(Culture, Illness, And Healing 12) Susan Reynolds Whyte, Sjaak Van Der Geest (Auth.), Sjaak Van Der Geest, Susan Reynolds Whyte (Eds.)-The Context of Medicines in Developing Countries_ Studies in Phar
(Culture, Illness, And Healing 12) Susan Reynolds Whyte, Sjaak Van Der Geest (Auth.), Sjaak Van Der Geest, Susan Reynolds Whyte (Eds.)-The Context of Medicines in Developing Countries_ Studies in Phar
(Culture, Illness, And Healing 12) Susan Reynolds Whyte, Sjaak Van Der Geest (Auth.), Sjaak Van Der Geest, Susan Reynolds Whyte (Eds.)-The Context of Medicines in Developing Countries_ Studies in Phar
Editors:
MARGARET LOCK
Departments of Anthropology and Humanities and Social Studies
in Medicine, McGill University, Montreal, Canada
ALLAN YOUNG
Department of Anthropology, Case Western Reserve University,
Cleveland, Ohio, US.A.
Editorial Board:
LIZA BERKMAN
Department of Epidemiology, Yale University,
New Haven, Connecticut, US.A.
RONALD FRANKENBERG
Centre for Medical and Social Anthropology, University of Keele,
England
ATWOOD D. GAINES
Departments of Anthropology and Psychiatry, Case Western Reserve
University and Medical School, Cleveland, Ohio, US.A.
GILBERT LEWIS
Department of Anthropology, University of Cambridge,
England
GANANATH OBEYESEKERE
Department of Anthropology, Princeton University,
Princeton, New Jersey, US.A.
ANDREAS ZEMPLENI
Laboratoire d' Ethnologie et de Sociologie Comparative,
Universite de Paris X, Nanterre, France
THE CONTEXT OF
MEDICINES IN
DEVELOPING
COUNTRIES
Studies in Pharmaceutical Anthropology
Edited by
and
The cover illustration is taken from a flipbook used for educating people in Bangladesh on
essential drugs. The text below the illustration reads: "Always ask when and how many
medicines to take".
The flipbook was prepared by PIACT/PATH Bangladesh and funded by the WHO Action
Programme on Essential Drugs. The illustrations are by Kamrun Nahar Rashid.
PREFACE vii
CH. LESLIE / Foreword ix
INTRODUCTION 1
Introductory Note 15
A. FERGUSoN/Commercial Pharmaceutical Medicine and
Medicalization: a Case Study from El Salvador 19
I. WOLFFERs/Traditional Practitioners and Western Pharmaceuticals
in Sri Lanka 47
A. UGALDE AND N. HOMEDEs/Medicines and Rural Health Services:
an Experiment in the Dominican Republic 57
H. KLOOS, B. GETAHUN, A. TEFERI, K. GEBRE TSADIK AND
S. BELAY !Buying Drugs in Addis Ababa: a Quantitative Analysis 81
K. LOGAN /'Casi como doctor': Pharmacists and their Clients in a
Mexican Urban Context 107
S. VAN DER GEEST /The Articulation of Formal and Informal
Medicine Distribution in South Cameroon 131
A. F. AFDHAL AND R. L. WELSCH/The Rise of the Modern Jamu
Industry in Indonesia: a Preliminary Overview 149
CONCLUSION 327
This collection of essays deals with the ways people in the developing world
today select and use their medicines. The book offers a view from the
grassroots, where people are actually taking medicines - not only those of the
trans-national companies, but also commercially produced indigenous medi-
cines and locally made remedies. It is pharmaceutical anthropology because it
seeks to explore the social and cultural contexts in which medicines are
produced, exchanged and consumed.
The emphasis on context is the special contribution of the present volume,
yet the problem addressed - drugs in the third world - has been of concern for
several decades. The role of western pharmaceutical companies has been at
the heart of the discussion up to now; little attention has been paid to the
manufacturers of non-western medicines. In order to understand the signifi-
cance of pharmaceutical anthropology and the contributions of the present
volume, it may be useful to review some of the issues and developments in the
debate about the proliferation of medicines in the developing world.
The modern period of commercial production is often said to have been
initiated by German chemical companies in the 1880s, but the manufacture of
brand name and patent medicines began in the 17th and 18th centuries, and
became a conspicuous and highly profitable market in the 19th century.
Muckraking criticism of patent medicines in the United States led to the Pure
Food and Drug Act of 1906. The debate has included such things as H.G.
Wells' novel, Tono Bungay, and in the United States, the highly publicized
hearings conducted by Senator Kefauver in the 1940s.
Antibiotics after the Second World War were new 'miracle drugs' that
promoted a period of rapid expansion in the international pharmaceutical
industry, and the world-wide prestige of injections. Anthropologists began to
report this phenomenon in the 1950s, and Clark Cunningham coined the term
'injection doctors' for practitioners that he observed in Thailand in the 1960s.
The danger of untrained practitioners prescribing and administering antibio-
tic injections was immediately apparent, and this initiated the concern among
anthropologists and health professionals about the effects of the international
pharmaceutical industry on health care in developing countries.
However, nationalist thinkers in at least some Asian countries were con-
cerned about international pharmaceuticals at an earlier time. For example,
in India the cost of importing British medicines and other manufactured
goods began to be criticized a century ago, and contributed to the Swadeshi
movement to buy Indian products. Entrepreneurs who initiated the commer-
cial production of Ayurdevic medicine in the 1880s argued that imported
ix
x FOREWORD
drugs drained the Indian economy, while indigenous preparations were better
suited to local conditions. Similar arguments were advanced by medical
revivalists in other parts of Asia, culminating with Mao's endorsement of
traditional Chinese medicine and the advent of barefoot doctors.
The post World War II advances in chemotherapy and expansion of the
pharmaceutical market are the immediate setting for the current debate on
how multinational companies affect health care in developing countries. Since
socialist enterprise has contributed almost nothing to modern chemotherapy,
the charge is that a few companies in the United States, Western Europe, and
Japan dominate the world market. Because most of their sales are in the
industrial capitalist world, they design their products for this market. They
are said to avoid competition by patent controL or to proliferate useless or
marginally useful products which they sell by competitive advertising rather
than by lowering prices. Thus, approximately 50,000 brand names are used to
sell about 700 generic drugs or chemical agents, yielding an average of 70
different market names for every useful product. These market distortions are
most severe in developing countries, where the need for cost-effective therapy
is greater because resources are more limited (see Gereffi 1983). Addition-
ally, the companies are charged with selling prescription drugs without regard
to problems of regulating their distribution, with dumping obsolete prescrip-
tion drugs in third world countries, and with having experimentally tried out
new drugs in these countries. They are said to use misleading promotional
materials, and so on. (These charges have been answered by representatives
of the companies - cf. Taylor 1986.)
A task force of United Nations agencies addressed these issues and its
report, 'Pharmaceuticals in the Developing World: Policies on Drugs, Trade
and Production' , was adopted in 1979 as a policy statement by the Conference
of Non-Aligned Countries meeting in Havana. Also, in 1977 and 1979 the
World Health Organization published a list of approximately 200 essential
drugs which would cover 90% of the medical problems in developing coun-
tries. The purpose was to provide a standard for rationalizing the production
and importation of drugs.
Responding to journalistic criticism, the outrage of international health
professions, and the threat of governmental actions, the International Feder-
ation of Pharmaceutical Manufacturers' Associations publicized a voluntary
code of practices in 1981. The code was concerned with providing information
about the effects of drugs, labeling, and other forms of sales promotion. It did
not consider the way prices are set for drugs and how they are distributed, nor
did it consider issues of research, development and technological transfer.
All of this discussion has been very much oriented around the international
role of Western pharmaceuticals. One important contribution of the present
volume of anthropological essays is that it makes us aware of the absence in
the debate of data on the commercial production of Chinese, Ayurvedic and
Unani medicines, and on the international market for them. The jamu phar-
FOREWORD xi
people are doing, it is necessary to take seriously the question of what they
think they are doing. What meanings do the different varieties of medicines
have for people in various cultures? How do they perceive the efficacy of
imported pharmaceuticals and the difference between them and indigenous
medicines? Answers to these kinds of questions provide the missing context
for the debate about pharmaceuticals. That context is first of all the local one
of cultural meanings and face-to-face transactions. Important as global con-
siderations are, they leave many issues untouched. In addressing these other
issues of what medicines mean and how they are used in local contexts, the
editors and contributors to the present volume have initiated a new field of
anthropological research. This field has much to contribute to the great
debate about drugs and health care in developing countries.
REFERENCES
Gereffi. Gary
1983 The Pharmaceutical Industry and Dependency in the Third World. Princeton. NJ:
Princeton University Press.
Institute of Medicine
1979 Pharmaceuticals for Developing Countries. Washington. D.C.: National Academy of
Sciences.
Patel. Surendra J. (ed.)
1979 Pharmaceuticals and Health in the Third World. Special Issue. World Development 2
(3 ).
Taylor. David
1986 The Pharmaceutical Industry and Health in the Third World. Social Science and
Medicine 22 (11): 1141-1149.
Velimirovic. Helga and Boris
1980 Do Traditional Plant Medicines Have a Future in Third World Countries? Curare 3
(3): 173-191.
CHARLES LESLIE
INTRODUCTION
SUSAN REYNOLDS WHYTE AND SJAAK VAN DER GEEST
thought to have the power to produce an effect. Thus one important part of
the meaning of medicine is its efficacy. The term efficacy may seem unprob-
lematic enough within a natural science framework. But an awareness of
cultural context calls for an examination of the ways people in different
situations actually perceive efficacy - what effects they look for and how they
evaluate them. This is the task which Etkin takes upon herself, criticizing the
biomedical standards with which ethnopharmacology has measured the ef-
fects of medicines and reminding us that efficacy, like other aspects of
medicines, is culturally constructed.
Another way to approach the meaning of medicines is to focus upon their
relation to other kinds of therapy. Whyte suggests that in East Africa
medicines may be constrasted with the ritual adjustment of relationships - a
form of therapy that necessitates dealing with spiritual and social situations.
In Western culture, this kind of meaning is recognized when it is said that
people 'pop pills' instead of dealing with the real social and psychological
causes of their distress.
Finally, people give meaning to particular qualities of medicines in terms
that are generally significant in other realms of culture. For example the color
or taste of medicines may be meaningful because of connotations of particular
colors and tastes in a given culture. Yellow pills are suitable against depress-
ion in Europe; red capsules are appropriate modes of strengthening the blood
among the Mende of Sierra Leone. As Bledsoe and Goubaud point out, such
qualities of medicaments may be reinterpreted as transactions are made
across cultural boundaries.
Because this book focuses upon Western pharmaceuticals in the Third
World, special problems in the analysis of meaning arise. Many researchers
report that commercial packaging, and 'high tech' modes of application,
especially the hypodermic needle, have a particular appeal. Obviously the
meaning of medicines is not a simple matter of consistency with established
patterns of 'tradition'. Plastic capsules in two bright colors and slick, shiny
products can be just as meaningful as time-honored potions and secret herbal
recipes. Buying factory-made products may be a way of identifying oneself as
'modern'. More than that, conceptions of power and efficacy may be tied to
'foreignness' and elaborate processing. Provenance and packaging seem to be
important dimensions of meaning for many people. The fact that medicines
have been produced in distant places or unfamiliar ways may add to their
value. (The Oxford English Dictionary gives an obsolete meaning of the word
'drug' as 'spices and other commodities, brought from distant countries, and
used in medicine, dying and the mechanic arts'.) What one cannot make
oneself may be able to accomplish what one cannot do oneself. The expecta-
tion that remote peoples have extraordinary knowledge that can be harnessed
for therapy is a theme in Western cultures as well as in many others.
8 S. R. WHYTE AND S. VAN DER GEEST
that they place them together with relevant ideas, historical processes and
social relations, rather than separating them into constituent 'natural' ele-
ments.
The impetus behind this book is the surge of interest in Western drugs on the
part of Third World people being 'invaded' by them, policy makers attempt-
ing to control them, and researchers trying to grasp what is going on. People
familiar with local communities in the Third World are aware that many kinds
of Western pharmaceuticals are easily available in markets, from local ven-
dors and even from 'traditional healers'. Drugs that are supposed to be
'prescription only' are obtainable over or under the counter. It is evident that
one part of the technology of biomedicine, the medicaments, has been
separated from the knowledge and practice in which it developed and is being
diffused and used rather independently. There are clearly big commercial
interests in this diffusion; profits are to be made from this extensive use of
medicinal commodities. Governments and international organizations have
discussed ways of regulating the situation; the most systematic and far-
reaching attempt is the World Health Organization's Essential Drug Pro-
gramme. It is against this background that anthropologists and their col-
leagues from other disciplines, who work in Third World societies, are
concerned to make their research relevant and available to national and
international policy makers. They are beginning to come forward with their
local contextual perspectives on the 'pharmaceutical invasion'.
The issue is timely. But the very timeliness of the anthropological interest
in pharmaceuticals in developing countries should give us cause to think. Why
were we not aware of this phenomenon before? Western drugs have been
present in most Third World societies rather longer than social scientists have
been. And medicines in the more general sense have always been there. We
believe that one important reason for this neglect of medicines can be found
in the exotic bias of the anthropological enterprise. The study of foreign
cultures involves an examination of how they are foreign - and a concomitant
blindness to the elements which are familiar. This has meant overlooking the
use of aspirin for headache while noticing the use of elephant dung for
dizziness.
The exotic bias and the neglect of medicines as cultural constructions is
related to the peculiar ability of culture to define what nature is. In Western
culture medicinal substances are perceived as having natural properties which
affect the human body in ways amenable to 'hard' scientific observation.
Medicines belong to the domains of pharmacology and biomedicine, while
anthropology has concerned itself with the more spiritual aspects of healing -
the symbols, rituals and conceptions which are not only exotic but clearly
cultural. One of the challenges of the present situation is to confront Western
10 S. R. WHYTE AND S. VAN DER GEEST
that they are misleading, since the pluralistic context transforms both im-
ported and native medicines. Thus we find 'modern' medicines being distri-
buted by 'traditional' healers and utilized in ways never imagined by the
manufacturers. Penicillin may become an ancient Ayurvedic medicine. And
we see 'indigenous' medicine being manufactured on an enormous scale,
advertised on television, and exported to other countries. Genuine jamu from
Indonesia can be purchased in Europe. The nuances involved here may serve
to remind us once more of the care needed in the use of terms like traditional
and Western medicine.
ACKNOWLEDGEMENTS
The editors would like to thank Michael A. Whyte for his suggestions
regarding the introduction and also Margaret Lock who kindly sent her
comments.
THE TRANSACTION OF MEDICINES
INTRODUCTORY NOTE
they diagnosed their clients' problems and advised them on the best cure. The
author concludes with some practical suggestions as to how doctoring phar-
macists could be helped to function more effectively.
Van der Geest studied the distribution of medicines in the southern part of
Cameroon. His research covered medical institutions dispensing medicines,
pharmacies, and unauthorized drug vendors. He shows that the formal and
informal (illegal) distribution of medicines are closely intertwined, at the
wholesale as well as at the retail level. The informal sale of medicines has
become an indispensable part of Cameroon's health care system. It fills the
gaps in the formal distribution, but it also helps to maintain those gaps. The
author views the situation as a process of 'articulation'; two apparently
competitive systems merge into one, to their mutual benefit. There is much
evidence, both within this volume and in other publications, that this articula-
tion occurs worldwide. However, this observation has hardly been taken into
account in actual health policy.
Afdhal and Welsch, finally, provide an overview of the history of jamu in
Indonesia, from about the beginning of this century to the present day. Jamu,
a traditional and locally prepared plant medicine, has undergone a shift to
Western-style production and marketing. Jamu is now sold on a large scale, in
the form of powders, creams, pills and capsules. Packaged jamu has become
an immense industry; 350 modern factories produce over five million doses
per day, a part of which is exported to other Asian countries and to Europe.
The modernization of jamu is strikingly paradoxical. On the one hand it is
conceived as an indigenous element of Indonesian culture and has become an
important symbol of national identity. On the other, its successful marketing
is in large part due to emulation of imported Western pharmaceuticals. Its
appeal lies to a great extent in its packaging. The authors remark that this
face-lift of jamu has led to a conceptual break with the past. Jamu is losing
some of its more general cosmological associations as it is increasingly
understood simply in terms of notions of physiology. They regard the mod-
ernization of jamu as a part of the medicalization of present Indonesian
society. The paper illustrates how indigenous and Western medicines consti-
tute one another's context.
ANNE FERGUSON
INTRODUCTION
France, the Federal Republic of Germany, Italy, Japan, and the US produced
roughly 80% of the total output of medications in 1970; and in 1974, exported
approximately 60% of the total value of medications transported in interna-
tional commerce (Gish and Feller 1979: 4). In 1976 it was estimated that only
25 firms located in the major pharmaceutical producing countries supplied
50% of the total world shipments of pharmaceutical products (Gish and Feller
1979: 9). Although precise figures are not available, marketing surveys
indicate that developing countries account for approximately 20% of world
pharmaceutical consumption. Reliance on these medications varies consider-
ably from one region to another. Drug consumption is significantly higher in
Latin America and Asia, for example, than it is in Africa (Gish and Feller
1979: 3).
Multinational pharmaceutical firms have also established production and
some research facilities in developing countries (Evans 1979). These areas are
attractive because they offer a cheaper labor pool and often have less
stringent regulations regarding the testing and marketing of new products
than do the developed countries. Regardless of geographic location, how-
ever, the majority of these firms tend to manufacture medications designed to
meet the health care needs of populations in the developed countries (Ledo-
gar 1975; Gish and Feller 1979).2 It has been reported that many of these
products are promoted in Third World countries in such a way as to have
adverse effects on health. Multinational firms have been found to export
medications considered unsafe for use in the home country, to exaggerate the
indications for use of many products, and to minimize their counter-
indications and warnings (Silverman 1976; Ledogar 1975; Mother Jones
1979). Although statistics on drug-induced illnesses and deaths are rarely
available in developing countries, investigators in these areas report that such
occurrences are not unusual (Sarasti 1970; Hellegers 1973; Ledogar 1975).
Medical authorities have voiced repeated concern about the inappropriate
use of medications, especially antibiotics. The misuse of these products leads
to the development of drug-resistant strains of infectious disease and it is
conceivable that epidemics comparable to those of the pre-antibiotics era may
occur (National Academy of Sciences 1979).
The money spent on medications in many Third World countries is a
significant drain on scarce financial resources. The World Health Organiza-
tion Expert Committee on the Selection of Essential Drugs reported that drug
expenditures account for more than 40% of the available public-sector health
funds in some developing countries. In 1977, the committee published a
guideline listing approximately 200 drugs regarded as sufficient to treat the
majority of illnesses in developing countries (WHO 1977). In Brazil, how-
ever, there are over 30,000 different products for sale; in Mexico there are
possibly as many as 80,000 (Gish and Feller 1979; Silverman 1976).
It is estimated that 80% of today's major preparations have been developed
in the last 20 years (Kewitz 1976). Unlike some of the older, biologically
A CASE STUDY FROM EL SAL V AD OR 21
derived products, the majority of these new chemically synthesized drugs can
produce harmful side effects, and the benefits and risks involved in their use
must be carefully considered. In the Western developed countries, the use of
these medications is usually limited by laws which regulate sale and require
certain products to be employed under the supervision of physicians or other
licensed practitioners. These prescription medications represent one of the
major healing strategies employed by Western biomedical personnel and are
integral components of the Western biomedical tradition.
Although many developing countries have modeled their official health
care systems along Western lines, the articulation of elements in this health
care tradition had not been replicated in all cases. In particular, in many
Third World countries Western biomedical practitioners do not exercise the
degree of control over the use of prescription drug products that is character-
istic in the developed countries. Throughout Latin America, for example,
prescription medications, usually manufactured by multinational pharma-
ceutical firms, often can be purchased over-the-counter in pharmacies, shops
or from medicine vendors. In this context, the Western-style health care
delivery systems has undergone a process of disarticulation and uneven
penetration. The link between healer and healing resource is not always
present and the products are frequently available in the absence of physicians
or other Western trained practitioners.
their customers; and (2) shot-givers, hospital and clinic workers, pharma-
ceutical company sales representatives and medical school drop-outs whose
work or experience is related to the Western medical establishment and who
often serve as important sources of advice and treatment.
Included in this medical sector are several important sources of health care
that have received little attention in the medical anthropology literature. In
the Western biomedical framework, pharmacy clerks, shop owners, medicine
vendors, pharmaceutical company sales representatives, and the like have
limited and largely supportive roles in the delivery of health care. They are
owners of, or employees in, health related enterprises, not medical practition-
ers per se. In many developing countries, however, trained Western medical
personnel are scarce, and these individuals often function as primary source
of advice and treatment. They are neither indigenous nor Western practition-
ers, but rather popular sector representatives who combine alternative and
Western knowledge of disease process and cure and whose practices bridge
the medical and business sectors of society.
These and many indigenous practitioners share a reliance on modern
pharmaceutical products in treating their patients and, in many cases, share a
similar training in their use. Indigenous curers frequently rely on advice from
pharmacy personnel about the use of medications (Taylor 1976; Cosminsky
and Scrimshaw 1979). These individuals in turn, depend on information from
package inserts included with products or on the pharmaceutical company
sales representatives who are themselves usually minimally trained (Ledogar
1975; Taylor 1976). A system of education has thus developed that serves to
integrate modern medications with lay and .alternative conceptualizations
about the nature and treatment of illness. While the integration of Western
and alternative medical practitioners into a unified system for the delivery of
health care has received considerable attention, other forms of integration
have been overlooked. It is suggested that medical practitioners from diverse
traditions have already achieved a degree of integration in their healing
strategies through shared reliance on drug company sales personnel and their
products.
As an outgrowth of the commercial pharmaceutical sector, a form and
process of medicalization different from that of the developed countries has
occurred in many parts of the Third World. In his work Medical Nemesis
(1979), Ivan Illich used the term medicalization to refer to the growing
tendency in Western society to define problems of living in medical terms and
to seek solutions by consulting licensed medical practitioners. He suggested
that the iatrogenic (physical or medical system induced) consequences of this
dependence appeared whenever Western biomedicine gained a predominant
position in society. To combat the various forms of iatrogenesis produced by
this medical system, Illich called for the deprofessionalization and demono-
polization of the health care establishment and a return to individual and
community autonomy in defining and treating illness.
A CASE STUDY FROM EL SAL V ADOR 23
service, a dental student and assistant, a public health inspector and assistant,
three nurses, a secretary, and a receptionist. Another physician worked part
time at the Health Post and also ran a private practice in the community. The
Health Post was open six mornings a week and offered free care and medi-
cations. 6 A public hospital and an additional twenty-two physicians were
located in the nearby town of Sonsonante. Other sources of care in Asuncion
included a small number of indigenous healers (sobadores, curanderos) ,
midwives and an array of Protestant churches in which healing sometimes
took place.
A central concern in this investigation was to determine patterns of reliance
on these sources of care by different socio-economic strata. 7 Initially, a census
of every fourth dwelling, or 525 households, was conducted to gather stan-
dard socio-economic and demographic data. These households were scaled
on the basi~ of four criteria: house type, possessions, household head level of
education, and household head occupation ranked by a panel of five com-
munity members in terms of prestige. On the basis of total points, they were
then divided into four socio-economic strata.
The two lower groups, representing 18.7% and 45.9% of households
interviewed, lived in homes that by community standards were regarded as
poor. These dwellings were constructed of straw, wood, scraps of metals or
adobe, had hard-packed dirt floors, and frequently lacked potable water and
electricity. In most cases, household heads had attended school for less than
three years and worked as day laborers or vendors or in small-scale trades
such as carpentry, shoe making and repair, and tailoring. Underemployment
in these two strata was substantial. Agricultural day laborers reported being
able to find steady work only during coffee, cotton and sugar cane harvest
seasons. Large landholders in the area seldom paid the government stipulated
wage of C4.50 (US $1.80) per day to their employees, and the average annual
income for households dependent on this type of employment was calculated
to be C798 (US $319.20).8 Incomes for those household heads employed in
the trades sector were slightly higher, but again there was substantial under-
employment. Many individuals, unable to find jobs locally, commuted daily
or weekly to work in the large cities of Acajutla, Sonsonante, and San
Salvador. At the time of this investigation, a small number of men had
contracted to work on building projects in Saudi Arabia. Others entered the
United States illegally in search of jobs. Together the two lower strata
comprised 64.6% of the households interviewed and will be considered as the
community's poor.
A middle class, representing 24.0% of the population, was composed of
owners of larger commercial enterprises, school teachers, and other admin-
istrative personnel and their families. In addition, some of these families
owned urban and rural properties. Household heads in this strata usually had
between four and twelve years of education. Most families lived in adobe or
brick homes that had tile floors, running water and electricity, and many
A CASE STUDY FROM EL SALVADOR 25
owned consumer goods such as televisions and stereos. The upper strata in
the community, comprising 11.4% of those interviewed, usually owned
medium to large agricultural properties and household heads generally held
high school or university degrees. These families often traveled and educated
their children abroad. They owned a wide range of consumer goods and one
or two motor vehicles. 9
While official health statistics do not provide information on the frequency
of illnessess and deaths as they are distributed among the various socio-
economic strata in the municipality, they do reflect the conditions of poverty
is which the majority of the population live. Of the 220 deaths recorded in the
municipality for 1978, 65 (30%) occured in infants under one year of age and
29 (13%) in children one through four years of age. The leading cause of
death was gastro-intestinal disorders (22%), followed by upper-respiratory
infections, other infectious processes and old age (each 14 % ).10 Health Post
records for the months of January and May 1979 provide an indication of the
most prevalent illnesses. Of the 1,656 patients who consulted at the clinic
during these two months, 655 (40%) were diagnosed as suffering from
upper-respiratory infections, 363 (22%,,) from gastro-intestinal disorders and
245 (15%) sought care for uro-genital infections or family planning measures.
One out of every three children under the age of five seen at the Health Post
was diagnosed as showing signs of some degree of malnutrition. 11
TABLE I
Health care resource employed by lower and upper strata households in treating illness
Strata
.
o
"".,c
>
I & II 109 62 47 10 4 6 18 3 4
(poor) 21 % 9% 13% 38% 6% 9% 2% 2%
III &
IV 77 35 42 27 2 3 8 0 o
(middle & 65% 5% 7% 19% 2% 2%
upper)
Totals 186 97 89 37 6 9 26 4 5
52% 48% 42% 7% 10% 29% 4% 6% 1% 1%
100% of 186 100% of 89
TABLE II
Type and source of medication employed by lower and upper strata households in the
treatment of chest colds
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pharmacies are run by owners or clerks who have received no formal training
in the use of the products they prescribe and who frequently have little formal
education. Of the seven pharmacy clerks employed in the stores in Asuncion,
for example, four had received a sixth grade education in local schools, two
had completed the third grade, and one had never been to school. Two of
these individuals were illiterate. In one of the stores, the owner's lO-year-old
nephew often prescribed and dispensed medications. Of the four pharmacy
owners, one was a licensed pharmacist who had graduated from the National
University, but due to other business interests, he left the running of the store
entirely to his wife and two hired clerks. Another owner was a physician, but
as result of a stroke had been bedridden for years and also relied on his wife
to run the shop.15 The two other owners of pharmacies in Asunci6n had
completed the fifth grade in the local schools. The pharmacies, then, were
staffed and run by individuals whose knowledge about medications was
gained from first-hand experience in their use rather than from formal
training.
