Introduction to the special issue ‘medical pluralism and beyond’

In this special issue, we build on and re-consider the concept of medical pluralism, criticised since its introduction, but still holding an important place in research done by medical anthropologists. As is well-known, the term ‘medical pluralism’, coined by Leslie (e.g. Leslie 1976, 1980) and originally applied to the situation of medical revivalism observed in South Asian societies, has been extended to the more stratified societies in the West. Over the last few decades, the concept has been criticised for, among other things, privileging the professionals’ rather than the patients’ perspective; creating a ‘false consciousness of choice’; neglecting or underplaying the importance of political, economic, structural and power issues as well as for (implicitly) reproducing a ‘monolithic’ concept of biomedicine (see Hsu 2008 for an overview of the concept's history and critique). The strongest criticism came from critical medical anthropology whose proponents stressed patterns of hierarchy and the dominance of biomedicine in the modern world, calling into question the notion of ‘pluralism’ itself (Baer, Singer, and Susser 2003; Baer 2004). Despite this, Baer, among others, admitted that ‘nevertheless, biomedicine's dominance over rival systems has never been absolute’ (Baer 2004, 111).

Nonetheless, despite much criticism, the notion has gained new currency in recent years. In Hsu's (2008, 317) view, the term ‘medical pluralism’ has nowadays become more popular in applied health research than among anthropologists searching for new, better ways of conceptualising the phenomena under study. The ‘resurgence’ of the concept has happened not only because of the growing popularity of complementary and alternative medicine (CAM) and the public health care funding crisis that is putting pressure on governments to change their health care policies (Cant and Sharma 1999). This is also due to the intensified exchange of people, goods, healing practices, etc., on a global scale (see, for example, Janzen 2002; Krause, Alex, and Parkin 2012). Drawing on the term ‘global assemblages’ coined by Collier and Ong (2005) on the one hand, and the work by Appadurai (1990) on the other, Hörbst and Wolf have proposed the concept of ‘medicoscapes’ that should allow us to critically reflect on ‘the distinct results of ongoing globalized entanglements in the international health arena’ (Hörbst and Wolf 2014, 183). The concept shares many similarities with another term that has been in use in Britain in particular, i.e. ‘medical landscape’ (Hsu 2008). According to Hsu (2008, 320), ‘the notion of medical landscapes implies social processes, relatedness, and movements between foregrounds and backgrounds, and across boundaries’.

Moreover, within recent debates on medical pluralism the focus has moved, as Krause, Alex, and Parkin (2012, 8) put it, from ‘an understanding of pluralism as consisting of separate systems to thinking about mixture and intersections of different therapeutic practices’. In the light of this, the authors prefer to speak of ‘medical diversity’. In Parkin's words,

Medical diversity refers to more than medical pluralism, if by the latter is meant a number of medical traditions coexisting relatively insulated from each other within a region. Diversification is more than this and implies mutual borrowing of ideas, practices and styles between them, and by implication more differentiated strategies adopted by patients in search of cure. (Parkin 2013, 125)

In addition, interesting new proposals based on the recently developed concepts of superdiversity (Vertovec 2007) and hyperdiversity (Hannah 2011) have emerged in sociology and anthropology. The experience of an ‘explosion’ of diversity, connected mainly with large numbers of new immigrants in European countries, has led scholars to such conceptualisations, and it has been noticed that hyper/superdiversity presents a challenge to healthcare settings. Thus, for instance, anthropologists are engaged in research on access to healthcare, as reflected in narratives of people from very different socio-cultural backgrounds in several European countries (Green et al. 2014). Utilising the concept of superdiversity allows for examining how it shapes people's healthcare needs and expectations. This seems a promising direction; however, more research is needed to understand how the new realities of superdiversity influence healthcare institutions and patients’ attitudes.

The contributors to this special issue make use, in different ways, of the notions discussed above, showing how they may be implemented in the analysis of particular ethnographic cases and, more importantly, taking into account diverse social, political and economic contexts embedded in medical landscapes or medical diversity in their field sites.

