Sot SC, & Med Vol 14B.

pp 191 lo 195
0 Pergamon Press Lfd 1980 PrInted m Gredt lhtd~n

MEDICAL PLURALISM IN WORLD PERSPECTIVE [l]

CHARLES LESLIE
Center for Science and Culture. Umverslty of Delaware. Newark, DE 19711. U S A

Abstract-Starting from the observatton of local medlcal systems, anthropologists culticate an even-
handed VIW of medlcal plurahsm. m contrast to the normative view that characterlzec health pro-
fessionals. From this perspective, the division of labor between dlffcrent kinds of practice appears as a
contmuously negotiated compromise structure and cosmopolitan medlcal practices are seen to adapt to
local cultures. Also, when the Chinese system IS described as a comprehenslve normative system. one
suspects that its pluralistic structure has been neglected and that planners who want to encourage the
utlhzation of traditional medicme in developmg countries should learn more about the on-going nature
of me&Cal pluralism

Local medical systems are the units of observation for that is ultimately linked to a world wide system of
anthropological field research. Because they are cosmopolitan medicine. This goal is a powerful force
embedded in local communities they vary from one in modern hlstory because it expresses the dream of a
part of the world to another according to the family future good society m which modern science will be
structures, religious, economic and political insti- used benevolently and rationally to relieve human
tutions of the regional and national societies m which suffering and distress.
they are located. Our first analytical task is to realize No real medlcal systems realize this dream. In the
that the concept of a medical system, which appears most advanced industrial nations the quality of medi-
simple and straight-forward, is in fact loaded with cal care is variable. and access to it differs among
historical assumptions. The concept is an artifact of rural and urban populations, members of different
the division of labor in nation states with Depart- social strata and ethnic groups. The cost of elimin-
ments and Ministries of Health, and of legislators, ating these variations by fully utilizing scientific
physicians and other specialists who claim the legal knowledge to meet all needs is greater than the
responsibility for supervising the health status of wealthiest industrial society is wllhng to pay. In all
populations. The generic conception of a medical sys- socieites. therefore. compromises are necessarily made
tem is thus based on a single. historically recent sys- in allocatmg medical resources.
tem: a bureaucratically ordered set of schools, hospi- In recent years reformers have drawn heavily on
tals, clinics, professional associations. companies and the example of the People’s Republic of China, where
regulatory agencies that train practitioners and mam- traditional Chinese medicine has been incorporated m
tain facilities to conduct biomedical research, to pre- the state sanctioned medical system. The idea 1s to
vent or cure illness and to care for or rehabilitate the consider “Irregular medicine” in a more objective
chronically ill. From this perspective other forms of sociological manner. All medical systems can then be
health care are outside the medical system and they conceived of as pluralistic structures m which cosmo-
are usually ignored. When they are not ignored they politan medicine 1s one component m competitive
are derogated as curiosities, or as frmge medicine, and complimentary relationships to numerous “alter-
quackery and superstition. native therapies”. This way of conceiving the medical
The triumph of modern medicine has been to im- system opens the door to serious practical studies on
prove care by applying scientific research and new how these therapies and their practitioners provide
forms of professional organization to biomedical resources for health care planning. The argument 1s
problems. Since the last quarter of the 19th century especially strong for developing countries where local
this has led to effective knowledge for controlling and medical systems are largely composed of indigenous
curing infectious diseases. and to the complex tech- practices and the immulation of costly mstltutlonal
nology that characterizes the modern hospital. Efforts planning from industrial countries is culturally and
to increase the scope and to improve the quality of economically inappropriate [?I,
health care have sought to eliminate or severely re- The contrast between these forms of medical socio-
strict “irregular practices”, so that ideally local medl- logy is simple, yet health professionals often display a
cal systems will simply become extensions of a nation- trained incapacity to grasp its implications. Havmg
ally and internationally standardized medical system. explicitly studied medical science and technology. it 1s
This ideal is expressed in plans that calculate desir- difficult for them to realize that along the way they
able ratios of trained personnel and facilities for dif- implicitly acquired an ideological view to medical
ferent units of the population and diagram their or- sociology. They do not question the objectivity of this
ganization in progressively larger and technically perspective because they learned it as tacit knowledge
more sophisticated units, from neighborhood clinics in a context that demanded the mastery of biomedical
to regional hospitals and research institutes. Whether theories and facts. Their objective skills are powerful
these diagrams describe health plans for the People’s means to achieve unquestionably virtuous ends of
Republic of China, for India or the United States. saving lives, minimizing suffering. and realizing a suc-
they all share the goal of making local medical sys- cessful career Their faith in a system in which local
tems standardized components of a larger structure health practices WIII be standardized by asslmllatlon
191
 192 CHARLES LEsm
to a transcultural medical science is sustained by the
rightness of these means and the virtue of these ends.
From this perspective the practical problems of medi-
cat sociology are:
(1) to train workers for different levels of com-
petency so that a hierarchy of skills will correspond