Pharmacy owners and clerks had few sources of information available
regarding the use of the products they prescribed and dispensed. At the time
of this study, many multinational pharmaceutical firms in Central America
had eliminated the package inserts they used to include with their prescription
products. Reportedly, this represented an effort to reduce the over-the-
counter sale of these medications. These inserts contained the companies'
suggested indications for use, counter-indications, warnings, dosage and
formula. In some cases doses and formula plus general indications for use
were printed on the drug carton or package, but in others no information was
provided. For example, Pfizer, S.A.'s Terrabron (tetracycline and nystadin)
and Terramicina (tetracycline), Abbott's Pantomicina (tetracycline) and Ped-
ralyte (electrolyte solution) MKesson's Diazepam, Searle's Dramamine (di-
menhydrinate) and Squibb's Steclin (tetracycline), all popular medications in
Asuncion, contained no information on the counter-indications and warnings
and only very general information regarding indications for use. Most multi-
national pharmaceutical firms package prescription pills, capsules and tablets
so that they can be sold on an individual basis. The only information included
in these cases was the name of the product and the manufacturer. National
Salvadoran firms were more likely to include inserts with their products. In
many instances, however, these inserts make no effort to alert the buyer to
the risks involved in using the medications and, therefore, must be considered
as promotional devices. The insert included with Laboratorio Lopez's Pal-
micetina (pediatric cloramphenicol), for example, did not indicate that there
were any dangers involved in using the product, although this medication is
known to cause aplastic anemia in some patients and should be used with
caution.
Another source of information about the use of medications - the PLM or
the Central American drug reference guide similar to the PDR in the United
A CASE STUDY FROM EL SALVADOR 31
'me serene' meaning that they had lingered outside their homes at dusk longer
than they should have. Children's colds were often said to have resulted from
a descuido, a carelessness on the part of either those responsible for their care
or the children themselves. The most common form of descuido reported was
children being given or sneaking cokes or popsicles on particularly warm
days. Although many people had heard of microbes, there was little under-
standing, especially among the poorer strata, of contagion or of exactly how
microbes produced illness.
Pharmacy owners and clerks shared in these attitudes regarding the nature
of this illness and combined Western medications with popular treatment
strategies in the advice they offered their clients. In the case of colds, patients
were reminded to avoid foods or drinks considered cold (fruits, cold drinks)
and not to bathe until their symptoms diminished. In addition, they were
usually prescribed tetracycline which was regarded as best for illnesses of the
chest and throat. Other broad spectrum antibiotics, such as cloramphenicol,
were preferred to treat stomach conditions and diarrhea. Again, these medi-
cations were combined with advice regarding foods or behaviors to be
avoided until the patient improved.
Quantity and presentation (liquid, pill, injection) of a medication recom-
mended to clients in the four pharmacies reflected both practical consider-
ations and shared understandings regarding the treatment of illness. During
periods of pharmacy observations conducted over a three month span, 171
cases of illness were treated in the four stores. In 131 of these cases it was
possible to gather information on the form of medication recommended to
the client and age of the patient. In the four pharmacies, presentation of
medication was found to be related to the age of the patient and the perceived
seriousness of the complaint. Because they were easier to administer, injec-
tions and medicines in syrup or liquid forms were usually prescribed for
babies and small children. Injections were also recommended for adults or
older children whose complaints were regarded as serious or who had not
responded to previous administrations.
Quantity of a medication was related to the manner in which products were
packaged and to the customer's ability to pay. Customers buying liquids,
syrups or injections were required to buy the entire bottle; these products
were not dispensed in small quantities in any of the pharmacies. Pills and
tablets, on the other hand, were sold individually from the bottles or, as noted
previously, came conveniently packaged in the unit dosage form. 16 Customers
purchasing pills and tablets generally bought no more than four. regardless of
the nature of the complaint or the type of medication. Pharmacy owners and
some clerks were aware that small quantities of drugs may not be sufficient in
treating certain complaints. Because many customers could not afford to buy
in large amounts, however, pharmacy personnel recommended that they buy
in small amounts and return to purchase more if the patient did not improve.
A CASE STUDY FROM EL SALVADOR 33
TABLE III
Total amount spent by illness category and average amount spent per customers by illness
category in groups of pharmacies
for advice and treatment. Table III presents the total amount spent by illness
category and the average amount spent per customer by illness category in the
two groups of pharmacies.
Patients at stores that purchased their stock from pharmaceutical firms and
distributorships paid, on the average, 260% more than those who consulted at
establishments that relied on wholesale pharmacies.
Pharmacy personnel in those stores that obtained their stock from pharma-
ceutical companies and distributorships also tended to recommend that their
clients buy greater numbers of medications to treat complaints. Thirty per-
cent of the 113 customers seeking advice at these pharmacies and 19% of the
58 customers seeking advice from shops that relied on wholesale pharmacies
purchased two or more different types of medications to treat their illnesses.
The differences in number of medications prescribed between the two groups
of stores is actually greater than these figures suggest. In those shops that
relied on pharmaceutical firms and distributorships, often the customers
could not afford to buy the number of medications recommended by phar-
macy personnel. These cases, therefore, are not reflected in the above figures.
Clerks and owners of stores that relied on the pharmaceutical firms and
distributorships, then, used the opportunity presented by customers seeking
treatment to unload more expensive, brand-name, and often new medications
that were either not selling well on their own or just getting established on the
market.
A CASE STUDY FROM EL SAL V ADOR 35
The pressures to sell that grew out of the different distributional networks
were also evident in the customer services offered by the two groups of
pharmacies. In an effort to increase customer reliance on their stores, owners
who purchased from pharmaceutical companies and distributorships offered
credit to select customers and administered injections to clients who bought
the medicine in their establishments. In none of the shops, however, did
pharmacy personnel undertake physical examinations of patients. In some
instances the sick person was not present and the client was a family member
who related the symptoms to the owner or clerks.
The pharmacies that relied on distributorships and pharmaceutical firms
were among the most successful business ventures in Asuncion, reflecting
both the profits to be gained through this supply network and the towns-
people's growing reliance on prepackaged medications. Table I, presented
earlier, indicated that pharmacies were the most frequently used sources of
care by people in the two lower socio-economic strata. Of the 47 lower strata
families seeking care from medical practitioners, 18 relied on the pharmacies
as their first health care resort. Of these 18, 15 sought care from those
pharmacies that purchased their stock from pharmaceutical firms and distrib-
utorships; one consulted at a pharmacy that relied on the wholesale pharmacy
supply network; and two used pharmacies located in the nearby town of
Sonsonante. Attracted by the lower prices on some of the over-the-counter
products and the services (especially the administration of injections) that
stores relying on pharmaceutical firms and distributorships offered their
clients, the poor were recommended medications that cost substantially more
than those prescribed at the other two pharmacies. Although the patterns of
prescribing found in the stores that bought from the pharmaceutical firms and
distributorships created a dependence upon more expensive, brand-name,
and often new medications among all strata in the community, the poor could
least afford to spend their small incomes on these types of products.
The absence of reliable information on the proper use of prescription
medications, augumented by their over-the-counter sale, their use by com-
mercial pharmaceutical practitioners, and their use by individuals in self-
treatment and preventive regimens, has brought about a form of medicaliza-
tion in Asuncion that differs from that found in countries where licensed
health care practitioners control access to these medications. In Asuncion,
the penetration of modern prepackaged pharmaceutical products has fostered
pluralism and led to the development of the commercial pharmaceutical
sector. The dependence on the sources of supply of these medications has
resulted in three forms of commerciogenesis or commerce induced illness.
These parallel the cultural, social and clinical forms of iatrogenesis discussed
by Illich for the Western developed countries; but, as this dependence is
channeled through a variety of medical practitioners, they assume a some-
what different form in Asuncion.
36 A. FERGUSON
began. The children chronically suffered from acute conditions. When Mrs.
Musto coud afford care for her children, she generally relied on one of the
town pharmacies that purchased its stock from pharmaceutical companies and
distributorships. On one occasion, I was present in the store when she came in
for advice and treatment with her youngest child and her husband. The child,
who had a cold and fever, was prescribed one injection of Terrabron (tetracy-
cline and nystadin), Bactrim (trimethoprim and sulfamethoxazole) in liquid
form and four Asawin (aspirin compound) pills. Mrs. Musto, who was
suffering from a sty, was prescribed Stetlin (tetracycline) ointment. The family
also asked for advice regarding vitamin tonics for their children
because they were so thin. Optotonico (a Merek product) and Ferrocebrina (a
Lilly product) were recommended. The bill for these medications totaled
C30.00 (US $12.00). This represented 40% of their average monthly earn-
ings. Three weeks later, on a regular visit to the home, the child was again
sick with a cold.
Although some of the diseases found in communities such as Asuncion can
be treated effectively through curative services and others will respond to
public health vaccination campaigns (McDermott 1980; Foege 1979), the
most frequent causes of illness and death - upper-respiratory and gastro-
intestinal infections, coupled with malnutrition - depend for their solutions
on alterations in the socio-political and economic conditions of life and are
beyond the scope of purely medical interventions (Smith 1979; Dubos 1952;
Segall 1975). McDermott (1979, 1980) has suggested that to address the
disease problems in Third World countries a major effort be launched by
multinational pharmaceutical firms in conjunction with international health
agencies, national governments, universities and national pharmaceutical
firms. This recommendation ignores the kind and amount of investment
multinational firms already have in these areas, their impact on national
pharmaceuticals industries, and their effect on public sector health care
budgets. These broader social consequences of the pharmaceutical invasion
are detailed in works by Lall (1974,1977), Bertero (1972), Evans (1979), Katz
(1973), Gish and Feller (1979) and were alluded to in an earlier section of this
paper. The case of this industry is only one aspect of a broader pattern of
economic exploitation by international cartels in the Third World that has
serious and direct effects on human health (Ledogar 1975; Mother Jones 1979;
Castleman 1979). The best known of these is the promotion of infant formulas
by large companies such as Nestle, Abbott and Bristol Myers.
woman who gave injections in the community told the researcher that clients
sometimes experienced a rash after a shot of antibiotic but that this was
nothing to be concerned about. Another case, ending in death, illustrates the
possible effects of the integration of modern medications into lay and alterna-
tive practitioner beliefs about treatment strategies. The four-month-old daughter
of the Martinez's, a middle class family interviewed in the illness episode
survey, had suffered from recurring bouts of upper-respiratory infections
since her birth. She had been treated by a private physician and at the Health
Post for bronchitis. On March 17, the child had difficulty breathing and was
taken to the Health Post by Mrs. Martinez, her mother, and her sister-in-law.
After waiting two and a half hours to receive care, they left the clinic, and at
the urging of the sister-in-law, went to an id6neo. He administered a 'strong'
injection, prescribed Binotal (ampicillin) and Broncovinotal (cough syrup),
and told Mrs. Martinez that the child should be given only these drugs in
order to avoid a possible choque de medicinas (a clash of medicines). The
baby initially responded to the treatment, but early the next morning was
again unable to breathe and shortly thereafter died at home. Although her
condition worsened, no other sources of care were sought because of the
family's faith in the id6neo's advice regarding the strength of the injection and
the possible effects if combined with other drugs. Mrs. Martinez's explanation
of the illness and death of her child (her third child to die out of five born)
combined popularized Western notions of illness and medications with beliefs
in witchcraft. She stated that, as the weakest family member, the child had
died of bronchitis as a result of a mal (hex or curse) sent to the family by an
undetermined source.
In the pharmacies, clerks were often confused by the proliferation of
identical products with different brand-names and would prescribe products
like Hostacilina to patients allergic to penicillin, unaware that Hostacilina is
penicillin. The widespread use of small doses of antibiotics to treat conditions
such as colds poses another type of health threat. As noted earlier, the misuse
of these products leads to the development of drug-resistant strains of
infectious disease, a problem reported in many developing countries (Na-
tional Academy of Sciences 1979). The lack of package inserts describing
indications for use, counter-indications, warnings and doses of medications
leads to product misuse. For example, one of the pharmacy owners was
hospitalized as a result of an over-dose of Lisalgil (no information on product
in the PLM or PDR), manufactured by a Mexican firm, to treat a headache.
The package contained no information regarding dose, very general indica-
tions for use and a label saying it should be sold only with a physician's
prescription.
These cultural, social and clinical manifestations of commerciogenesis were
found among both lower and upper strata families. Although the two strata
shared a reliance on modern prepackaged pharmaceutical products, usu-
ally manufactured by multinational firms, this dependence was mediated in
40 A. FERGUSON
ACKNOWLEDGEMENTS
surpassed mine. Pharmacy owners requested that the issues regarding the
lack of information on the proper use of medications be brought to the
attention of a wider public.
This article has been published before in Culture, Medicine & Psychiatry
vol. 5, pp. 105-134 (1981). The present version has undergone some revision
and editing.
NOTES
1. Asuncion is a pseudonym.
2. Interestingly, some new products for the treatment of intestinal helminths - a major health
problem in many developing countries - were originally developed for veterinary and
insecticide use and were afterwards found to be effective in treating human populations.
Peters (1979: 73) comments that the market prospects for veterinary products and insecti-
cides are far more lucrative than those for products used in treating poor people.
3. Although figures are not available. it was reported to me in conversations with medical and
pharmacology faculty at the National University of EI Salvador that the country relies heavily
on the importation of pharmaceutical products manufactured by multinational firms and that
this reliance, and the consumption of modern medications, has increased substantially in the
last thirty years. Similar reports are available for Guatemala (Schieb et al. 1977). Some
multinational firms, notably Bayer and MKesson, have established plants in EI Salvador.
While it was beyond the scope of this investigation to examine the effects of the penetration
of multinational pharmaceutical firms on the Salvadoran pharmaceutical industry, it was
found that many of the sales and promotional practices of Salvadoran firms parallel those
employed by multinational firms.
4. Although both alternative and Western biomedical practitioners promote the use of modern
medications, they, in addition to their clients. are often the unwitting victims of the
pharmaceutical companies' sales and promotional practices. The origins of the term commer-
ciogenesis are uncertain. It was relayed to me in a personal communication from Ms. Dianna
Melrose of OXFAM in Oxford. England.
5. Mediums at spiritist centers in Asuncion were consulted for a wide range of problems in
addition to illness.
6. Those who could afford it were requested to donate C1.00 (US $0.40) to the Health Post.
7. It was initially planned to include a small number of rural families in the study. but the
political situation during the research period made interviewing in the surrounding rural
cantones unfeasible. The percentages for the socio-economic strata presented here differ
slightly from those published in the original article. The data has since been computerized
and errors in calculations corrected.
8. Large landowners in Asuncion reported that they paid their workers C3.00 (US $1.20) per
day. In a study conducted by Concepcion Clara de Guevarra (1975). it was estimatcd that
agricultural day laborers in the Department of Sonsonante received a daily salary of C 1.50
(US $0.60).
9. In addition. a small number of upper strata families maintained homes in Asuncion and large
agricultural estates in the region but resided in the capital and returned to town only for
holidays.
10. Injuries and deaths resulting from the political turmoil that characterized EI Salvador during
the research period were less frequent in the western part of the country than they were in the
north and east. This may be because western EI Salvador. particularly the Departments of
Sonsonante, Sta. Ana and Ahuachapan. were the seats of the 1932 peasant uprising that took
an estimated 10,000 lives (Anderson 1971: 136). Memories of these events were still fresh in
A CASE STUDY FROM EL SAL V AD OR 43
many people's minds in Asuncion, one of the centers of the rebellion. From April through
July 1979, however, five teachers, members of the ANDES (the national teachers' associa-
tion) were killed in the municipality, reportedly by the right-wing terrorist organization
Mano Blanca. A bomb was set off in the National Guard Post in Asuncion at the end of
April, injuring a number of children in a nearby home. These types of occurrences have been
the leading cause of death in EI Salvador since 1978.
11. Public-sector health facilities in EI Salvador rely on the index for malnutrition employed by
INCAP and based on age and weight of the child. Of the 301 children under the age of five
diagnosed as suffering from malnutrition, 197 showed signs of Grade I malnutrition, 82 of
Grade II and 22 of Grade III. These figures undoubtedly underestimate the incidence of
malnutrition in the town and municipality. They are based only on those families who bring
their children to the Health Post and also reflect individual differences in diagnostic catego-
ries employed by the two physicians. The medical student did not consider malnutrition an
illness and only listed it as a diagnosis when he could find nothing else wrong with the child.
The other physician frequently recorded the condition as a primary diagnosis.
12. In many Third World countries, the Western biomedical tradition can be considered a
disarticulated social formation in two senses. As Navarro (1974) indicates. the hospital-
centered and curative orientation characteristic of this medical tradition addresses the needs
of only a small portion of the population and therefore is disarticulated from the wider social
context. As indicated here, the Western biomedical tradition may also be considered as
disarticulated or fragmented in the sense that its medical practitioners do not control access
to one of its major healing resources. prescription drug products.
13. In most cases, patients interviewed before and after their consultation with Health Post
physicians had gained little understanding of their illness but had received a Western-style
disease label. These types of interactions with physicians may contribute to the populariza-
tion of Western biomedical terminology. In the community, for example. the term 'bron-
chitis' was commonly used to refer to any persistent cough, and 'ulcer' to pain in the region of
the stomach.
14. In an effort to reduce the amount of selfmedication. public-sector health facilities in EI
Salvador do not inform patients of either the name or manufacturer of the medication
prescribed. Public-sector policies such as this one have difficulty competing with the unregu-
lated private-sector sale of pharmaceutical products.
15. Although it is illegal in EI Salvador for physicians to own pharmacies, this doctor was able to
circumvent the law. He was trained as a physician in Mexico and, while he practiced medicine
in EI Salvador for many years. was never formally licensed to do so.
16. This manner of individually packaging pills and tablets has been found to reduce medication
errors in busy hospitals (Siler (977). At pharmacies, however. it allows for the sale of
medications on a pill-by-pill basis and may therefore encourage the misuse of certain types of
products, in particular, antibiotics.
17. The other three pharmacies in town carry a limited line of pharmacy-made remedies. These
medications are sometimes used by townspeople but are more frequently relied on by the
rural population. At the time of this investigation the owners of three of the town pharmacies
were considering the discontinuation of these remedies because the cost of ingredients had
risen substantially and their market appeal had diminished. The wife of one of the pharmacy
owners reported that the ingredients used in making the medications were routinely diluted.
Some products. in fact. consisted only of food coloring and cooking oil or water. She
explained these practices by saying that what cures is the faith the customer has in the
medicine, not its contents.
18. In interviews conducted with five shot-givers in San Salvador. the capital. two reported that
women sought their services to induce abortions. Products employed for this were: diethyl-
stilbestrol (DES), paranethadione and piperazine.
44 A. FERGUSON
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IV AN WOLFFERS
Sri Lanka is one of the few developing countries where a low-income eco-
nomy combines with favorable health indicators. Infant mortality and mater-
nal death rates show a steady decline over the years (see Table I).
The dramatic fall in maternal death rate and infant mortality between 1945
and 1950 was caused by the elimination of malaria in 1947 with the use of
DDT for vector control. The success in the following years is in part a result
of the public health care policy of successive Sri Lankan governments.
Already in the 1930s the famous Kalutera Experiment with Public Health
Nurses, Public Health Midwives and Public Health Inspectors was imple-
mented. These preventive health workers form the link between the villagers
and the modern health care institutions of Sri Lanka. The curative modern
health care system is also well organized and of good quality. The facilities are
free and within easy reach. Within 0.8 mile there is always some source of
medical care, and there is a Western facility at least within 2.5 miles (Simeo-
nov 1975). Moreover, the island is relatively small and a good and cheap
public transport system insures that within a few hours one can be in the
capital or one of the other major cities. This has caused large-scale bypassing
of the lower health care levels and increased medicalization; for example 79%
of all deliveries in the country are institutional (Nichter 1986).
The free curative health care system proved a heavy financial burden for
this poor country, and over the years the government's expenditure on health
care could not keep up with the rising costs. Since the change of government
in 1977 a different policy has been followed with more privatization of health
care facilities; a detoriation of the quality of the public facilities has been the
consequence. Sri Lanka still has the reputation of a country with a reasonably
good public modern health care system, but those who can afford it prefer
TRADITIONAL PRACTITIONERS IN SRI LANKA 49
TABLE I
Maternal death rate and infant mortality rate in selected years
private facilities, that always have medicines in stock, and are not under-
staffed.
Traditional medicine for its part has always played an important role in the
country's health care. Sri Lanka is the only country in the world with a special
minister for Indigenous Medicine. There are several public traditional facili-
ties, though the majority of the traditional practitioners work privately. Their
importance in the national health care system is reinforced by the gaps in the
modern medical system in rural areas, which lack doctors. In the whole
country there are about 1,800 modern doctors and 900 Assistant Medical
Practitioners. Of these 1,800 doctors, 544 can be found in the capital Co-
lombo. Waxler (1984) concludes that in Sri Lanka modern doctors and
traditional practitioners do not find themselves in a competitive situation
because they are working in different areas, not only geographically, but also
in terms of social background and career aspirations.
The indigenous medical system in Sni Lanka, Ayurveda, is not the same as
the Ayurvedic medical system of India. Ayurvedic medicine in Sri Lanka is
synonymous with indigenous medicine, and covers practitioners of Unani,
Siddha, Ayurveda and folk medicine (Wannaniyaka 1982).
There are two important training institutes that have been in existence
since 1928. The biggest is the Institute of Indigenous Medicine in Borella (Co-
lombo), the other is the private Gampaha Institute (40 km East of Colombo).
Training is also available from famous priests and healers who assemble
students around them. The paramparika are practitioners who have been
trained by their fathers; they have to pass an exam to be registered. Most
traditional practitioners are now registered.
Students who want to enter the Institute of Indigenous Medicine need high
school at least. The Institute is supposed to be comparable with Medical
School, and receives many young people who have been turned down at the
University. These students, who were basically interested in a career in
50 1. WOLFFERS
Mr. N. is not an exception in Sri Lanka. Pharmacies are often run by people
with insufficient pharmaceutical training. A survey in Colombo has suggested
that people working in pharmacies lack a basic knowledge of pharmaceuticals
more often than not. It appeared that the personnel in pharmacies is almost
entirely dependent on the information given by the pharmaceutical compa-
nies (Wolffers 1987b). At the same time, self treatment with ready-made
modern pharmaceuticals is increasing in Sri Lanka, especially among the
literate urban middle class (A bose de 1984). One of the people working in a
pharmacy in Colombo said: The patient knows what he wants. I know what it
costs, and I don't see the need for any additional information'.
The following case shows the situation of a drug representative:
Mr. S., 32 years old, married with two children, works for Glaxo. He was born and still lives in
Colombo and belongs to the urban middle class. He got a job as a drugs representative and
started work after two months' training by the company. He has a car and visits modern doctors,
pharmacists, shop-keepers and others who dispense modern pharmaceuticals. As he receives 2%
commission on his sales in addition to his salary, he is motivated to sell as many products as
possible. When I ask if he ever visits traditional practitioners, he hesitates. His superior, the sales
manager, who is present at the beginning of the interview, states that it is not the policy of the
company to approach them, but if the traditional practitioners ask for it, the compnay will visit
them. Mr. S. explains that he is constantly looking for new selling points, and it does not matter if
these are modern doctors, pharmacies or traditional practitioners. "If I don't go there, somebody
else will, and in that case it is better that I have the profit." He gives examples of well-known
traditional practitioners who need 10,000 tablets of acetominophen and 2,000 capsules of
ampicillin per week. In one of the villages he visits, he deals with two practitioners who compete
with each other and have become rather demanding. They ask for stronger medicines to be more
powerful than the other and often buy corticosteroids.
52 1. WOLFFERS
Waxler (1984) writes that 50% of the traditional practitioners in Sri Lanka use
modern pharmaceuticals, and that these practitioners are the most successful
in business. Elsewhere (Wolffers 1987a) I have tried to analyse in more detail
how traditional practitioners make use of modern pharmaceuticals, and what
their specific background is. In one village, 50% of the practitioners used
modern medicines. The ones who did not had an average age of 61 years,
while the others were 42 years old on average. Most of the practitioners using
modern pharmaceuticals were trained at the Institute of Indigenous Medicine
in Borella (Colombo), while those coming from the Gampaha Institute were
very strict about not using modern medicines. The practitioners using modern
medicines usually had a busier practice and charged higher fees.
A closer look at the practitioners dispensing modern medicines reveals
different patterns. Of the practitioners dispensing modern medicines 28.6%
restrict themselves to simple painkillers and rely mainly on herbal treatment.
In this group, the paramparika (the practitioners without formal education
but trained by their fathers) were found. Another 21.4% dispense also
antibiotics, whereas herbal remedies played a minor role in their treatment,
and 17.9% would go as far as dispensing the whole range of modern medi-
cines, including corticosteroids and sedatives, while refraining from herbal
remedies. These results are summarized in Table II.
More or less the same was found in a village closer (12 km) to Colombo:
40.7% of the general traditional practitioners used modern pharmaceuticals.
They were younger, had a busier practice, asked higher fees and had studied
at the Institute of Indigenous Medicine.
We turn now to a discussion of how modern pharmaceuticals are used in
specific situations. It appears that traditional practitioners who prescribe an
antibiotic in an acute situation like cough and fever, stick to herbal treatment
in the case of a catarrh. This treatment seems to reflect a general pattern of
treatment choice in Sri Lanka (Wolffers 1988). Our survey suggests that
patients with acute complaints tend to go to the modern doctor, those with
very serious diseases to a modern facility, those with chronic non-
TABLE II
Traditional practitioners' use of modern pharmaceuticals in a rural community
No modern pharmaceuticals 14 50
Using modern pharmaceuticals 14 50
a. Only painkillers 8 28.6
b. Only antibiotics + painkillers 1 3.6
c. Corticosteroids + antibiotics + painkillers 5 17.9
Total 28 100
TRADITIONAL PRACTITIONERS IN SRI LANKA 53
Doctor S. was trained at the Institute of Indigenous Medicine right after the Second World War.
He also followed an obscure course in Great Britain. He himself talks about a training in
pharmacy. but others in the village call it a trainirlg for medical analyst. Doctor S. has a successful
practice. Many patients consult him. and he is one of the three most popular private general
practitioners in the village. His patients see him as a modern doctor, though he does not use
modern pharmaceuticals exclusively. When asked what he is, he answer 'I am both, and I use
both methods. Every patient needs different treatment. One needs modern pharmaceuticals and
the other Ayurvedic treatment. But you cannot combine the two systems. Either you do it in the
modern way, or you do it in the Ayurvedic way. It is a different way of thinking. In Ayurveda for
instance, there is a disease called "Whateroga" (translated as "windy pains"). The disease is
caused by too much air in the body, especially in the abdomen. Any Ayurvedic doctor will
recognize it immediately. In modern medicine however you have to know what causes the pain in
the abdominal system. It may be due to worms, gastritis, indigestion of food, abdominal
obstruction, abscess, gastric ulcer, pregnancy, labour pains, abortion, tumor, or an actopic
pregnancy. As a doctor you have the responsibility to look at these things. A diagnosis like
"whateroga" is not sufficient. There are of course very good medicines against "whateroga", like
Hingua Steca in tablet or powder form, but panadol (acetominophen) is also very effective.
Sometimes you can satisfy the patient by giving him panadol as well as Hingua Steca. In the old
days people worried a lot about the right treatment. The prescriptions were complicated. There
are now many drugs which makes the work of a practitioner much easier. In acute diseases I will
always use modern pharmaceuticals for immediate result'.
When I ask him about the treatment of rheumatic complaints he says: 'My patients never
complain about my treatment. I give them indomethacine. They never use it for a long time,
because after a while they will go over to Ayurvedic treatment'. Asked about the information
from the pharmaceutical salesmen he says: 'They are a great help for me. I do not know where I
could otherwise obtain my information. Every week they come and talk for about 5-10 minutes.
Last week they gave me some samples of imodium (loperamide). I will give it to all my patients
with diarrhoea, and if that does not have effect within two days, I will prescribe antibiotics'.
These developments are recognized by those who are responsible for health
care in the country. In 1978 a Committee was appointed by the Department
54 I. WOLFFERS
CONCLUSIONS
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Balasubramaniam. K.
1985 The Neglected Solution. HAl News 24. August 1985, 1-2.
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Bhatia, J.e., Dharam, V., Timmappaya, A., and Chutani, C.S.
1975 Traditional Healers and Modern Medicine. Soc Sci & Med 9: 15-21.
Cunningham, e.E.
1970 Thai 'Injection Doctors': Antibiotic Mediators. Soc Sci & Med 4: 1-24.
Ferguson, A.E.
1981 Commercial Pharmaceutical Medicine and Medicalization: a Case Study from EI
Salvador. Cult Med & Psych 5: 105-34 (also in this volume).
