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Exploring health care

Print edition : Jul 15, 2011 T+T-

A diverse set of papers based on micro-level studies that straddle the domains of health, culture and religion.

SOCIAL scientists, more specifically those involved in the public health sector, have been concerned about access to health care, particularly to the biomedical development initiatives driven by modern medicine. There have been fierce debates on the degree, spread and quality of private medical care vis-a-vis a strong public health care system. In the latter, access is not determined by the thickness of one's wallet but by a public policy to make health care free and equitable. Clearly, not everybody is able to gain access to modern medicine. The authors of the papers presented in this volume explore how other forms of treatment, traditional or otherwise, are able to find a place in the system without posing a real challenge to modern medicine or leading to social conflicts.

Although the papers are essentially part of a wider series on South Asian History and Culture, a few volumes of which have already been published, South Asia has not been represented in its entirety in this particular volume. There are a number of fieldwork-based analyses from India, mainly micro-level community studies, and very little from Nepal, while the rest of the countries in the region go more or less unrepresented. However, according to the editors, the contributions produce a range of fascinating studies that straddle the distinct but interplaying domains of health, culture and religion and seek connections between the rich empirical findings arising from their research and larger practical and theoretical implications.

The 10 contributions look at the interface between biomedical systems of medicine and traditional systems, albeit in a very limited sense. Some of the papers, especially the ones written by Kalpana Ram (Class and the clinic: the subject of medical pluralism and the transmission of inequality), Victoria Loblay (Spatial boundaries and moralities of gender: considerations from obstetric and gynaecological practice in Chennai, South India) and Maya Unnithan's work on infertility among women in Rajasthan look at the hierarchies in public health and how class shapes the attitudes of health care providers. They look at culture, its patriarchal roots, and how it sometimes hinders access to health care, especially for women.

The editors, Assa Doron and Alex Broom, the former an anthropologist at the School of Culture, History and Language at the Australian National University and the latter a sociologist at the Faculty of Health Sciences at the University of Sydney, have focussed on micro-level field studies that draw micro-level conclusions. Had the micro-level studies been related to broader policy issues that would have added value to the work.

The papers put together are diverse, making it difficult to draw a commonality of understanding. This is surprising as the editors make it clear that they are writing at a time of significant global economic turmoil. This could have been an appropriate context for the authors to locate their arguments and base their field work in their overall research and writing. There is no central argument in any of the papers barring Jamie Cross' work on Occupational health, risk and science in India's global factories.

The editors write that rapid deregulation and privatisation over the past two decades have produced new forms of polarisation and marginalisation and that health practices in rural and remote areas are ideologically marked and geographically isolated, producing a hugely differentiated health care landscape that is evolving but leaving many behind. Given the socio-economic background of the people, the disparity in access to health care is stark not only between rural and urban areas but within urban and rural settings too. It is the economic factor that determines everything. Increasingly, the benefits of medical technology, including the sex determination test, are not being used by those who do not have the means but by those who are educated and have the means to deal with a range of issues from infertility to sex determination. Culture is hardly an impediment here; if anything, modern science and regressive cultural practices cohabit the same space, conveniently. And governments often use the cultural argument for not intervening where they should. The eternal question is: whether one should leave culture and its interpretations as they are, leave people to their cultural destinies giving anthropological or sociological arguments of preserving things as they are, or intervene in the interests of creating an equitable society where culture plays a progressive role, devoid of patriarchal moorings and without reflecting the practices of dominant groups in society.

According to Doron and Broom, illnesses and pathological behaviours do not take place in a cultural vacuum, and existing health conditions are shaped by class distinctions, caste structures and gender relations. There is no doubt about this particular argument, though as Kabita Chakraborty points out in her paper, Unmarried Muslim youth and sex education in the bustees of Kolkata, conservative approaches to sex education were dealt with and dispelled with an innovative programme using cultural idioms to drive home the message of safe sex. This perhaps underscores the argument that culture can be devastatingly resistant to change, but given an overall environment where the elements of change are introduced gently, cultural idioms can be used in a modern sense.

POOR PATHOLOGISED

Doron's own paper on the misunderstood alcoholic boatmen and divers of Varanasi provides a neat sketch of the drudgery and degradation these people suffer. This case study shows how the poor are pathologised as people given to excessive drinking and points out how empirically false and socially reckless such notions are. Such views, Doron says, merely reproduce the dominant public health approach to alcohol consumption as a predicament of the poor; it also serves to reinforce a morally dubious argument that renders the poor as irrational people with little knowledge of the ill effects of drinking. For the boatmen, it is a source of both pleasure and angst; it is seen as holding both regenerative and destructive properties but circumstances of occupation lead people to excessive drinking, as in the case of the divers who often have to fish out corpses on the orders of the local police.

Doron mentions in passing the unorganised nature of the work of the divers and the boatmen, which makes them susceptible to oppression by the system. It is an interesting case study, one that exposes the duality of religion, where the boatman and the diver are considered necessary evils by a heavily prejudiced social order that derives its sanction from religion.

However, Doron makes an interesting point. He says: Regular displays of drunkenness, especially among divers, is a problem and one that calls for certain forms of intervention. But interventions that demand stricter legislation and policing would ultimately lead to further criminalising and marginalising of the poor. He says drunkenness must be dealt with in a holistic manner with attention to the material and cultural realities and the aspirations of the boatmen, an approach that foregrounds their health and well-being as people who are structurally disadvantaged. One of the more interesting papers is Jamie Cross' Occupational health, risk and science in India's global factories. Cross, who is with the Department of Anthropology, Goldsmiths College, University of London, worked and trained as a diamond polisher in the Worldwide Diamonds factory in the Visakhapatnam Special Economic Zone.

He argues that the sites of global production offer an important topic for debate about the political economy of science and public health. He says public understanding of science is not equal it depends on the relative autonomy of the individual and his/her place in the hierarchy of work relations. Having worked in the factory himself, Cross has been able to experience first hand the health hazards workers face owing to dust pollution. His study, focussing on the anthropology of globalisation and industrial labour, however microscopic it might be, stands out.

Cross has a holistic understanding of the problem and locates the various cultural responses and arguments within that framework. The autonomy of a source or a person in the hierarchy of work relationships makes other factors secondary, he says: the notions of risk at the workplace circulated among the managerial sections and workers in this factory interacted with science not through a benign social and cultural filter but through specific calculations, direct observations, feelings and emotions, relations of power, obligation and dependency and social histories of exclusion and marginality. Life in the zone is an economic strategy where health is traded for social protection. Notions and perspectives of risk are not just rooted in a localised cultural imagery but are constituted, reproduced and transformed in wider structures of power.

The other papers, on the meaning of spiritual healing in Nepal (Asha Lal Tamang and Alex Broom), of the health issues of Paniyas in Wayanad, Kerala (Sumant Badami), HIV and the gurus (Nalin Mehta and Upahar Pramanik), and HIV and drug use through injections in north-eastern India (Michelle Kermode, Peter Deutschmann, M.C. Arunkumar and Greg Manning), broadly illustrate the importance of understanding cultural and local beliefs in the implementation of public health programmes. There is concern about the involvement of religious gurus and institutions in matters of public policy. These papers do not reflect such concerns.

The papers are diverse in content and they must be read independently and appreciated for the distinctiveness of the ethnographic work involved.