Thursday, October 1, 2015

Insights from India: Health care, fifty years hence

Various Ayurvedic medicines are fast becoming "commodified" in India, underscoring a medical pluralism
that continues to evolve. (Sept. 2012)

by Gideon Lasco

LEH, JAMMU AND KASHMIR - In another essay, I reflected on how Ayurveda functions here in India. With this as a sort of background, how we can now prognosticate the health care systems in the Philippines in the coming decades?

India shows us two of the main phenomena that I think will play a major role in shaping the health care in the future. The first is medicalization, and the second is medical pluralism. Later, after explaining these two different but interactive concepts, I will speak of the means and trends by which these phenomenon will take off.

Medicalization is, simply put, the ever-increasing influence of medicine in the performance and sanction of society and our everyday lives. Foucault, in his Birth of the Clinic, traces the rise of biomedicine, and this theme of medicalization was articulated n Medical Nemesis, a book which warned that biomedicine has actually given rise of diseases – a process its author, Ivan Illitch, refers to as iatrogenesis. He saw medicalization as a dire phenomenon that would unfold towards greater detriment to people.

Theorizing in the Western world, Illitch did not see the manifold consequences of medicalization in a society where Western medicine does not have a monopoly in health care. For one, what we see in India is the utilization of medicalization as a tool towards the acquisition of legitimacy, as in the case of Ayurveda and even Siddha and Unani. Moreover, he did not anticipate the ways in which technology will liberate people from being subjects of biomedicine – for instance, through the proliferation of information in the Internet, the ubiquity of drugs that people themselves use. Finally, critiques of medicalization lose the potency of their arguments in a society where various, divergent, and at times complementary systems of health care exist, a state that Nguyen and others term medical pluralism.

These two trends are concepts by which we can plot the course of the future.

Medicalization remains a powerful and relevant idea in our contemporary society, and can be used as a heuristic device to describe how biomedicine has profoundly affected our culture. Without going through the extent of medicalization, we can just cite one example to make our case: the medicalization of childbirth.

In the past decade, the WHO declared that childbirth must be done in the hospital or the clinic, not at the home. The shift of the locus of birth from its traditional place is both significant and symbolic, it indicates not only the uprooting of previously-held practices, but also the impeachment of previous, culturally-designated bearers of knowledge on pregnancy, childbirth, and child-rearing. In my Tagalog-language health website, one of the most popular topics relate to pregnancy. “How to know if you're pregnant?” is one of the most viewed articles, and even “trivial” stuff like “Is it safe to drink cough syrups when you're pregnant?” come up on a daily basis. These are the questions that people ask – pointing to an area which our health care system has not provided for: the explanatory utlity of medicine in everyday choices and situations.

Thus the notion of medicalization is related to cultural upheavals that take place in its aftermath. The medicalization of knowledge, which we hinted at, means that the proportion of health care information available to laypersons has decreased. In traditional medicine, going through normal processes of life, such as birth and death, were handed down as part of folk knowledge, from generation to generation. Traditional healers were at hand to faciliatate these life stages, but everyone was familiar with what is being done. In biomedical childbirth, as in many medical procedures, the woman (who becomes a “patient”) has little idea of what is going on.

Ultimately, this informal asymmetry paves the way for other health care providers, formal or informal; virtual or real, to enter the health landscape. Ironically, medicalization leads to medical pluralism. And it also leads to a clogged healthcare system, with overconsultation, overmedication: symptoms of overdependence in biomedicine.

Medical pluralism does not always lead to the best outcomes. In some cases, these providers prove unreliable, or worse, deceitful. Self-care, in the absence of an environment which provide (or foster) knowledge among the lay, can also lead to destructive practices like self-medication.

In the above paragraphs, I illustrated how medicalization has far-reaching consequences in society. It is not difficult to see how this will continue in the future, with technologies that challenge and redefine our notions of health, wellness, and beauty.