Fernando, J.
1987 Drug Situation in Sri Lanka, 1987. Paper presented at ARDA meeting Bangkok 1987.
Geest, S. van der
1982a The Illegal Distribution of Western Medicines in Developing Countries: Pharmacists,
Drug Pedlars, Injection Doctors and Others. A Bibliographic Exploration. Medical
Anthropology 6: 197-219.
1982b The Efficiency of Inefficiency: Medicine Distribution in South Cameroon. Soc Sci &
Med 16: 2145-53.
Greenhalgh, T.
1987 Drug Prescription and Self-Medication in India. An Exploratory Survey. Soc Sci &
Med 25: 307-18.
Good, Ch. M., Hunter, 1.M., Katz Selig. H., and Katz, S.S.
1979 The Interface of Dual Systems of Health Care in the Developing World: Toward
Health Policy Initiatives in Africa. Soc Sci & Med 13D: 141-54.
Hardon, A.
1987 The Use of Modern Pharmaceuticals in a Filipino Village: Doctors' Prescription and
Self Medication. Soc Sci Med 25: 277--92.
56 I. WOLFFERS
INTRODUCTION
During the last two decades Western medical services have become much
more accessible to Latin American rural populations. Several reasons could
be singled out to explain the change:
(1) Transportation improvements have given rural dwellers the possibility
of moving back and forth between countryside and towns with relative ease.
When in need, an ever growing number of peasants visit free or low cost
urban public medical services and private clinics. 1 They also go to town to buy
medicines that cannot be purchased at home.
(2) Since World War II, rural-urban migration has been phenomenal.
Today many peasants have close relatives in the cities and, thus, visits to
urban medical services including those which require an overnight stay are
facilitated. Visits to town fulfill multiple purposes.
(3) Since 1970, with the financial assistance of international agencies, many
Latin American countries, have developed extensive networks of rural clinics
and polyclinics staffed by physicians doing their compulsory year(s) of social
service. As will be discussed later, these clinics are greatly underutilized, yet
for the first time, peasants find Western medical facilities in their midst.
It would be exaggerated to say that accessibility of medical services has
ceased to be a problem in rural Latin America; in some countries and in
regions with scattered rural popUlations, the problem continues to be severe,
but, unquestionably, for a rapidly expanding number of rural dwellers, access
to Western medical services has improved greatly in the past two decades.
Studies in several Latin American countries (Eoff 1980; Lopez Acuna 1980;
Menendez 1981; Martin 1981; Tunon et al. 1981), including the Dominican
Republic (Lesbow 1983; Ugalde 1984), indicate that in spite of the new and
extensive physical infrastructure and the deployment of physicians, auxiliary
nurses and health promoters in rural areas, the utilization and quality of these
services are low, while public expenditures in the provision of the services are
high. These findings have also been confirmed in some countries in Africa and
Asia. For example, Segall (1983: 1948) pointed out that 'PHC is not a cheap
option in national terms', and Dunlop (1983: 2020) added, ' ... one can find
a number of examples of underutilized facility and staff in many publicly
operated health care systems in Africa'. In her work in rural Philippines, Hardon
(1987) found that 'people in the village generally are not satisfied with the
treatment in the health center. They prefer consultation of doctors in town'.
57
S. vanderGeestandS. R. Whyte (eds.), The Context ofMedicines in Developing Countries, 57-79.
1988by Kluwer Academic Publishers.
58 A. UGALDE AND N. HOME DES
At the same time, in part because of the inefficiency of the public sector,
out-of-pocket rural health expenditures are also high, and the quality of care
purchased by the peasants is questionable. The reasons behind this unfortu-
nate misuse of public and private resources are numerous and complex.
Several authors have pointed out the relation between underutilization of
rural health services, high public and out-of-pocket expenditures, and the
inadequate supply of low-cost essential drugs. One of the first to note this
relation was Van der Geest. In his field work in Cameroon (1982a: 2148) he
found: 'The most conspicuous consequence of this chronic lack of medicines
is the underutilization of health services. Health centres which are known to
be without medicines are no longer visited and people seek alternative
solutions for treating their ailments: private institutions, the pharmacy in
town, illegal medicine vendors who often function as practitioners as well,
and of course, traditional medicine. Meanwhile the state continues to pay for
the - non-functioning - infrastructure of health centres'. This point was also
voiced by Melrose (1983: 183): 'the most obvious consequence of rural dispen-
saries running out of drugs is that people stop going to them. Meanwhile
government facilities that are under-used and paramedics find it doubly hard
gaining acceptance as health educators when they cannot deliver essential
drugs. This adds to the urgency of improving the availability of essential drugs
for primary health care'. Our own research in the Dominican Republic
(Ugalde 1984), which will be discussed later in more detail, revealed an
almost identical situation.
The issue of drug supply is of particular importance because drugs repre-
sent a large percentage of primary care expenditures and because of the
dependency that patients, even in rural areas of the Third World, have
developed upon modern medicines. According to some estimates (Taylor
1985: Table 3 citing IMS World Drug Marketing Manual), in developing
countries the consumption of drugs represents between 30 and 50% of health
care expenses, although the figure estimated for Latin America is 21 % (Patel
1983: 196).2 It is well known that for the poor, the purchase of medicines
represents the largest out-of-pocket health expenditure, and that the lower
the income the higher the percentage of health expenditures in medicines. 3 In
our study of a rural health district in the Dominican Republic we found that
58% of out-of-pocket health expenditures were for drugs; (only 10% were for
fees, 6% for hospitalization; 6% for laboratory work, and 20% for other
expenditures) (Ugalde 1984: 446). The dependency of rural dwellers on
modern and expensive drugs, and the reasons behind it, were well illustrated
by Hardon (1987) who at the same time described the unnecessary costs and
health risks incurred by the use of modern medicines in the rural areas of the
Philippines, an issue raised by several other authors (Ferguson 1981; Melrose
1982; Van der Geest 1985). Alland (1970) also showed the adoption of
modern medicines even in societies that rejected Western medical practices.
The lack of adequate supply systems for the provision of drugs coexists with
AN EXPERIMENT IN THE DOMINICAN REPUBLIC 59
the ample availability of modern medicines even in rural areas of the Third
World. Many writers have critically discussed the questionable marketing
techniques of multinational pharmaceutical corporations and the existence of
weak government controls in developing countries (Lall1981; Melrose 1982;
Silverman et al. 1982; Wartensleben 1983; Gereffi 1983). It is well known that
many drugs which in industrial nations require a prescription are purchased
over-the-counter (Ferguson 1981; Van der Geest 1982b). In the Dominican
Republican, as in much of Latin America, little rural stores (colmaditos) carry
a variety of analgesics and antibiotics (see Appendix 1 for the list of drugs sold
at one general store at El Rio) all of which are sold over-the-counter. It is
obvious that most Latin American peasants have easy access to a large array
of pharmaceuticals. In fact, it is the wide commercialization and penetration
of medicines in the countryside which is, in part, responsible for the depen-
dency on drugs, excessive self-medication, improper use and high costs of
medicines, and which requires policy attention. In this article, we will discuss
the relation between drug availability and the utilization of medical services in
a rural health district (secci6n) in the Dominican Republic and the results of
an experiment with a communal pharmacy which was designed to solve some
of the above problems.
THE SETTING
The Dominican Republic (population 6.2 million in 1985), like many other
Latin American countries, has experienced a massive rural-urban migration.
The urban percentage of the total population has increased from 24 in 1950 to
52 in 1981 and is expected to reach 68 by the end of the century.4 Today,
many peasants have relatives in the cities. Improvements in transportation
during the last 25 years have also bridged the distance between country and
city, and placed a large majority of pe:asants within easy access to towns. As
recently as 1974, a national assessment of health care services in the Domini-
can Republic indicated that: 'The lack of medical resources, especially of
doctors in the rural areas, has been especially serious in view of the poor
health status of the rural populace' (US H.E. W. 1974: 98). Due to this
scarcity, rural dwellers took advantage of the relatively easier access to urban
centers and went to the near-by cities and towns for medical care. According
to the first national morbidity study of 1974 about one fourth of peasants were
receiving modern medical services (Perez Mera 1978: 220, our estimate from
Table 10), and since very few of these services were available in rural areas,
we must conclude that the majority were obtained in the cities.
Starting in 1975, the development of the rural health physical infrastructure
has been extraordinary. With the financial assistance of US AID, the World
Bank, and more recently the Inter-American Development Bank, subcenters
and clinics were built: by 1984 there were 341 rural clinics and many addi-
tional ones under construction, a remarkable increase over the 59 rural and
60 A. UGALDE AND N. HOMEDES
urban clinics available in 1971 (US H.E.W. 1974: 88). Concomitantly, the law
of pasantia was approved by Congress. According to the law, all physicians
upon graduation had to serve for one year in a rural clinic before receiving
certification for practice. 5 The pasantia insured the presence of physicians in
the countryside. In the rural clinics, the physician assisted by an auxiliary
nurse provided free consultations and distributed monthly about 240 pesos of
free medicines. National budget allocations to the Ministry of Public Health
and Social Welfare (SESP AS) grew likewise, from 17 million pesos in 1970 to
131 million in 1985, or about 9% of the national budget (until 1984 the official
value of the peso was equivalent to the US dollar).6 In sum, in the Dominican
Republic the physical accessibility of modern care has greatly expanded in the
last ten years and the economic barriers to utilization have been reduced
considerably.
Our research was carried out in the health district of El Rio which has
approximately 5,500 inhabitants distributed in about 18 hamlets. 7 This is a
mountainous region, with small fertile valleys well suited for agriculture, and
irrigated by streams and creeks. A mild climate and abundant rain allow for
almost year-round agricultural use of the land. A wide variety of vegetables,
tubers, tropical fruits, legumes, commercial flowers and coffee beans are
harvested at different times of the year. In this part of the country there are
many small family farms, but there are also some very large tracks of good
agricultural land owned by absentee landlords which are left idle or used for
grazing. Typically, households are dispersed, although there are some ham-
lets along the main road where it is possible to find a concentration around the
school, the church and the stores.
From the end of 1982 through 1984 our study had several phases and
followed an anthropological approach with field workers residing in the
community and spending many hours of conversation and observation in the
households. In the first nine months, two sociologists and one physician
randomly selected 70 households in eight hamlets, for an in-depth study of
their economy, social organization, morbidity and illness management.
Household income and expenditures were analyzed meticulously, including
income from subsistence crops. Morbidity was studied through the records of
the clinic (attended morbidity), through a detailed morbidity survey in the 70
households (reported morbidity) and through a physical medical exam and a
laboratory analysis of feces and blood of a 40-household subsample (clinical
morbidity). Our study included the estimation of out-of-pocket health expen-
ditures of every illness episode that occurred in each household during the
period of six months previous to our interview. We let respondents define
illness, and we included within the health expenditures the costs of transpor-
tation to and from clinics and hospitals in near-by-towns and cities, and costs
of food and lodging for patients and for persons who accompanied them
during the visit to urban clinics or hospitals. We also studied the organization
of formal and informal health services such as the clinic, health promoters,
AN EXPERIMENT IN THE DOMINICAN REPUBLIC 61
traditional healers, midwives, and drug sellers. Findings from this study which
have been reported elsewhere (Ugalde 1984), were the basis for experimental
changes and additional research which will be discussed in the next pages.
During Summer 1984, a team of two health educators, one physician, one
social worker and one sociologist studied the role of health promoters and
physician-patient relations at the clinic and two health outposts, organized in
1983 in hamlets of the district as part of the efforts to increase the utilization
of medical services. Included in this research was the study of the communal
pharmacy (opened in January of 1984) focusing on its dispensation of medi-
cines and patients' compliance (Ugalde et al. 1986).
During the first phase of our study we found a low utilization of the clinic.
Two months previous to the beginning of our research (October and Novem-
ber 1982), the daily number of consultations was 14 (based on 22 working
days per month). We timed the consultations, and as an average the patient-
physician contact was 3 minutes 50 seconds, in other words, the clinic was
empty most of the day. The national rural health service statistics suggested
that EI Rio was not an unusual clinic; 46 percent of the rural clinics had less
that 15 consultations per day (see Table I). We also discovered that the
utilization of the clinic was very erratic, some weeks there could be as few as
20 consultations and others, more than 150.
We directed our research efforts to understand the reasons behind the poor
and unusual pattern of utilization of the services. We identified the following
causes: the dispersion of the population, the temporary nature of the appoint-
ment of rural physicians due to the system of pasantia, very poor managerial
practices, low educational levels of providers and users, and a dismal supply
system of pharmaceuticals by SESPAS (Ugalde 1984: 443).
TABLE I
Utilization of rural clinics in the Dominican Republic, 1983*
* Daily consultations were calculated by dividing total yearly consultations by 264 working days
or 22 days per month. According to the law rural clinics should be opened on Saturdays but the
law is disregarded. In 1983 many rural clinics had more than one physician in residence,
therefore the number of consultations per physician is much lower.
When the rural health service was organized in the Dominican Republic in
the mid-seventies, rural clinics were assigned a monthly subsidy of 350 or 500
pesos (250 or 416 US dollars) according to population. The subsidy was
distributed in medicines, supplies for the clinic (cotton, alcohol, syringes,
soap, detergent, toilet paper, etc.), all shipped from the national rural storage
center located in Santo Domingo, the capital city, via the regional offices. El
Rio receives 240 pesos of some forty essential drugs as established by the
country's list (which is very similar to PAHO's) many of which are generic,
and the rest, up to 350, in clinical and cleaning supplies. In EI Rio, and we
verified that this was the case in other clinics, the monthly shipments arrives
on irregular dates, often two shipments arrived two weeks apart, and other
times many weeks passed without a shipment. Every so often a monthly
shipment would never arrive. Pilfering of medicines along the distribution
route was common. The invoices sent with the supplies did not correspond in
quantity or in kind with the content of the shipment: if the physician refuse to
sign the receipt, the supplies were not delivered. In theory, rural physicians
were supposed to make a monthly request of essential medicines from a list
provided by SESPAS, but since the requests were disregarded, most physi-
cians did not bother to fill out the forms. Complaints by rural physicians were
routinely disregarded, and because of the temporary nature of their appoint-
ment, physicians seldom took enough interest in the rural clinic to persist in
reporting administrative deficiencies. We also discovered that the free dispen-
sation of medicines was not contributing to equity; those who had limited
access because of distance, age or poverty received fewer medicines or no
medicines at all.
Conversations with the clinic's physician and the study of the consultation
records suggested that there might be some relation between the disorganized
and free dispensation of medicines and the large fluctuations in the number of
consultations at the clinic. According to the attending physician, when people
knew that the monthly supply of medicines had arrived, they hastened to the
clinic, not in search of diagnosis but to request free medicines. In conversa-
tions with villagers we found that it was not infrequent to give chickens the
antibiotics received at the clinic. The physician at El Rio added that he
preferred to satisfy the patients' demand for medicines, even if on many
occasions they might not have been needed. He did not want to give the
impression that he did not care for them; many had walked one hour or more
and would get upset if they knew that medicines were available and not given
to them. Within a few days after their arrival, the medicines were gone and
the number of consultations declined. The physician's interpretation of the
reduction in consultations was that when patients heard that the clinic had run
out of medicines they preferred to by-pass the clinic and go to town to private
or public health clinics. The same view was expressed by physicians we visited
in several rural clinics in other parts of the country. A malevolent observer
might think that it was to the advantage of the attending physician to rapidly
AN EXPERIMENT IN THE DOMINICAN REPUBLIC 63
reduce the stock of medicines, for without medicines there were very few
consultations and less work. Thus, rural physicians had a perfect excuse to
curtail the number of days and hours of consultation. It was well known at the
Ministry that rural physicians seldom kept the official hours, and absenteeism
was rampant. A vicious circle of mutual blame was prevalent in the rural
health service: SESP AS officials accused rural physicians of irresponsibility
and lack of dedication, and the physicians charged their superiors with
incompetence, claiming that under the conditions prevailing in the rural
clinics it was impossible to carry out their work.
Under these conditions when the clinic was out of medicines, many patients
did not think that it was worth their time and effort to go to the clinic only for
diagnosis and chose self-medication instead. It should be noticed that the
diagnostic capabilities of rural clinics in the Dominican Republic and in other
countries in Latin America are limited generally to osculation, and that
patients are aware that lab and other clinical tests are required in some cases
for adequate diagnosis. For example, during our morbidity study, one of the
respondents indicated that she was not feeling well and that she was planning
to go to Santo Domingo to have a cardiogram. She thought that perhaps
something was wrong with her heart and added: 'I have never had one and it
is time to have a cardiogram'. Free medicines were not available in the cities
(free medicines were only part of the rural health program), but patients
believed correctly, that physicians in towns had more experience than the
newly graduated physician in the rural clinic. Besides, when medicines were
not available at the rural clinic, patients frequently had to go to town to buy
medicines even if they visited the rural clinic, and therefore, by-passing the
clinic was a logical decision.
In El Rio self-medication and urban consultations were contributing to high
out-of-pocket expenditures. As an average, each household in El Rio spent
126 pesos per year on health (24 pesos per person or 16 US dollars in 1983).
As has been indicated earlier, drugs represented 58% of health expenditures.
Out-of-pocket expenses for medicines were high because of the following: (1)
the relatively high costs of medicines in the little local rural stores, due in part
to the small volume of their operation (Thus, one aspirin was sold for 1 cent in
the local stores, but the bulk price was one-third of 1 cent); (2) the purchase
of me-too-drugs which tend to be more expensive than generic medicines; (3)
the purchase of many remedies of doubtful therapeutic value because of
self-medication (see Appendix 1 for the list of popular drugs used in self-
medication which are not prescribed by physician; these are not traditional
remedies and are manufactured by modern laboratories); (4) overmedication
- patients buy one medicine, only to buy a second one when they find no
improvement after the first; (5) the unnecessary use of drugs in illness
episodes which do not require medication such as common coughs or non-
severe diarrhoeas; (6) the abuse of medicines to alter behavior, for example,
valium was liberally prescribed as a sleeping pill for the elderly; and (7) the
64 A. UGALDE AND N. HOMEDES
TABLE II
Average cost of medication per illness-episode by prescriber in 70 households,
EI Rio (Constanza), 1983 (in pesos)'
Prescriber
The figures do not include pre- and postnatal care or dental care. One illness episode could be
treated by medications prescribed by one or more persons.
lack of concern by many physicians about the cost of the medicines they
prescribe; often there are medicines of equivalent therapeutic value which are
less costly.
Table II shows the large differences in the cost of prescriptions according to
prescriber (the Table is based on the morbidity study of the 70 households
where 347 episodes were reported within six months previous to the study),
As could be expected self-medication was the least costly, and urban physi-
cians the most expensive. It could be argued that the higher costs of medicines
prescribed by physicians outside the rural clinic reflected the higher complex-
ity of the illness treated by them. To verify this point we looked into the
nature of each illness treated by physicians outside the rural clinic and found
that the majority of them could have been cared for at the primary level. As
we have just indicated we interpreted the higher costs of medicines prescribed
by urban physicians to their lack of concern about the cost of medicines they
prescribed. It should be noticed that, contrary to what might have been
predicted, the cost of prescriptions given by traditional healers and those
recommended by pharmacists were quite high as well.
tend to acquire them only when prescribed; as a result, medicines would last
longer at the clinic, and patients would not need to by-pass the clinic and go to
town, thus saving money by not incurring transportation expenses or physi-
cian's fees, and by buying less costly prescriptions received from the clinic (as
indicated in Table II prescriptions by the rural physician were less expensive
than those prescribed by urban physicians); (2) utilization of the clinic would
also produce savings by reducing much unnecessary self-medication that, as
mentioned earlier, we had found economically wasteful and in some cases
harmful; (3) a positive side effect of the previous points would be the
reduction of overmedication and iatrogenesis.
As an alternative, we also considered the possibility of increasing the
monthly shipment of medicines from SESP AS to the amount required to
insure that essential drugs would be available at the clinic at all times. We
decided against this choice because: (1) the elasticity of demand for free
medicines could be very high, and, consequently, at a. national level this
policy could increase substantially SESPAS' expenditures which, as it was
indicated earlier, were already 9% of the national budget; (2) more impor-
tantly, this policy would almost certainly foster overmedication and iat-
rogenesis; and (3) we had doubts about the organizational capabilities of
SESP AS to guarantee the availability of larger amounts of medicines at all
times. As indicated, SESPAS had serious difficulties in adequately distribut-
ing small supplies of medicines. We thought that this strategy would only
contribute to additional wastefulness without resolving the problem. Van der
Geest (1982a) expressed similar fears in his Cameroon study and also consid-
ered inappropriate the free dispensation of drugs. It should be remembered
that many socialist regimes and socialized health care systems sell essential
drugs at cost. We thought that the key issue was to make essential medicine
affordable to the community. A conclusion was reached that the sale of
essential drugs at a communal pharmacy in the clinic and in the two newly
organized health outposts would be a better solution than an increased supply
of SESPAS medicines to reduce outof-pocket expenditures and to increase
therapeutic efficacy.
The research team recommended that the communal pharmacy comply
with the following policies: (1) no person should be deprived of medication
because of his/her inability to pay; this condition responded to the basic
principle that access to health care is a human right; (2) the pharmacy should
never be without essential medicines, in other words, a supply system had to
be organized that would guarantee essential medicines at all times. We
wanted to avoid having patients, particularly mothers with small children,
come to the clinic from far away only to find out that the prescribed medicine
was not available in the communal pharmacy; (3) in accordance with the
custom of rural local stores, a tradition that exists in many Latin American
countries, a liberal credit system should be established for those patients who
might find it difficult to pay in full for the medicine at the time of purchase.
66 A. UGALDE AND N. HOMEDES
This principle, would also guarantee that patients who did not bring enough
money to the consultation would not have to go back home to get additional
cash; (4) the pharmacy should be organized and managed by the local health
team.
SESPAS authorized the clinic of EI Rio to organize the communal phar-
macy following the above principles and continued to donate the 240 pesos of
essential medicines and the 110 pesos of clinical and cleaning supplies. The
clinic (and the pharmacy) remained under SESPAS, but it was given some
financial autonomy. The local health team decided to sell medicines at the
same price paid by SESPAS to its suppliers plus a 5% surcharge. The
pharmacy opened an account in a bank at the near-by town with the two
signatures of the physician and the supervisor of health promoters required
for withdrawals; these were the two persons responsible for the management
of the communal pharmacy. The proceeds of the sales were used: (1) to buy
additional medicines directly from manufacturers or wholesalers when the
SESPAS supplies failed or were late, as was often the case, or when the stock
of some medicines was low. (Ideally, the pharmacy should buy the needed
medicines from SESPAS, but at times SESPAS did not have the organiza-
tional capabilities nor the flexibility to satisfy the communal pharmacy's
needs);8 (2) to finance the free dispensation of medicines to families consid-
ered paupers by the health promoters in each community; (3) to buy a few
medicines which were not included among the drugs shipped by SESPAS but
needed by some chronic patients such as those with hypertension. Previously,
patients had to go to town to buy the drug in local pharmacies, incurring
transportation costs, time losses, and higher retail prices; and (4) to supply
the clinic with materials, such as paper, folders for clinical histories, working
materials for the twelve health promoters, etc. and to repair equipment in
order to improve the quality of care. It was expected that the administrative
decentralization produced by this economic autonomy would improve the
quality of medical care provided by the clinic by breaking the vicious circle of
mutual blame.
The communal pharmacy and the new policy of selling medicines began in
January of 1984. From October through December 1983 the physician and the
health promoters explained the impending change to community leaders, to
patients attending the clinic, and to the inhabitants of the health district.
During the first weeks of 1984 there was some unhappiness about the
innovation. Towards the end of January, the physician met with the leaders of
the communities at their request. The meeting was tense, but he was able to
explain the reasons behind the change and its purpose: to reduce out-of-
pocket expenses for medicines, and to guarantee the presence of essential
medicines in the clinic at all times. The leaders accepted the explanation and
since then there have been no complaints about the operation of the com-
munal pharmacy. As one of them said: 'From now on, we will eat less
medicine'.
AN EXPERIMENT IN THE DOMINICAN REPUBLIC 67
By the way of summary of this section, we present the hypotheses that the
research team formulated at the time: the communal pharmacy was estab-
lished: (1) the selling of medicines will not affect the number of consultations;
(2) the erratic fluctuations in the number of weekly consultations will be
reduced, and (3) the out-of-pocket health expenditures will decrease. In the
next section we will describe the results of the first year of operation of the
communal pharmacy and some of the issues that remain unresolved.
TABLE III
Communal pharmacy of EI Rio: selected statistics, 1984
a Our own research in EI Rio (Ugalde et a!. 1985) yielded an estimate of 1.9 prescriptions per
consultation.
68 A. UGALDE AND N. HOMEDES
1983 prices, and, consequently, we can conclude that the communal phar-
macy produced major savings to the inhabitants of El Rio. Further saving
would be possible if the pharmacy could purchase from PROMESE (see note
7 and Appendix 2).
About 16% of the households (160 families) were classified as paupers by
the health promoters and continued to receive free medicines. Generally,
these were elderly people without relatives, and large households headed by
females. The selection of the families was a relatively easy task; as had been
expected some promoters in the first listing included a few blood and ritual
relatives which did not fall within the category of poor and the supervisor
corrected the abuses without problems. The selection and adjustment of the
families entitled to free medicines did not produce any protests; the com-
munities were small and most people were aware of who the paupers were.
The amount of free medicines given to them was 4% of the value of all
medicines sold at the pharmacy during the year. If the need should arise, free
medication could be increased substantially because by the end of the year the
pharmacy had accumulated several thousand pesos. Thus, this model could
be applied to other communities in the Dominican Republic (and perhaps in
other Latin American countries) which are less affluent and may have more
paupers.
As have been indicated, a liberal policy of credit was established from the
beginning. In order to avoid possible abuses, it was made clear that the credit
was expected to be paid back. Table III shows that the credit given during
1984 was 15% of the value of the medicines sold and that most of it was paid
by the end of the year. The outstanding credit at year's end was 4% of total
sales; much of it was credit given in the last few weeks of the year that was
expected to be repaid in 1985. We do not know the precise figure of losses due
to bad debts, but certainly it was less than 4%, perhaps as little as 2% of sales,
an amount that can be easily absorbed by the pharmacy.
As Figure 1 shows, the extreme fluctuations in the number of consultations
that had characterized the clinic in the past, and which presumably were
caused by the uneven supply of medicines, reduced in 1984, when medicines
were available at all times. The eleven high peaks in 1983 correspond quite
closely with the arrival of medicines. Some variations continued to exist in
1984. As we found out, some low peaks responded to holidays, when people
tend to go less to the clinic and when the clinic is open fewer days of the week,
to the physician's absenteeism, to extreme weather conditions, and other
unusual circumstances. lO
The number of consultations was minimally affected by the communal
pharmacy. In 1983 there were an average of 96 consultations per week; this
figure went down to 83 in 1984. As can be seen in Figure 1, most of the
decrease took place during the first weeks of 1984 immediately after the
implementation of the change. The number of consultations during the
second semesters of 1983 and 1984 was very similar 2,484 and 2,340 respec-
AN EXPERIMENT IN THE DOMINICAN REPUBLIC 69
300
2SO 1983
- 1984
is0 200
.'!!" t\
ac: 1\
/
ISO
\
0
u
'0
.8e 100 //1 \
z"
i
SO
10 15 20 25 30 35 40 45 50 52
Weeks
Fig.!. Number of consultations per week at the rural clinic of El Rio (Constanza),
1983 and 1984.
tively, or a 5.7% decrease. The 1985 figures suggest also that the loss was a
temporary one, consultations increased from 1,175 in the first 18 weeks of
1984 to 1,457 during the same period in 1985 (the latest information available
at the time of writing). It is logical to suppose that many of the people who in
1983 went to see the physician only tOi receive medicines ceased to do so in
1984, and to conclude that the 1984 visits to the clinic were more genuine
medical consultations than in the past (over-the-counter drugs could be
purchased at the communal pharmacy without a consultation, and these visits
were not counted as consultations). In other words, in the past the clinic was
used primarily as a pharmacy or dispensary of free medicines; now it was used
for consultations. 11 In sum, the data from the communal pharmacy of EI Rio
confirmed the hypothesis that the selling of medicines at low cost was not a
barrier to the utilization of the clinic.
