part
clinics
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local
with
range
Kathmandu
healers laypersons.
Subedi/ administrative
contacts
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the
houses
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be
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medical
whom
the
their
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people's
health
sequence
availability,
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here
of
Healer
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as
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Kathmandu
horne
at
the
laypersons
with
towards
of
health
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as
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by
behind
The
is
Valley?
authorities,
tradition.
locally
made allopathic
their
different
well
talked.
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these
Choice
designed
ideas
of
healers
hierarchy.
of
along
as
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people
basic
problems
hours
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defined
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informants
concerning
healers)
from
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Valley, in
I
with
terms
method
in
also
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informants
with
medicine
to
and
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illnesses?
illness.
discussed
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of
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me.
describe
where
medical
number
point
healers
of
healing
varied which
illness
health
illness
within
other ...
social
data
My
and
and
the
the
are
131
of
to
of
of
I I 132 Occasional Papers M. S. Subedi/ Heoler Choice in Medically... t33
What are thought to be the causes and the degree of severity and organizations and dominant worldviews are patterned. Kleinman symptoms? What treatments are sought? From whom? I also (1980) has suggested a useful way of looking at the process by wanted people to talk about their explanation for their state of which illness is patterned, interpreted and treated, which he health; what they identify about themselves or their physical or terms the 'Explanatory Models'. This is defined as the notions social environments as important, and what, if anything, they about an episode of illness and its treatment that are employed believe can or should do to protect or enhance their health. by all those engaged in the healing process. Both patients and One further interesting venue of research was the practitioners hold explanatory models, and they offer attitude of different healers towards the other healing practices explanations of illness and treatment to guide choices among and the extent, which the therapy traditions overlap or diverge. available therapies and therapists and to cast personal and social My intention was to focus on the interaction of healers and the meaning on the experience of illness. The explanatory model for patients, and how they deal with the different cases of dlness a particular illness consists of (i) signs and symptoms by which they are confronted with. the illness is recognized; (ii) presumed causes of illness; (iii) Theoretical Framework recommended therapies, (iv) the pathophysiology of the illness; and (v) prognosis (Kleinman, 1980: I05-7). People construct multiple and discrepant worlds by As Kleinman points out, individuals are likely to have means of different traditions of knowledge available to them. We quite vague and indefinite models of explanations for their need to discover how much the different constructions are in fact illnesses, depending on past experiences of the patients and his/ distributed in their action and interactions (Barth 1993 :271). her circle of kin and friends. This tendency in research arose, in Following this idea, I have developed my conceptual framework. part, in relation to the growth of cultural pluralism, especially in Understanding of Bodily Afflictions and Explanatory Models matters of health and illness (Pelto and Pelto, 1996). Human illness is not only a physical condition but a symbolic one as well. What we experience as health or illness is Knowledge and Concerns based on the perceptual judgements we make about the relative Knowledge in itself is the result of a learning process quality of our physical and psychological condition. The that is strongly influenced by a number of factors. Once meanings individuals assign to their health status are strongly internalized this knowledge becomes belief. Each medical influenced by their cultural backgrounds and experiences. These tradition provides a range of beliefs from which people make culturally based meanings strongly influence the health care their reality and the culturally constructed reality. Healers and choices and decisions they make, their relative confidence in lay belief about health and ill-health may differ widely, and these their health care providers and the treatment regimen, and even influence the types of conditions that people bring to healers, their actual physical responses to health care treatment. how they present themselves to the healers, the types and quality In understanding bodily afflictions, it is useful, in my of treatment that they are given. A major emphasis here is on view, to consider the types of questions that people ask exploring the variation within both lay and professional views. themselves when they feel unwell, or when they experience any Connected to those considerations of knowledge and concerns, I sudden, unexpected events in their daily lives. My theoretical have used Barth's (J 993 :5) idea of variation to make a sense of it framework, in this thesis, is mostly based on people's in people's health seeking behavior as: understanding of the culturally constructed reality. I argue that • There are variations in the definition of illness, and each the reality can only be fully understood by examining the medical tradition provides a unique cause and treatment specific contexts in which an ill person's socio-economic for a distinctive set of illnesses. Thus the over- M. S. Subedil Healer Choice in Medically... 135 134 Occasional Papers
generalization is perhaps the most serious and frequent cultures are the responses made by human groups in the path of weakness of research on health seeking behavior. successful adaptation. Conceptualization of disease, including • There are variations in level of "expertise ,. withill the etiology diagnosis, prognosis or cure, all are part of the cultural same medical tradition in the populatioll. There is nO repertory and equipment of human beings. Various identical, highly rigid pattern of the expertise. That is the conceptualizations of ill-health or disease can consequently not interpretation given concerning the cOllses of illness and be understood apart from an understanding of the culture and medicine prescribed varies within the same medical social structure of groups holding them (Blustain, 1976; tradition. Helman, 1996; Kleinman, 1980; Stone, 1976; Lesl ie, 1978; These variations are important for better understanding 1980; Justice, 1986; Levitt, 1988; Subedi, 1989; Durkin of the lives of people, through processes involving those people's Longley, 1984; Streelland, 1985; Dixit, 1999). own ideas and activities. The different styles of knowledge Medical anthropology looks at cultural conceptions of transmission generate deep differences in the form, scale, and the the body, health and illness. It also focuses on health behavior as distribution of the knowledge (Barth, 1990:640). The knowledge a way to learn about social values and social relations. In western that is acquired, retained, and transmitted contains the key to research traditions, medical sciences have made important explaining variations. contributions to understanding of the natural laws, which regulate the operation of these