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Coversheet for Thesis in Sussex Research Online A University of Sussex DPhil thesis Available online via Sussex Research Online: http://eprints.sussex.ac.uk/ This thesis is protected by copyright which belongs to the author. This thesis cannot be reproduced or quoted extensively from without first obtaining permission in writing from the Author The content must not be changed in any way or sold commercially in any format or medium without the formal permission of the Author When referring to this work, full bibliographic details including the author, title, awarding institution and date of the thesis must be given Please visit Sussex Research Online for more information and further details The Commodification of Health Care in Kerala, South India: Science, Consumerism and Markets By Caroline Wilson Thesis Submitted for Doctor of Philosophy in Social Anthropology University of Sussex April 2010 -1- I hereby declare this thesis has not been and will not be submitted in whole or in part to another University for the award of any other degree. Signature…………………………………………………………………………………………………….. -2- SUMMARY In India, alongside Information Technology, health care has become a leading sector in the country‘s development as a ‗knowledge economy‘ (World Bank 2005). One of the major achievements and beacons of economic reform is the growth of some of the most technologically advanced hospitals in the world. This thesis examines the social processes shaping the expansion of the private health care system in the state of Kerala, South India, where large corporate hospitals and ‗super-speciality‘ medicine have spread throughout urban and many rural areas. It explores the intersections between the local and the global, as the health system becomes the major driver of industrial development, unevenly linking the local health care system to the global marketplace for technologies, health care professionals and patients. It examines the three faces of the health care system in Kerala - as a knowledge industry and route to social mobility for the middle classes, in particular doctors and nurses; secondly, as a consumer economy, as people prioritise spending on health care and shop for treatment in the urban marketplace; and finally as a moral economy, as people develop high levels of dependency on doctors, hospitals and technologies in the hope of receiving good health care. The ethnography is set in Malabar, Northern Kerala, where the expansion of private health care has been financed by remittances from migration to the Arabian Gulf countries. The thesis examines the influence of migration and economic reforms on local ecologies of health and health care; the impact of the globalisation of trade in health services in the developing world; the relationship between the private health care system and the middle classes in South Asia; and the role of markets in the delivery of health services. Based on 18 months of participant observation across the urban and rural health care market with local communities of doctors and patients, it examines how doctors and patients adjust to a changing ecology and economy of health care. -3- CONTENTS Map 1: India ............................................................................... 8 Map 2: Indian Ocean .................................................................... 9 Map 3: Map of Kerala .................................................................. 10 List of Acronyms, Abbreviations and Medical Terminology ................. 11 Acknowledgements ..................................................................... 15 Introduction .............................................................................. 18 Purpose, Contribution, and Argument of the Thesis ....................... 21 The Organisation of Chapters .................................................... 28 Literature Review The Marketisation of Health Services and the Commodification of Health Care ............................................................................ 29 Markets, Economics and Global Connections ................................ 30 The ‗New Middle Class‘, Doctors and Hegemony ........................... 32 Doctors and the Accumulation of Capital ..................................... 35 Privatisation, Marketisation and the Commodification of Health Care 36 The Marketisation of Health Care: From Social Good to Product ...... 39 Medicalisation, Pharmaceuticalisation and Modernity ..................... 41 Objectification, Commodification and Standardisation .................... 45 Market and Professional Values .................................................. 49 Consumerism, Choice and Inequalities ........................................ 53 The Moral Economies of Medicine ............................................... 55 Informationalisation of the Health Care Economy .......................... 59 Conclusion ............................................................................. 60 Introduction to Kerala ................................................................. 60 Chapter 1: Markets, connections and the global economy of health care ............. 63 The Rise of Market Ideology: From National Development to Global Trade in Health Services ........................................................... 63 Transitions in Economic Development and Health Care .................. 64 The Global Contexts of Health Sector Reform ............................... 66 Health Sector Reform in India.................................................... 68 -4- Regionalism and the Rise of the Knowledge Economy in India ......... 74 The Middle Classes and the Knowledge Industries ......................... 76 Conclusion ............................................................................. 79 Chapter 2: Researching the Medical Marketplace ............................................. 81 Entering the field ..................................................................... 82 Selection of the field site .......................................................... 86 From Controlling Islands to Permeable Spaces: Multi-sited Hospital Ethnography ........................................................................... 90 Participant Observation in the Health Care Market ........................ 93 Shadowing Doctors: Participant Observation in the Health Care Market ............................................................................................ 93 Entering the Field and the Fieldwork Process ................................ 95 Accessing the Patient Lifeworld ................................................ 100 Studying Experts and Cultures of Expertise ................................ 102 Data Analysis ........................................................................ 106 Chapter 3: Medical Mediations: Doctors, Science and Social Power .................. 108 The Rise of the Professions ..................................................... 109 The Social Contexts of Medical Knowledge and Practice in Kerala and India ................................................................................... 111 The History of Western Medicine in India ................................... 112 Two Histories of Medicine in Kerala........................................... 115 Medical Pluralism and the Health Care Market ............................ 120 Doctors in Society: Elites, Social Reformers ............................... 122 Professional Powers, Healing and Translations ............................ 124 Implications and Conclusions ................................................... 127 Chapter 4: Health Care Transitions in Kerala: From Model of ‗Low Cost‘ to Liberalisation and Migration ....................................................... 129 State Expansion and the Local Medical College ........................... 130 Marketisation and the Government Sector ................................. 134 -5- The Kerala Model for Growth ................................................... 136 Gulf migration and the Private Health System ............................ 136 From ‗Good Health at Low Cost‘ to Luxury, Morbidity and Mortality. 138 The Problem: ‗Mediflation‘ and health inequalities ....................... 141 Private Medicine and Caesarean Sections .................................. 144 The Transformation of the Medical Profession ............................. 146 Medicine and Migration ........................................................... 148 Local Patterns of Migration ...................................................... 150 Post-graduate Qualifications .................................................... 154 The Privatisation of Medical Education ....................................... 155 Conclusion ........................................................................... 157 Chapter 5: The Rise of Super-Speciality Medicine .......................................... 159 Characteristics of the Private Sector in India .............................. 160 The Growth of the Private Sector in Malabar .............................. 162 Making a Hospital: Super-Speciality Medicine in Kerala ................ 166 Pathways to Development ....................................................... 167 Super-Speciality Hospital A ..................................................... 168 The Community Super-Speciality Hospital ................................. 170 From Super-Speciality Medicine to Corporatisation ...................... 171 Doctor Memorial Hospital ........................................................ 171 The Corporatisation of Doctor
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