The communal pharmacy allowed financial decentralization and local aut-
onomy. Its impact on the quality of care is difficult to assess but for the first
time in the history of the clinic, patients' records began to be kept properly,
the clinic could supply itself with folders, paper and other office and clinical
supplies necessary for the adequate operation of a health care institution. It
was able to keep the cold chain without interruptions because it had the
resources to refill the gas tanks and repair the refrigerator without having to
depend on the Ministry, and it was able to repair and purchase gasoline for
the two motorcycles used by the supervisor of health promoters and the
physician to visit the hamlets of the health district. During 1984 the pharmacy
70 A. UGALDE AND N. HOME DES
spent 1,656 pesos on maintenance and operation of the clinic including the
purchase of plastic containers for the sale of medicines.
A number of questions emerged during the first year of operation of the
pharmacy some of which remain unresolved. One of the issues for which
there was no clear answer was the sale of disposable syringes at the communal
pharmacy. In the rural areas of Latin America, as in many other parts of the
Third World (Cunningham 1970; Alexander 1971; Bhatia 1975; Jones 1977;
Wyatt 1984), there is a general belief that injections are superior to other
forms of medication, and when a medicine is available in injectable form, the
patient prefers it. This is also the case in El Rio. Some patients who lived far
away from the clinic and from the health outposts wanted to buy disposable
syringes and have the medicine injected by a local midwife or other person in
the community. The problem is that the disposable syringes in El Rio, and we
suspect in other places as well, are used many times before they are disposed.
In fact, we found this practice at the clinic itself, where a disposable syringe
was normally used two or three times before being disposed of and the
physician considered the practice safe (attempts to find glass syringes in the
country failed). Even if disposable syringes are boiled, the advisability of
encouraging this practice can be questioned. In rural households, sanitary
conditions leave much to be desired and we can assume, as other researchers
have documented, that syringes are not sterile (Wyatt 1984: 913 and the many
references cited by the author). The health risks of injecting medicines under
these conditions are obvious. During our field work, members of the health
committee in the hamlet of Arroyo Bonito elected the health promoter
because of her experience in injecting. On the other hand, the refusal to sell
the syringes would not change the custom, as patients or those who inject
would buy them in town at a higher price. 12
A second problem was the custom of buying medicines in very small
amounts. It is traditional in rural areas to go to the store daily and buy only
what is needed for the day. Even items such as salt, spices, sugar and matches
are purchased in minute amounts; eggs are bought one at a time as needed,
and cigarettes are bought by the unit. The same practice applies to the
purchase of medicines. Patients may buy one or two aspirins at a time, and
they or some member of the family will return to the store the following day
to buy the medicines needed for the day. For example, none of the seventy
households we surveyed in-depth kept any medicines on hand. Patients who
live at a distance from the communal pharmacy are not inclined to walk to the
pharmacy everyday to buy the medicines and prefer to acquire them at the
little stores along the way even if they have to pay more, and if the stores do
not have the medicine, as frequently is the case, the attendant suggests a
substitute. The field notes taken by a field worker in the hamlet of Arroyaso,
where a branch of the communal pharmacy was functioning under the care of
a health promoter, reflect this problem and that of the injections discussed
earlier:
AN EXPERIMENT IN THE DOMINICAN REPUBLIC 71
They (patients) also go to the little store here where they may buy injectable medicines in smaller
amounts (than those prescribed). They then simply buy a syringe from the health promoter. She
has noticed that these (the syringes) are not well taken care of (by patients), are used over and
over again, and are passed from one person to another without disinfecting them. As far as
amounts of medicines dispensed: the syrups and cremes come in containers already mixed and
measured by the physician. As for fills and items which the botica (communal pharmacy at the
health outpost) has in bulk: sometimes the patient requests a certain amount in which case the
health promoter simply fills the order, and other times they ask her how much.
Patients who preferred not to return to the communal pharmacy and bought
the prescribed drugs at the little local stores incurred higher out-of-pocket
expenditures and the risk of taking the wrong medication and/or dosage.
Buying small amounts of medication probably encouraged the termination of
medication when the conditions of the patient improved before the comple-
tion of the treatment. In the case of antibiotics, early termination or use of a
different type of antibiotic may have negative health effects. The opening of
branches of the communal pharmacy at the two health outposts where the
physician had consultations once a week was an effort to bring the communal
pharmacy closer to the villagers. Yet, for those peasants in the other hamlets
of the health district, and even for those who resided in the hamlets where the
pharmacy operated but at a distance from it, the daily purchase of the dosage
was a barrier to the full utilization of the communal pharmacy.
A third factor that reduced the utilization of the communal pharmacy was
the common belief that low priced medicines were of lower therapeutic
quality than more expensive ones. The poor presentation of the medicines
sent by SESPAS, and the low quality of packaging at the communal pharmacy
for the medicines received from SESP AS or purchased in bulk from whole-
salers, tended to reinforce the perception that the medicines sold at the
communal pharmacy were of inferior quality. In the Dominican Republic, as
in many other countries, if a low-priced product is supplied by the govern-
ment, the suspicion about its quality is heightened. Furthermore, some
patients are acquainted with brand-name drugs that the communal pharmacy
did not carry and preferred to pay a higher price for them at the local stores or
in town. The more affluent the patient the more the tendency to demand
brand-name medicines. To encourage the utilization of the communal phar-
macy by all social classes of the community, the physician in El Rio decided to
stock the pharmacy with some of the most popular brand name medicines.
The research team was not sure about the desirability of this practice but the
following observation made by the clinic's physician is worth mentioning to
present the problem as perceived by the local health team:
It appears as if there were medicines for each social class. For example. middle class patients
come and ask which is the most expensive medicine we carry for influenza. This is common for
analgesics, antispasmodics, and other drugs. If the patient can afford it, he/she buys it and goes
home most satisfied. I have tried to teach them that they are wasting their money, it has been of
no avail. On the other hand, poor patients ask for a good and inexpensive drug. Of all the
medicines that patients request, the least solicited are those sent by the SESPAS.
72 A. UGALDE AND N. HOMEDES
CONCLUSIONS
In the last 20 years, many governments have built expensive health facilities
in the countryside and staffed them with physicians, nurses and auxiliary
personnel. The costs of these services are substantial but unfortunately, their
utilization and quality are low. At the same time, and in part because the
public services are so inadequate, peasants are incurring relatively large
out-of-pocket health expenditures, the majority of which goes to purchase
drugs. The reasons for this are complex. In our study of a rural clinic in the
Dominican Republic we found that the inadequate supply of medicines was
one of the many problems affecting the performance of the clinic. Utilization
of the clinic was limited to those times when medicines were available.
Because medicines are free, many villagers, whether in need or not, would
come to the clinic only to request them. The free distribution of medicines
was not contributing to equity, instead it was fostering overmedication and
paradoxically, it was increasing out-of-pocket health expenditures. In an
effort to remedy this situation, a communal pharmacy was organized at the
clinic, under the management of the local health team, where essential and
generic medicines were sold instead of given away. The results of the first year
of operation of the communal pharmacy confirmed the hypotheses which
supported the ideas behind its organization, namely: that the erratic use of
the clinic would decline, that the cost of medication would be reduced, that a
credit system for users would be feasible, that the number of consultations
would not decline to any extent, and that the quality of care would be
improved. The experience of the communal pharmacy demonstrated that
essential generic drugs were affordable by many villagers and that the medica-
tion needs of the paupers could be satisfied with a very small subsidy. It can
be suggested that the centralization of the supply of medicines is very
positive, and that the main role of the central government should be the mass
procurement of essential generic drugs for distribution at cost to regional or
local health centers. While finding ways to supply generic essential drugs is
urgent, there are other problems which also require immediate attention.
One of them is the tendency among villagers to buy in the market brand name
medicines or popular medicines of doubtful therapeutic value with the eco-
nomic wastefulness that these practices entail. A second problem is posed by
AN EXPERIMENT IN THE DOMINICAN REPUBLIC 73
APPENDIX l.
Medicines sold at the largest general store in EI Rio, 1983
APPENDIX 2.
Price increases between 1983 and 1984 of selected essential drugs in
the Dominican Republic, in pesos.
Prices %
Medicines purchased by SESP AS
for rural clinics Dec. 1983 1984 Increase
a After the initial increase, the prices of these drugs were lowered slightly.
APPENDIX 3.
Comparative prices of selected drugs available to the public through PROMESE and
commercial channels, Dominican Republic 1985 (in US dollars)*
NOTES
1. The impact of improvements in transportation on the utilization of health services during the
second half of last century in the United States has been discussed by Starr (1982: 65ff).
Today in the Dominican Republic, the availability of international transportation makes it
possible for many Dominicans of all social classes to receive care overseas. For example, the
Dominican Communist Party makes arrangements for an unknown number of Dominicans to
receive high technology medical care in Cuba. It is estimated that about 8% of the Domini-
can population resides in the United States, mostly in the New York area; some Dominicans
with the assistance of their overseas relatives also travel to this country to seek care.
2. As Patel (1981) observed these percentages are based on factory prices and do not include
the profits of importers, wholesalers and retailers. In the Dominican Republic, retail prices
for some medicines could be ten times higher than factory prices.
3. Instituto de Investigaciones Econ6micas, 1968: 108 for Venezuela; Secretaria de Economfa y
Hacienda, 1970: 147, 153, 159, 165 for Honduras; Bureau of Labor Statistics, 1967: 44-63 for
Puerto Rico; Perez Mera and Cross Beras, 1981: 70,79 for Dominican Republic; Katz, 1974:
13 for Argentina.
4. The 1950 figure is from Secretariado Tecnico de la Presidencia de la Republica (1980: 3) and
the 1981 from the national census of the same year.
5. In a different study (Ugalde and Homedes: in preparation) that we carried out in all rural
clinics (39) of a health region we found that the year of service is not completed at the same
clinic. Frequently, within the year a physician is assigned to two or three clinics.
6. The 1970 figure is from (Perez Mera 1979: 124) and the 1985 is from the Budget Law.
Commonly, only part of the approved budget is transferred to SESPAS. the cuts can be as
high as 10 or 15% of the approved budget.
7. The precise number of hamlets is difficult to determine in dispersed rural areas in the
Dominican Republic. The national census identification of hamlets does not coincide with
that of the local population. Local people are not in agreement among themselves: for
example, if a group of neighbors decide to change the neighborhood into a hamlet the change
may be acceptable to some and not to others.
8. In 1984, due to the exorbitant price increase of pharmaceutical products (see footnote no 9)
SESPAS and INESPRE, the government agency in charge of price stabilization, decided to
organize a program to procure and import large amounts of essential drugs, many of which
were generic. The new program known as Essential Medicines Program (PROMESE)
organized non-profit pharmacies in public hospitals, in urban centers and in the government-
owned sugar mills. PROMESE's prices were so low (see Appendix 2) that private pharmacies
requested the government's permission to buy from PROMESE. The permission was granted
and the government established an official rate of profits for the medicines purchased from
PROMESE. However, as of this writing, PROMESE had not been able to handle distribu-
tion in rural areas. Perhaps in the future, PROM ESE could extend its services to rural clinics
and lower even more the costs of drugs for tbe peasantry.
9. The reason for the increase was the removal of the public subsidy that the pharmaceutical
imports had enjoyed from the time the peso began its devaluation. The subsidy was removed
under pressures from the IMF.
10. We learned too late that two useful statistics on utilization would have been the number of
weekly consultations divided by the number of working days in the week, and the number of
weekly consultations divided by the number of days worked in the week. The latter would
have removed the influence of absenteeism.
11. At the clinic of El Rio, in 1984 the number of yearly consultations per person was 0.8, below
the norm of 2 recommended by the Pan American Health Organization. However, the
number of yearly consultations should also include referral and self-referral consultations.
Our information for 1983 suggests that the number of consultations outside the rural clinic
AN EXPERIMENT IN THE DOMINICAN REPUBLIC 77
was higher than those in the clinic, and therefore, the total number of yearly consultations
per person in EI Rio could be close to the norm. If we take into account the barriers posed by
rural dispersion we can conclude that these statistics are very satisfactory.
12. This example raises some doubts about the wisdom of primary health care policies which
placed the responsibility of selecting the health promoter within the communities.
REFERENCES
INTRODUCTION l
Since the Ethiopian revolution in 1974 some pharmacies in Addis Ababa and
most drug importers/wholesales have been nationalized as part of restructur-
ing the national health care system under the principles of centralized plan-
ning and socialism. 2 In addition to price control, there has been a curtailment
of the types of drugs private retailers can sell and a prohibition on treating
clients in retail shops. The remaining private pharmacies and druggist shops
are to be nationalized with further extension of government control over the
private sector of the economy. In 1984 we examined the utilization of private
and government pharmacies in Addis Ababa by different socioeconomic
groups. We found a distinct preference for government retailers, largely due
to their lower drug prices and larger inventories. Due to the usual limitations
of pharmacy based studies, particularly sampling bias, we recommended that
population based studies of drug retailing and utilization be carried out
(Kloos et al. 1986a, 1986b). The present paper is based on integrated
household surveys in four kebele (urban dwellers' associations) and additional
pharmacy based studies in December 1984 and April/May 1985. The objec-
tive of this study is to examine relationships between disease prevalence,
disease perception, decision making in drug selection and geographic and
socioeconomic accessibility of retailers in drug purchasing in Addis Ababa.
Case histories of pharmacy clients are included to complement the statistical
data. Together they allow us to view drug purchasing within its urban context.
The paper thus emphasizes the sociogeographical and cultural character of
the retailing and use of drugs.
Addis Ababa has a population of 1.5 million (Office of the Population and
Housing Census Commission 1984: 46). It is located at an elevation of 2,400
meters in the humid, temperate highland zone characterized by warm days
and cool nights. Founded in the late nineteenth century, Addis Ababa has
experienced rapid growth, generated primarily by rural-urban migration. In
1978 nearly half of the population was still reported to have been born in rural
areas (Hailu 1982). Rapid urban growth resulted in shortages and deficiences
81
S. vanderGeestandS. R. Whyte (eds.) , The Context ofMedicines in Developing Countries, 81-106.
1988 by Kluwer Academic Publishers.
82 H. KLOOS ET AL.
suburbs of Addis Ababa contribute little to meeting the drug needs of the
population.
Thirteen of the 24 government pharmacies were operated by the Ministry
of Health in hospitals. Six of the remaining eleven government pharmacies
were operated by the Municipality and five by the Ministry of Health. These
eleven pharmacies apparently sell as many drugs as the 34 privately owned
pharmacies, based on the sales volume of several retailers (Kloos et al.
1986a). The greater use of government pharmacies by the public is largely due
to a combination of their lower prices (H}-20% less than in private shops), the
larger number of drugs they carry and their location on major traffic routes.
Both the Ministry of Health and the Municipality reduced the profit margin of
retailed drugs from 40% to 25%, with further price reductions anticipated in
the future. Furthermore, they supplied their own pharmacies with, but
prohibited private retailers to sell, certain prescription drugs, including some
higher antibiotics, insulin, tuberculosis drugs, several tonics and psychotropic
drugs. Government are supplied by the state-owned EPHARMCOR corpo-
ration but private retailers depend for some of their drugs on private
importers/wholesalers. The latter have come under increased government
pressure through taxation and restrictions on the number of brand drugs they
can import since the Ministry of Health wants to develop an essential drug list
in line with primary health care objectives. 3
As a result of these developments most private retailers either continue
certain sales practices from pre-revolutionary times or resort to new strategies
to stay in business. These include the sale of prescription drugs without
prescription, sale of large amounts of drugs to individual clients, mostly illegal
peddlers and injection doctors (Kloos 1974), employment of family members
and relatives, and reductions in sales prices. Illegal sales practices are still rare
in government pharmacies, which pay fixed salaries to their personnel,
regardless of sales volume and are subject to frequent internal and external
audits (Kloos et al. 1986a).
Pharmacies and drug shops, by far the most important sources of drugs for
the Addis Ababa population, offer several distinct advantages over hospitals
and clinics. In addition to being more accessible to residents because of the
fast service they provide and the absence of long waiting lines, they stay open
longer hours, their personnel readily advise clients on what drugs to purchase
and many of them sell prescription drugs without prescription.
Private, illegal clinics, operated by non-physicians and cut off from whole-
salers also depend on retailers for drugs. Registered private clinics operated
by physicians or health officers, by contrast, issue prescriptions which their
patients can fill in any pharmacy or drug shop. Moreover, as part of the recent
emphasis by the Ministry of Health on primary health care, retired health
officers, dressers and other health auxilliary workers are now permitted by the
kebele to give injections and other basic services. They too obtain their drugs
from commercial drug retailers.
BUYING DRUGS IN ADDIS ABABA 85
METHODOLOGY
Data on drug retailer use and drug purchasing behavior were collected from
five sources. First, an interview questionnaire was administered by university
geography student to 1,143 clients of two government (municipality) pharma-
cies. One is located in the high-density slum environment of the Merkato
Market area and the other in the more suburban, socioeconomically mixed
Mekakelegna District. Information gathered about clients buying medicines
concerned their residence, the place they visited before coming to the phar-
macy, level of education, age, sex, type of illness to be treated (in Amharic),
type and price of drugs purchased, and reason for purchasing specific drugs.
Proprietory and generic names of drugs and cost of purchases were deter-
mined by visual inspection of drug containers receipts. Second, unstructured
interviews were carried out with several local pharmacists, clients (case
studies) and officials of the Ministry of Health and Addis Ababa Municipality.
Third, personnel in the two study pharmacies interviewed 220 clients on what
drugs, if any, they had used in the past or knew about for the same illness or
disease. This information was used to evaluate drug selection. Fourth, direct
observations were made of drug purchasing behavior in pharmacies to obtain
further information on drug selection and purchasing and on the operation
and management of retail shops.
Fifth, a questionnaire interview survey was carried out among 10% random
samples of all households in four of Addis Ababa's 285 kebele to evaluate the
link between illness episodes and use of pharmaceutical drugs in a representa-
tive population. A total of 284 households with 1,775 people was studied. In
order to control for differences in socioeconomic level and location in the city,
one central inner city, two peripheral and one semi-peripheral kebele were
selected.
The prevalence of acute illnesses and their treatment were studied retros-
86 H. KLOOS ET AL.
pectively for the 30-day period preceding the survey, and chronic illnesses and
their treatment for six months. Disease symptoms were classified into 'possi-
ble diagnoses' using the lay health reporting system developed by the World
Health Organization (1978) and adapted for Ethiopia (Tekle-Haimanot
1985). This permitted the establishment of relationships between symptom
clusters and multiple illness in the same person and treatment behavior, a
persistent methodological problem in health surveys (Kroeger 1985).
TABLE I
Households studied, prevalence of illness and drugs stored at home in four kebele,
by education of head of household
Education
Illiterate or
literacy
campaign
education Grade school High school University Total
(n= 187) (n==91) (n=42) (n=31) (n=351)
Total number of
households studied 128 92 36 28 284
Percentage of households
with ill persons 76.6 68.5 61.1 71.4 71.5
Number of persons in
sample 772 612 234 157 1775
Number of ill persons 187 95 38 31 351
Percent ill persons 24.2 15.5 16.2 19.7 19.8
Number of households
storing drugs 19 18 9 16 62
Number of drugs stored 32 29 26 57 144
Mean number of drugs
stored per household 0.25 0.32 0.72 2.04 0.5
Ovel '-1.11, most ill persons and their families were said to have done nothing
in response to illness (22.5%). Failure to seek medical treatment was attri-
buted mostly to knowledge of the transitory nature of the seasonal upper
respiratory infections, including influenza (gunfan) , common cold (berd) and
tonsilitis (gororo or tonsil). Lack of money and the widespread view that the
use of drugs cannot eliminate nutritional deficiencies were other reasons. A
few persons in the slums mentioned lack of transportation to government
clinics or hospitals, where they could have obtained free service. Pharma-
ceuticals purchased either with or without prescription in pharmacies, drug
shops, small rural medicine vendor shops, or in small neighborhood shops
represented the most frequently used health resource (21.0%), followed by
the use of government clinics and hospitals (17.0%), household remedies
(12.8%), private clinics (12.3%), holy water (tsebel) from churches and holy
springs (4.3%), and drugs stored at home, injection doctors, traditional
healers and small shops (all less than 2%). Only 5.2% of the 423 contacts with
health services constituted combined or successive treatments for the same
illness episode, probably due to underreporting. Treatment for diseases
carrying a social stigma, particularly venereal diseases and tuberculosis were
crossly underreported. Also the seasonal respiratory infections, cultural
syndromes, epilepsy and mental illnesses were underreported. Common
colds, if treated at all with either traditional or modern medicines, were
gg
TABLE II
Health resources employed by 351 ill persons in four kebele, by illness group
Health resources used Acute UR Chronic Headache Intestinal Other Non- Nutritional Others Total
infections! respiration parasitics, infectious infectious deficiencies (percent)
infections diarrhea, diseases diseases
or stomach
ache
Self-medication:
Drugs from pharmacies 182 3 24 34 21 22 19 6 21.0
Drugs stored at home 2 0 3 0 0 2 0 6 1.4
Household remedies 16 9 16 17 9 9 0 0 12.8
Nearby shop or
traditional medicine
shop 0 0 0 2 2 0 0 0.9
Government clinic or
hospital 8 5 14 13 18 32 31 31 17.0
Private clinic 11 9 5 16 21 9 6 19 12.3
Injection doctor 2 0 0 5 0 0 0 0 1.7
Traditional healer 0 0 3 1 0 5 0 0 1.2
Holy water (tsebel) 0 21 11 0 9 5 0 0 4.3
Did nothing 40 9 14 7 16 16 38 31 22.5
Combination 6 33 37 76 44 55 16 16 5.2
1 Upper-respiratory infections.
2 Percentage of all illness episodes in this illness category; multiple illnesses in the same person are included.
BUYING DRUGS IN ADDIS ABABA 89
medical services (Van der Geest 1982; Fraser 1985) and in more affluent
societies (Slater et al. 1986) does not exist in Ethiopia. Type of drugs stored
varied also with level of education. More educated households stored mostly
analgesics, expectorants, decongestants and antacids and less educated
households, antibiotics. These differences reflect prevailing diseases in diffe-
rent socioeconomic environments together with differences in disease percep-
tion and affordability of drugs. The fear that stored drugs lose their potency
after several weeks or months and that they may be even harmful was most
commonly expressed by less educated households. Concern over old medi-
cines was also expressed in the study of pharmacy preferences of clients. Thus
an important reason Addis Ababa residents prefer government over private
retailers is that the former have generally fresher drugs due to the more rapid
turnover of inventories (Kloos et al. 1986a).
According to Kitaw (1984b) who studied self (lay) care in two rural
Ethiopian communities and in Addis Ababa, the major reasons for wide-
spread practice of self-care are the perception that the illness is minor or
beyond cure, poverty and urbanization but not the unavailability of modern
practitioners. He found that self-care is often the first measure taken in
illness, which, if not successful, is usually followed by consultation with a
practitioner of modern medicine. This pattern indicates that self-medication
will continue to be an important first and last step in illness treatment in Addis
Ababa.
Information on what transportation means people use, how far they travel to
obtain drugs and which retailers they patronize can assist health planners in
evaluating constraints in drug utilization and in the location of new retail
shops (Kloos et al. 1986a). Most health services used by the study population
were located within a 3 km radius of their homes. Preference for nearby
facilities indicates the importance of distance constraints on the utilization of
modern, transitional and traditional health resources. Our previous studies
on pharmacy utilization in Addis Ababa showed that few walked more than 3
km (Kloos et al. 1986a). Trips to more distant hospitals were due to their
specialized services and extended trips to some pharmacies and clinics were
attributed mainly to daily commuting and shopping patterns of respondents.
Other factors included patronization of facilities based on social and ethnic
ties to pharmacists, shop owners and practitioners, and contractual credit
arrangements between employers and government health care facilities. Type
of transportation other than walking did not influence distance travelled but
major differences were noted between the low and high socioeconomic
kebele. Whereas practically all trips in the former were made either on foot or
by using taxis and public buses, half of the trips in the latter were made with
private cars and nearly all of the others with taxis and buses. In poorer
BUYING DRUGS IN ADDIS ABABA 91
Pharmacy
- Keftegna boundary
_ .. - City boundary
;?
\
21
T \ ..
.J
.. (
J
./\..~
.. /
Number of clients living in the individual keftegna are shown above the line; number of
clients starting the trip to the pharmacy from the respective kebele are shown below the line.
revealed by the fact that only two households in the kebele survey reported
having used it.
Pharmacy
- Keftegna boundary
_ .. - City boundary
(
t~
22
T
\
"----'
"\
l.
""--...
Number of clients living in the individual keftegna are shown above the line; number of
clients starting the trip to the pharmacy from the respective kebele are shown below the line.
Fig. 2. Place of residence and origin of trip to pharmacy, by keftegna: Pharmacy in the
Merkato Market.
information sources and treatment options available to the patient and his/her
family. Frequently children, neighbors, relatives and friends are sent to drug
retailers to obtain drugs for the sick person. They usually rely on oral
instructions on what medications to obtain. Drug retailers in turn often give
only oral drug dosage instructions. These widespread practices suggest that
misinformation and improper drug use are serious problems in Addis Ababa.
Of the 682 clients interviewed in May 1985, 320 (46.9%) purchased drugs
for other persons, mostly family members (78.4%), followed by friends
(7.2%), other relatives (5.9%), neighbors (4.7%), and co-workers and super-
visors (3.8%). Although all types of drugs were purchased for family mem-
bers, they included few antibiotics for the widespread venereal diseases,
largely due to the social stigma attached to gonorrhea (chebt) and syphilis
(kitign), indicating that venereal disease was underreported and information
on venereal disease drugs unreliable. This was also evident from the evasive
answers of female clients, who commonly referred to venereal diseases as
mahitsen (uterus disease) instead. Males talked somewhat more freely about
the purchase of venereal disease drugs and commonly admitted that they had
bought them for themselves or for friends. Discussions with pharmacy per-
sonnel revealed that many clients pretending to buy antibiotics for various
other infections, actually obtained them for venereal diseases. The secrecy
surrounding their purchase is also suggested by a study of rural drug vendors
in Wollega Administrative Region. It was estimated that these small retailers
saw seven times as many gonorrhea cases as all hospitals, health centers,
clinics and health stations combined (Nordberg 1974:30). Multiple drug
resistance, an indication of indiscriminate and unregulated use of pharma-
ceuticals, is common among Ethiopian gonorrhea cases, particularly in Addis
Ababa (Gedebou and Tassew 1980; Dodge and Wallace 1975).
Tuberculosis drugs, antispasmodics for asthma, antihypertensive drugs and
diuretics, on the other hand, were frequently purchased for family members.
Heart conditions are considered particularly serious in Amharic thinking.
Over pulsing of the heart as a result of exertion is thought to result in pain,
fever, fatigue, mental confusion and occassionally in death (Young 1976).
Multi-vitamin preparations were commonly purchased together with heart
medications, both with and without prescription, in an effort to regulate and
strengthen the heart.