processes. A vast institutional The Arts of Impression Managemcnt complex has emerged directed towards further development of In each medical tradition, we can see the interaction as a the medical research tradition (often referred to as biomedicine, "performance", shaped by the envirollment and audiences, allopathic medicine, modern medicine, western medicine or constructed to provide others with "impressions" that are cosmopolitan medicine) and training of practitioners qualified to consonant with the desired goals of the actor (Goffman, prescribe treatment to health seeking clients. The western 1959: 17). Each healer promotes the psychological excitement for medical tradition involves both knowledge about how the a realization ofa goal. In this way, a healer develops an identity general environmental interactions (for example, food habits and or persona as a function of interaction with others through an hygienic practices) affect the body, and knowledge about how a exchange of information that allows for a more specific specific treatment (prescription of medicines and surgical definition of identity and behavior. There is often a tendency for operations) may counteract particular disease. The disciplinary fields include genetic, paleopathology, epidemiology, nutrition all types of healers to try to present themselves in such a way as to impress their patients in a socially desirable way. Thus and demographic anthropology. impression management has, in my view, considerable Ethnomedical studies of health and healing are a second implications for areas ofheahh and healing. major emphasis in medical anthropology. This approach often attempts to discover the insiders' viewpoints in describing and Medical Anthropology analyzing health and systems of healing. Among the topics Health and ill-health are biological phenomena but their studied in this field are ethnoscience, ethnopharmacology, distribution and scale in particular populations are affected by shamanism, and use of alternative therapies, medical pluralism the knowledge (including value pattern, technology, and view of and others. Third, many anthropologists focus their work on the universe) and the social ties in terms of which people interact social problems and carry out interventions through applied with their natural habitat. III other words, there is 3n intimate medical anthropology. Among the areas of this subfield are linkage between disease, medicine and human culture. In part, studies of addictions, disabilities, and mental health issues; 136 Occasional Papers M. S. Subedi/ Healer Choice in Medically... 137
public health and family planning; clinical anthropology and The particular tradition of western medical knowledge and its health care delivery in pluraJistic setting. accompanying health care tradition represent one way of dealing Whatever their disciplinary orientation, whether with illness. Other societies have developed different biomedicine, ethnomedicine, or policy and intervention work, understandings with different types of healers and medical many medical anthropologist agree that the concept of traditions to deal with the fundamental concern of health. It is adaptation, defined as change and modification that enable a within the subject matter of anthropology to deal with socio person or group to survive in a given environment, is a core cultural contexts of medical traditions and their practitioners and theoretical construct of the field (McElroy and Townsend, 1996). clients wherever they are found whether in so called western or The application of medical anthropology have contributed much non-western societies. However with its comparative perspective to our understanding of the mechanism by which modern the anthropologists have been particularly interested to medicine and health programs are introduced into, get accepted understand the conceptualization of illness and healing traditions or get rejected by different societies. The medical in different parts of the world. In an applied context anthropological literature abounds with the theoretical discussion anthropological investigations can provide a most important and case studies on the persistence of traditional medical insight into the way different medical traditions are practices and practitioners even in the presence of modern institutionally embedded in particular societies and of the medicine, description of traditional medical systems in pluralistic conditions (symbolic as well as material) which affect people'S medical setting. choices with regard to which health practitioner they seek out By the early 1960s, the term medical anthropology has when illness strike. come to be used increasingly by anthropologists working in and The existence of several therapeutic traditions in a single around problems in health and disease in human societies. cultural setting, is an especially important feature of medical care Therefore, it is not surprising that an anthropological study of in the developing world (Leslie, 1978). Patients may feel health and occurrence and means of coping with disease can uncertain as to what type of care provider can cure their illness, involve one deeply in the manner in which people perceive their leading them to consult different medical therapists. Or they may world, in the characteristics of the human social system and in decide that treatment of certain illness requires more than one social values (Good, 1994). In this perspective, medical type of assistance. Generally care is sought from several types of anthropology is not only a way of viewing the state of health and providers and medical traditions concurrently or sequentially. disease in society, but a way of viewing society itself (Lieban, The practitioners of different medical traditions may interact 1977). One can not really understand how people react to illness, with each other in a variety of ways - at times they borrow the death or other misfortunes without understanding the type of ideas and knowledge from one another, compete with and culture that they have grown up in, or acquired -that is, of the oppose the other system, they may co-operate with one another lens through which they are perceiving and interpreting their developing referral systems or they may simply co-exist world. In addition to the study of culture, it is also necessary to independently of one another (Kleinman, 1980: Levitt, 1988: examine the social organization of health and illness in that Subedi, 1989). society (the health care traditions) which includes the ways in The pluralistic character of health and medical system in which people have become recognized as ill, the way that they almost everyone society, be it simple or complex is being present their illness to other people, the attributes of those they increasingly recognized (Minocha, 1980). This pluralism may present their illness to, and the ways that the illness is dealt with. receive state recognition and patronage, or the state may discourage it or remain neutral to its existence.
(of
an
post,
but tradition.
try
the cross-section
of
type
illness
The
quasi-legal
medicine 1989).
People's bureaucracies
heterodox
drugs.
Examples
estimates healers special
communities.
island
themselves, overlapping
sector
(1980)
about
present traditions individual
popular
by
Understanding
138
ayurvedic
patients
a
within
to
different
different
of
professional
or
Occasional
particular
seek
occur
episode,
it.
healers
Secondly,
of
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Kleinman,
consists
developed
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Republic
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include
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South
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herbs,
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in
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herbalists,
it Medical
%
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China.