A special incentive to rethink the concept of medical pluralism and to discuss its transformations was realised in a two-day workshop entitled ‘Medical Pluralism – Research, Problems and Prospects’, organised at the Department of Ethnology and Cultural Anthropology, Adam Mickiewicz University in Poznań, Poland in 2013. This issue comprises a selection of papers that were presented at that workshop. At the same time, it shows the directions of research and areas of interest of a relatively young, but vivid Central and Eastern European medical anthropology. The papers are written by anthropologists who are based in or recently returned to Poland, a region in which medical anthropology has long been underdeveloped and is rarely present in university curricula (Bartoszko and Penkala-Gawęcka 2011). This special issue provides a valuable insight into the ways medical anthropology is developing as a new sub-discipline in Poland (for more on the state of the art of medical anthropology in Central and Eastern Europe, see Cargo 2011; for special issues that all but ignore the region cf. Hsu and Potter 2012; Hsu 2012).

To sum up, in taking as a point of departure ‘medical pluralism’ and its variants, our aim in this special issue is twofold: (1) to attend to health-related choices and practices made by patients against a background of broader political and socio-economic issues, and (2) to raise interest in medical anthropology of ‘neglected’ regions of both locally and more globally oriented anthropologists.

Contributions

Despite socio-economic, political, and religious differences between Kyrgyzstan and the Ukraine, as analysed here by Danuta Penkala-Gawęcka and Iwona Kołodziejska-Degórska respectively, these two post-Soviet countries share a number of similarities in regard to healthcare. In particular, people's attitudes toward their healthcare systems are characterised by a lack of trust. Although biomedical healthcare is theoretically free for all Ukrainian citizens (according to the Ukrainian Constitution) and/or consists of a range of free medical services provided for several categories of people in Kyrgyzstan (introduced by the 1996–2006 Manas reform), this is not so in practice. Informal and semi-formal payments, which patients are expected to make on behalf of doctors, prevent those less well off from engaging with the system. Additionally, mistrust of state healthcare is partly a result of changes in the position and authority of physicians. As viewed by informants, the ‘responsible’, ‘enlightened’ and educated physicians of Soviet times have been replaced by ‘corrupted’ and often poorly educated current ones. The latter demand informal payments from patients in an open manner, thus contradicting, for instance, Ukrainian villagers’ moral sensitivities and ideas of a proper doctor/healer–patient relationship, which may include a payment but never a direct one.

Finally, both authors emphasise that there is a common mistrust of pharmaceuticals sold by pharmacies in the studied countries. Unlike artificially and chemically produced biomedical medicines, herbal treatments and healing plants (Ukraine) and traditional/folk medicine (Kyrgyzstan) are deemed to be ‘safe’ and ‘natural’ – a common trope found cross-culturally as the paper in this issue by Monika Kujawska on Polish migrants to Argentina confirms (cf. for example, Whyte, van der Geest, and Hardon 2002).

In response to declining trust in state (biomedical) healthcare, people studied in these two contexts turn to self-medication (largely with medicinal plants) and complementary and alternative medicine (CAM) both in Ukraine and Kyrgyzstan. Kołodziejska-Degórska (this issue) argues that Ukrainian villagers seek to establish health security or even health ‘sovereignty’ from state institutions (including pharmaceuticals sold in pharmacies) by (self-)gathering and possession of plants and herbal medicines. Although the possession and use of medicinal plants ‘is never the only possible therapy option’ (Kołodziejska-Degórska, this issue), it is nonetheless the primary one. It imbues villagers with a sense of agency and a feeling of security; moreover, medicinal plants give them hope and independence in their search for healthcare. Inhabitants of Bishkek, the capital of Kyrgyzstan, on the other hand, regularly consult ‘traditional’ healers. In both cases, biomedicine is often regarded as a last resort, even to the point where avoiding ‘encounters with doctors if possible’ becomes a ‘quite common health-related strategy’ of Bishkek inhabitants (Penkala-Gawęcka, this issue).

Nonetheless, in emphasising the diverse health-seeking options available to people in these two countries, Penkala-Gawęcka and Kołodziejska-Degórska turn to different theoretical approaches. In the case of Kyrgyzstan, Penkala-Gawęcka utilises the concept of ‘medical diversity’ (e.g. Krause, Parkin, and Alex 2014; Parkin 2013). Unlike the static view provided by ‘medical pluralism’, it allows for acknowledging mutual borrowing between diverse medical traditions. Thus, in Kyrgyzstan, non-biomedical practitioners (of Kyrgyz spiritual healing, bone-setting, phytotherapy, and Chinese, Korean and Tibetan medicine, among others) practise alongside their biomedical counterparts; ideas and practices of diverse medical traditions may be used in treatment provided by biomedical doctors themselves. Additionally, in her analysis Penkala-Gawęcka points out the importance of emotions, distrust and uncertainty in particular, as well as perceptions of risk, which in her view are crucial to understanding people's pathways to care.