In the selection and evaluation of self-prescribed drugs in Addis Ababa,
attention is paid primarily to their efficacy and only secondarily to their side
effects. Responses to the question 'Why did you select the drugs you pur-
chased now?' are shown in Table III. Of the 422 (68.1 %) clients interviewed
who purchased drugs without prescription, 245 (58.1 %) responded that they
had used them before and found them to be effective or curative; 45 (10.7%)
had consulted the pharmacist or dispenser in the same pharmacy where they
purchased the drugs; 46 (10.6%) said that they had consulted with family
members, friends, neighbors or colleagues at work or were instructed by them
BUYING DRUGS IN ADDIS ABABA 95
TABLE III
Reasons for selection of specific drugs by 422 clients in two pharmacies
(self-selection of OTe and prescription drugs)
No. of Percent
Reason given clients
I used this drug before; it was effective or cured me before 245 58.1
The pharmacist or dispenser recommended this drug 45 10.7
I always use this drug because it is effective or curative and
has no side effects 32 7.5
I always use this drug because it has no side effects 14 3.3
My family, friends. neighbors or colleagues at work
instructed me to purchase this drug for them 25 6.1
Friends recommended this drug 14 3.3
My family recommended this drug 5 1.2
Neighbors recommended this drug 3 0.7
Various people recommended this drug 9 2.1
I was a medical, pharmacy or biology student or had
worked in a drug retail shop and I know the properties
or usage of this drug 6 1.4
I like the taste of this drug 3 0.7
I do not want any other drug for this illness 8 1.9
Other reasons 13 3.8
to purchase drugs for them. The large number of clients basing their selection
solely on efficacy and the few clients mentioning absence of side effects
reflects the concern in Amharic etiological concepts with expelling the disease
agent and the associated use of powerful purgatives, emetics and fumatories.
Strong medicines are expected to produce violent effects, occasionally result-
ing in death, and are also associated with pungent smells and unpleasant
tastes. The traditional concern over the adequacy of the amount of medicines
prescribed (Young 1976) and the practice of taking the whole prescription at
once has frequently been associated with side effects. Particularly taenicides
are used in this manner and accounts of drug poisoning resulting in death or
permanent damage are widely known in the population. These effects have
been confirmed by bioassays in the laboratory (Tsega et al. 1978; Arragie
1985; Rokos 1969). Use of powerful antibiotics for illnesses yielding to less
potent drugs, represents another health hazard. The pharmacological action
of drugs is not known to the average client and oral and written dosage
instructions by pharmacy personnel are not always followed; thus children,
the very old, pregnant women and drug sensitive patients in particular are at
risk. Ascaricides, including Unipar, were purchased for children as young as
one year, Metronidazole for a six month old girl with influenza, and codein
and penicillin for influenza in three year olds. Chloramphenicol, in spite of its
well known side effects (Silverman 1976: 8), was prescribed for a six month old
96 H. KLOOS ET AL.
infant with diarrhea and vomiting and for older children with common cold.
Nevertheless, the acquisition of drugs with fewer side effects, such as the
taenicide Taeniapassin, indicates a concern over side effects by some clients.
In an effort to study the knowledge clients had of different drugs for the
same illness they had during the interviews, we asked them what drugs they
had taken during previous illness episodes. Less than 40% of 200 clients
interviewed had used another drug and nearly all those who did, reported
having used only one other drug for the same illness. Many clients were
surprised that there existed other drugs for their illness, indicating a lack of
drug information in the public and little experimentation with new drugs once
clients decided to use a particular one. This is also indicated by the impor-
tance of personal acquaintance with specific drugs in the selection process
(Table III).
Case histories of ten pharmacy clients and clinic patients are included here
to illustrate in greater detail the processes of selecting, purchasing and using
drugs. These individuals were interviewed in private and government phar-
macies and at their places of work. Although not necessarily representative in
a statistical sense, description of their health behavior may contribute to an
understanding of the context of drug purchasing and use in Addis Ababa.
Case 1
A 19-year-old male shop keeper with gonorrhea (chebt) and stomach ache
(hod makatel) for the last eight months, took 18 capsules of ampicillin upon
the recommendation of his neighbor soon after appearance of symptoms. He
purchased the drug from a nearby private pharmacy which sold him this
partial dose without prescription. After initial improvement his illness, espe-
cially his abdominal pain, became worse. He suspected gastritis (chequara)
and decided to go to a government clinic, where venereal disease was
diagnosed. He was prescribed tetracycline and Optalgin, which he purchased
one week later in a government pharmacy upon receiving his monthly salary.
Case 2
A mother, a housewife with literacy campaign education and her one-year-
old baby came from a town near Addis Ababa to purchase vitamin drops for
the baby's diarrhea (tekmat) and poor appetite. She reportedly had taken the
baby two weeks earlier to a private clinic in her home town, where she was
given Worm Expel, an ascaricide. The diarrhea persisted and the mother
went to another clinic in her community. The 'doctor' gave the baby an
injection and prescribed the vitamin drops. The woman purchased them in a
government pharmacy next to the bus station in Addis Ababa from where
buses leave for her home town.
BUYING DRUGS IN ADDIS ABABA 97
Case 3
A 23-year-old male, with grade school education, a trader in the Merkato
Market, purchased the taenicide dichlorophen in a government pharmacy as
usual every two months. He had first been infected with beef tapeworm some
ten years ago. At that time he had self-diagnosed the infection from the
presence of Taenia segments in his stool and had been advised by a friend to
purchase dichlorophen as the most effective drug without side effects. He
claimed that dichlorophen had always cured him and that he never used any
other taenicides, either of the modern or traditional types, considering the
latter to be too dangerous due to their toxicity.
Case 4
A male high school student 17 years of age had developed diarrhea three days
earlier. At the suggestion of his friend he ate a beef dish (ketfo) with much hot
pepper (berbere) in it. The illness persisted and the next day he purchased
tetracyclin capsules in a private pharmacy, thus following the usual practice of
his family in such circumstances. His severe diarrhea persisted, however, and
his father suggested that he go to a government pharmacy, where prices are
lower than in private shops, and seek advice from the pharmacist on what
specific medicine to take. There he purchased the antidiarrheal drug Lomotil
and the amoebicide Entreseptol.
Case 5
A 24-year-old male hotel worker had had vitiglio (lemts) for a year. For the
first nine months he did nothing, hoping that it would go away by itself. When
new areas became depigmentated in his face he self-diagnosed the problem as
mich and applied the leaf juice of damakase (Ocimum sp.), a mich medhanid
(mich medicine), with which he was familiar and which he obtained from a
neighbor. For several weeks afterwards he noted some improvement but
subsequently the problem worsened in spite of continued use of the medicine.
After another month he decided to go to a hospital at the suggestion of a
friend. Based on the diagnosis (which the patient did not know) the physician
prescribed Multivitaplex Vitamin C. He chose to fill the prescription in a
government pharmacy near his work place.
Case 6
A 35-year-old male, a daily laborer with literacy campaign education, deve-
loped what he himself diagnosed as gonorrhea as evidenced by burning
sensation during urination and the presence of puss (megel) in the urine. He
had been informed about the symptoms of chebt (gonorrhea) by a neighbor
98 H. KLOOS ET AL.
friend who had often been infected in the past. This man also advised him to
purchase Penacine in a pharmacy since it had always cured him of gonorrhea.
He also gave him dosage instructions. The patient purchased this drug in a
private pharmacy near his work place.
Case 7
About ten years ago a 50-year-old male high school teacher was diagnosed as
having asthma (assim). Ever since that time the same physician (the patient's
family doctor) regularly prescribed Franol. During episodes of common colds
he also prescribed tetracycline and ampicillin, to be taken together with the
Franol. During upper-respiratory infections and when working hard physi-
cally the patient himself increased the dosage of Franol for comfort, using one
tablet daily instead at the two to three day interval. He preferred to buy his
drugs in a government pharmacy due to more reliable drug supply and lower
prices than in private shops.
Case 8
A 52-year-old farmer from Arsi Administrative Region, who had come to
Addis Ababa primarily to visit his son and to purchase some household
goods, stopped in at a private pharmacy in the Merkato Market which he had
patronized for many years to obtain Worm Expel for a child of his neighbor
with ascariasis (wosfat). He had brought with him an empty package of this
drug, given to him by his neighbor, to assure that he obtained the desired
medicine. When told by the pharmacist that this pharmacy no longer carried
this brand but that he could sell him an equally effective ascaricide (a generic
drug) for a lower price, the farmer refused, saying that his neighbor would not
be satisfied with any other drug, particularly since the child had a bad case of
wosfat, requiring a strong medicine.
Case 9
A middle-aged man, said to be a local 'hakim' (injection doctor) and,
according to a pharmacy sales clerk, quite wealthy, purchased under the
counter from a private pharmacy two tins of tetracycline, 50 vials of injectable
penicillin and five packages of cotton bandages. He refused to answer the
questions of the interviewer. Seeing his client's discomfort, the pharmacy
owner reprimanted the interviewer, saying that the survey harmed his busi-
ness by driving away old customers.
Case 10
A 33-year-old university instructor had developed a kidney/urinary infection
a year ago. He purchased ampicillin over the counter in a government
BUYING DRUGS IN ADDIS ABABA 99
pharmacy since that had been effective for other urinary infections he had had
in the past. He took the normal dose recommended by the drug manufac-
turer. He obtained no relief, however. After a 'short time' he went to a
hospital in Addis Ababa, where the physician prescribed bactrim, which
reduced symptoms somewhat. When his family doctor returned from over-
seas two months later he went to see him in his private clinic. This physician
declared that he was determined to cure him and prescribed gentamycin in
spite of the expressed concern of the patient over the fact that he had already
taken two antibiotics for this infection. The physician injected ten ampulles of
gentamycin 80ml intramuscularly at eight hours intervals. Upon completion
of the treatment the patient noticed ringing in his ears and low level abdomi-
nal pain. Reading the drug manufacturer's literature the patient learned
about the possible side effect of ear problems and that he should have been
hospitalized during the administration of gentamycin. This prompted him to
seek out 'many physicians' for consultation and advice. He had obtained the
names and addresses of these urologists and ear/nose/throat specialists from
friends. None of these specialists could help him. At last he visited an
ear/nose/throat specialist in a hospital who told him that his problem was due
to overdosage of gentamycin. Subsequently the patient experienced contin-
ous low-level ringing in his ears, which was aggravated by severe headaches
whenever he used any type of drugs and even certain foods. He discontinued
taking zinc supplements even though they eliminated his abdominal pain
since they aggravated the ear problem. Out of fear of additional drug
reactions he declined to use a sulfa drug prescribed by a physician when his
kidney/urinary tract infection flared up again. Instead he used garlic, with
beneficial results. At the end of the study period the patient decided to use
homeopathic medicine which he obtained from an Indian colleague, resulting
in marked improvements in his overall health without side effects.
COMMENTS
All cases illustrate the functional role of social networks and geographical and
ecomonic accessibility in the various steps involved in drug purchasing. Five
of the patients had self-diagnosed their illness and self-medicated drugs. In
the selection of drug retailers and drugs six patients were influenced by
friends, relatives, neighbors and pharmacy personnel. The tendency of pa-
tients with a new illness to seek the advice of persons close to them before
going to pharmacies indicates the need to discuss and confirm self-diagnoses
and evaluate different treatment options with experienced and trusted indivi-
duals. Patients repeatedly affected by the same illness had already developed
diagnostic and treatment strategies, as evidenced by their use of the same
type or brand of drug. That this may occasionally prevent utilization of new
brands or generic drugs and thus possibly delay treatment, is suggested by
Case 8. On the other hand, user perception of the 'proper' use of drugs may
deviate from doctors' prescriptions (Case 3), as in the earlier mentioned
100 H. KLOOS ET AL.
modifications in the use of antibiotic capsules. Shopping around for the most
effective drugs was illustrated by Cases 1, 2 and 10. The latter also revealed
the danger of overdrugging by physicians without the necessary precautionary
clinical measures and the beneficial effect of patient education in drug
evaluation. Use of pharmacies near bus stops, places of residence or places of
employment and homeopathic medicine obtained from a colleague all reflect
the effects of social and geographical proximity on the acquisition of informa-
tion and buying medicines nearby. Preference for government or private drug
retailers by patients in different socioeconomic classes and with different
illnesses is in agreement with results from this and previous studies (Kloos et
al. 1986a). These case studies, then contribute to an understanding of drug
purchasing in an urban environment from the user's point of view, by
identifying opportunities, barriers and adaptive responses.
CONCLUSION
This study indicates that numerous factors determine if, when and where
Addis Ababa residents seek medical treatment. Commercial drug retailers
have come to occupy an important position in the city's health care system. In
an environment characterized by high incidence of diseases which were
traditionally dealt with at home and by professional healers, the utilization of
over-the-counter drugs is becoming an acceptable and even preferred health
strategy. Recent government restrictions on traditional healers and provision
of cheaper commercial drugs through the rapidly expanding government
pharmacies appear to have hastened this trend.
The quality of the quantitative data produced by this study varies consider-
ably due to differences in method and research setting. The results of the
retrospective household studies are probably least reliable owing to a combi-
nation of recall difficulties, unfamiliarity of the population with survey re-
search and the hurry of some student interviewers to complete the interviews.
Recall of illness events declines even during the first week (Kroeger 1985).
The problem of unfamiliarity of Ethiopians with survey research and resultant
misconceptions and biased or wrong information was described by Pausewang
(1973). Some interviewees misunderstood the survey as an attempt to
determine family income for taxation purposes or to recruit people for kebele
duties. Others expected the interview team to set up health programs or to
construct clinics and pharmacies. Carrying maps and notebooks, the inter-
viewers were also thought to be urban planners and fears were expressed in
the slums about the possibility of urban renewal and associated evictions.
Whereas these misconceptions could be largely eliminated by explaining the
objectives of the interviews, the limited contact between household and
interviewer, ranging from 40 minutes to one hour, resulted in shallow
answers. The fact that about 10% of all interviewees, especially of the Dorze
ethnic group, spoke little Amharic contributed to information loss.
BUYING DRUGS IN ADDIS ABABA 101
NOTES
1. The authors are indebted to Mr. Eshetu Wondemagegnehu. Head of the Department of
Pharmacy and Laboratory. Ministry of Health. and Mr. Abebe Engedasew. Head of Health
and Community Services. Addis Ababa Municipality. for their assistance and stimulating
discussions. Thanks are also due to the residents and officials of the study kebele. the officials
of the respective keftegna and the pharmacy personnel for their cooperation and support. The
Department of Geography. Addis Ababa University. kindly provided technical assistance.
2. In Ethiopia nearly all studies by social scientists of health services have been confined to
traditional medicine (Giel and Workneh 1968; Rodinson 1967; Messing 1958; Mercier 1979;
Workneh and Giel 1975; Young 1976. 1977; Kloos and Ahmed Zein 1988). Only one
sociological study of modern health care in Ethiopia. examining factors in the utilization of
primary care services and injection doctors. paid some attention to pharmaceuticals (Bus-
chkens and Slikkerveer 1982: 53-55.104). Studies of rural drug shops (Nordberg 1974; Lundin
1974). pharmacies in Addis Ababa (Sekhar 1981; Sekhar et al. 1980. 1981) and national drug
distribution (Desta 1971) were concerned primarily with public health aspects. In a prelimin-
ary study of the utilization of private drug retailers in prerevolutionary Ethiopia one of us
evaluated several factors. including their location. transportation facilities used by clients. size
of retail shops and management practices (Kloos 1974).
3. Government pharmacies have larger proprietory and generic drug inventories than private
shops. Thus their clients are more successful in obtaining the drugs of their choice (Kloos et al.
1986a). Whereas the great majority of the government pharmacy clients patronized retailers
either because of low prices. availability of drugs. or good services. most clients of private
shops mentioned their nearby location and their familiarity with them (Kloos et al. 1986a).
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KATHLEEN LOGAN
consult pharmacists about their illness symptoms and take the medications
they recommend (Young 1981: 124-125; DeWalt 1979: 7; Chinas 1963: 61).
Other studies refer to the pattern of medical pluralism that develops when
OTC's and traditional healing practices are linked, as Higgins (1975: 35) does
when he observes that pharmaceutical products are often used to cure in
conjunction with traditional remedies such as herbal teas and massages.
Similarly, Brown (1963: 100), in describing how local curers have adapted to
the availability of patent medicine reports that curanderos have updated their
healing arts by incorporating OTC's into their practices. Fabrega and Silver
(1973: 44, 84), Kelly (1965: 61), and DeWalt (1977: 8) also state that
traditional healers in Mexico have added OTC's to their curing repertoire.
Despite the readily observable importance of pharmacists, self-diagnosis,
and self-medication with OTC's in Mexico, these topics have received only
passing mention in the anthropological literature. This omission is an illustra-
tion of Young's (1981: 6) point that anthropologists studying health care
usually center on the exceptional rather than the ordinary. It is the 'ordinari-
ness' of pharmacists, self-diagnosis, and self-medication then that had
brought these topics to be side-lined rather than high-lighted in health care
studies of Mexico. The near absence of these topics in the literature also
demonstrates a central theme of this volume - that anthropologists studying
health care have often failed to take account of the use of Western pharma-
ceuticals in the Third World.
It is the 'ordinary' responses to illness - self-diagnosis and self-medication -
that are the most frequent responses. And increasingly in the Third World,
self-diagnosis and self-medication incorporate OTC's and consultation with
pharmacists. Since this trend was evident in Mexico, it seemed to me that a
quantitative study needed to be done to address the lack of data on the role of
pharmacists, self-diagnosis, and self-medication with OTe's in that country.
Not only were quantitative data needed on these topics but also it seemed to
me that a study of the context in which they occurred was necessary, since few
studies of the role of pharmaceuticals have provided data of this kind. For
these reasons, I did a study of the role of pharmacists, self-diagnosis, and
self-medication with GTe's in Ciudad Juarez, Chihuahua, Mexico during the
summer of 1980.
RESEARCH SITE
Ciudad Juarez lies in a narrow, fertile valley at the base of two mountain
chains at the international boundary between Mexico and the USA, directly
across the Rio Grande from EI Paso, Texas. Because of its location at the
lowest mountain pass for hundreds of miles, the Juarez area has been a
transcontinental crossroads since pre-colonial days. With the establishment of
the international border in 1848, however, Ciudad Juarez has become even
PHARMACISTS AND THEIR CLIENTS IN A MEXICAN URBAN CONTEXT 109
more important as a crossing point. Today the city is a major border crossing
for the thousands of Mexicans entering the USA, legally and illegally, to seek
employment. Like several other northern Mexican cities such as Tijuana,
Mexicali, and Nogales, Juarez is rapidly becoming a major metropolitan area;
it now has a population of one million. In its growth, Juarez draws thousands
of workers from the interior of Mexico to work in its industrial and tourist
sectors. The major industry of the city at present is the 180 in-bond assembly
plants that employ some 77,000 workers. I Juarez is also a tourist center to
which North Americans come for Mexican food, crafts, entertainment, and a
taste of a different culture. Visitors also flock to the city to take advantage of
lower prices for consumer goods such as gasoline and food or such services as
dental care and automobile repair. Some tourists come to Juarez to partici-
pate in activities which are either illegal or difficult to find in the USA such as
bullfights, off- track betting, dogfights, prostitution, and cockfights. The
ambience of Juarez is not only one of vitality and growth but also one of
poverty, unemployment, and exploitation.
The general health status in the northern border regions of Mexico where
Ciudad Juarez lies is better than in the rest of the Republic (Loewe-Reiss
1978: 255). The area's higher standard of living permits a healthier diet with a
greater comsumption of meat and vegetables than elsewhere in Mexico
(Leon-Portilla 1972: 112). The greater per capita income of the area's resi-
dents allows them more economic resources with which to purchase health
care and to choose among health care options (Ardon 1978: 22; Loewe-Reiss
1978: 255). Another factor contributing to the city's better overall health
status is that the metropolitan northern border areas of Mexico fare better in
health care facilities than the rest of the Republic. There are both more
physicians and more hospital beds per capita in border cities than elsewhere in
Mexico (Nolesco 1978: 54-55; Rubel and O'Neil 1978: 195). Also aiding the
city's health status is the fact that urban areas in Mexico generally are better
serviced by all kinds of medical facilities than rural ones (Canedo 1974: 1131;
Schendel 1968: 250).
Despite higher than national average standards of health and better health
care facilities, however, ecological and socio-economic factors create serious
health problems for residents of Juarez. Since the city lies in a desert area,
there is considerable seasonal variation in temperature and rainfall. During
the long, hot, dry season, such problems as dehydration, drownings in the Rio
Grande and irrigation canals, poor sanitation because of chronic water
shortages and respiratory ailments caused by high dust levels are all health
hazards. During the short, summer wet season with its sudden heavy rains,
the flooding of low-lying areas and contamination of over-flowing sewage
create additional health risks. High density living and poverty exacerbate
these environmental health problems. Under these conditions, influenza and
pneumonia have become the primary causes of mortality. Enteritis and other
110 K. LOGAN
diarrhetic diseases have become the second leading causes of death. Common
chronic illnesses include tuberculosis, cirrhosis of the liver, diabetes mellitis,
heart disease, and vitamin deficiency (Loewe-Reiss 1978: 244--245).
METHODOLOGY
women in Latin America have the primary responsibility for family health
care (Rubel 1966: 180; Erasmus 1952: 420; Young 1981: 104; Weaver 1970:
143, 144; McClain 1977: 342). Second, Latin American women traditionally
take care of children under five years, the age group most likely to be ill
(Young 1981: 78). Thus, women are the individuals who make the initial
decisions regarding family illnesses and who minister to the ill. Given these
factors, women were the preferred sample.
The sample consisted primarily of married, middle-aged housewives who
were long time residents of Juarez. Most were either born in the city or had
migrated there earlier in their lives from one of the northern border states of
Mexico (particularly from the other parts of Chihuahua, the state in which
Juarez lies). Almost all had children. They had an average family size of five,
two adults and three children, making their families slightly smaller than the
average family size of 5.4 reported for the Mexican border states (Loewe-
Reiss 1978: 254). Seven of the 48 households were headed by single women.
Some variation in the sample occurred with husbands' occupation, infor-
mants' education, and family income. Nearly half of the informants' husbands
worked as vendors, construction workers or unskilled blue collar laborers.
The other half were office or skilled workers. A small number wero retired or
unemployed. Half of the informants had some primary school education; the
other half had completed primary school or received additional schooling
beyond the primary level. Two-thirds of the informants had family incomes
above the average for Chihuahua, one third had incomes at or below the
average. In this sample, female headed households did not correlate with low
income. Since these single women worked in the in-bond plant industries of
Juarez, they earned a higher income than would normally be expected for
female headed households in Mexico. Thus, their income placed them in the
above average range. Single women who headed households were also
younger and had fewer children than the rest of the women in the sample.
In the questionnaire, the women were asked to describe and to evaluate
their use of health care facilities in Juarez. The health care options included
on the questionnaire were selected based on the results from a questionnaire
pre-test administered in a neighborhood demographically similar to the
sample neighborhood. Only those health care options named by the infor-
mants in the pre-test were included on the questionnaire.
Informants mentioned the following health care facilities (in alphabetical
order): Centros de Salud, curanderos.~ government dispensaries. household
remedies, IMSS, ~Te's, pharmacies, private physicians, and the Red Cross.
Each is described briefly as follows:
The Centros de Salud are government sponsored public health clinics which charge set fees for
specific services.
Curanderos are local healers who diagnose. prescribe. and carry out treatment for illnesses. The
methods and substances ued in treatment vary and have been described widely in the literature
(Kiev 1968; Trotter and Chavira 1980).
112 K. LOGAN
Dispensaries are operated by the government and by labor unions that charge set fees for specific
services which are similar to the Centros de Salud. Fees are usually lower than with a private
physician.
Household remedies (remedios caseros) include a wide range of substances considered to
promote healing. Household remedies mentioned by informants in the sample included herbs
(yerba buena), mineral elements (bismuth), and foods (sugared water, carbonated lemon water,
salt, and bread).
IMSS is the Mexican social security system whose services are available only to those with stable,
salaried jobs. For this reason, only 20% (Loewe-Reiss 1978: 247) to 36% (Purcell 1981: 45) of the
Mexican work force is covered by IMSS. Generally, the poorest people, because they have
unstable jobs, are excluded from this system. In this sample 41.7% of the informants were
eligible for IMSS, slightly higher than the percentage eligible in the Mexican working population
as a whole. This is a reflection of the industrial work force employment of many individuals in the
sample neighborhood.
OTe's include a wide variety of medications sold at the 200 pharmacies in Ciudad Juarez.
Pharmacies range from tiny, one person stores selling only pharmaceutical products to large
chain stores selling all kinds of retail items in addition to pharmaceutical goods. The largest are in
the downtown area; smaller pharmacies operate in neighborhoods. The downtown pharmacies
are likely to be run by a university trained pharmacist and to sell many products unrelated to
health care (cosmetics, toys, and household furnishings). Neighborhood pharmacies are often
operated by men who have apprenticed in a pharmacy and have learned their trade through
experience rather than formal education. These pharmacies commonly carry only health care
merchandise.
Private physicians see patients at specific times when patients present particular complaints.
Patients are charged on a fee for service basis.
The Red Cross operates as a private charity, offering free medical service at a single central city
location. Ambulance services are also available through the Red Cross.
Tables I and II show the informants' responses to questions about their use of
health care facilities. Analysis of the responses as shown in these two tables
reveal that pharmacists do playa significant role in Mexican health care.
Pharmacists were the most widely used medical option by the informants
with 41. 7% stating that they consult a pharmacist at least once a month. Only
10.4% of the informants reported never using pharmacists at all. The 89.6%
who report consulting pharmacists are spread throughout the sample. No
demographic criteria proved to be significantly related to the use pharmacists
- informants in all categories made use of their services.
Informants indicate that they consult pharmacists in conjunction with their
use of OTe's. They do not seem to consider consultation with pharmacists
and the use of OTe's as discrete forms of treatment. The combining of these
two forms of treatment is the reason, no doubt, why pharmacists were not
cited separately by informants when they were asked about their initial
responses to illness symptoms. (See the discussion in section entitled, 'Re-
sponse to Illness Symptoms').
Informants' responses to questions about why they use the health care
options they do reveal that they consult pharmacists more frequently than
other health care providers for a variety of reasons. In an open ended
question about how pharmacists were able to help them, the most frequently
114 K. LOGAN
TABLE I
Frequency of use (N = 48)
TABLE II
Use of services (N = 48)
given reason cited by informants (listed by 22) was the pharmacists' abilities
as diagnosticians and prescribers of medicine. Typically, people reported that
they go to a pharmacy and describe their symptoms to the pharmacist. He
then either asks further questions about the symptoms or begins to select
medications that he believes will alleviate them. Through discussion, the
pharmacist and client come to agree on which medications the client will
purchase. In this way, operating at their best, pharmacies can provide useful
information about the OTe's they sell. They give basic information about
various medications, describe how they work, and tell what side effects they
may have. They also recommend particular medications for specific afflictions
and give information to enable people to choose among similar products.
Based on my observations, pharmacists seldom seem to push people to buy
medications. Their advice seems informative, given in the spirit of providing
information rather than trying to make a sale.
Yet not all pharmacists are knowledgeable, well-trained, and willing to give
PHARMACISTS AND THEIR CLIENTS IN A MEXICAN URBAN CONTEXT 115
advice about illness symptoms and OTe's. The quality of health care given by
pharmacists varies considerably. Some pharmacists I observed were perfunc-
tory in giving advice or information. Some were not well informed about the
products they were selling. Nonetheless, pharmacists' effectiveness as health
care providers is constantly being evaluated by their clients. If the advice they
give and the medications they sell do not prove effective, their clients will
consult other practitioners instead.
The second most frequently cited reason (listed by nine informants) for
going to a pharmacist was to get prescriptions filled. Since informants report
consulting physicians as the second most common response to the four illness
symptoms and the most frequent response to persisting illness symptoms (see
the discussion in section entitled 'Response to Illness Symptoms'), it is clear
that they would receive prescriptions that would need to be filled at pharma-
cies.
The use of prescriptions links physicians and pharmacists in health care. An
interesting side-light to this doctor-pharmacist link as health care practition-
ers is that some physicians own part interest in pharmacies, especially ones
located near offices. The consequences of this linkage for health care delivery
need to be explored.
The third most frequently cited reason (given by seven informants) for
consulting a pharmacist was a belief in the efficacy of the OTe's they sell.
Many people not only seem to think that the OTe's they select cure their
illnesses but they also seem to think that they, as patients, are well-informed
enough about their illnesses to be able to select them. Especially when the
same illness symptoms re-occur, people are very prone to diagnose the
symptoms as indicating the same illnesses as they have had before. Thus, they
ask the pharmacist to 'give me something for parasites' or 'give me something
for conjunctivitis', apparently not thinking that they need to consult a physi-
cian or anyone else to diagnose their illnesses. In this way, informants choose
to consult pharmacists because this choice allows them to self-medicate and
thereby retain control of their own treatment. The use of OTe's with a
pharmacist's guidance fits easily into a traditional system of self-treatment
that once included only household remedies.