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sector.
given
Pluralism
mean
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health
Each
village
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doctor
midwives,
of
function
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1984;
them
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conducted
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sectors
practicing
typically
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medicine sector
has
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local
what
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clients
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model care
a
have
conducted
in
or
Minocha,
has
treatment
baths,
choice
a
or
as informally
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a
use
choice
coexIstence
mediums
folk
(Kleinman,
to
emphasizes
private
are
traditions. been
town,
laws,
clinical
common
in
and
ayurvedic
social
attracts
in
of
that
research
them
practitioners
of
within
allopathic
and
succession
or
sector
between
these
called
therapies,
traditions
defined
more
to
an
over-the in
episodes
1980).
recognizes
professionalized
by
clinic
during
acupuncture
go
and
and
realities.
network,
clients a
the
settings
understanding
illegal
encompasses
The
folk
nearby
the
than
1980)
the
in
of
ill
and
consulting
magicians.
often
medicine,
differently
particular
or
Kleinman
(Subedi,
hospital
a
position
Taiwan,
and
ITIllitlple
such
counter
popular
persons
on
sectors,
one
from
to
health
single
which
basis.
unani
often
Each
three
or
on
that
and
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the
of
in
as
a
a
a
care
of
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various
episode
and
attitudes,
dimension
system
hot-cold
modern
stethoscope,
from
in
themselves.
could practitioner
For
causes
dichotomy.
supernatural
dimensions. Anderson,
different
and
illnesses
may
and
others
are
Kristvik,
who
from
distant
treatment
different
his
pluralism)
other practices.
example,
modern
notice
illness,
work
contribute
specialists
aspects
of
medical
add
Medical
who
explanatory
To people
medicine
dichotomy
city.
Extending
and
illnesses.
personnel, 1999),
relates
as
systems,
1978), and
draws
this
medical
as
economic, the
causes
There
not
opthalmoscope
medicine
Then
Villagers
beliefs
For
their
wherever
of
Thus,
an
personalistic
traditions.
have
health-care
medical
Pluralism
to
only
extended
and
healing
pluralism
to
may
ayurvedic
natural
from
the
of
instance,
the
of
there
is
resort
a
including
armoury.
pluralism
different
that and
other
M.
it
help
illness
wide
meaning
considerable
practice
into
explain
institutional
it
varied
is S.
and
resort
persons
The
is
serve
includes
occurs)
versus
Subedi!
their
meaning
delivery
the
registered
easily
to
his
range
among
pluralism
and
and
treatment
versus
practitioner
inhabitants
social
nurses, theories
in
doctors
medical
systems
(M Similarly,
kit,
of
of
dietary
as
to
supernatural
responses
to
people's
Healer
other
it
possible
(Dixit,
medical
inocha, of
same
both
guidelines
and
system.
allopathic
and
is
of system
evidence
the
medical
medical
technicians,
indigenous
naturalistic
3n
in
traditions.
but
of
restrictions germ
the
medical
in
practices
Choice
medical instruments
organizational
the
impOItanl
medical
can
may
1980). causality
conception
practitioners
his
pluralism 1999;
independently
cognitive
that
In
dimension
to
and
types
healers practitioners,
concepts,
for
(Devekota,
looking
medical
that
in
categorize
incorporate
in
pluralism,
tradition.
other
The
Medically
Justice,
virus
dispensers
health
belonging
(Foster
healers
practitioners
in
one of to
the
among
further,
and
and
for
cognition
of
at
examine
terms
refers
personnel
practice.
theories
aspects
values,
medical
general
of
illness
health
disease
action
natural
social
drugs
advise
1984)
...
Apart
1986;
their
there
the
one
the
and
the
one
and
for
to
of
139 to
}
140
doctors,
acupuncture healers,
the
numerous
comprised
formal medical assistants, practitioners,
A practices,
medical
both
The
Sketch
traditional
of
distinguished
now
practitioners
(blowing). division
dificrent ayurveda.
surgeons).
Ayurveda.
methods
Similarly. conservative ancient
vaidyas.
call
that
the Practitioners not medicine"
is 1
individual
use
Occasional
the
synonymous
the
Unani
words
going
called
other
it
the
Unani
The
or
traditional
doctors
cognitive
"modern
knowledge,
Hindu
spiritual
and can
words
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and
term
of
of
alternative
to like
practitioners
the
health
astrology
medical
is
tradition
even
doctors.
Both
literally
nurses,
therapists,
are
in
to
daily
"traditional
be
of specify
Nepali
Unani
patient.
of
in
diagnoses. a
is.
"allopathy"
word \ileratlln:
"cosmopolitan",
Papers
this
overlook
arc
with
also
this
made
local
wide
ayurvedic
distinctive assistants.
medicine"
who
(specialized
illegal
used
tradition systems
and
healers,
"the
birth
of
tradition
now
Vaidya
and
aflgre=i
the
life
medical
usage.
between
dispensing
usc
are Medical
these
range
medicine
concerned
synonymously
Tibetan
therapies.
medicine:
social
terminological
its
and
knowledge
called
trantric
attendants,
in
usually
of
practitioners
the
nurscs.
use
are
arc
medical
suggests
refcrs
this I-Iowcwr.
(English)
those
in
categories
dhallli-jhClllkris
doctors
"western",
of
those
tcchnique
usually
doctors.
in health
unscientific.
Nepal
aspects
practitioners'
paper
in
rituals.
came
other
referred
with
medical
assistant
to medical
Pluralism
to
who
of
allopathic
who
call
a
a
chemists
In
system.
cal~ed
to
medical
are
to
traditions
health
issues.
parts
and
and
to Wide
life".
conlrasllvc
and
make
The
and
jiwnllI
rerer
it
be "modern.
of
to
stick
the
of
called
Nepal
nurse
"scientific
ritual
Similarly.
as
practitioners,
neutral.
or
other
beliefs, }.:av.iraj
health
variety
rekrs.
and
funct,ona:,es
lallt;r
to
din~n;nt.
~s
usc
healing
hakims.
healers
gmdllatt:s
the
exclusively
application
midwives.
(swcepll1g) folk
doctors
the
medicine)
healers
disease. through
Leslie.