Genetics is one of these technologies. By claiming to see the future of the human body, it transposes “diseases of the future” as “illnesses of the present”, and this will play into cultural beliefs and practices as well. The emphasis on biological (i.e. genetic) determinism will challenge perceptions of health and wellness, and shape expectations of children, especially when these kind of determinism begins to pervade social, intellectual, and emotional development.

In India, technologies that allow couples to determine the sex of the fetus at several weeks' age of gestation, has led to abortions of females. This has led Nobel Prize laureate Amartya Sen in 1989 to decry the demise of the “missing women” that should have been born in India.  Again, it will be interesting how foreknowledge of traits will influence child-rearing practices, and what impact it will have on children, marriage, and family life. Perhaps the long-held notions of “pinaglihi” will give way to the notion of “genes” and “physical identities” will be expanded to mean not just phenotype, but also genotype.

For instance, many Chinese families are known to inspect their child's future wife or husband and screen them for genetic “defects”. A suitable match can be determined not just by congruence in personality, but also in genetics.

On the other hand, while novel medical technologies will expand the diagnostic capabilities of biomedicine almost to the level of prophecy (i.e. “Someday you will have breast cancer”), the therapeutic capabilities will also be increased. Genetics, in the long run, not only has the capability to identify future diseases; it can also eliminate them. Yet these technologies will be, at least initially, available only to those who can afford it. As the latest of numerous example, the recent craze of stem cell therapies among the uber rich

Moreover, what needs to be treated – i.e. what should be considered as a disease – will continually be expanded. “Physical defects” can now be managed by cosmetic surgery and dermatology; to look  “beautiful” is to look normal, even though this so-called “beauty” is a social, and oftentimes a commercial construct. When Dr. Vicky Belo and her crew invented the term “Belo-fied” as a desirable process of “beautification”, they are articulating both the reality of the process and contrived nature of it.

Indeed, technology is driven not just by pathologic or physiologic need, but by economics, and it is likely that these technologies of body enhancement will continue. As an indication of this, the Olympic Games are chronically marred by doping scandals. The other day, The Times of India ran a story about Lance Armstrong, whose spectacular record in the Tour de France has been tarnished, and will perhaps be retrospectively stripped off, as a result of  “more than a thousand pages of evidence” of systematic doping using EPO, steroids, and blood transfusions.

Perhaps, ultimately, humanity has to accept that body enhancement is not being artificial, but being human. But this acceptance will come at a high cost. For one, there are fears that these body enhancements will, like the firstfruits of genetic engineering, create a divide between the rich and the poor: Homo technologius and Homo sapiens.

Yet while these inequities would be magnified by further technology, they are seen even today, in procedures that are taken for granted in the West, but remain prohibitively expensive in nations like the Philippines. According to Dr. Alberto Romualdez, a former health secretary:
Every year, 8000 Filipino suffering from chronic kidney diseases will need renal transplantation. However, due to prohibitive cost of the procedure, only 500 transplants are done, virtually all of them on upper-class patients.
Technology, indeed, can be a driver of health inequity. However, whenever there is a need that is not met, any of the participants in the pluralism of medical systems can come in, especially if it offers the same therapeutic effect for a much cheaper cost.

Technology, however, does not only make aspects of health care exclusive to people who can afford it; in some ways, it also opens up health care to a greater segment of society. In the case of the Internet, for instance, it has liberalized knowledge, opening up technical and non-technical information to the general public. The challenge now is not the ability to store information, but the ability to interpret it.  Increasingly, patients will use online information to validate their doctors' diagnosis and treatment; or else, to self-medicate. In Kalusugan.PH, a website I created – the only health website in the Tagalog language, people's questions reflect their search for information and reassurance, but at the same time, the need for interpretation. At times, the simple “Which doctor to consult?” is an important question; the Internet will not oust the physician; but it will lead to a renegotiation of the doctor-patient relationship.