The fourth most frequently cited reason (listed by five informants) for
consulting a pharmacist was cost. Pharmacists do not charge for their services
as do other practitioners (including some curanderos). They are also more
economical to consult because they can provide medications without a pre-
scription and thus allow people to bypass costly visits to physicians. In
addition, pharmacists are willing to discuss various OTe's in terms of their
cost effectiveness. Informants also mentioned that pharmacists save them
money by giving them free medications or by selling them medications at a
discount. Usually these free or discounted drugs are samples given the
pharmacist by pharmaceutical salesmen. Additionally, Mexican pharmacists
routinely sell OTe's in small amounts, i.e., it is possible to buy two aspirin
116 K. LOGAN
rather than having to buy the entire bottle. Pharmacists, then, are less
expensive than other health care practitioners.
Their ability to diagnose illnesses, to sell medications, and to fill prescrip-
tions, their clients' belief in the effectiveness of the OTC's they sell, and their
provision of low cost treatment were the reasons most often given by infor-
mants for consulting pharmacists. Observation suggests several others. Since
many pharmacists live and do business in the neighborhoods they service,
they may be more knowledgeable about the health problems and living
conditions of their clients than other health practitioners. Thus they are
perhaps better able to diagnose and treat the most common ailments afflicting
their clients. The effectiveness of their care is questionable, however, when
they are confronted with complicated or unusual illness conditions. The
pharmacists' lack of medical training is a handicap for dealing with the out of
the ordinary illnesses their clients may suffer. In these cases, there is always
the danger of mis-diagnosis and the prescription of medicine harmful to the
client.
Observation also suggests that people select pharmacists because they
provide convenient health care. Pharmacies are often located in places easily
available to their clients. In some new urban neighborhoods, especially
lower-income ones on the outskirts of the city, pharmacists are the only
medical practitioners available. In addition, many neighborhoods pharmacies
are open seven days a week and for longer hours than other health care
services. Another convenience of consulting pharmacies is that it is simply
less time consuming to use them than any other health care alternative. There
are no lengthy waits; no troublesome forms to fill out.
Informants may also prefer pharmacists because they provide a more
comfortable social context for medical care than do other health care practi-
tioners. Consulting a pharmacist involves no interaction with intimidating
medical personnel, no lengthy examinations, and no unfamiliar language.
Mitchell (1980) reports that in Jamaica many people choose to consult
pharmacists rather than physicians because the socio-economic status differ-
ences between physicians and patients involve conflicting health beliefs and
role expectations. These differences disrupt the physician-patient relationship
and make the delivery of effective health care difficult. For this reason, many
choose to go to a pharmacist instead. While such a gap between patients and
physicians does not seem so important in Ciudad Juarez, given that infor-
mants report that they frequently consult physicians, they still prefer to go to
pharmacists initially. To them, pharmacists are more social equals than social
superiors; individuals who have specialized health knowledge to whom they
can turn when they are ill.
Finally, my observations suggest that because pharmacists must please their
clients to stay in business, they are perhaps more willing than other practition-
ers to be amenable to their clients' ideas about appropriate health care. Since
many pharmacists are from the same socio-economic background as their
PHARMACISTS AND THEIR CLIENTS IN A MEXICAN URBAN CONTEXT 117
clients, they may share the same ethnomedical beliefs and thus offer treat-
ment and prescription more congruent with the health care notions of their
clients.
The cultural and legal contexts in which Mexican pharmacists function
allow them to flourish as primary health care providers. Since few medica-
tions require a prescription and, since it is common practice to be able to
purchase 'prescription only' drugs without a prescription, the range and
number of medications available for pharmacists to use are large. As one
pharmacist noted, the quasi-legal status in which pharmacies function persists
because Mexican authorities understand that medical care of this kind may be
the only medical care affordable or available to some people.
Other factors in the cultural and legal contexts also facilitate the role of
pharmacists as primary health care providers. Mexican law dictates a tiered
structure of pharmacies; the first tier pharmacies are headed by individuals
who have university degrees training them to be pharm.acists; second tier
pharmacies are headed by those who have been trained by the practical
experience of serving as apprentices in pharmacies. Many more pharmacists
learn their profession by serving as apprentices to other pharmacists than by
receiving university training. As the head of the pharmacists' professional
association in Ciudad Juarez noted, second tier pharmacists are legally
permitted to operate only in rural areas because of the scarcity of university
trained personnel there. Despite this law, however, second tier pharmacies
do operate in urban areas. In Ciudad Juarez, I observed that large, center city
pharmacies were usually run by university trained individuals affiliated with
the pharmacists' professional association. Pharmacies in neighborhoods were
more likely to be run by pharmacists who were trained as apprentices.
Both kinds of pharmacists, however, receive information about OTC's
from pharmaceutical salesmen. The accuracy of the information these sales
representatives give may be questionable (Silverman 1976) yet their influence
on the prescription practices of physicians and pharmacists in the Third World
is notable. Since they are vendors and not health care practitioners, they are
more interested in selling OTC's than dispensing accurate information about
them. Clearly, more needs to be known about their influence on health care,
especially in developing countries where their number seems to be very high.
The widespread consultation with pharmacists as though they were physi-
cians raises some interesting points about the appropriate health care role of
pharmacists. Observers in the USA have noted that pharmacists there have
augmented their duties by offering advice about drugs and their use (Ritchy
and Raney 1981). One argument in favor of such an expanded medical role
for pharmacists is that the number of pharmaceutical preparations is increas-
ing at such a rate that no single physician can keep track of them and that
pharmacists, who because of their training know more about drugs than
physicians, should have a greater decision making role in the use of pharma-
ceuticals (Silverman and Lee 1974: 192). Other observers argue that a third
118 K. LOGAN
Table III shows what informants reported doing if someone in their family
had one of the four illness symptoms or susto and Table IV shows what they
reported doing if these problems persisted. The answers indicate that self-
medication, either with OTe's or household remedies, is the most frequent
initial reaction to all four illness symptoms and to susto. That informants
self-medicate as an initial response to illness is often cited in the literature for
Mexico (Kelly 1965: passim; Young 1981: 168; Brown 1963: 99); and in the
literature for other places as well: Western Malaysia (Colson 1971: 230),
Lower Zaire (Janzen 1978: 219), India (Beals 1976: 192), Nigeria (Maclean
1965: 238), Manus (Romanucci-Ross 1977: 438) and the USA (Schaller and
Carroll 1976: 196: 204). Yet despite the widespread practice of self-
medication, very few anthropological studies have dealt with this topic. They
have more often focused on later stages of the illness referral system where
treatment is sought from specialists for symptoms that have not responded to
forms of self-medication.
What are the consequences of self-medication? It may represent competi-
tion for other medical practices, a supplement to others, or dangerous
practice in the hands of the unknowing (Dukes 1963: 8). Many people who
self-medicate do not think it is dangerous and have great confidence in their
ability to treat themselves (Whiteford 1976: 100; Erasmus 1975: 420; Young
1981: 104). Some believe that information about drugs and the availability of
drugs should be in the public domain and used at the patient's own risk
(Alland 1970: 173). Unfortunately, few ethnomedical studies have systemati-
cally investigated the results of self-medication or other forms of indigenous
self-treatment (Kleinman and Sung 1976).
OTe's are the most frequent form of self-medication for all four illness
symptoms. The importance of pharmaceutical preparations is clear, support-
ing the observational data that such medications have a significant role in
Mexican health care.
Although not asked for specific product names of OTe's in the question-
naire, some informants referred to particular remedies by their commercial
brand-names such as: Alka-Seltzer, Breacol, Desenfriol, Kaopectate, Mejor-
ales, Pepto-Bismol, and Tylenol. These informants answered the question, 'If
a member of your family had a stomach ache (headache, diarrhea, cough),
what would you do?' by saying 'I would give them Pepto-Bismol (Alka-
Seltzer, Kaopectate, Breacol)'. It seems, then, that informants not only use
OTe's widely but also that some are quite specific about which ones they
prefer. Although some informants responded by citing the use of specific
commercial brand-name products, no informants responded consistently by
naming them for all four illness symptoms.
Table V shows that the naming of particular products most commonly
occurred in responses to questions about headaches. Given that informants
120 K. LOGAN
TABLE III
Treatment of illness symptoms (N = 48)
TABLE IV
Treatment of persisting illness symptoms (N = 48)
report using OTC's more frequently to cure headaches than any of the other
illness symptoms, it is likely that they think they have more knowledge about
and have more confidence in these name brand OTC's. Some informants
listed more general names for the OTC's they reported using. Nine stated
using aspirin as a treatment for headache; two cited analgesics. Twenty-five
informants reported using cough syrup for treatment of coughs, without
naming a specific brand.
PHARMACISTS AND THEIR CLIENTS IN A MEXICAN URBAN CONTEXT 121
TABLE V
Brand-name OTC's (N = 17)
Alka-Seltzer
Anacin
Breacol
Desenfriol
Kaopectate
Mejorales 7
Pepto Bismol
Terramicina
Tylenol
For stomach pains, 50% of the informants reported that they self-
medicated, 29.2% named OTC's and 20.8% household remedies. Nearly a
third (31.3%) mentioned seeking treatment from a private physician. Again,
younger informants, those with above average incomes, or more formal
education chose a physician over other forms of treatment, if they did not
initially choose OTC's. Older informants, those with less formal education or
below average income tended to choose household remedies over other forms
of treatment, if they did not initially choose OTC's. No other demographic
criteria were shown to influence choice of treatment.
In summary, it seems that OTC's have widespread acceptance among
informants as a means of self-medication. In the informants' view, OTC's
seem to have proven useful, especially in treating headaches and coughs.
Although still widely used, OTC's were less frequently reported for the
treatment of diarrhea and stomach pain. In these cases, the percentage of
informants using OTC's dropped while the proportion of informants who
reported using household remedies and physicians rose. Young women, those
with above average family income or more formal education tended to opt for
physicians rather than household remedies to treat diarrhea and stomach
pain, if they did not initially report using OTC's.
Since age seems to have affected the choice of treatment of diarrhea and
stomach ache, it may be that younger women do not yet have the knowledge
of household remedies that older women do and therefore do not employ this
form of self-medication as much. It could also be that knowledge of house-
hold remedies is not being passed on to younger women.
For treatment of susto, 62.5% of the informants state that they would
self-medicate with home remedies; none report that they would use an OTe.
The same pattern holds for treatment of persisting susto - of the nearly 17%
who continue to self-medicate, all name household remedies; none OTC's.
Clearly, in the informants' view, home remedies, not OTC's, are the appro-
priate treatment for susto. Apparently for many people, traditional, locally
used remedies are the most effective treatment for traditional, locally defined
illnesses (Whiteford 1976: 104, 105). Nonetheless, Martin et al. (1985: 234)
found that people in the Texas-Mexico border area consulted physicians also
for treatment of locally-defined illnesses. Thus, they found less insularity
between cosmopolitan medicine and indigenous medicine.
As we have seen, for initial treatment of susto, the majority of informants
report using household remedies. Yet within this treatment choice, variation
occurred. While some informants (6) simply cited household remedies as a
general treatment category, most others reported employing one or the other
of two distinct kinds of cures. On the one hand, of the 24 informants who
named a particular household remedy for initial treatment of susto, 17 cited a
food item which they eat or drink. The following list shows the food items
these informants named: sugared water (8); sugar (3); water (2); salt (2);
lemon (1); and moistened bread with sugar (1). On the other hand, seven
PHARMACISTS AND THEIR CLIENTS IN A MEXICAN URBAN CONTEXT 123
other informants replied that they would 'try to calm' the individual afflicted
with susto, although none described exactly how they would do this.
Similar patterns of intra-sample variation occurred with informants' re-
sponses to questions about treatment of persisting cases of susto with house-
hold remedies. Nearly 17% state that they would continue to use such
remedies. Most report continuing to use general household remedies or to
ingest particular food items. One informant chose to continue an undefined
'calming' treatment and another chose to make a ritual sweeping (barrida) of
the body with a candle (the only informant who mentioned such a cure).
Ingesting food, trying to calm individuals or performing a barrida seem to
be quite different approaches to treating susto. Trotter (1982: 220) also found
a variety of treatments for susto among the Hispanic popUlation. In his
sample of 35 cases of treatment for susto, approximately 2/3 reported ingest-
ing food (primarily herbal teas) and 113 reported using ritual treatments such
as the barrida.
Other informants (6.5%) reported choosing physicians to treat susto ini-
tially and 25% named them for treating persisting susto. Among those who
chose physicians were two informants who reported that they would go to a
psychiatrist to treat persisting susto. Perhaps they view susto as a psychologi-
cal illness or they think that having susto is in itself reason to suspect
emotional problems.
Some informants reported that they do nothing or wouldn't know what to
do if they did get susto (16.4%). Over a third of the informants report that
susto does not persist after initial treatment. Nearly 15% state that they don't
get susto at all. These responses perhaps indicate that for some, susto is not a
serious illness nor one that affects them. It may also be that some of these
people categorize the symptoms of susto as indicating some other illness, as
Rubel and O'NeIl (1978: 150) have found in their research on susto in Mexico.
They report that what people once diagnosed as susto, they now diagnose as
tuberculosis, hypertension or diabetes.
To treat susto, informants use a variety of household remedies, physicians,
psychiatrists, or state that they don't know what they would do, do nothing,
or don't get this illness. This variation in responses to susto may reflect that
informants do not share the same beliefs about its etiology and thus do not
share ideas about what constitutes appropriate treatment.
If the variety of responses to susto reflects that individual informants have
different notions about this locally defined illness and its treatment, it is
important to know what factors account for these differences. The data here
do not indicate what might be salient factors, since only income level proved
to be a possible factor in treatment choice for susto. Both the 6.5% who chose
physicians initially and the 25% who chose them for persisting susto had
above average incomes. These informants may select physicians because they
can afford to do so or because they believe susto to be an illness which can be
treated effectively by physicians. Of the nearly 15% who state that they don't
124 K. LOGAN
get susto, all have above average incomes, but showed no other demographic
pattern to distinguish them from the rest of the sample. 6
CONCLUSIONS
'Casi como doctor' is a quote from one of the housewives who was inter-
viewed for this study. Her expression encapsulates the idea that many people
in Mexico have about the appropriate role of pharmacists; i.e., that they
perform many of the same health care functions as physicians. As quasi-
doctors, pharmacists diagnose illness and prescribe medicines. To the infor-
mants, pharmacists are not only quasi-physicians but also better than physi-
cians in some respects. The health care services pharmacists offer are low
cost, convenient, fast, easy, uncomplicated to use, and allow people to retain
control over their treatment. It is not surprising that many people resort to
pharmacists for relief from illness symptoms.
This study underscores the importance of OTC's as an established form of
treatment central to the health care system in Mexico. In this system,
pharmacists and OTC's are inseparably linked, since the former give advice
about the latter. In the opinion of the informants, the linkage of pharmacists
and OTC's produces a kind of health care that functions well to cure the
illnesses they suffer.
There are also drawbacks, however. Self-medication as described in this
paper may cause considerable health hazards. Misdiagnoses, overdoses,
inappropriate medicines, over-reliance on OTC's, out of date and dangerous
medications remain potential dangers for those who depend on pharmacists
and OTC's for primary care. Azarcon, for example, was readily available in
Mexico in the early 1980s and self-prescribed as a cure for stomach illnesses.
Unfortunately, it is a toxic lead compound that can cause acute lead poison-
ing. During the mid-1980s, shortages of OTC's began to occur in Mexico,
creating problems for all those who had developed a reliance on them to cure
their illnesses.
Given that this kind of health care system is unlikely to be replaced by
other health care alternatives, what can be done to make this system function
better? First, the important role of pharmacists should be recognized. With
this recognition, could come training, particularly for the pharmacists who
learn their craft as apprentices, that would teach them to do better what they
now already do. Specific courses in pharmacology and symptom diagnosis
geared toward application in the setting of pharmacies would enhance the
already existent skills of pharmacists and make their diagnostic advice more
appropriate and less harmful to their clients.
Second, public service announcements on Mexican radio and television
could be made to educate the public about the proper use of OTC's and
potential dangers in their use. Such public service announcements already
appear on Mexican radio and television about alcohol abuse and child
PHARMACISTS AND THEIR CLIENTS IN A MEXICAN URBAN CONTEXT 125
molestation. Another possible means to educate the public about the use of
OTC's are the comic book style romantic and adventure nove/as that people
everywhere in Mexico read. Public service advertisements in these novelas,
like the media broadcasts, would reach a wide audience with helpful informa-
tion.
The dangers of self-medication are augmented by the marketing practices
of pharmaceutical firms. Exporting drugs to developing countries can be
profitable business which pharmaceutical firms are unlikely to discontinue
voluntarily. By implementing a rigorous essential drugs program, the Mexi-
can government could curtail the sale of useless and harmful medicine and
guarantee the steady supply of medicines which are needed in primary care.
In addition to demonstrating the link between pharmacists and OTC's in
Mexican health care, this study also casts light upon the relationship between
traditional, locally defined ideas and practices regarding illness and health
care and cosmopolitan notions and practices. The interaction of these two
medical traditions is complex, as the often contradictory results of health care
studies show. Some scholars have found the widespread use of curanderos
(Trotter and Chavira 1980); others report declining use (Keefe 1981; Edger-
ton, Karmo, and Fernandez 1970; Teller 1978; and Press 1973). This study
and others find that people separate the use of the OTC's and local indigen-
ous treatment (Whiteford 1976), but other studies report that curanderos mix
OTC's with traditional cures (Brown 1963; Fabrega and Silver 1973; Kelly
1965; DeWalt 1977). Responses to susto in this study show great variation
among the informants ranging from seeking treatment from a psychiatrist, to
making a barrida, to not getting the illness at all. Other studies also have repor-
ted such variation in responses within an Hispanic population (Trotter 1982).
On one hand, then, the traditional, locally defined health care sector
clearly persists and intersects with the cosmopolitan. On the other hand,
health care choices in Mexico have been much affected by cosmopolitan
medicine. Physicians have been found to be widely consulted in Mexico in this
study as in others (Ardon 1978; DeWalt 1977). One study reports that people
even consult physicians for help with traditional, locally defined illnesses
(Martin et al. 1985). People continue to incorporate new, modern elements
into traditional household remedies.
These contradictory findings point up the need for research which will
analyze how traditional and cosmopolitan medical beliefs and practices in-
tersect in Mexico. Rapid change, variation between and within Hispanic
populations, socioeconomic variables., and differences in education all suggest
themselves as factors which contribute to the complex interrelation between
these two medical traditions, in particular with regard to the use of medicines.
The participant-observer approach of anthropology which is geared toward
collecting contextual information and getting at community level practices
should be very useful at bringing an understanding to this complex relation-
ship.
126 K. LOGAN
ACKNOWLEDGEMENT
NOTES
1. Established in the late 1960s, the border industries program was set up to provide jobs for the
many unemployed workers in the area. With low wages and tax breaks as incentives.
multinational companies were encouraged to build plants where the component parts of
products (clothing, electronics, toys) could be assembled in Mexico and then shipped out to be
sold elsewhere.
2. COMO (Centro de Orientaci6n de La Mujer Obrera) students collected the data for the
questionnaire as part of their research training.
3. Population statistics were taken from a community study of the area done by COMO
4. Questions about susto or curanderos are noted as sensitive or controversial to Hispanics (Kay
1977: 89-90; Keefe 1981:46). For this reason, the results of studies on these topics are often
questioned. Every precaution was taken in this study to insure the accuracy of the data on
susto and curanderos. The questionnaires were administered in Spanish by native speakers of
Spanish; by women to women; and by those of a lower income socio-economic background to
those of the some background. The only differences between the interviewers and intervie-
wees was that the former had slightly more formal education and were somewhat younger than
the latter. No one in the sample refused to answer questions about susto or curanderos. None
of the interviewers reported embarrassment or reluctance to discuss these topics by those
interviewed.
5. None of the tendencies noted here were statistically significant at the .05 level. Because of the
small sample size, these findings should best be viewed as indications of possible differences
among the informants in the sample.
6. A recent work by Rubel, O'Neil, and Collado-Ardon (1984) breaks new ground in the
examination of susto and will re-structure the framework for future studies of this illness. They
find that susto occurs when an individual's capacity to adapt is overwhelmed by a combination
of biological disease load and the victim's inability to perform role expectations. With the
catalyst of a frightening event at some point in the victim's life, the individual succombs to
susto.
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PHARMACISTS AND THEIR CLIENTS IN A MEXICAN URBAN CONTEXT 129
policies. It is also these data which end up in the international reports of the
World Health Organization.
Between these two areas of research there is, however, a large fallow area:
informal modern health care. Medical anthropologists have little bothered
with this area because it is, after all, modern medicine. The fact that it is
informal was not enough to attract their attention, although they are
generally interested in deviant and marginal phenomena. On the other hand,
the medical sociologists have not bothered with this area because they found
it to be too informal. Perhaps they did not even notice it. It could not be
revealed by surveys and, apparently, it was not very important for general
policy. It was to this subject that my research was directed.
The fieldwork was carried out in the Division of Ntem in the extreme south
of Cameroon. This chapter describes the situation as it was in 1980 when
most of the research took place. Ntem has an area half that of the
Netherlands, but the population is only 140,000, which gives a population
density of nine people per square kilometre. The area falls within the rain
forest zone. Agriculture is by far the most important means of subsistence.
The main town and capital is Ebolowa with 20,000 inhabitants. It is not only
an important administrative center but also one of trade, education, medical
care, and other infrastructural services. Most people of Ntem live in villages.
The health situation in these villages leaves much to be desired. There is a
shortage of clean drinking water and sanitary facilities. Pigs, goats, and other
domestic animals wander freely around; refuse disposal is insufficient; and
the housing is often of bad quality (Amat and Cortadellas 1972: 342-356).
Certain food habits, such as that whereby the best food is reserved for the
adults, especially the men, form an extra threat to child health and are a
cause of infant protein deficiency. A survey (RUC 1978) has shown that
twenty percent of the children urider five years of age in the tropical rain
forest area of Cameroon are malnourished and that fifty percent are anemic.
According to Ministry of Health statistics (MSP 1978), malaria and
intestinal helminthiasis are the most common diseases for which the people in
Ntem consult the medical services (respectively, fifteen and ten percent of all
reported diseases). They are followed by skin diseases (eight percent), colds
and influenza (eight percent), rheumatic complaints (eight percent), bron-
chitis (five percent), and gonorrhea (three percent). According to the same
statistics, measles is by far the most important cause of death among
children, but the actual cause of death is always a complication such as
pneumonia, malaria, or encephalitis. Weanling mortality in Cameroon as a
whole is estimated to be one hundred and fifty per thousand and infant
mortality eighty-six per thousand.
In the Ntem division there are three hospitals with a total of 450 beds. The
two largest, with a total of four hundred beds, are both situated in Ebolowa,
about five kilometres apart. In addition to this, there are forty-five health
centres and only one officially recognized pharmacy. Other medical services,
MEDICINE DISTRIBUTION IN SOUTH CAMEROON 133
state hospitals and 277 public health centers together distributed to their
patients. A year later, in 1978, the value of medicines distributed by the
commercial sector was fifty percent greater than the public sector (see Van
der Geest 1981: 140). It is quite likely that this tendency has continued.
The shortage of medicines in public hospitals and health centers forces the
people to go to the pharmacies. Doctors and nurses in these institutions often
write prescriptions for medicines which are only available in the private
pharmacies. Sometimes patients or family members must travel for hours in
order to reach a pharmacy which has the required medicines. The Division of
Ntem is a large area. Travelling is difficult due to lack of transport and poor
quality of the roads, particularly in the rainy season. With some bad luck it
may take villagers a whole day (of waiting) to travel a distance of forty
kilometres. The fact that there is only one pharmacy in this whole area is
bound to cause problems. The same situation exists in the two neighbouring
divisions.
Next to and (as we shall see) within this formal sector exists an informal
medicine trade which has ramifications into the farthest corners of the region.
There are at least five categories of informal medicine sellers. The most
important are the shopkeepers who sell general provisions, including medi-
cines. In the capital Ebolowa there are approximately seventy-five shops
where one may purchase at least one or two medicines. The second group
consists of market vendors who also sell medicines alongside other products.
The third group can best be referred to as 'hawkers'. They travel from village
to village during the cocoa harvest when the villagers have extra money at
their disposal. These hawkers provide a variety of articles in addition to
medicines. The fourth group consists of traders who are specialized in the sale
of medicines and have a much larger assortment than the previously men-
tioned three groups. In Ebolowa, I found four such traders. They not only sell
medicines but may also give medical advice when asked. One of them even
gave injections. The fifth group consists of the personnel of medical institu-
tions. They privately sell the medicines which should be provided to the
patients free of charge.
After having shown who is involved in the informal retail trade in medi-
cines, the questions which arise are: where do these people get their products;
and what is the nature of the informal wholesale medicine trade? There are
three types of wholesalers who supply the informal sector with medicines:
those who sell smuggled medicines from Nigeria, official pharmacists, and
personnel from medical institutions.
The smuggling of medicines from Nigeria has taken on enormous propor-
tions, but it is impossible to discover the exact extent of this trade. The import
and sale of medicines is much more free in Nigeria than in Cameroon. In
136 S. VAN DER GEEST
Cameroon unqualified sellers may not import medicines, so they are forced to
import their products illegally from Nigeria. The medicines are transported
by taxi or van and are allowed to pass by customs officials who are bribed.
According to some informants, large amounts of medicines are carried over
the border by foot or in boats along the coast. In West Cameroon there is a
large number of depots where the medicines are stored and from where they
are later distributed throughout Cameroon and even to neighboring countries
such as Gabon and the Central African Republic.
The second group of wholesalers consists of legally recognized pharmacists.
Here it is necessary to mention that the laws governing the exercise of the
profession of pharmacist (RUC 1980) are very rigorous. According to these
laws, only qualified pharmacists may sell medicines. (This of course is absurd
when one considers the fact that there are so few pharmacies and that these
are concentrated in the urban centres). In any case, the laws do not change
the fact that almost all medicines can be purchased in large quantities and
without a prescription in the pharmacies. Informal medicine sellers make use
of this opportunity to purchase their supplies from the pharmacies. They pay
the normal retail price which means that they have to sell them in the villages
for a price which is a good deal higher.
The third group of wholesalers consists of hospital and health center
personnel. As I have already mentioned, these institutions receive medical
supplies from the Ministry at regular intervals, which they should provide to
patients free of charge. I estimate that approximately thirty percent of these
medicines do not reach the patients, at least not directly, but are appropriated
by the health workers themselves. 3 The health workers then distribute them
among friends and relatives, sell them to patients whom they treat at home,
or sell them to informal medicine sellers (Van der Geest 1981: 61-86, 1982).
It is this last possibility which makes them wholesalers in the informal
medicine trade. It is impossible to determine the size of this 'wholesale trade'.
THE PRODUCTS
In the Division of Ntem, I noted seventy different medicines which are sold in
the informal sector. The most common were analgesics (thirteen sorts),
antibiotics (twelve sorts), remedies for coughs and colds (eleven sorts),
laxatives (eight sorts), vitamins (six sorts), remedies for worms (five sorts),
remedies for anemia (five sorts), and anti-malarials (three sorts). 4 Most
medicine sellers were quite prepared to allow me to interview them about
their trade even though it was illegal. Research was easiest at the markets
where the medicines were prominently displayed. In the larger shops I was
often forced to explicitly ask if medicines were sold. This sometimes caused
suspicion. 5
Most important was the work which I did among the three specialized
medicine sellers. Because a large number of unknown medicines were in-
MEDICINE DISTRIBUTION IN SOUTH CAMEROON 137
volved, the research required long discussions and extensive note taking. This
took place between sales. I was afraid that this situation would be inconve-
nient, but the three sellers cooperated fully. They did not object to my pulling
up a chair and carefully noting all the names, ingredients, prices, and
instructions for use of the medicines. They patiently answered all the ques-
tions which I put to them about the uses of the various medicines. At my
request they allowed me to see receipts for medicines which they purchased
elsewhere. One of them regularly asked me to purchase medicines for him
during my travels. Because these enquiries were so successful, I was able to
gather extensive data on the seventy medicines which I had encountered in
the informal sector, but it would be beyond the scope of this article to give an
exhaustive exposition of the medical aspects of these findings. 6 However, in
order to understand the informal medicine trade, it is necessary to make a few
general remarks.