(shama~ls),
of
and world.
practitioners.
relatIOnship arc
are
"blOmedlcmc
to
Although.
an.d
01
care
allopathic.l~cdicine.
an
medicine"
(Q
knowledge
Medical
healers,
the
wrile~s
hcalers. ~alled
(197?)
\'Clidya
01
use
(phySICians eclcctic
call
in
a~e
available
However.
1
phannaclsts;
Islam
available
and
.vast
he
ayurveda
to
ayurvedlc
and
not
Nepal
it
,:,cludll1
.ha~e
jahrphllke
different
tr.adltlonal
here.
of
ayurvedlc so
graduates
,
111
"western
notes.
A
to
suggests
b~d.y
pill/klill
and
tantnc
sharply
herbal
health
mix
on.
Nepal.
whIch
bro~d
their
some
Non
these
u~ed
I
and
and
are
am
its
as
of
to or
to
is
g
noted
medical
of
of
treatment
traditions
people's
recognize
make
more
completely
expects medical
illness
practitioner
associated
different
charges,
centers,
private,
estimated
numerous
Tribhuvan
and public
various
are
health
Asian
manifestations
societies,
specialization
Although
develop
forms
alternatives
disease
also
than
that
during
Army
episode
civilizations.
In
service
settings Within
of
Medical
health
traditions.
The elhposts, health
missionary
or
with
outdoor
in
therapies
medical
pluralistic
there
causality,
one
and
causes
order
that
the
in
others.
each
different
one
diagnosis,
University
their
requests.
a
Hospitals
state
their
medical
to
services.
epal modify
there
are
people
various
the
and
seeks
in
of
health
and
choose
certain
to
health
times
of
Colleges
decisions.
funded
present
the
independent
wide
Therefore,
Within
diagnostic
this
cultural
pluralistic understand
in
and
illness
curing
are
their
theories
M.
initially
sub tradition
therapy
However,
may
character.
institution.
country,
Teaching
the
and complication
To
preferred
variation
S.
from.
medical
variations
community
more
health
variation
health
the
Subedi/
associated
or name
old
the
seek
Hospitals,
indoor
pluralism
practices
In
of
health for
health
methodologies,
Below
it
until
medical
than
classification
and
traditions
the
Kathmandu
nor
services,
only
is
Hospital
There
posts,
causality
Nepal,
is
help
help
Healer
traditions, a
for
in
facilities
they
pervasive,
not health
350
medicines.
is
single
episodes,
problems
seeker
managed
in
are
practices
a
traditions.
and
them
from
that is
there
Mission
and
setting,
few,
is
surprising
Choice
are
agencies,
the
descriptions
for
and
medical
found
and
not
which
care
among
with
cured.
the characterizes
illness
of
and
Valley
there
practitioners
and
example which
uniformity
practitioners
several
and
determine it
only
hospitals,
make
in
and
other
illness,
symptoms
They
others.
is
choice
specialties
Hospitals
a
It
Medically
treatment
in
are
their
important
it
that government,
wide the
the
should
one
may
itself
knowledge,
may
almost
innuence
private
new
the
of
theories
elaborate,
medical
in
various beliefs
Service
people
in
type
family,
menu
which among
three
Nepal,
health
Police
be
from
have
...
many
and
ones. it
one
one
and
be
and
are
to
the
141
or
all
of is 142 Occasional Papers M. S. Subedi/ Healer Choice in Medically... 143 among different ethnic groups found in the country. The following is a very simplified version of these systems to provide household vary as does the impact of their illnesses, then their the reader with some sense of distinctions between them. access to treatment also differs. Household Based Self Medication Further, a person's position within the household not only influences his/ her access to medical care but also The concept of "household production of health" influences his/her sick role behavior. Thus a I;igh status recognizes that a person's access to and use of various forms of IIldlvldual or wage earner may receive concern and medical treatment are connected to his or her social power in relation to attention over a cough, whereas a lower status individual may other household members. Here, a "household" is examined have to really moan in order to appear sick enough to receive rather than a "family", as a household may be easier to define. A attention. When an illness strikes, the afflicted person generally household in this case may include, for example, other relatives does not cope individually- whole network of supporting social Iiving in the same house. Household productions of health ties are mobilized. The composition of members in this network examine how household members cooperate and compete for is of course decided by the structural principles according to resource in order to restore, maintain and promote health. which right and obligations as well as emotional involvement tie Caretakers attend to the patient through examinations, diagnosis individuals to each other in enduring groups. and treatments. In epal, the most important group is the patriarchal Medical condition necessitatzs a variety of changes in a hOl~sehold(nuclear or joint). Although there is significant household. Indeed, the full extent of the resource and variatIons among households with regard to social, cultural and responsibilities, which need to be negotiated, may not be economic 'capital' (Bourdieu, 1977), one of their dominant recognized by outside observers. These include fees for concerns is biological reproduction. Socialization of its children medications, analyses and examinations, transportation costs, and provision of livelihood for their members, households arrangement for accompaniment, and loss of a worker and more everywhere in Nepal, is the immediate group, which is mobilized likely of two workers either in wages of housework. All of these when a disease strikes. Important stores of knowledge factors, and no doubt more, can influence heath-care seeking transmitted within households are brought into play when the decisions. A consideration of the impact of the medical condition health of its members is threatened. Exclusively households to the household helps explain why patients may come to the support the children, old and disabled members of the family. hospital too late for treatment. Almost all households, at least at the initial stage of As mentioned, a member's access to health care is often illness, utilize a fairly wide stock of intergenerationally influenced by his or her position within the household. One transmitted as well as newly acquired knowledge and practices member may receive immediate treatment or the more of healing to nurse the ill back to good health. The localized prestigious treatment, while another member may receive care nature of society, limited access to, and relatively low quality of only if the symptoms are prolonged or may receive less public health institutions and the prohibitive costs of allopathic prestigious treatments, such as home remedies. Among the med,cll1e and modern health services also force most households characteristics influencing a person's status within the household to rely on home remedies which span from divination to faith are his or her age, gender, generation, marital status and work healing and the use of local herbs. Increasingly, they also involve status. Because of the variations in roles and responsibilities the use of off-the-counter allopathic drugs, which remain almost within a household, medical condition of various members affect completely unregulated (NESAC, 1998). Using massage, the household differently. Since members' status within the admll1lsterlng herbs, manually removed obstructions, applying heat compresses and recommending dietary restrictions and 144 Occasional Papers M. S. Subedi/ Healer Choice in Medically... 145