The Internet is significant not only for providing knowledge, but also by creating new communities in cyberspace. In health, this has led (and will continue to lead) to patients and their families, suffering from a similar disease, to forming forums, websites, and interactive pages in the Internet where they can find common cause, and where they can exchange their experiences. With the global scope of the Internet, this sort of community-building acquires a transnational nature, and previously scattered groups, such as people suffering from beta-thalassemia, can gain political power through this coalescence.

Globalization is another important driver, not only as a vehicle to proliferate technology, but also as a means to introduce various ideas on health, including health care systems. These global ways of healing do not only come to Filipinos; we also apprehend them in their native sites through our Overseas Filipino Worker (OFW) population. Conversely, we export our own beliefs with our OFW population; it will not be surprising to find a manghihilot in Hong Kong. However, in the same way that it has been criticized for favoring multinational companies over small businesses, globalization favors organized health systems, not fragmented ones like our indigenous system of healing. It is Ayurveda and Chinese Medicine that have a big chance of making inroads in other countries' health system. On the other hand, new forms of media would still allow voices from individuals: a best-selling author can easily change health habits overnight: we saw this in the faddist South Beach and Atkins diets in the 1990s.

Medical pluralism allows the comparison of various health care systems, and the public appraisal of  which among them work for particular conditions. This, in the long run, can pave the way for a synthesis of medicine that draws from the best of each of the systems. Ultimately, features of a particular form of medicine may be integrated into the dominant system of medicine, beyond recognition of its original form or source.

What is the implication of these trends for the health care system in the Philippines? Unlike India, we do not have a codified system of traditional medicine. Thus, the geography of health care systems consists of just one supercontinent, that of biomedicine, surrounded by islands of indigenous forms of healing. On the other hand, it can be argued that although traditional medicine is disorganized and therefore minute in scope, this is only true insofar as professional practice is concerned; its concepts continue to pervade the lay population, and its practiced by folk healers; it thus inevitably intersects with biomedical practice at the level of individual patients, families, and communities; it comprises the corpus of practice and knowledge through which biomedical prescriptions are filtered and interpreted. The physician's advice to buy an inhaler for asthma, thus, can be modified to include lagundi leaves, or plasters; its dosage and frequency can likewise be modified. Health systems are never just top-down regimes; “patients” continually challenge and reinterpret prescriptions according to their own knowledge and practices. The works of Tan, Nicther, and Hardon in the 1990s are demonstrative of how Filipinos do this – often in creative ways. In interviewing traditional healers around the Phlippines, I have personally witnessed how antibiotics such as Penicillin are eviscerated from their capsules, and are smeared on wounds as topical treatment – a form of therapy that Alexander Fleming would never have imagined.

Medical pluralism in the Philippines, thus, takes a different form, one in which a dominant health system has no clear rival.  This does not preclude the introduction of other health systems: acupuncture is making inroads in the Philippines, particularly for pain relief.  A growing number of physicians are taking up pranic healing and other healing modalities. Moreover, whenever changes in the health landscape take place – such as the emergence of new illnesses – the curative and explanatory power of the dominant health system may be challenged by novel forms of healing that arise from the cognitive milleu made possible by the “islands” of indigenous medicine. During the dengue outbreaks in 2010 and 2011, healers using tawa-tawa (Euphorbia hirta) as “cure” for dengue became popular, and enough people believed them to a point that they could charge several thousands for each case. This phenomenon can easily be reproduced in the future, following resurgent and emergent health threats. Curiously, the availability of biomedical knowledge in the Internet can easily be used by present and future healers to enhance their syncretism to one that is more “educated”, more “medical”, and therefore more credible. This is no different from the strategy being used by Ayurvedic schools here in India that we mentioned in the first essay: the utilization of elements of the dominant health system to validate others.