with a hierarchy of rewards and responsibility:
(2) to persuade physicians who are the apex of the
system to work outside of urban centers:
(3) to make expensive care less expensive and more
accessible to ail classes of people:
(4) to allocate resources between preventive and
curative measures;
(5) to persuade laymen to utilize and to comply
with professional care.
These problems are fek to be interim problems in
progress toward an inc~as~~e~elZ-regulated medical sq‘s-
tern. but the faith that sustains efirts to solve them may
be misleading. What appeurs to be practical may be
impractical.
The normative bureaucratic perspective involves an
enormous simplification of the ways that medical sys-
tems are organized. and thus encourages self-decep
tion. For example, the wilhngness of health pro-
fessionals who visited the People’s Republic of China
to believe claims of miraculous successes was self-
deceptive when the system was described as a perfect
bureaucracy that worked without conflict or ambi-
guity from the level of the barefoot doctor in the rural
commune on up to that of the surgeon in a large
urban hospital. The description neglected the ambi-
valence of negotiations between practitioners, familes
and patients who often have different ideas about how
to cope with health problems, it assumed that laymen
readily comply with the recommendations of prac-
titioners, and it ignored the spirit-mediums, diviners,
priests and other specialists who probably still per-
form many health care functions in Chinese culture,
although they are excluded from the state system.
Anyone who was familiar with the ethnographic
studies of medical practices in Chinese communities
would have asked how these “alternative therapies”
and their practitioners were related to the state sanc-
tioned medical system in the People’s Republic. To
have learned how that system really worked the
pluralistic structure of local practices would have had
to be studied in an objective manner.
Since the successes claimed for the People’s Repub-
lic of China were attributed to a system that inte-
grated traditional medicine, planners began to ask
how other countries could utilize such medical
resources. However. the perspectives of traditional
practitioners may be slighted by the way the question
is asked and answered. A common proposal,
example, is to conduct modern scientific research on
mdigenous medicines. Chemists and biologists per-
form this kind of work. isolating the medications from
the context in which practitioners understand and use
them.
For anthropologists the interesting proposals are
those to train and use practitioners who are normally
excluded from the state scanctioned medical system.
Proposals have long been made to train midwives and
to give them a place in the referral system of pro-
fessional medicine, but on the whole professional
health workers have been hostile to them, and m
industrial countries they have been almost completely
displaced by physicians and “qualified midwives”. In
developing countries, however, traditional midwives
still play significant roles in local communities, and
although the prospect of replacing them is remote,
health professionals criticize them endlessly with
stories to prove their ignorance, superstition, unsani-
tary habits and uneducatability.
Thorne and Montague show that traditional mid-
wives in Islamic communities have numerous roles
other than that of birth attendant-they do house-
hold chores for the mother in the period following
birth, they are consulted at other times about health
matters, they wash the corpse for funerals and they
serve in the transition rites for women. Similarly, in
other cultures the midwife is a member of the local
community in which she practices and her role is
woven into the fabric of that society. Detailed ethno-
graphic descriptions of the number, training, charac-
ter. roles and practices of midwives are needed so that
planners will have a base of contextural research to
provide data for policy decisions. Thorne and Monta-
gue conclude that the limited evidence from Islamic
communities indicates “we should be pessimistic
about the possibilities of integration or association of
traditional midwives in any major way with modern
health sectors.. no matter what the useful outcome
might be in terms of public health.. . there is massive
reluctance on the part of both trained medical person-
nel and traditional midwives to open a dialogue” [3].
On the contrary, if the laws that made their practice
illegal were repealed and they were treated with re-
spect by health professionals, the reluctance of those
traditional midwives to learn from and to cooperate
with the professionals would probably melt away.
Among anthropologists, Brigitte Jordan’s work richly
documents the skill and responsibility of Maya Indian
midwives [S].
In marked contrast to research on folk prac-
titioners by health professionals, anthropologists
report that they are often intelligent and curious
people who learn what they can about modern medt-
tine. All researchers agree that they are eager to use
modern drugs and this in itself is a major problem
since powerful industrially manufactured drugs are
commercially available to them in many countries.
Throughout the world health professionals inter-
pret proposals to use practitioners of “alternative
therapies” as recommendations to legitimize quack-
ery. In China the cosmopolitan medical profession
was politically disciplined with slogans such as “Red
versus expert”. The medical schools were closed and
self-criticism sessions were held in which physicians
for tramed in modern science were taught to see their
error in rejecting theories and practices of ancient
Chinese medicine.
In the absence of revolutionary measures that
quash the issue. the concern of health professionals
about quackery can be treated as an analytic and
empirical sociological problem. A survey of the litera-
ture will show that anthropologists who have studied
practitioners in local medical systems have reported
few charlatans among them. The reason this may be is
that traditional curers are often avocational prac-
 Medical pluralism in world perspective 193