prescriptions are the major self-medication practices in Nepal. The magical spirit world affects health and can cause Generally such medical problems are first treated at the home illnesses through the network of angry ghosts (spirits of persons with some remedies suggested by relatives and neighbors. It is who have died in violent or other unnatural deaths), monster-like only after several attempts fail that a specialist is called in. bhut-prets (spirits), angry gods and anti-gods, and bokshis While access to the health post or hospitals are easier than in the (witches-person who can cast evil spells by performing inverted past (MoH, 1997), home based system of remedies are playing religious rituals). Illness in this tradition is believed to be caused an important role in health seeking behavior. For example, by "supernatural attacks (Iagu, lagu-bhagu) resulting from almost 90 percent of the childbirth in Nepal take place at home jealousy (especially in the case of witches) or one's having rather than in such f.acilities (NESAC. 1998). The rise and ignored or offended a spirit. Attacks can be in the form of expansion of institutions for enhancement of. individual-based possession or some type of physical harm. Specialists who help knowledge (for example, hospitals and other health institutions) to diagnose and cure illness brought on by such attacks are call be expected to change in its structure. commonly referred to as faith healers including sorcerers (those who can cast and break spells and have the ability to Local Indigenous Medical Traditions communicate with the spirit world), shamans (those who go into In "aeneral, when the home remedy to cure an ill person spirit possession trances, can perform exorcism and can act on fails, a larger net of intervening agents are brought in, namely the behalf of spirits), and mediums or jannelllallche (those who community level healers. They may vary among and within can act as transmitters between the spirit world and the non spirit religions; ethnic groups and locally they operate without any world). One study (reference year 1977) estimated the number of government recognition of formal coordination. Their medical various categories offaith healers between 400,000 to 800,000 in traditions and practices may be based on religion and beliefs Nepal (Shrestha and Lediard, 1980) for a population of Ca. 13 regarding cosmos, ideas about cultural construction of persons. million people, which roughly translates one faith healer for personal relationships between humans and the cnvironment, and every six households. The number of doctors at the same time diet. Healers often specialize in particular techniques and which was 500, and the number of nurses 334 (Shrestha and Lediard, specialist is consulted depends on the nature of illness itself. 1980:34). This figure can itself be taken as an indication of the In terms of religion one's health or ill health can be legitimacy of the tradition. Different research findings (for attributed to one's relationship with the spirit of. world of anti example, Okada, 1976, Durkin-Longley, 1984, Gellner, 1994) gods (demons) and gods (whether one has satisfied or angered show that even next to the hospital in Kathmandu Valley, them), the relationship between the deeds of one's past lives and traditional healers are many, and in high demand. Diagnosis is one's present Iife's predest ination (f.ate), and one's deeds done by going into trance, divination, and by inquiring about and according to Hindu and Buddhist scripture (virtuous or sinful observing physical symptoms. Prevention of attack is done (Hitchock and Jones 1976; Dietrich 1998; Miller 1979). In this through rituals, by providing the individual with an amulet, by tradition one explains illness in terms of dl",rllla (religion) or being careful not offend spirits or persons suspected of being karllla (fate). prevents illness by properly attending to ritual, witches, by keeping a fire lit, by being cautious of persons seen making promises to the gods, giving offerings and doing at night and by staying away from haunted places. Treatment is sacrifice, through prayer, and by following the scripture. Illness done by chanting mantras and shouting at the spirits to leave the is diagnosed and cured by jyolisis (astrologers), guru-purohits person's body, violent exorcisms by which the patient is burned, (priests), or monks through prayers and rilLJals. frightened and beaten until the spirits flee the patient's body, and by giving offerings and doing sacrifices. The significant role of 146 Occasional Papers M. S. Subedi/ Healer Choice in Medically... 147
local healers has been widely noted (Blustain, 1976, Okada, there were 1500-2000 ayurvedic practitioners in epal and 113 1976; Wake, 1976, Stone, 1976) in different parts of epal. The government ayurvedic dispensaries (Streenfland, 1985). Most majority of sick persons in the rural area, who eventually visit ayurvedic healers in Nepal work within the private domain. the allopathic healers, consult the traditional healers first as the Recently, ayurvedic healing in the public sector is performed hierarchy of resort. through one central ayurvedic hospital with 50 beds, one IS-bed Ayurvedic, Homeopathic and Unani Traditions zonal hospital, 172, dispensaries in 55 districts, and a central drug-manufacturing unit (MoH, 1997). However, fewer The ayurvedic medicine is based on the classical resources are devoted to them than to allopathic medicine. Sanskrit medical tradition of 'Ayurveda' (literally "science of Homeopathy was introduced in Nepal as early as 1920 as a life"). This tradition of healing has been practiced in South Asia natural healing system. Homeopathic healing is largely a private since ancient times. It bases itself on a well-developed system of sector initiative, which encompasses approximately 500 physiological characteristics of the ill person, symptoms of practitioners and 100 clinics (MoH 1997). Within the public illness and detailed pharmacological knowledge of herbs and sector, there is only one homeopathic facility with their processing techniques. hospitalization facilities for six patients. Within the ayurvedic medical tradition a person's body The unani healing tradition, with preventive, promotive is composed of prakri!i (the female component of the cosmos and curative services, has an extremely limited reach. In which forms the body) and three dosas (humors) (wind, bile, and addition, the Tibetan healing tradition, acupuncture therapy, phlegm) which are responsible for all bodily processes. The Japanese healing cults (Seimeiko), and naturopathy are also equilibrium of the dosas maintains health and imbalance results practiced in the selected areas of the country. in ill health. In this tradition, diseases or disorders are caused by physiological imbalances resulting from