It is not only healers that expropriate the validity of biomedical knowledge to boost their credibility; commercial interests also do so, in fact, they do the same thing for indigenous medicine, creating and marketing products which, like the Ayurveda in India, have a “double validity”, this time coming from indigenous medicine (i.e. the use of herbs) and biomedicine (i.e. the presence of enzymes, vitamins, antioxidants, and other 'high-sounding substances'). It must be recognized that in a state of pluralism, “individual medicine” - self-care and self-medication – is an important player – and we can expect this to grow in importance in the coming decades. In the same way that indigenous forms of healing gain prominence in illnesses where biomedicine is having problems, such as difficulty in accessing it, or difficulting in effecting cures, commercial products also succeed where biomedicine does not offer a clear cure or definitive treatment. Today, popular products are those that claim to cure cancer, “aging”, reproductive and sexual health concerns such as virility and potency, as well as beauty needs like skin whitening. Sellers of these products will also make use of the Internet, as well as traditional media, to bolster their claims. Again, the important thing to observe here is that in the future, there will be a co-evolution of new “technologies of the self” and technologies that convey and communicate these technologies.

Biomedicine, thus, will be under continuous pressure to reaffirm its dominance by demonstrating its efficacy in people's health needs. Because it has a built-in mechanism to validate its own claims, as well as an organized membership that works to perpetuate its hegemony (i.e. medical societies), it is likely to remain the dominant health system. Nonetheless, a state of medical pluralism will continue to challenge it, particularly whenever there is economic impetus to do so, or there is a void in biomedicine which opens up the possibility of a competitor. In India, exponents of Ayurveda are keenly marketing it for chronic illnesses, preventive and holistic care, and particularly diseases like psoriasis and rheumatoid arthritis. What these aspects of health care have in common is that they are among the weaknesses in biomedicine.

Medicalization, on the other hand, will continue to put biomedicine in a position of profound influence in society, its weaknesses notwithstanding. Illitch reasoned that this emergence coincides with the collapse of other institutions such as the religion and the church. The best illustration for this is the field of psychiatry. While still relatively new in the Philippines, it is a growing field, and can be held responsible for the medicalization of various forms of behavior. Depression, anxiety, hyperactivity among children, and addiction to various substances, are also under the domain of psychiatry, and the medicalization of these novel “illnesses” will shape perceptions of them, and these will have implications even in our legal system. Perhaps as the influence of organized religion in the Philippines wanes, we can expect more of Psychiatry.  There is so much that we do not understand yet of mental illnesses, particularly in cultures apart from that in which psychiatric concepts were developed, including the Philippines. Medicalization of the mind and of behaviors, which is the project of Psychiatry, is worth observing in the coming decades. What threads in our social fabric need to be loosened, in order to trigger a rise of these mental illnesses? What are the forces at play when a community begins to abandon belief in kulam, and embrace instead the notion of mental illnesses determined by biology, genetics, and the environment?  It ought to be considered a 'moment' in our cultural history when people begin to replace notions of 'deviance as sin' and 'deviance as crime' for 'deviance as mental illness' – to paraphrase Thomas Szasz, a psychiatrist who has criticized the far-reaching powers and scope that Psychiatry has assumed for itself.

Medicine derives much of its curative power from technologies, and radical technologies can alter the health landscape in unpredictable ways; these in turn influence society in manifold ways.