In order to examine the multidimensional webs of relations that villagers in the Central Ukraine not only weave, but are also embedded in, Kołodziejska-Degórska proposes utilising two concepts: that of a ‘meshwork’ (Ingold 2011) and that of a ’medical landscape’ (e.g. Hsu 2008). The concept of a ‘meshwork’ allows her to attend to things, organisms and people – in this case healing plants, money, pharmaceuticals, state medical institutions, healers, family members and villagers/patients – as ‘not of interconnected points but of interwoven lines’ and as relations (Ingold 2011, 70). The medical landscape pertains to each individual living in a village, for whom, however, it is not wholly visible or reachable at one glance. Depending on their web of relations, individuals are able to access a part of their medical landscape.

Even in a ‘plural’ medical environment such as Germany, characterised by a wide range of therapeutic options available and even encouraged by the state, biomedicine is not perceived as a ‘last resort’. In the case of Jehovah's Witness patients in Germany studied by Małgorzata Rajtar (this issue), who refuse blood transfusions, biomedical treatment is not abandoned in favour of complementary and alternative medicine. In fact, Witness patients do not challenge biomedical diagnosis and treatment in general, rather they criticise individual physicians who are unwilling to perform and/or are inexperienced in conducting ‘bloodless’ surgeries; thus they do not positively respond to Witnesses’ wishes.

In order to characterise the therapeutic options available to Witnesses and their reasons for choosing them, Rajtar also utilises the concept of a ‘medical landscape’ (Hirsch 1995; Hsu 2008). This enables her to situate experiences of Witness patients at the intersection of different medical landscapes: an immediate and foregrounded landscape of the German medical system and a backgrounded North American landscape which privileges biomedicine. As the site of the organisation's headquarters, the latter constitutes an intellectual, theological and actual point of reference for its believers. This also shows that unlike ‘medical landscapes’ woven like cobwebs by individual villagers in Central Ukraine, as analysed by Kołodziejska-Degórska, the medical landscape of Jehovah's Witnesses is of a different nature. The term allows for accommodating both understandings.

Finally, this special issue includes two papers on the health-seeking options and therapeutic experiences of Polish migrants in distinct socio-cultural and geographical environments. Focusing on pregnancy, childbirth and paediatric care, Izabella Main (this issue) analyses the cultural differences present in the narratives of Polish women, who recently migrated to London, Barcelona and Berlin. ‘Armed’ with a broader knowledge and having experienced different medical practices as the result of their migration, Polish women ‘are exposed to therapeutic pluralism, which gives them more choice in medical treatment’ (Main, this issue). At the same time, their experiences attest to a diversity of interpretative models practised by biomedical personnel; this issue is also raised in the aforementioned paper by Rajtar.

In a rarely undertaken analysis of ethnomedicine of migrants from a temperate climate who have settled in the subtropical climate of South America, Monika Kujawska (this issue) attends to the continuities and changes in complementary medicine (mainly medical ethnobotany) of a Polish migrant community in Argentina. Faced with unknown flora and fauna upon their arrival in the late 1930s, Polish migrants, and later their descendants born in Argentina, acquired their knowledge about medicinal plants primarily from Paraguayan Mestizo migrants and the descendants of nineteenth-century Polish migrants to Brazil who eventually settled in studied communities. Aiming at describing ‘patterns’ of medical pluralism, the notion that she has found useful in her field site, Kujawska argues that phytotherapy has remained a preferred form of illness healing, which is partly due to the weakness of biomedical healthcare in the region. Moreover, some plants (e.g. tea) also serve as cultural markers of identity to an extent far exceeding their importance in folk medicine in the migrants’ country of origin. Despite the medicalisation of both childbirth and fractures, and biomedicine's claims to monopoly, different treatment systems coexist in a competitive relationship with one another while the local (Polish) population still turns primarily to self-medication with herbal medicines and to local healers.

The contributors to this special issue invite us to build on and critically engage with the notion of medical pluralism. In fact, the concept of ‘medical pluralism’ is rarely used here; rather, it serves as a springboard for attending to phenomena that, depending on their context and theoretical framework, are labelled ‘medical diversity’, ‘medicoscapes’, and ‘medical landscape(s)’. All these terms have proved to be useful in the analyses presented in this collection.

Acknowledgements

We would like to thank three anonymous A&M reviewers for their helpful comments.

Disclosure statement

No potential conflict of interest was reported by the authors.