The reactions of Western-trained doctors and pharmacists to the list of
seventy medicines may vary. A pharmacist who gives priority to the norms
concerning the preservation and prescription of medicines which he has
learned during his training and which are applied in most Western countries
will perhaps disapprove of their free availability. But anyone who takes the
actual health situation in Cameroon into consideration will probably be less
critical. The informal medicine sellers are often the only available 'represen-
tatives' of modern medicine, and when there is some knowledge as to the
correct use of medicines, then self-medication with remedies bought in the
informal sector is probably the best alternative in the absence of modern care.
Expert opinion on this matter is only useful if it is realistic; and in order to
be realistic it must take the whole social and medical context into considera-
tion. With this in mind, I presented the list of seventy medicines to a physician
who worked in the research area and was reasonably aware of the health
situation. His opinion was that forty-one of the listed medicines were useful
or at least harmless when freely available, but he thought that twenty-four of
the medicines should no longer be sold. Because of a lack of data, he could
not form an opinion about the remaining five medicines.
The forty-one medicines which the physician considered to be harmless can
be divided into two groups. The first group contains medicines which are
extremely useful because they are effective against common diseases, they are
relatively safe, and their correct application is probably generally known.
This group includes analgesics, anti-malarials, and remedies for intestinal
helminthiasis and colds. The medicines which fall into the remaining group
are of questionable value. The fact that these medicines are freely available is
not problematic because they are generally not very potent. They are really
superfluous. This category includes vitamins, remedies for anemia, and a
number of laxatives.
Of the twenty-four medicines which this physician would like to see
removed from sale, twelve are antibiotics. Opinions about the free availabil-
138 S. V AN DER GEEST
ity of antibiotics are, however, varied. Opponents point to the fact that
misuse can lead to resistence. They see self-medication with antibiotics as
exacerbating medical problems. The advocates argue that since doctors are
often not available, the free sale of antibiotics is necessary. People living in
isolated areas benefit from this sale. In addition, the advocates argue, people
are generally well aware of how to apply the antibiotics in question. It seems
that this subject will remain controversial for some time to come. Other
medicines which this physician would like to see taken off the free market are
strong laxatives which may cause dehydration, especially among children, and
a number of remedies which only repress symptoms. thereby leading to the
postponement of consultation with a doctor and possibly detrimental conse-
quences for the patient.
Here it is necessary to mention a number of additional considerations that
make the free sale of medicines problematic. One of these is the method of
application. Injections which are generally popular, can be dangerous. When
they are given as self-medication, the needles are often not sterile. Storage
and the age of the medicines also constitute a problem . Because medicines
are stored under unsuitable conditions (temperature, light, humidity, and
atmosphere pressure), it is doubtful whether they will remain effective. The
labels of a number of medicines state clearly that they should be kept cool,
but I have never seen a refrigerator for medicines on the informal market,
though I have for beer. Also, no attention is paid to the date of expiry.
However, the most important problem is the lack of adequate information.
Naturally, information which is normally contained in the doctor's prescrip-
tion is lacking. But even the information on the package insert usually does
not reach the client. There are various reasons for this. The most important is
that the inserts are not sold with the medicines because the latter have been
removed from the original packages and placed in various bottles and jars to
be sold in very small quantities. In the rare case that a client does purchase
medicines with an instructional leaflet, the information may be inaccurate, as
has been shown by research elsewhere (Silverman 1976; Silverman et al.
1982). Many of the medicines which are produced in Nigeria or in England for
Nigerian firms immediately catch the eye because of their extremely tenden-
tious advertizing and sometimes misleading directions for use displayed on
the package. Finally, almost all products that come from Nigeria have texts in
English, which most people in the French-speaking part of Cameroon cannot
read.
Unavoidably, lack of information leads to wrong application. During my
research I came across many cases of incorrect use of medicines, some with
serious consequences. But even if there are no negative medical effects, the
non-medical consequences are bad enough. The fact that people in a poor
society spend money on useless medicines means that a scarce resource is
withdrawn from items that are necessary for the maintenance of health, for
example food, housing, and good medicines. On a larger scale, this wrong use
MEDICINE DISTRIBUTION IN SOUTH CAMEROON 139
of the medicines forms one of the greatest obstacles for the improvement of
health in the Third World. Finally, it should be noted that the ignorance of
consumers makes deception by the manufacturer and seller easier. Both types
of deceit were seen during my research and both led to wrong use.
It is difficult to generalize about the prices which are charged and the profits
which are made in the informal sector. Sales policy is capricious and can vary
from one seller to another and from one day to another. Some prices are
lower than those in the official pharmacies, but most are higher. It should be
noted, however, that in the informal sector much smaller amounts are sold, so
that the consumer only spends a small amount of money in each transaction.
The data on the profits of medicine sellers are no less difficult to determine.
It was possible to compare the purchasing and selling prices which applied to
nineteen products sold by one trader. The profit varied from fifty to 1,150
percent. The average was three hundred percent. This may appear to be high,
but it should be remembered that the turnover of most traders is very limited.
Medicines are sold in extremely small quantities, sometimes only one or two
tablets at a time. In spite of the wide profit margin, most medicine sellers only
have a meagre existence, except for some vendors in the markets of big cities.
In the rural areas the trade only flourishes in the cocoa season when the
people have money to spend. During this season cocoa farmers travel to the
city to purchase supplies and fill their medicine chest.
One of the medicine vendors described his function as 'depanner les petits
problemes'. The South Cameroonians have a long tradition of self-
medication. In the past they ~sed only herbs which grew in the vicinity, but
now pharmaceutical products are being increasingly used. This development
is made possible by the medicine vendors who bring these products as far as
the most isolated villages.
In four respects the vendors have more success in satisfying the needs of the
average Cameroonian than the pharmacists; all four are related to availabil-
ity. First, the vendors are financially more within reach, even though their
products are relatively more expensive, because the pharmacists only sell
fixed amounts of medicines in standard packages while the vendors in the
informal sector sell any amount that is asked for. This makes it possible for a
client to obtain which he urgently needs, such as analgesics, cheaply. This is
what the medicine vendor meant when he described his work as 'depanner les
petits problemes'.
Second, the vendors are literally more within reach. It is always possible to
find a medicine vendor without having to travel more than a few kilometres,
whereas one may have to travel fifty or a hundred kilometres, or sometimes
even further, to reach a pharmacy.
Third, the vendors are available day and night. They only close when
140 S. VAN DER GEEST
everyone has gone to bed, and even after that it is still possible to purchase
medicines. If someone urgently needs a medicine during the night, he will not
hesitate to wake the vendor. The pharmacies maintain European working
hours, to which they strictly keep. It is unthinkable that someone, who does
not have some form of personal relationship with the pharmacist, would be
sold medicines when the pharmacy is closed.
This brings us to the fourth factor, social distance. The difference between
the pharmacist and the vendor can probably best be illustrated by two
quotations from my fieldnotes:
28 June 1980
I spent two hours at the market with a medicine vendor, a Nigerian boy of about fifteen. It was
Saturday afternoon. I noted the country of origin, price, and if present, instructions for use for
forty-two medicines. The boy was very helpful; he knew all the prices by heart and showed me all
the medicines about which I enquired. He apparently found it quite normal that I wrote
everything down. While I was there many people came and purchased medicines. I did not have
the impression that they were disturbed by my presence. A lot of [olk%go, the local term for
Tetracycline (an antibiotic), was sold. People kept asking: "Have you got anything for worms?"
or "What's that for?" People who do not know very much about medicines but who do not want
to reveal their complaint may be able to find the right medicine in this way. It would be
impossible to act like this in a pharmacy.
11 August 1980
I have just spent half an hour sitting with E., an old man who sells medicines at the market. While
I was there he was visited by six clients.
A small boy comes and pays 25 francs and E. gives him three Quinacrine tablets (anti-
malarial). These tablets actually cost 10 francs each, but E. explains that the boy is poor.
Two youths. One of them buys six Tetracycline capsules for 50 francs. A young woman with a
child dawdles around and finally purchases six Mintezol tablets (for worms) for 375 francs.
A man of about thirty-five, purchases without hesitation Nivaquin tablets (anti-malarial) and a
vial of Bipeniciline (an injectable antibiotic). I ask him who is going to give the injection and he
replies: "I am, I'm a nurse.[ He then goes on to say that he used to be an infirmier journalier (a
very lowly qualified nurse) but that he lost his job, after which he became a planter. He now helps
his neighbours when they have medical problems. However. he feels primarily responsible for
the health of his own family.
A middle-aged woman who speaks in pidgin asks for a remedy for filaria. E. says that he
doesn't have anything. He tells her to try the pharmacy. But she complains that she doesn't know
which medicine to ask for .... Once again, I become aware of the fact that many people are
inhibited to go to the pharmacy. You can't casually look around, pick up medicines, and ask:
"Have you got anything for filaria?[ There are all sorts of people who stare at you, and the people
behind the counter are different from yourself. They are not patient and friendly. You do not feel
at ease. It is a bit like a hospital.
Although the medicine vendor is more within the reach of most people and
satisfies their needs better than the pharmacy, there are also many disadvan-
tages connected with purchasing medicines from a vendor. The consumers are
well aware that usually vendors have products of inferior quality, that they
MEDICINE DISTRIBUTION IN SOUTH CAMEROON 141
offer less choice, and that their knowledge of medicines is limited. The
preference for the vendor should, however, be seen in the context of the
whole health-seeking process. People who become ill first employ strategies
which require very little extra effort, self-medication. Only when this does not
succeed do they employ other strategies which require more effort and are
more expensive. Now, within this 'hierarchy of resort' (Romanucci-Ross
1977), self-medication and medicine vendors share the first place. It is only
when this choice of therapy does not produce the required results that the
above mentioned objections to the medicine vendors begin to playa role in
the choice of further therapy.
The relationship between the formal and informal sectors of medicine distri-
bution has two important characteristics. First, both sectors are closely
connected, even complementary. Second, this connection is unequal in na-
ture.
The statement that the formal and informal sectors are intertwined and
have common interests may be initially surprising. One is more likely to get
the impression that both sectors are at daggers drawn, especially in the
medicine trade. Let me give a few examples. In the law governing the exercise
of the profession of pharmacist (RUe 1980), it is emphasized that medicines
may only be distributed by qualified persons, i.e. pharmacists. It is also
forbidden to advertize medicines publicy. The law suggests that the utmost
care should be taken to ensure that medicines are used properly. Distribution
which does not take place within the formal sector as defined by law is
contrary to the basic principle of the profession of pharmacist, which is: the
optimal distribution of optimal medicines to ensure optimal health.
Art. 48
The sale to the public of any medicament, product or accessory article as defined under Section 6
above, by the intermediary of commission houses, groups of buyers or any other establishments
owned or managed by persons who are not in possession of the diploma of pharmacist, shall be
unlawful with the exception of those establishments mentioned under Section 32.
Art. 49
Any sale, display or distribution of medicaments on the highway, in fairs and markets, by any
persons, even in possession of the diploma of pharmacists, shall be unlawful.
It is not only the official legislation which gives the impression that the
interests of the formal and informal sectors of medicine distribution are
opposed. The reports and other publications of pharmaceutical firms conjure
142 S. VAN DER GEEST
up the same picture. They suggest that the pharmaceutical industry does its
best to supply products which are as safe and as effective as possible. In the
International Code of Pharmaceutical Marketing Practice compiled by the
International Federation of Pharmaceutical Manufacturers' Associations we
read:
The pharmaceutical industry, conscious of its special position arising from its involvement in
public health, and justifiably eager to fulfil its obligations in a free and fully responsible manner,
undertakes:
- to ensure that all products it makes available for prescription purposes to the public are
backed by the fullest technological service and have full regard to the needs of public health;
- to produce pharmaceutical products under adequate procedures and strict quality assur-
ance.
And in connection with the way in which medicines are sold, the same code
remarks:
Information on pharmaceutical products should be accurate, fair and objective, and presented in
such a way as to conform not only to legal requirements but also to ethical standards and to
standards of good taste. Particular care should be taken that essential information as to the
pharmaceutical products' safety, contra-indications and side effects or toxic hazards is appropri-
ately and consistently communicated subject to legal, regulatory and medical practices of each
nation. The word 'safe' must not be used without qualification (cited in Health Action Interna-
tional 1982: ii-iii).
On the basis of this statement, one would think that the formal and informal
sectors have opposing interests. These strict rules, which the pharmaceutical
industry formulates for its own practice, seem to imply that the industry does
its best to prevent its prescription-only products from being sold on the free
market without a prescription or an instruction leaflet. In the same vein, one
would expect that doctors, nurses and pharmacists in Cameroon would take
measures to prevent the inexpert distribution of medicines. The reality is,
however, quite different. It is true that the rules and statements of the
representatives of the formal medicine trade are extremely negative in their
judgement of the informal sector. But it has not been sufficiently realized that
these rules and statements are mostly rhetorical. They are not applied
literally, but rather veil the actual state of affairs or make it appear as if the
informal practices occur against the will of the formal institutions. In reality,
however, the informal trade exists with the approval of the representatives of
the formal sector, and they have a direct interest in its existence.
That both sectors of the medicine trade in Cameroon are intertwined and
mutually dependent becomes clear when we look at the origin of the products
which are sold in the informal sector. The medicine vendors purchase their
products from authorized pharmacies and from personnel in the formal health
institutions. The transactions in both cases serve mutual interests. The phar-
macist increases his turnover by selling to far-off villages through the vendor.
MEDICINE DISTRIBUTION IN SOUTH CAMEROON 143
Health care personnel increase their income by selling medicines which were
meant to be provided free of charge to patients. The relationship is more
complex in the case of medicines which are smuggled from Nigeria. In that
case, the intertwining of formal and informal takes place mainly in Nigeria
where the medicines are bought. My research did not extend into Nigeria but
there are indications that the medicines are purchased from legitimate institu-
tions there.
This intertwining of sectors is, however, not limited to the origin of the
product. There is also a direct connection between both sectors in the
distribution itself. The two sectors have unclear 'boundaries' and often tend
to merge. I will illustrate this with four examples. Hospital and health center
personnel are expected to supply the patient with the necessary medicines
free of charge. Instead, they sometimes sell the medicines to the patient,
either inside or outside the medical institution. So informal trade occurs
within the formal health care institutions; but can we caIl this 'informal
trade'? The transaction may be carried out by a professional health worker,
perhaps even within the context of formal health care. The second example of
the merging of the two sectors is the fact that patients purchase medicines
from vendors in the informal sector and take them along to the health center
when they go for treatment. This is a common practice, since people know
that the health centers often lack medicines.
I encountered the third example in the hospital where a large part of my
research was concentrated. Patients sometimes have to wait a long time
before they see a doctor, and treatment is not started until they have been
examined. As a result, there is a demand for medicines, especially analgesics,
which can be taken during the waiting period. For this purpose, they can turn
to the medicine vendor who has set up his stand on the hospital grounds, right
next to the polyclinic. The fourth example is related to the pharmacies. In
spite of the strict regulations mentioned above and the professional training
of pharmacists, there are a number of striking similarities between pharma-
cies and informal medicine vendors. They have in common that clients can
purchase any medicine without prescription or expert advice. Moreover, the
pharmacist is usually absent from the pharmacy and difficult to reach. The
medicines are sold for him by employees who, as far as their training goes,
can hardly be distinguished from the informal vendors. The question thus
arises as to what extent one should view the pharmacies as part of the formal
sector. These examples, to which others could be added, illustrate the nature
of the connection between formal and informal. We shall now see that this
relationship is an unequal one; the informal sector tends to be subordinate to
the formal sector.
Some anthropologists who study politico-economic development in Africa
use the concept of 'articulation of modes of production' to describe the
co-existence and symbiosis in which one mode of production, the capitalist,
dominates the other. In his study of the Maka society in Southeast Cameroon,
144 S. VAN DER GEEST
... the capitalist mode of production has become dominant, but where the old, pre-capitalist
relations retain some importance as subordinate modes of production .... [A) mode of produc-
tion is dominant when surpluses from the old production relations are used for its reproduction
(i.e. its expansion. Concretely, ... capitalist expension in Africa has not led to the immediate
demolition of the old units of production; on the contrary, the old relations of production were
very often consolidated to a certain extent and used for the further development of the capitalist
sector.
effects. Pharmaceutical firms do not voluntarily reduce their sales because this
would be better for public health. The informal sale of medicines is in the
interest of the legitimate industry. The informal medicine trade in Cameroon
may not be very large, but in some other developing countries such as India,
Thailand, Indonesia, and Nigeria the informal sale of medicines has taken on
gigantic proportions. It would be an enormous loss for the pharmaceutical
industry if these markets were to disappear.
I am not suggesting that all pharmaceutical companies consciously promote
this informal trade. A conspiracy theory is not necessary to understand the
developments which we have described here. The system has an internal logic
which ensures that the interests of the strongest party are favoured. One
might call this the 'articulation of modes of distribution'.
As I said at the outset of this paper, it is not possible in reality to neatly
separate a formal and informal sector. I have only used the terms as analytic
concepts, for didactic purposes. The last examples show clearly that a division
between formal and informal is indeed analytical and not real. When the
formal pharmacist engages in transactions with informal vendors he turns into
an informal actor as well. 7
CONCLUSION
The problems associated with the informal medicine trade are acute in many
Third World countries, but they are hardly recognized by researchers con-
cerned with the formal aspects of health care. The formal and informal
aspects of medicine distribution are closely interwoven. This applies to both
the public and private sectors of the formal system of distribution. The
formal/legal medicine trade makes use of the informal/illegal trade. The two
cannot be separated. This means that a part of the supply of medicines to
official institutions is likely to end up in the informal circuit. This complicating
factor is medicine distribution to developing countries is not sufficiently
recognized by official health care planners and entirely 'overlooked' by
representatives of pharmaceutical firms.
Medicines in the informal sector can be detrimental to health because of
insufficient knowledge and information (and sometimes pure deception)
about their correct use. In addition, scarce money is often spent on useless
medicines instead of food and other means which really benefit health. It
should also be noted, however, that the informal sector often provides useful
medkines to sections of the rural population which would otherwise go
without. Because of this, it can hardly be dismissed.
This means that practical suggestions to improve the current situation
should not recommend the liquidation of the informal sector. Such a 'solu-
tion' would rob part of the population of its only source of modern medicines.
Realistic solutions should therefore aim at maintaining and improving the
informal sector. Improvement could perhaps be realized by excluding useless
146 S. VAN DER GEEST
and dangerous medicines from this sector and increasing the knowledge of
vendors and clients as to the proper use of medicines. These two conditions
can only be fulfilled if drastic restrictions are imposed on the importation of
medicines. If the number of medicines is limited to approximately 250
essential and relatively cheap medicines, monitoring the trade would become
more feasible and laypeople would learn the proper use of the most common
medicines more easily. A number of "dangerous' drugs will undoubtedly be
included among those 250 essential medicines, but it should be remembered
that the dangers decrease as knowledge of proper use increases. Suggestions
for such limitations have already been made by the World Health Organisa-
tion (WHO 1977 ,1979). It is because of resistance by those who have vested
interests in the present situation (pharmaceutical companies, physicians,
pharmacists, and politicians; see Lall and Bibile 1978; Yudkin 1980) that this
obvious political choice is only infrequently made by developing countries. R
NOTES
1. The research on which this article is based was financially supported by the University of
Amsterdam and the Netherlands Foundation for the Advancement of Tropical Research
(WOTRO). It was further facilitated by the assistance of Mireille Visser whose unpublished
report (Visser 1980) furnished me with much data. I was assisted by Kosso Felix-Fayard, Bita
Jean-Claude, Mbang-Bita'a Nicolas, Robert Rempp, Robert Pool, Susan Whyte, and many
others, both during and after my research. Useful comments were received from five anony-
mous readers. The research was approved by the Cameroon government (DGRST Authorisa-
tion No. 288). I would like to emphasize that the critical tone of this article is in no way meant
to belittle the results which have been attained in the field of health care in Cameroon. This
article is meant as a constructive contribution to the search for solutions to the country's health
care problems. A slightly different version of this paper was published in the Canadian Journal
of African Studies 19 (3): 569-87 in 1985.
2. It should be noted that the authorities have tried to solve this problem by setting up so-called
'propharmacies', noncommercial, government-supported, small drugstores that sell a selec-
tion of essential medicines. Propharmacies are allowed in areas where there is no private
pharmacy. Their main purpose is to enable rural health centers to continue functioning even if
their drug supply has been exhausted. The nurse at the center simply writes a prescription with
which the patient can obtain the necessary drug in the nearby propharmacy. Elsewhere (Van
der Geest 1983) I have pointed out that the lack of commercial incentive has proved fatal for
most propharmacies. In 1980 only one propharmacy functioned in the whole of the Ntem
Division. Experiences with the propharmacy seem to be better however in the West of
Cameroon (see Nchinda 1978).
3. It should first be emphasized that the figure of thirty percent is indeed a guess and second that
the incidence of unlawful private medicine use will vary extremely in different health institu-
tions. The guess of thirty percent was suggested to me by some knowlegeable informants who
also guessed. In one (church-related) hospital I was able to calculate the loss of medicines not
accounted for. I found that about thirty percent of all medicines had not passed through the
appropriate channels.
4. A distinction could also be made between products confected and or marketed by small
Nigerian firms and products from multinational companies. The former are commonly called
'patent medicines' in West Cameroon and tend to be rather harmless, often dubious and
superfluous medicines. Many of the multinational products are dangerous 'prescription-only
MEDICINE DISTRIBUTION IN SOUTH CAMEROON 147
drugs' which are also available without a doctor's prescription. This distinction is not further
discussed in this paper.
5. Apparently someone complained about my activities to the authorities. One afternoon a
police car picked me up from the street and took me to the police station where I had to
'explain' once again the purpose of my research (I had done so before when I was granted the
research permission). After I had satisfied the chief of police I was brought back to the place
where they found me and I continued the visits to the shops.
6. For a complete list of these medicines see Van der Geest 1987.
7. The same applies to the pharmacist in EI Salvador who has his 10-year-old nephew prescribe
and dispense medications (Ferguson this volume), to the pharmacist in Addis Ababa who sells
vials with injectable penicillin to 'injection doctors' (Kloos et al. this volume, and to the
pharmaceutical firm that sends its representatives to Ayurvedic practitioners in Sri Lanka
(Wolffers this volume).
8. This policy, which would have many economic advantages as well, has been efficiently applied
by only a handful of developing countries (see Lall and Bibile 1978; Gish and Feller 1979;
Melrose 1982; Muller 1982; Mamdani 1986).
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AHMAD FUAD AFDHAL AND ROBERT L. WELSCH
Jamu is the Indonesian term for indigenous medicines usually prepared from
herbal materials such as leaves, bark, roots and flowers. Each of the more
than 300 major ethnic groups that make up modern Indonesia has its own
repertoire of traditional recipes, preferred ingredients and methods of use for
these varied herbal preparations, which were characteristically mixed
together as needed by a member of the family or a dukun (traditional healer).
Some herbal medicines have long been part of the public domain, that is,
general knowledge in their respective communities. Others, particularly more
elaborate mixtures and concoctions have traditionally been regarded as
privately owned knowledge, secret heirlooms passed on by the families of
dukun's, the royal courts and nobility, or by ordinary citizens.
In the past 20 years Indonesia has begun to modernize rapidly; nevertheless
rural communities continue to rely heavily on locally prepared jamu's made
from plant materials. But during this same period, the termjamu has increas-
ingly become associated with the rapidly expanding assortment of powders,
creams, pills, capsules and cosmetics packaged and manufactured both in
small cottage industries and by large factories with increasingly sophisticated
equipment. Packaged jamu is now a large multi-million dollar industry in
Indonesia with over 350 factories, both large and small, producing five million
doses each day. Moreover, the industry has begun exporting its products to
more than a dozen countries in Asia and Europe.
This essay examines the history and recent growth of this modern jamu
industry in an effort to understand how an indigenous Indonesian cottage
industry emerged so rapidly from a relatively insignificant sector of the
non-formal economy to become a powerful element in the Indonesian health
care industry. The development we describe illustrates some of the complexi-
ties and paradoxes of pharmaceutical pluralism. Jamu, conceived as an
indigenous element of Indonesian culture, has become an important symbol
of national identity; much of its appeal lies in its association with Indonesian
'tradition'. At the same time, its ability to compete successfully on the
national market is in large part due to its emulation of imported products.
Modern processing, packaging and marketing are also part of the appeal of
jamu.
149
S. vanderGeestandS. R. Whyte (eds.) , TheContextofMedicines in Developing Countries, 149--172.
1988 by Kluwer Academic Publishers.
150 A. F. AFDHAL AND R. L. WELSCH
WHAT IS JAMU'}
capsule form - and quite a number have rather little to do with any 'authen-
tic', 'indigenous' or 'traditional' recipe.
For the Indonesian public, what seems to be jamu's most important
distinguishing characteristic is that it is nearly always made from ramuan
(bark, roots, leaves, wood, flowers etc.), though jamu may contain other
ingredients as well (e.g. minerals). This emphasis on the herbal nature of
jamu seems to be closely linked to two popular images, (1) the potions sold by
jamu sellers on the streets, and (2) the even more esoteric concoctions
prepared by traditional dukun's. Both the 'traditional' and 'natural, unadul-
terated' aspects of herbal preparations are key themes used by most contem-
porary jamu manufacturers in their advertizing, and it is clear that the
Indonesian public is quite sympathetic to both images.
The Indonesian laws regulating jamu are based on 'UU No.7, 1963,
concerning Pharmacy' which legally defined 'Obat Asli Indonesia' as 'medi-
cines (obat-obat) that are obtained directly from natural materials available in
Indonesia, processed in a simple manner based on experience and used in
"traditional (medical) treatment".'3 Public conceptualizations are, of course,
in no direct way bound to legal definitions, but it should be noted that this
definition is broad enough to accomodate almost anyone's interpretation,
since in essence it only stresses the 'natural' ingredients and the 'traditional'
uses of jamu.
This legal and regulatory definition of jamu as obat asli Indonesia gives the
industry considerable flexibility to develop and market new products in
virtually any form and for almost any purpose. In the last few years this has
allowed the large firms to expand their products to include tonics, pills,
tablets, capsules, skin and body-care lotions, creams, shampoos, cosmetics
and Western-style make-up, all of which are marketed either directly or
indirectly as jamu. 4
Smaller companies still tend to be more specialized and often their products
have a simple, home-made appearance. The least sophisticated of these firms
package dried but otherwise unprocessed roots or barks, or finely ground
powder-mixtures packaged in plain plastic bags, perhaps with a small slip of
paper with the name of the jamu and the factory's trade name. But in most
shops, sitting next to these simple and extremely traditional looking herbs are
attractively designed boxes of tablets, pills, capsules, creams, and expensive
cosmetics and make-up, manufactured with sophisticated machines. These
represent the two ends of the contemporary jamu spectrum, and yet neither
are typical of the main line of jamu that gave rise to the industry and
continues to provide the bulk of the industry's gross sales: jamu bubuk,
'powdered jamu', sold in inexpensive, single-dose packets.
Jamu bubuk is usually sold individually in single-dose foil envelopes con-
taining a standard 7 grams of finely ground jamu powder. 5 The consumer
empties the contents of the packet into an ordinary drinking glass, adds
boiling water, stirs and the jamu is ready to drink. Because of the bitter taste,
152 A. F. AFDHAL AND R. L. WELSCH
many consumers add honey or sugar; others routinely drink jamu with honey
and an egg yolk, both of which are widely felt to be healthful in their own
right. Some of the products recommend mixing with lemon juice and honey in
their 'directions for use'.