titioners with other sources of status and income, and where villagers had limited access to the government
their practice is conducted in a public manner among health service or to college trained doctors in private
people familiar with the fundamental ideas and pro- practice.
cedures that it involves. While secret medications,
In such contexts. practitioners hke Balakrishna and
charms and rites often play a role in therapy, they are
Krishna Bhat have played a crucial role in imtrally mtro-
usually forms of mystification to enhance a common ducing villagers to modern ideas, medicines, techmques
faith that supports positive responses to treatment. and the framework of modern therapy. Moreover, they
A recent study in South India describes a physician have won villager’s confidence by functionmg within the
with an MBBS degree who had adapted his practice culture, paying credence to the moral and social aspects of
to the conventions of the rural area where he grew up. disease and.. the symbohc aspect of medicine. It is not
He treated numerous patients by proxy and since he unusual to see Balakrishna placing his stethoscope on a
was expected to give injections, he frequently used patient’s paining leg. This is not because he does not know
the proper use of the instrument, nor is it as ludicrous as it
distilled water. By the standards of his college training
may first appear. Patients are impressed by the instrument
he disparagingly described the clinics of rural phys-
and Balakrishna uses it symbohcally the action affirms
icians as “900,/, quackery and loo/, medicine” [S]. the patient’s worth, emphasizes the importance of the con-
Another study refers to “the myth of scientific medi- dition and assures the patient that the specialist IS using all
cine” to describe the exigencies of cosmopolitan medi- of his available resources to promote a cure [S].
cal practice in urban as well as rural India, and par-
ticularly in primary health centers where a physician This is not charlatanry, but a kind of “quackery”
must deal with hundreds of patients every day [6]. that is nevertheless useful to the community. The
When considering the issue of quackery raised by community would benefit from a program that pro-
health professionals it is useful to distinguish between vided such practitioners training and opportunities to
disease as a biological reality and illness as an experi- improve their practice.
ence and social role [7]. People have diseases without A division of labor exists in every medical system
being ill or assuming sick roles and they experience between practitioners who represent different tra-
illness and take sick roles when they do not have ditions. Thus, in the United States clinical psychol-
diseases. Although the biological and social realities ogists, yoga teachers, health food experts and Chris-
are interdependent they are not isomorphic, and their tian Science healers follow various systems of therapy.
relationship is culturally constructed. Scientific medi- Cosmopolitan medicine does not meet the demand
cine is composed of rules, categories and metaphors for health care in the United States, despite its elabor-
that ar? particularly effective for discovering and ate structure of specializations, extensive facilities and
treating diseases, but even if unlimited funds were clear professional dominance. For some illnesses and
available to create the best system of scientific medi- kinds of patients it provides less effective care than
cine planners could design, laymen would probably one or another “alternative therapy”. This is most
continue to resort to “alternative therapies” because a obvious in psychotherapy. Alan Harwood’s research
central clinical fact of the way medical systems work on spiritism in New York City calls it “a Puerto
is that they are social systems that give meaning and Rican community mental health resource”, and de-
form to the experience of illness. scribes spiritist centers as places where people learn
The experience of illness, not the biological reality from each other to cope with health problems, includ-
of disease, causes people to consult others about their ing how to use the system of medical welfare. In
health. Generated in these acts of consultation, medi- psychotherapy, however, spiritism provides the treat-
cal systems inextricably mix other social functions ment of choice for Puerto Rican believers. The inter-
with efforts to prevent or cure illness. Because the action between the healer and sufferer occurs within a
exemplars of cosmoplitan medicine make disease the framework of common understandings so that
central domain of their competence, they shun the patients can judge the talent of practitioners and
symbolic, political and economic functions of clinical choose between them. Also, research demonstrates
transactions. However, most private practitioners use that spiritism differs from the psychiatry available to
symbolic clinical forms suited to the culture of these people in that it “is consonant with certain basic
patients and their families. The proportion may not premises of the culture, does not stigmatize the suf-
be the 90”; quackery and 10% medicine of the young ferer and deals with clients’ problems by direct coun-
Indian doctor, but cosmopolitan medicine is almost seling and by symbolic reeducation” [9].
always less scientific than it appears. In the United States this division of labor appears
Health professionals know these things, but they to be a compromise structure related primarily to cul-
are not always fully aware of them, and the suggestion tural enclaves (American Indians. Puerto Ricans.
to utilize rather than to suppress “unqualified prac- Mexican-Americans), small religious groups and be-
titioners” appears to them to be a Pandora’s box. The havioral disorders (Alcoholics Anonymous, encounter
rule is, Other people’s quackery appears worse than groups). While “alternative therapies” interest anthro-
one’s own. Understandably, they do not want to con- pologists, few planners fully realize their role in the
front the perplexing problem of how to evaluate such overall system. Comparative research that includes
practices in their social context. The South Indian developing countries where large numbers of people
study described eighteen varieties of practitioners and depend almost entirely on the “alternative therapies”
the complex set of traditions that they use to inter- should provide sensitivity training for planners and
pret, prevent and cure illnesses. Two kinds of regis- social scientists to realize that medical pluralism is
tered practitioner used allopathic medicines, but one not a phenomenon of social enclaves in our own
was self-instructed, while the other had a course of society but a structural characteristic of the whole
training in homeopathy. They practiced in an area system.
 194 CHARLES L~.IE