Medicalization can also be spurred by novel diseases, which, by posing a threat of society-at-large, provokes a reliance of that society to medicine. The rise of HIV/AIDS, Nguyen writes, “remedicalized” society, giving rise to a 'therapeutic state' whose surveillance function necessitated the testing of people, and their classification either was 'positive' or 'negative', in itself creating identities that Nguyen terms “therapeutic citizenship”. HIV/AIDS likewise served as a metaphor for the danger of sex, and, at least in the West, it is said to have a put a halt to the libertine sexual lifestyle of cities like San Francisco and New York. In mountaineering circles, there is a joke which goes: “In the 1960s, sex was safe and climbing was dangerous. Nowadays, climbing is safe and sex is dangerous.” This statement reflects the changes in the perception of sex which was brought about in large part by notions of medical harm. And these perceptions affect us in concrete terms, through strict medical tests performed on applicants for work, and the inevitable moralizations that HIV/AIDS evoke. When Paul Farmer denounced the identification of Haitians as a high-risk group for the then-poorly understood HIV/AIDS, he is reminding us of the grave potential for stigmatization of groups that are 'high-risk' for particular illnesses, particularly infectious ones. In 2009, the report that call center agents had a high prevalence of HIV/AIDS caused a nationwide furor. This is just one of the consequences of illness in a globalized, “media-fied” world. It is speculative whether such diseases will emerge in the coming decades. The WHO predicts that a pandemic may happen anytime, and globalization will facilitate this. The world is at once a safer and a more dangerous place.

Medicalization is assured by an endless race between pathogens and technologies, and exacerbated by an ever-expanding taxonomy of diseases, which now range from the organic to the functional to the speculative (genetics) and the contrived (i.e. aging, “ugliness”, “short stature”).

At the end of a lengthy discussion on medical pluralism and medicalization, perhaps the reader will have the sense of uncertainty about the future, and this is exactly the case: While we can speculate on things to come, we can by no means make accurate forecasts. In the same way that HIV/AIDS caught the entire world off-guard, there may be future diseases that would transform the health landscape in a radical way. On the other hand, there are also technologies that might accomplish the same thing.

However, what we can do with a greater degree of accuracy is to anticipate how people will react to these changes. We can approach the future of health care at according to the various lenses of medical anthropology, and here is where I will conclude my piece:

At the level of phenomenology, these diseases and technologies will be received and approached by people according to their personal experiences and circumstances. They will develop their own explanatory models of not only illnesses, but therapies and technologies, and they will also develop their own practices that may be dystonic or syntonic to that which the medical establishment wish to. Technological tools, such as the Internet, will provide them with more access to knowledge as well as a wider social universe in which these practices are introduced, circulated, and reinforced. The initial project of anthropology was to come up with ethnographies that capture and preserve a moment in a particular culture, hence it clings to what it calls an “ethnographic present”. The modern-day function of medical anthropology, however, is to document change in practices and knowledge and relate it to these aforementioned dynamics of health care systems, technologies, and diseases. The locus of ethnographies will increasingly shift towards this new “social universes” created by the Internet and future technologies.

At the level of medical ecology, which looks at interactions between individuals and communities, society and the environment, populations and pathogens, we would see how transformations in one member of the ecosystem could lead to changes in others; and with the Internet and globalization – major trends we identified – new ecosystems will be created, which will feed back into old ones. Even “non-health” trends such as global warming,will have far reaching health implications, altering not only the geography of disease, but also changes in human practices and perceptions. The utility of medical ecology as an approach is its ability to look into these relationships.

Finally, at the macro-level, a political economy perspective must take a critical look at how technology is driven by various interests, and how a globalized world is creating wider, more potent forms of hegemony. The conspiracy theory of a global pharmaceutical company manufacturing a disease then selling a “cure” for it, while extreme, is nonetheless a good metaphor of what the confluence of globalized “political forms” has enabled.

Here in the Ladakh province in Jammu and Kashmir, where Tibetan Buddhist stupas point to the sky, and where the barren, mountainous landscape has changed little since the time of Alexander the Great, it is easy to think that the future has not yet arrived. Yet, I am able to access the Internet here, albeit intermittently, and in the world news today is the report of a new, “SARS-like virus” from Saudi Arabia. The two cases -  one in the United Kingdom and the other in the Middle East – are both traceable in Saudi Arabia. Although no new cases have been reported, fears of global pandemi are juxtaposed with calls for reassurance from WHO and other health agencies. The discourse unfolds.

The future will come sooner than expected.

Leh, Jammu and Kashmir, India
September 29-30, 2012

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