poor food habits, Allopathic Medical Tradition environmental changes, and shock to the system. Diagnosis is This tradition is based on the germ theory of disease and done by pulse reading, physical examination, and appraisal of studies of anatomy and physiology. The worldview that has symptoms. Disorders are treated with herbal medicines, diet shaped the allopathic medicine is commonly referred to as the control, lifestyle control, surgery, meditation, and changing mechanistic paradigm'. The characteristic of this mechanistic one's environment. Many Nepalese believe in its efficacy in the paradigm is the separation of the component part and emphasis long run, that is, as capable of achieving more permanent healing on the detail study of it. According to this tradition i1lhealth, with no harmful side effects. manifested by various signs and symptoms, results from The government of Nepal has formally recognized this pathological processes in the biochemical function of the body. medical tradition in Nepal. There are several government In this medical tradition health and normality are defined by affiliated institutions of ayurveda. For example, there is an reference to certain physical and biochemical parameters, such as ayurvedic campus in Kathmandu under the Institute of Medicine, weight, height, blood pressure, heart rate or visual activity. For Tribhuvan University, and the Department of Ayurveda in the each measurement there is a numerical range-the normal value- Ministry of Health, and some recognized health centers and pharmacies. Some ayurvedic practitioners have their own private 4 The mechanisticparadigm describesthe notion ofth~body asa machine. clinics. Ayurvedic doctors attend the medical schools either in disease as the consequence orthc: breakdown of the machine:.and Iht: Nepal or in India for a degree in Ayurvedic Medicine and doctor's task as a repairer to Ihe machine. Surgery. As early as the mid-eighties it had been estimated that 148 Occasional Papers M. S. Subedi/ Healer Choice in Medically... 149
within which the individuals are normal and healthy. Above or services provide care unevenly in the countryside; it is remote below these ranges are abnormal condition. This model is the and inconvenient for allopathic practitioners (Macfarlane, 1994; conceptual tool for the analysis of the bodily problem for Pigg, 1995). Maintaining a supply of drugs to remote health allopathic medical practitioners in Nepal. posts is a constant problem, as is keeping health posts and In this tradition, medical treatment is based on the theory district hospitals staffed with trained, active practitioners that a disease can be carried from person to person, through the (J ustice, 1986). air, the blood or bodily secretions or from contact with a septic In my view, Biomedicine must be seen in the context of object or substance. Officially, the allopathic medicine was capitalist world system. Some of the particular agents of the introduced in epal at the end of the nineteenth century when world system operating in the biomedical sector include the Bir Hospital was established in Kathmandu. Organized international health agencies, foundations, national bilateral aid development of allopathic services started in mid-1950s. This programs, all multinationals (especially drug firms, medical system is formally associated with the public health care delivery technology producers and suppliers, polluting and exploiting in epaI through the Ministry of Health and a number of private industrial firms, agribusinesses, commercial baby food suppliers, offices staffed by physicians, public health professionals, nurses, purveyors of chemical fertilizers and pesticides, and seller of midwives, health assistants, pharmacists, village health workers, population control devices), and a medical cultural hegemony and trained volunteers. Diagnosis are made by the physical supportive of the activities of these agents on the world scene examinations, appraising symptoms, taking blood pressure, and in particular nations and locales (Elling, 1981 quoted in doing the laboratory test of blood, urine and stool, taking the Baer et aI., 1997). At all levels the state care systems of body temperature, taking X-ray, and doing cathscans. Treatments advanced capitalist nations reproduce the structure of the class are given through the injections, medicines, blood transfusion, relations. The profit making orientation caused allopathic surgery, and electric shock, bed-rest, recommending changes in medicine to evolve into a capital-intensive endeavor heavily behaviors or diets, and physiotherapy. Prevention of diseases and oriented to high technology, the massive use of drugs and the illnesses are done through immunizations, health education and concentration of services in medical complexes. The state promotion, birth control, dietary restrictions, and an early legitimizes the corporate involvement in the health arena and examination and screening tests. Nepali people have a reinforces it through suppOl1 for medical training and research considerable faith in the technology of allopathic medicine, (Baer et aI., 1997). particularly in injections and antibiotics (Gellner, 1994). A wide There a re a number of tendencies that are the range of allopathic medicine manufactured in India and Nepal characteristics of allopathic medical tradition in Nepal. The first are freely available without an authorized person's prescriptions. tendency is that the locations of medical hospitals and research The in-charge of medicine sellers at medical halls (so called institutions, allocation of resources are central ized in urban pharmacies) who lack any formal training are selling the areas. The largest, most prestigious, most specialized and most "prescription only" drugs. money consuming curative institutions are located in the large Allopathic medical facilities, pharmaceuticals, and urban centers (Streefland, 1985; Subedi, 200 Ib). The same trained personnel, however, are neither reliable nor easily applies to the location of institutions where medical knowledge available in rural areas. Almost fifty percent of the country's is developed, stored and taught. It is difficult to find medical doctors, most sophisticated and large private nursing homes and schools, libraries and research centers outside the larger towns. hospitals, trained medical professionals, and the health facilities The politicians and administrators who steer and take decisions are concentrated in Kathmandu Valley. Government-run health regarding the health policy of the country stay in Kathmandu, the M. S. SlIbedi/ Healer Choice in Medically... 151 150 Occasional Papers
