This essay will discuss what medical pluralism is and why it occurs, including some disputes over the economic connotations of a medically pluralistic society. Medical pluralism is the coexistence of various medical or healthcare systems in one society. As well as exploring why medical pluralism exists, it aims to show that different people measure the eminence of one healthcare system over others in “hierarchies of resort”. A hierarchy of resort in terms of medical pluralism ranks healthcare options considering how well they may solve a medical issue, but with regards to cultural background. To explore the hierarchy of resort further, it will discuss the access different people in one society (those affected by HIV) have to healthcare, and what the path of healthcare the choose conveys about their social background.
Medical pluralism describes the existence of more than one medical or healthcare system in one culture. In the event of a medically pluralistic culture, biomedicine (cosmopolitan or ‘western’ medicine) competes or collaborates with alternative or ‘traditional’ medicine. In a society where medical pluralism occurs, the healthcare system is recognised as divided into three sectors: professional, folk and popular (McElroy and Townsend, 2009). Increasingly, professional healthcare (biomedicine) is not consulted as often as the popular sector (knowledge taken from the internet, women in the family, friends or colleagues) – between 70% and 90% of episodes of sickness are ‘treated’ without consulting a doctor or professional (Zola, 1972). Hardey discusses in his enlightened paper on ‘E-health’ that the increasing sophistication of the internet expands the forum for medical advice within the popular sector, displaying that health narratives within culture change all the time – he argues that medical pluralism is increasingly within every culture because of the internet, and that the percentage of illnesses treated by the popular sector has increased further (Hardey, 2001). Changes in the healthcare system and power shifts in medical pluralist societies have an effect on cost and on the availability and effectiveness of biomedicine, which can negatively impact the people who use it. These studies display the reliance in some cultures of biomedicine on folk and popular healthcare systems; because they treat a high percentage of illness. A holistic healthcare system, and therefore medical pluralism, is essential in many cultures.
This study on the necessity of popular healthcare in capitalist societies provides an interesting comparison to the occurrence of medical pluralism in other cultures that are shifting towards a more ‘western’ approach – away from their traditional systems of healthcare. For instance, China. Traditional Chinese medicine has been successfully implemented for thousands of years at every level of healthcare. This traditional medicine requires lengthy consultations and often prescribes a lengthy healing process. When comparing this with the immediate (and often detached) pace of “western” medicine, younger people view traditional Chinese medicine as outdated and based on superstition. Astutely recognised in their study of medical pluralism, Cant and Sharma discuss what the nature of the user in medical systems is becoming – “consumer or patient” (Cant and Sharma, 2004:20). They are indicating that biomedicine is a capital intensive medical system, treating patients in a bureaucratic way; patients and professionals have no rapport and pharmaceutical companies make a huge profit – a neo-Marxian statement (Ember and Ember, 2004). However, whilst biomedicine can be viewed in this way, the healthcare system overall cannot be: as condemned by critical medical anthropologists (Singer and Bauer, 2018). Alternative healthcare systems dominate over biomedicine, and where medical pluralism exists, the healthcare system is not controlled by profit, as statistically proven in the study of professional versus popular healthcare. Therefore, it is incorrect to state that the hegemony of biomedicine is so pervasive, since the medical system is not a monopoly yet.
In light of medical pluralism, hierarchies of resort describe the decision made in prioritising one healthcare solution before others. This decision can sometimes be made deliberately or involuntarily, and is often influenced by social standing regardless of the consciousness of the decision: “people choose healthcare solutions according to principles that follow a cultural logic” (McElroy and Townsend, 2009:253). This concept was first recognised by Romanucci-Ross in a seminal study of the stages of progression in seeking a cure; leading to the recognition that there was a thought process behind choosing a solution to illness (Romanucci-Ross, 1969). This conscious logic has basis in recognised severity of the illness, cause of illness, financial means and also what is considered appropriate therapy. These are calculated decisions since they are influenced by easily identifiable reasons. However, although choices of health system seem like cognitive decisions, often the choice is not made, but forced by social structure. Observing medically pluralist societies helps recognise that decisions behind a hierarchy of resort are not consciously made, societies where medical pluralism flourishes are consistently class divided (Frankenberg, 1980:198). Several factors are known to influence the hierarchy of resort and invariably in a society of medical pluralism, the patient’s social role and cultural status decide medical treatment. Frankenberg’s verdict should not rule out the influence of gender and race too – an all-inclusive version of the divisions in a society of medical pluralism would do better to include these cultural ‘categories’.
The best way to explain medical pluralism in light of hierarchies of resort is through a study of how different people in one society access healthcare. People suffering from HIV become affiliated as one society, and there are many ways the different people afflicted with the disease access healthcare; those affected are hugely diverse in social position. In rural South Africa, there is a 3-month to 4-year delay in seeking antiretroviral treatment (ART), with just 11 patients using the HIV clinic at the third level of care (Moshabela, Pronyk, Williams, Schneider and Lurie, 2011). This is the result of “lack of information and knowledge, stigma and denial, and high cost barriers” – 72% of the participants who were unemployed lacked the financial means for pursuing biomedicine, and also lacked an incentive for being treated with no job to remain at. Women more commonly waited longer before resorting to any medical treatment and only once fallen pregnant did one woman seek ART. In all societies, certain diseases have a stigmatisation attached, possibly no more so than HIV. In this way, the consulted hierarchy of resort for patients of rural South Africa is influenced by the cultural stigma attached with suffering from HIV. Patients do not want to be associated with the disease.
In a study of Hispanic HIV patients living in America, there is further testimony that the pursuit of ‘folk’ treatment is influenced by cultural position – 73.7% of respondents believed in evil spirits and had participated in folk or spiritual healing (Suarez, Raffaelli and O’Leary, 1996). Conversely to rural South Africans, Hispanic patients in America were more likely influenced by their religious beliefs; seeking spiritual healing, and their primary care seeking method was not due to the social stigmatisation of HIV, but a religious fear. Furthermore, in the South African study, the authors should proceed with caution when firstly treating biomedicine as the only kind of treatment, and secondly blaming the structure of medical pluralism for the delay in seeking healthcare. Collaboration between biomedical doctors and ‘traditional’ herbalists can clearly be observed in a Kenyan community, and dispels the claim that ART is the only ‘worthy’ treatment. The collaboration should be encouraged given that the ingredients in the herbs and the ART ingredients are concomitant, the herbs are cheap, and the cultural practice behind traditional medicine allows for some relief of mental symptoms providing comfort (Nagata, Jew, Kimeu, Salmen, Bukusi and Cohen, 2011). Interestingly, India as a case study for HIV patients highlights the idea that medically pluralist societies exclusively occur in class divided societies, since India has a large wealth disparity. This idea is reinforced by an article about patients in Pune, India. It states that contextual situational differences in HIV patients mean “highly individualistic management practices” (Datye, Deshmukh, Deshpande, Kielmann, Porter, Rangan, 2005:1544). This reinforces the idea that hierarchy of resort is created by circumstance (especially Frankenberg’s idea about the prevalence class division) – in this case, financial. These different examples of people afflicted by HIV are attempting to show that, chosen or not, hierarchy of resort conveys a great deal of information about the sociological contours of a society.
This essay has explained what medical pluralism is and has placed it in the context of economy, which helps to explain why medical pluralism exists and how the different systems of healthcare interact – namely collaboratively, and the professional sector reliant on the popular sector. In light of hierarchies of resort, the essay has aimed to show that in a medically pluralist society, people rank different resources of medical care with regards to their cultural belief or indeed inherently through social standing. It has attempted to explain how different types of people in an HIV community prefer to or are forced to access various forms of treatment.