The concern of workers trained in cosrno~J~tan

medicine with professional dominance has led them
to study pluralism in developing countries through 1. The regular health professions are the major
surveys in which peasants and other people who are source of resistance to the rational utilization of
not accustomed to being interviewed are questioned “alternative therapies” for planning m both industrial
about their con~ptions of disease and their prefer- and developing countries. Programs to change re-
ences in consulting different kinds of therapists. These cruitment and training in modern medicine would im-
surveys are misleading because they assume modes of prove the functional relation between different forms
thought that are alien to members of these societies. of medical practice and would have the greatest effect
For example, they assume that people everywhere use on the welfare of people in countries where the alter-
the perspective of cosmopolitan medicine in which native systems provide a large proportion of health
specific illnesses have specific causes and therapies. In care.
fact. people in these societies think about illness in 2. The practitioners of traditional medicine and the
humoral and punitive terms, and have little or no unqualified practitioners of modern medicine in de-
clinical conception of signs and symptoms. Or the veloping countries are probably no more frequently
questionnaires assume the universality of individual- charlatans than members of any other occupation and
istic decision-making and of dyadic doctor-patient in- the amount of “quackery” they practice is only differ-
teractions, which are normative for the clinical prac- ent in degree from that of trained health professionals
tice of cosmopolitan medicine in industrial countries, who adapt their practice to the culture of their
but not for other societies and forms of practice. patients. Programs to train these practitioners would
These surveys thus provide unreliable descriptions of benefit their patients and would not detract from the
beliefs and practices in developing countries. How- status of more highly qualified practitioners.
ever, they do record the fact that everywhere in the 3. Fundamental comparative research on the plura-
world people admire and desire access to cosmopoli- listic structures of medical systems would be an
tan medicine. Most people have a practical rather instrument of planning and also a technique for train-
than ideological concern for therapy, and see nothing ing personnel to design such programs in a realisttc
inconsistent in using modern and traditional medica- manner. The essays in this issue of Sociul Science unrl
tions together. or m combining chemotherapy with Mrdicine contribute toward this end. as does much
rituals to alleviate sorcery. In a suburb of Lusaka, for other current research in medical anthropology.
example, Frankenberg and Leeseon interviewed 1123
patients of traditional healers (ng’cmgas), and found
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 Medical pluralism in world perspective 195

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