capital city. Similarly, the drugs to be used are generally healers for lagl/ or evil spirits. Millor discomfort, wounds and manufactured in the urban centers or in the rich countries. The sores are often treated at homes with foods and herbs; more ruling elites that control country collaborate with international serious injuries, the hospitals, clinics or health post (allopathic agencies, foundations and bilateral aid program to determine health healers) are consulted. But except for this, the larger pattern is policies (Justice, 1986). These elites and the agents they deal with not a matter of who consult when, but whom one consult first often advocate nationalize and preventive medicine, but their and why. actions favor curative rather than preventative approaches to health People's actual health behavior in situation offering care for themselves and even for the lower social strata. This choices is the outcome of the weighing process. Various factors situation clearly shows that the further away people live from the are known to be taken into account. One such factor is the center in physical and / or social distance, the more difficult it perception which villagers have of health care personnel. This becomes to get good quality and sufficient quantity of medical study, has, for instance, made clear that people's performance supplies, facilities and staffs (Streefland, 1985). This holds for a largely explains why certain healers who belong to the same peripheral village and for an urban slum. Although for the urban village and relate to their clients also as kinsmen, neighbors or poor health-care institutions and medicines are at a reasonable a/no manche are often more popular than the healers from distance, the costly nature of allopathic medicine plays an important outside. Other determining factors are the cost of treatment in role for not consulting the allopathic medical practitioners. relation to what people can afford and to the quality of service The second tendency of the allopathic medicine is that in they will get. The actual cost of using the services, those of the developing countries like Nepal, allopathic medicine is capitalist reaching the services, the opportunity cost (loss of money which and commercial in orientation. Many curative institutions, pharmaceutical companies and medical equipment industries are could have been earned in the same time) all are important in this privately owned. The goal of many medical practitioners is to work respect. privately and earn more money. Profit making is an important Cultural and Historical Forces consideration in the delivery of health care, and production and sale of drugs and materials. The consequence of such factors is that, People's understanding of the bodily affliction and broadly speaking, the best services and facilities are available in searching for cure is one of the most powerful forces in those places where most people are living and where most wealth is maintaining the continued acceptance of any medical traditions. concentrated. For the rural villages it means relatively low numbers The members of each cultural group have deep rooted beliefs of drug sellers and relatively unqualified medical practitioners that their own tradition must be useful if not the ideal system for (Subedi, 200Ib). On the other hand, the large demand for curative handling the illness recognized by the culture. Many informants services create an excellent environment for the activities of say that allopathic medical practitioners have no curative unqualified medical practitioners and unlicensed drug sellers. treatment for illnesses caused by ancestors, bokshi caused Factors Influencing Developmeut and Acceptance of Medical illnesses, Ajima and other types of lagl/ illnesses. According to Traditions them thejhakphllke or janllelllallche do have such treatments. In particular, since the illhealth is defined some what differently Different medical traditions in Nepal are co-existing very from culture to culture, and certain diseases state reputedly due well. Each tradition has own expertise, especially in certain to supernatural causes including phl/I-prel and bokshi, are illnesses. In many cases, the question of which specialist to therefore recognized only by its own members. These types of consult depends on the nature of illness. For example, most of understandings serve to reinforce the value of the particular the people seek ayurvedic vaidya or Kaviraj for jaundice, and medical tradition. Some culture bound syndromes, such as sarka, dhami-jhankri, janne manche, jharphl/ke vaidya or other local
geographical
are
or
medicines.
locally
generally doctors'
Economic remains the
janaikai,
beyond
factor actions,
them
live they
perceived
to 152
culturally
whereas
of
patients
injuries. of preferred
simultaneously,
the
certain cultural
not
existing psychological
Many
individual
them,
different
minor,
take
developing
all,
cultural
Occasional
in
healers
consult
to
in
informants
poor
will
Cost
feel,
their
available
Most
their
beyond
allopathic
infiuencing allopathic
concept
with
medical
Likewise, fees,
low. over-the-counter,
ayurvedic illness
bokshi
perceived more
most
and
Consequently,
Forces
eventually
economic
healers
context
perceive
and
the
means.
experience
of
within
and
The
illhealth,
Papers
constipation,
countries
pathological
the
the
altering
people
the
effective
accessibility
varieties
think bigar
differs
traditions.
phenomena,
medical
remedies
large
drugs
economic
reach
patient's
healers
therapist, Iranlric
was
the
diseases
of
The
and
conditions,
rid
as
that
in
are
play
its
choice
or
numbers
with
varied
like
value
of
relieved
him
against
government
very
Kathmandu
of
people
well
they
concept
sequentially
best
due
facilities
easily
were
this
jaundice
version
an
test,
healers
of
In
healers
Nepal,
and
the
of
this
reach.
of
those
substantially
to
should
the
explained
according
important
their
medical
the
particularly
of
as
mostly a
lagu relative
the
often
their them
long
and
will
medical
tradition
accessible
of
people on
healers
contexts
where
or
with
cost illness.
which
Valley
between
expenditure
or
In
the
try
and
the
term
expertise.
medicines
in
temporarily.
be
have jharphuke
effective
sector.
performances
respiratory
to
and
such
of
the a
to
universe.
role
relative
living
bokshi
care
extremely
the
they
of
find and
range
seek specialist
between
are
the
to
dealt
hope
of
in
medical
and
to
When bulk
is
the
areas,
employed.
durable
different
depend
nature in
on
each
For
within
local
an
on
continue
bigar.
performance
are
relation
of
with
that
vaidya
the
affordable
Where
According
accidental
of
important
traditions
problems
health
remedial
instance,
illnesses
difficult.
the
medical
care.
compel
usually
healers
culture,
village locally
people
one,
of
within
action
After upon
types
their
sick
are
the
the
the
In
is
to
if
cultural
Interaction
side
seek
any
And
way,
cheerful, health
discussion
concerns,
patients
cure perceived
performance
country
of responses
painful
as
the
accessible
example,
them.
pragmatic tradition
cure
traditions
is adequately
Influence
that
available
the
unable
rupees
effects
way
other
patients
if
patients
in
are
the
the
professionals.
final
These
systems.
different
They
Finally,
life
and
from
within
seek
If
friendly
without
by
acupuncture,
disease. remedy
healers,
of
healers
not
commented
or
fill
and
healers
to
reason
the
attempt
with
"why of
of
responded
many
healers
search
for
after
different
may,
them
these
recover,
of
which
them Medical
Other
dominant
visited
the
Their
procedures
health
chronic
the reacted
fully
which
healers not
effects.
efficacy.
