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

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130

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Nepal,

1997:39).

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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 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 , 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).

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heterodox

drugs.

Examples

estimates healers special

communities.

island

themselves, overlapping

sector

(1980)

about

present traditions individual

popular

by

Understanding

138

ayurvedic

patients

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different

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mediums

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(Kleinman,

to

emphasizes

private

are

traditions. been

town,

laws,

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common

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and

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attracts

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of

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them

practitioners

of

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and

succession

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sector

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therapies,

traditions

defined

more

to

an

over-the in

episodes

1980).

recognizes

professionalized

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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

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popular

persons

on

sectors,

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from

to

health

single

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basis.

unani

often

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three

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and

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of

in

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various

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and

attitudes,

dimension

system

hot-cold

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stethoscope,

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in

themselves.

could practitioner

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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

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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

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the

Unani

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or

traditional

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knowledge,

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spiritual

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words

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to like

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astrology

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tradition

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Nepali

Unani

patient.

of

in

diagnoses. a

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word \ileratlln:

"cosmopolitan",

Papers

this

overlook

arc

with

also

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wide

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distinctive assistants.

medicine"

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illegal

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tradition systems

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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

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medical

assistant

to medical

Pluralism

to

who

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allopathic

who

call

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a

chemists

In

system.

cal~ed

to

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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

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to

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an.d

01

care

allopathic.l~cdicine.

an

medicine"

(Q

knowledge

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(197?)

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use

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1

phannaclsts;

Islam

available

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he

ayurveda

to

ayurvedlc­

and

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Nepal

it

,:,cludll1

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tr.adltlonal

here.

of

ayurvedlc so

graduates

,

111

"western

notes.

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to

suggests

b~d.y

pill/klill

and

tantnc

sharply

herbal

health

mix

on.

Nepal.

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some

Non

these

u~ed

I

and

and

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as

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to or

to

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noted

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of

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traditions

people's

recognize

make

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completely

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illness

practitioner

associated

different

charges,

centers,

private,

estimated

numerous

Tribhuvan

and public

various

are

health

Asian

manifestations

societies,

specialization

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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

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causality,

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and

causes

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in

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their

requests.

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their

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epal modify

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to

health

times

of

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present

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independent

wide

Therefore,

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diagnostic

this

cultural

pluralistic understand

in

and

illness

curing

are

their

theories

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initially

sub tradition

therapy

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may

character.

institution.

country,

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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

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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

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and

setting,

few,

is

surprising

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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,

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in

various beliefs

Service

people

in

type

family,

menu

which among

three

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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 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, , 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

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perceived

to 152

culturally

whereas

of

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simultaneously,

the

certain cultural

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individual

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poor

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available

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beyond

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infiuencing allopathic

concept

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ayurvedic illness

bokshi

perceived more

most

and

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context

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and

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important

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particularly

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and

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contexts

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expenditure

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try

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and

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seek specialist

between

are

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to

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in

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and

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durable

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on

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instance,

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difficult.

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compel

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village locally

people

one,

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types

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of

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or

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attempt

with

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of

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of

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and

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practitioners

care medical

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that

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other

grasping

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sufferings.

with

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number

not. tries

medical

who

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recover

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to

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For

listen

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the

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prefer

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behavioral

interact

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physical,

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accepting example,

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knowledge medical

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recover

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have

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variety

or

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informants.

acupuncture?"

not

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mental

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aspect

view, specialists

unable

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and

sufferings.

patients

in

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spent

exist

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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 . 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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