They
behaviors
and
people.
that
economic
via
before
gaps.
for
in
and
As
could
or
M. once
practitioners
care medical
Medical
that
he
care
as
their
other
grasping
a that
relatively
different
they
most
adapt patients
S. could
Traditions
sufferings.
with
If
an
number
not. tries
medical
who
the
Subedi/
go
they
employed
a
practitioners they
recover
of
alternative
medications
perceive
Besides,
play
means patient
words,
of
death.
or
harmful
to
help
traditions
the
For
listen
Traditions
the
and
prefer
approached
on sources
experience
the
expert,
find
of
Healer
tradition
the
behavioral
interact
them,
physical,
of
them
They
They
accepting example,
uses
patient's
population,
seek
medical
for
the
to
it
people.
side
kind-hearted,
decisive
knowledge medical
senior
is
as
do Choice
of
diagnosis,
are
their
a
alternative
recover
quickly
were
have
closely
with
them
variety
or
being is
informants.
acupuncture?"
not
acupuncture
only
mental
after
aspect
view, specialists
unable
the
and
sufferings.
patients
in
tradition
frustrated
spent
exist
one
roles,
for
other
Medically
without
forms
effective.
theory
of related
is
experienced
effects
treatment
and
another
or
therapies
remedy
smiling
remedy
as
of
desirable.
the
thousands
to
spiritual
whether
Most
closed
medical
became
during
of medical
provide
clinics
behind
in
with
to
purely
value
such
they
This
were ...
cares
the
in
For
the
or
in
but
or
of 153
or a 154 Occasional Papers M S. Slibedi/ Healer Choice in Medically... 155
a variety of ways, and at times they borrow from one another, public acceptance and play a significant role in meeting the compete with and oppose each other. They may cooperate wIth health-care need of the villagers. The patients in the hilly regions each other in moving patients through particular referral systems. of Nepal are more likely to contact "dhami-jhankrP' first than Through such interaction there may develop a certain integration other health-care providers. of elements of. knowledge from different traditions. Other Most patients in Nepal use home remedies and delay elements in their traditions and practices may remain insulated seeking professional help. These remedies included the herbal and co-exist independently of one another. For example, remedies and foods to eat / avoid. If the problem continues, the traditional healers may give modern medicine, faith healers and next resort is a traditional healer. The modern health care traditional birth attendants are being trained as village health services are only sought as a last resort, usually for the serious volunteers and community health leaders, physicians prefer and persistent problems. This finding also shows that patients ayurvedic medicine for hepatitis, local ayurvedic healers or who do seek treatment at health facilities use both traditional and herbalists after being unsuccessful in curing a patient refer modern medicine according to their perception of effectiveness. patients to the hospitals, whereas spiritual healers or shamans The point here is that treatment decisions in medically pluralistic condemn beliefs about ghosts and witches as superstitIOus. settings typical of the developing countries like Nepal are Durkin-Longley (1984), in a study of urban Nepal, shows that complex. The choice of healers is shaped by a wide range of specific illness ideally are brought to practitioners of one factors, among them perceptions of efficacy, practical medical traditions; Jaundice (kama/pilla) is brought to the considerations (such as distance), symbolic considerations, the ayurvedic doctor, mental illness to the dhami-jhankris and perceived cause of the ailment and whether it is viewed as life jharphuke vaidyas, and accidents to the modern (allopatlllc) threatening, and personal attributes of the patient. This body of medical practitioners. research shows that the existence of biomedicine is only as a Not all systems exist to an equal extent in all parts of treatment option. The presence of alternative sources of health Nepal. The local indigenous system exists to a far greater extent care can significantly effect the choice of health care services. It in rural areas than either the modern medical or ayurvedic is apparent from this paper that anthropological knowledge and systems do. However, wherever one is in Nepal, there is a research method have not yet realized their full potential for pluralistic medical setting in which people must make their contributing to contemporary health issues. Thus, in assessing health care choice. health care service utilization, various factors associated with medical pluralism need to be considered seriously. Concluding Remarks REFERENCES A number of studies in Nepal have shown that persons seek different types of healers based on their perception and Baer, Hans A. et al. (1997). Medical Anthropology and the World beliefs regarding the illness problem, which in turn are System. Bergin and Gravey, Westport. influenced and defined by their social surroundings and network Barth, Fredrik (1993). Balinese Worlds. The University of Chicago Press, Chicago. of relationship. The most widely prevailing medical system in ...... (1990). "The Guru and the Conjurer: Transactions in Knowledge Nepal is faith healing. The fatalistic nature of people playa and the Shaping of Culture in South-east Asia and Malanesia." distinct role in Nepali society, especially when someone in the Man 25: 640-653. family suffers from chronic illness, mental illness, or is not able Blustain, Harvey S. (1976). "Levels of Medicine in a Center Nepali to have even a single child. Hence faith healers or shamans such Village." Contributions 10 Nepalese Studies. Center for Nepal as Dhami, Jhankri, Lama, Guruwa and the like receive wide
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