Each of the three largest manufacturers (Air Mancur, Nyonya Meneer,
Jamu Jago) have a wide selection of these jamu powders (about 100 different
kinds each) for almost any imaginable purpose, each numbered, color-coded
and given a simple name descriptive of the health purpose for which it is
intended. Nearly all of these jamu names refer to popular Indonesian folk
categories of illness and health problems, typically in Indonesian, though a
number of names are derived from Javanese, English or Dutch. 6 The exact
dimensions of these packets varies with each manufacturer, though they are
all rectangular or square with a colorful photograph or drawing on the front
that typically symbolizes the kind of jamu inside.
Color-coded, numbered and labeled in vernacular terminology there can be
little doubt that these inexpensive packets are aimed at a mass market with
minimal education but a wide variety of health concerns. The cost of a single
packet varies with each manufacturer and sometimes with the type of jamu
(presumably because some use more expensive ingredients), but they average
about Rp 100 each (less than 10 American cents). In most shops vendors
display their jamu in racks provided by the manufacturers which proudly bear
the brand-name and simultaneously allow the public to see several dozen
different packets at once.
To assist their more educated clientele and perhaps more importantly,
independent vendors and retailers, every major firm publishes a booklet
describing the intended uses and benefits of each of their numbered products.
This information is also published on the back of each packet and usually in
English as well as Indonesian. To satisfy governmental regulatory require-
ments, each packet lists the major plant ingredients as a percentage of the
total.
The recent expansion of the industry into sophisticated capsules, pills,
creams, lotions and cosmetics seems very clearly an attempt to compete with
imported pharmaceuticals, beauty products and cosmetics, primarily by pro-
ducingjamu andjamu-related products in forms that are identical to imported
products. The recent growth of the industry suggests that most manufacturers
have been fairly successful in this regard. But in doing so they have had to
resolve the central contradiction inherent in their industry: how to be both
'modern' and 'traditional' at the same time.
To meet regulatory requirements as obat ash Indonesia manufacturers must
produce 'traditional' medicines made from natural ingredients. But to com-
pete successfully with imported pharmaceuticals they must establish them-
selves as a 'modern' industry and their products must imitate the forms and
functions of 'modern' pharmaceuticals and related products. Thus, almost
without exception the major jamu companies speak of modernizing the
MODERN JAMU INDUSTRY IN INDONESIA 153
industry without altering its basic 'traditional' premises (see, e.g., Simandjun-
tak 1984; Winarno and Maran 1985; Kristanto 1984; Soedibyo 1984; Tilaar
1985). The brochures and advertizements of many firms resolve this inherent
contradiction in the following way:
'AIR MANCUR' Ltd. with its factories in Wonogiri and in Palur, as a modernly organized
company, and at the same time the heir of the traditional medicines, has successfully elevated our
old medicines to a stage equal to that of modern pharmaceutical products of the West (Air
Mancur n.d.).
While many industry leaders promote their new products as if these were
the essence of the jamu industry, it is clear that powdered jamu's, in num-
bered, single-dose packets, continue to be the backbone of the industry. In a
very real sense it is this line of customary products that legitimates and
validates the newer products as 'traditional' jamu in the eyes of the consuming
public, because when the average Indonesian from any socio-economic class
is asked about the manufactured jamu, it is almost invariably these little
packets of powder that first come to mind.
When discussing the traditional roots of their modern and increasingly sophis-
ticated industry, most jamu manufacturers emphasize that jamu's are Indone-
sia's heritage of herbal medicines and cosmetics that have been passed down
through the generations as a pusaka or warisan nenek moyang - 'an heirloom
or inheritance from early ancestors' (see, e.g., Nyonya Meneer n.d.; Air
Mancur n.d.; Mustika Ratu n.d.). Some emphasize the traditional medical
philosophy of Javanese or Indonesian health care (e.g., Soedibyo 1984; Tilaar
1985); others the mysterious secrets of the royal courts of Central Java (e.g.,
Mustika Ratu n.d.; Soedibyo 1984).
While an outsider is tempted to view such claims from manufacturers as
simply a clever advertizing strategy, this is only partly the case. Indonesians
are genuinely proud of and attracted to such medical traditions, and typically
understand jamu as a concrete link with the past. This is amply demonstrated
by the plethora of medical self-help books about jamu that have appeared in
the bookshops, bookstalls and arms of street vendors throughout the country
in the past decade. This popular literature makes many of the same points
when discussing jamu and traditional medicinal plants. 7
It is certainly true that every Indonesian ethnic group has its own tradi-
tional repertoire of herbal medicines. Many of these traditional recipes are
indeed held as family secrets. And there are many early manuscripts from
Java, Bali, Sumatra and Sulawesi which attest to the fact that the early royal
courts and ancient nobility were interested in the practical aspects of plant
medicines as well as the complicated medical philosophies, mysticism, numer-
ology and the like which made sense of these plants and their uses. s
154 A. F. AFDHAL AND R. L. WELSCH
For most Indonesians the Second World War represents an era of extreme
hardship and suffering. This is not so much because of military action per se,
but because the Japanese occupation itself was so harsh. From 1942 to 1945
the Japanese military government in the territory was concerned almost
exclusively with provisioning its war effort, and as a result many of the
colony's resources, privately owned supplies and local products were taken by
the military for its own use. Supplies of imported goods, including such
necessities as cloth and pharmaceuticals ceased altogether; livestock, rice and
other foodstuffs, and personal possessions were appropriated by the military
government, its officers and soldiers, typically without compensation; and
toward the end of the occupation most Indonesians faced tremendous short-
ages of food and other basic necessities. In short, the Japanese occupation
was for most Indonesians a period of hunger, sickness and want.
Needless to say, with such hardships there was a greater than ever need for
the services of the Indonesian medical community.ll But as medical needs
increased, supplies of imported drugs were running out, with no hope of
replenishing stocks of even the most standard and basic pharmaceuticals. The
Japanese administrators, particularly toward the end of the occupation,
encouraged Indonesian obat manufacturers to continue and even expand
their production of medicines. But such efforts had little significance in light
of such staggering shortages. Moreover, these firms were producing few of
the most important drugs. As a result, faced with shortages of necessary
pharmaceuticals and growing needs, Indonesian physicians turned to the only
medicines available: jamu, particularly freshly prepared jamu.
Sastroamidjojo's (1967: 1-20) vivid description of the period points out the
irony of this tragic situation. Although forced to rely on obat asli Indonesia
and preparations that could be made from local materials, few Indonesian
doctors had any significant experience using these medicines in their individ-
ual medical practices. While recognizing the need for jamu to treat serious
illnesses such as malaria, dysentery, tuberculosis and pneumonia, few physi-
cians had more than a vague idea of which plants to use, in what proportions
they should be mixed with other ingredients, or in what doses they should be
prescribed. Even for less serious conditions, such as scabies, worms, septic
sores and fever, few of these doctors who were born and raised in Indonesia
could confidently prescribe medications made from indigenous plants because
of their limited experience and information.
This situation, of course, had its roots in the Dutch colonial period, when
these Indonesian doctors were trained and enculturated into a modern,
Western-oriented medical profession. Sastroamidjojo (1967: 2) laments the
fact that at the time virtually nothing had been published of a practical nature
that could help physicians in selecting, preparing and prescribing herbal
MODERN JAMU INDUSTRY IN INDONESIA 157
TABLE I
Production of jamu in pill, tablet. capsule and parem (solid) form during 1976. 1981 and 1984
(in millions of units)
TABLE II
Value (in millions of rupiah) of jamu produced in pill. tablet and parem form during
1976. 1981. 1984
Source: 1976 and 1981 adapted from Simandjuntak (1984); 1984 adapted from the official records
of the Indonesian Food and Drug Administration. lakarta (Dirjen Pengawasan Obat dan
Makanan) but includes data for only 292 manufacturers.
TABLE III
Production and value of jamu produced in 1984
Source: Data adapted from records of the Indonesian Food and Drug Administration, Jakarta.
Data includes the production of 292 jamu manufacturers.
attitude of the medical community, which still tends to ignore jamu, but the
fact that such research is being carried out probably adds to the appeal of
jamu for certain consumers interested in 'modern' products. The attention of
government and universities seems to legitimate jamu as a modern pharma-
ceutical that is being taken seriously by the scientific community. At the same
time, for the majority of Indonesians the results of such research are of little
consequence since they evaluate jamu in their own terms and seem more
interested in traditional forms of medications than scientific verification.
This illustrates a key characteristic of manufactured jamu, that it is widely
recognized as both a 'modern' and a 'traditional' pharmaceutical, although
the importance of one or the other of these associations seems to vary greatly
with different individuals and certainly with ethnic background and educa-
tion. Indeed, the industry has been successful in cultivating both images
simultaneously. Jamu's wide appeal seems to be due to its subliminal associa-
tion with imported pharmaceuticals on one hand and its differences from
them on the other. In the last analysis, this diffuse configuration of associa-
tions and symbolizations allows jamu, as a category of pharmaceuticals, to
appeal to an extremely broad consuming public; in fact, to virtually everyone
in a country where the idea of herbal medicines has been around since very
early times.
Jamu manufacturers have begun exporting their products to more than a
dozen countries in Asia and Europe and would like to export more of their
products to Europe and North America, though import regulations have
proved difficult (see Simandjuntak 1984). The majority of exported jamu is
currently sold to Malaysia and Singapore where it seems particularly popular
among ethnic Malays rather than ethnic Chinese (see Table IV).
It is almost certainly the case that the popularity of jamu in Malaysia is due
to essentially the same factors as in Indonesia. In Europe, however, jamu's
appeal is often associated with the 'back to nature' movement (Simandjuntak
1984: 77) and thus is attractive as a reaction to modern pharmaceuticals. The
appeal of jamu in Europe is therefore rather different from that in Indonesia
where the general public is attracted to anything modern or imported.
Indonesians are not involved in either 'back to nature' or even a 'back to
tradition' movement in the pharmaceutical field in any proper sense, which is
demonstrated more clearly by the fact that the jamu industry's most rapid
growth is in the most modern-looking forms of jamu and traditional cosme-
tics. Nevertheless in a number of respects jamu's appeal in Indonesia is
related to vague associations with natural ingredients and tradition.
Closely associated with some of these non-specific claims made about jamu
is the fact that the industry is highly diversified, both in the kinds of products
available as we have already discussed and also in the regional character of
many firms. Indonesians are highly aware of the ethnic diversity in their
country and a number of ethnic groups are well known for their particular
stereotyped qualities and benefits of their jamu's. Thus Madura, with its
166 A. F. AFDHAL AND R. L. WELSCH
TABLE IV
Exports of Indonesian jamu, 1979-84
CONCLUSION
and satisfying needs recognized by its consumers. With its many forms and
many producers, jamu is many things to many people and it is difficult to
know which of these views is the most adequate way to describe jamu. In the
words of Sudarmilah Suparto who has published a book on jamu and is herself
a manufacturer:
... many doctors in the Department of Health say that jamu is traditional medicine. But that's
really incorrect. That definition is not precise because up to now we are not yet able to say that
jamu is medicine .... Jamu is jamu, full stop (quoted in Winarno and Maran 1985).21
However, for the 'outside' observer one conclusion can be drawn from most
comments made about modem jamu, whether the industry is seen as selling
useless aphrodisiacs, simple cold medicines or modem versions of traditionally
important medicines. This is the fact that modern jamu represents one
important conceptual break with the past: the industry almost exclusively
associates its products with a physiological notion of health and medications.
If we look at the claims made about jamu, whether positive or negative, jamu
is almost invariably evaluated in terms of its presumed effects on basic body
processes. There is almost no mention of associated spiritual, metaphysical
and psychological concepts that are characteristic - in one form or another -
of traditional aspects of health and health care in Indonesian societies. Unlike
the traditionaljamu's in Indonesia, modernjamu is not sold as one element of
a more holistic concept of health care and health maintenance, but as a
product that deals directly with physiology quite independently of other
human processes. It seems that this subtle reorientation is hardly recognized
by the manufacturers themselves, however.
Traditional Indonesian societies probably tended to compartmentalize
jamu medicines as one branch of healing art, but jamu never seems to have
been totally divorced from the spiritual, mystical, metaphysical, social and
psychological aspects of mankind (see, e.g., Jordaan 1985; Suparlan 1978;
even Geertz 1960). All of these aspects of jamu are disregarded by modern
manufacturers - though it does not necessarily follow that they are disre-
garded by consumers. Manufacturers appear to have accepted a distinctively
Western view of health and medicine, patterning their industry on the
concerns and preoccupations of the manufacturers of imported pharmaceuti-
cals. Much more research is required on this topic, particularly from the
perspective of users, but it does appear that in this sense jamu is very much a
part of the growing medicalization of modern Indonesian society that began
early in this century.
ACKNOWLEDGEMENTS
The authors acknowledge the help of R. 10rdaan and the editors in the
preparation of their paper.
168 A. F. AFDHAL AND R. L. WELSCH
NOTES
1. See also Poerwadarminta (1984: 682). For example, anti-mosquito incense coils that are
extremely popular in Indonesia are generally referred to as obat nyamuk ('mosquito medi-
cine') and marketed as obat anti-nyamuk. Similarly, one often hears the chemicals used to
purify drinking water described as obat, probably reflecting the foul smell such chemicals add
to the water. In a slightly different sense, the poison sometimes added to standing water to
kill mosquito larvae is also called obat. Nevertheless, the most common sense of the term is
'medicine' or some preparation for medical purposes. The broad definition of 'medicine' is
also reported from elsewhere. See Whyte, this volume.
2. These definitions are from Echols and Shadily (1983: 22). Poerwadarminta (1984:62) gives
the following 'yang asaf; yang semula; yang sebenarnya (bukan salin an atau terjemahan);
tulen (sejati); yang berasal dari daerah (negeri dsb) itu sendiri; pembawaan dari lahir' ,
('origin/source'; 'from the beginning'; 'actual (not a copy or translation),; 'pure/genuine';
'which originates from the region (country etc.) itself; 'something brought from birth'). In
the case of honey (madu) , for example, Indonesians are careful to distinguish between madu
asli and madu campuran (honey mixed with some other substance). Thus madu asli is
unadulterated, 'original' or what in the United States is called 'pure honey', even though it
may not be indigenously or locally produced and may even have been processed to some
minor extent.
3. Sastroamidjojo (1965: 19) gives the following text from a report of the 'Traditional Medicines
Section' of the 1964 National Seminar to Search for Natural Indonesian Sources For
Pharmacy, which he claims follows the text of Undang-Undang No.7, 1963 (Bab II, pasal2,
ayat c):
"Obat asli Indonesia" ialah obat-obat jang diperoleh langsung dari bahan-bahan alam jang
terdapat di Indonesia, terolah setjara sederhana atas dasar pengalaman dan penggunaanja
dalam "pengobatan tradisionil".
Translation: "Obat asli Indonesia" are medicines that are obtained directly from natural
materials available in Indonesia, processed in a simple manner based on experience and
used in "traditional (medical) treatment".
Sahly (1983: 18) gives a slightly different version of the ayat in question, using the new
spelling (see also Winarno and Maran 1984).
4. Regulatory restrictions differentiate obat asli Indonesia from obat moderen 'modern medi-
cine' according to the kinds of ingredients used. It appears that jamu may be made from
simplisia 'active ingredients' extracted from raw herbs, but may not be mixed with chemicals.
The firm Jamu Jago has recently begun manufacturing jamu IUjuh angin ('7 winds jamu')
from extracts mixed with menthol, but is legally obliged to register this product as obat
moderen (Simandjuntak 1984: 78). Although legally obat moderen, there is nothing to
prevent consumers or retailers from considering it as a jamu, particularly since it is produced
by a jamu manufacturer and probably sits on the shelf next to registered jamu's.
5. Both the jamu industry and the Indonesian Department of Health use 7 grams as the
standard dose, both for jamu bubuk 'powdered jamu' and jamu param, 'solid form'.
Tradition, more than any other factor, seems to be the basis for choosing 7 grams rather than
6,8, or 10 grams. According to Jaya Suprana (President Director of Jamu Jago), when his
grandfather, Poa Tjong Kwan, began manufacturing jamu bubuk, he sold it in 7 gram units.
He seems to have pulled this figure out of the air with no particular rationale. Since then it
has become something of a tradition within the industry (see Winarno and Maran 1984).
6. Most jamu names are in simple but medically vague language that refers to symptoms or
popular syndrome categories. Most are from Indonesian or Javanese that has almost become
popular Indonesian. For example, Nyonya Meneer markets 'Jamu BalUk' ('cough'), 'Jamu
MODERN JAMU INDUSTRY IN INDONESIA 169
Sakit Kencing' ('difficult urination'), Jamu Kuat Laki-Iaki ('strong man'); Jamu Darah Bersih
('dean blood'), and Jamu Datang Bulan Tidak Cocok ('period doesn't fit').
7. See, e.g., Dharma (1985); Mardisiswojo and Rajakmangunsudarso (1985); Muji (n.d.);
Rianggoro (1982); Sahly (1983); Soeparto (1984). These range the entire spectrum of
Indonesian publishers, from Sinar Harapan and Balai Pustaka which publish scholarly works
and books accepted as being of high quality for a general audience, to Pustaka Karya which
does not give a date or place of publication and is often sold by vendors on the street. A
related but somewhat different tradition is represented by Mudakir & Soleh (1984).
8. Soedibyo (1984) refers to the Serat Centini written in the 18th century for Kanjeng Gusti
Pangeran Adipati Anom, Crown Prince of Solo, which does indeed document medical
knowledge and philosophy of health (including plant medicines) (see Adisasmita 1974, 1975;
Sumahatmaka 1981). Similar kinds of early writings can be found in Bali, Sumatra and
Sulawesi in the early manuscripts written in indigenous scripts. The existence of these early
manuscripts, however, does not mean that they are the basis for the modernjamu industry.
but merely attests to the fact that health was a traditional concern of the literati.
9. This is not to say that these manufacturers were not using old recipes, since the Chinese are
also well known for their traditional herbal medicines (see, e.g., Kleinman 1980; Kleinman et
al. 1975; and several of the papers in Leslie 1976). Peranakan Chinese, who have intermar-
ried with Javanese, would also have access to old Javanese recipes in addition to Chinese
ones. The point here is that whatever the ethnic background of these individual manufactur-
ers, the basic tendency during this early period was to innovate upon basic ingredients and
recipes. This tendency has not changed today.
10. It is not clear to what extent the terms jamu and obat were differentiated prior to the Second
World War, although the medical community had certainly started making a categorical
distinction between the two at least sometime before 1940 (see, e.g., Sastroamidjojo 1967,
originally published in 1948, for a sense of how the medical community viewed jamu's just
prior to and during the Japanese occupation.) Similarly, it seems likely that jamu may have
had a somewhat more restricted meaning early in the century. Gimlette, for example, in his
posthumously published A Dictionary of Malayan Medicine gives the following definition of
jamu, based on his experiences in Malay early in the century:
Preparations which do not exactly serve as medicines, but have the object of maintaining
health and excluding mischievous influences. Ridley gives as an example of ubat jejamu, a
nostrum compounded of over thirty spices, astringents, etc.: it is in the form of a powder to
be taken in water after childbirth (Gimlette and Thomson 1971: 89).
This term seems to contrast with ubat (Malay form of the modern Indonesian obat) which he
defines as 'A medicinal drug; a magic simple; a medicine' (1971: 246). Gimlette lists a dozen
different kinds of ubat, whose usage seems to parallel that of the Indonesian obat (see
Sastroamidjojo 1967: 10-14).
Indonesian and Javanese during the colonial period may have distinguished these terms in
a similar way, which would be another reason for not using the term jamu for herbal
preparations intended more as a curative medicine than a tonic or elixer. This interpretation
remains uncertain since Javanese contained both obat andjamu; it is not clear how they were
being used in the 1920s and 1930s (see Gimlette and Thomson 1971: 174; Suparlan 1978: 207;
cf. Jordaan 1985: 192-194,203-204,214-216).
11. European physicians were for the most part in internment camps during the occupation;
Japanese doctors were busy serving the needs of the Japanese army and navy. This left the
health needs of the indigenous community in the hands of Dutch-trained Indonesian physi-
cians (both pribumi and non-pribumi, as well as pharmacists, other health workers, jamu
sellers and village dukun's.
12. The best evidence for this is that at the 1940 Congress of the Vereniging Indonesische
170 A. F. AFDHAL AND R. L. WELSCH
REFERENCES
Adisasmita, Ki Sumidi
1974 Pustaka Centini Selayang Pandang. Yogyakarta: U.P. Indonesia.
1975 Pustaka Centini Ikhtisar Seluruh Isinya. Yogyakarta: U.P. Indonesia.
AfdhaI, Ahmad fuad
1981 Drug Delivery and Drug Marketing: A Comparative Study Among Southeast Asian
Countries. Unpublished manuscript, University of Minnesota.
Air Mancur
n.d. A Booklet of Indonesian Traditional Medicines for Health Maintenance and Beauty
Care. Wonogiri: Air Mancur.
MODERN JAMU INDUSTRY IN INDONESIA 171
Dharma, A. P.
1985 Tanaman Obat Tradisional Indonesia. Jakarta: Balai Pustaka.
Echols, John M. and Shadily, Hassan
1983 An Indonesian-English Dictionary. Jakarta: Gramedia.
Geerstz, C.
1960 The Religion of Jara. New York: The Free Press.
Gimlette, John D. and Thomson, H. W.
1971 A Dictionary of Malayan Medicine. Kuala Lumpur: Oxford University Press. (first
published 1939)
Jordaan, Roy E.
1985 Folk Medicine in Madura (Indonesia). Ph.D. Thesis, Rijksuniversiteit, Leiden.
Kleinman, Arthur M.
1980 Patients and Healers in the Context of Culture. Berkeley: University of California
Press.
Kleinman, Arthur M. et aI., (eds)
1975 Medicine in Chinese Cultures: Comparative Studies of Health Care in Chinese and
Other Societies. Washington: US Government Printing Office for Fogarty Interna-
tional Center.
Kompas
1984 Peranan Balai Penelitian Menunjang Industri Jamu. Kompas, 17 December 1984.
Kristanto J. B.
1984 Industri Jamu, Yang Besar dan yang Kecil Hidup 'Damai' Berdampingan. Kompas, 16
Dec. 1984.
Leslie, Charles, (ed.)
1976 Asian Medical Systems. Berkeley: University of California Press.
Mardisiswojo, Sudarman and Rajakmangunsudarso, Harsono
1985 Cabe Puyang Warisan Nenek Moyang. Jakarta: Balai Pustaka.
Mudakir, K. and Soleh, Moh.
1984 Pengobatan Tradisional Secara Islam. Pekalongan: T.B. 'Bahagia'.
Muji, Musaro
n.d. Resep Pusaka Tradisional Madura. n.p.: Pustaka Karya.
Mustika Ratu
n.d. List of Jamu & Traditional Cosmetics. Jakarta: Mustika Ratu.
Nyonya Meneer, P. T.
n.d. Daftar Jamu, untuk memelihara kesehatan dan kecantikan. Semarang: Nyonya Me-
neer.
Poerwadarminta, W. J. S.
1984 Kamus Umum Bahasa Indonesia. Jakarta: Balai Pustaka.
Rianggoro, Krisna
1982 Pengobatan Tradisional Jamu Jawa. Surabaya: Bina I1mu.
Sahly, Salim
1983 Petunjuk Pengobatan Dengan Resep-Resep Asli. Solo: Penerbit & Toko Buku
Aneka.
Sastroamidjojo, A. Seno
1967 Obat Asli Indonesia, Chusus Daripada Tumbuh 2 an Jang Terdapat Di Indonesia.
Jakarta: Dian Rakyat. (3rd edition, first edition published 1947)
Simandjuntak, Edward Soaloon
1984 Meningkatan Pemasaran Jamu, Menjual Gairah Seks. Prisma 2: 74-84.
Soedibyo, Mooryati
1984 Traditional Medical Philosophy. Paper delivered at the Second International Congress
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Soeparto, Soedarmilah
1984 Jamu Jawa Asli. Jakarta: Sinar Harapan.
172 A. F. AFDHAL AND R. L. WELSCH
Suparlan, Parsudi
1978 The Javanese Dukun. Masyarakat Indonesia 5 (2): 195-216.
Surindo Utama, P. T.
1984 Media Monitoring
Tilaar, Martha
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Universitas Sumatera Utara. Medan.
Winarno, Bondan and Maran, Canisyus
1985 Jamu Tradisional. Tempo 15: 10, suplemen khusus "Pariwara".
THE MEANING OF MEDICINES
INTRODUCTORY NOTE
This section contains eight chapters that focus on the perception and under-
standing of medicines by those involved in their transaction. For manufactur-
ers as well as for pharmacologists, physicians, pharmacists, drug pedlars and
patients, medicines have a meaning that goes far beyond their chemical
properties and therapeutic reputation. Medicines are artifacts that can only
be adequately understood when viewed in their cultural context.
A recurrent theme in many of these chapters is that medicines are under-
stood - and used - according to local perceptions. Their function and mode of
application are conceived in terms of culturally specific notions of the nature
of sickness and healing. In some societies the concept of medicine is stretched
far beyond the Western pharmacological definition and covers experiences
that Westerners would describe as psychological, social and religious.
Another intriguing - and somewhat contrasting - observation is that
pharmaceuticals become promotors of greater personal autonomy as they
enable people to treat themselves individually rather than within the common
framework of relationships to healers, kinsmen or spirits. This, together with
the fact that they are seen as 'modern' and exotic, means that Western
pharmaceuticals assume the role of vehicles of cultural change. The pharma-
ceutical invasion that we witness in developing countries is in fact part of a
cultural transformation.
Unschuld applies a cultural perspective to a comparison of dominant
European and Chinese cognitive dynamics in general and of ancient Euro-
pean and medieval Chinese pharmacological paradigms in particular. In both
cultures, at a certain period, empirical knowledge of medicines was combined
with theories that had earlier served to provide meaning for illness.
The author discusses the implication of a major cognitive reorientation of
China where no one will be left untouched by modern science and
technology-oriented culture in the future. While he foresees a continuing
application of traditional pharmaceutics for a long time to come, he doubts
the survival of traditional Chinese theories as an independent mode of
thought.
Sussman carried out a household survey on therapeutic choice among
Creoles and Indo-Mauritians in two adjacent villages in the southwest of
Mauritius. She reports a growing use of Western doctors and pharmaceuti-
cals. Self-treatment with herbal medicine is also common. Remarkably, the
choice of treatment hardly depends on diagnosis. According to the author,
Mauritians do not classify illness primarily by their symptoms. Rather they
designate causes of illness and choose therapeutic resources in a specific
175
S. van der Geestand S. R. Whyte (eds. J, The ContexlofMedicines in Developing Countries, 175-177.
1988 by Kluwer Academic Publishers.
176 THE MEANING OF MEDICINES
sequence. In most cases the use of biomedical facilities is the first step. The
use of Western pharmaceuticals is both treatment and a technique to establish
the cause of the complaint. If an illness does not respond to biomedicine it is
classified as supernaturally caused, requiring other treatment.
Whyte, doing fieldwork in East Africa, takes a very broad view of medi-
cines: 'Medicine is a substance that transforms something - for better or
worse'. She mentions examples of 'treating' hunting dogs, cotton, flat tires,
lovers and senior relatives with 'medicine'. She suggests that 'traditional'
medicines and Western pharmaceuticals share important characteristics
which distinguish them from ritual and relational modes of transforming the
human condition. The most important of these is that 'medicines' as sub-
stances have an innate power which can be acquired by any individual. This
enables therapy to be 'liberated' from the social relationships in which it
would otherwise be embedded. Medicines thus become the vehicle of a
growing individualism.
Another characteristic of all medicines is that foreign provenance is asso-
ciated with power. Whyte convincingly argues that both Western and African
medicines are often brought from far away and are believed to derive their
efficacy from their 'exotic' origin. The pharmaceutical invasion of local
African cultures was in process long before Western drugs reached the
continent.
Niehof's contribution describes the use of jamu medicines in the manage-
ment of gestation and birth on the Indonesian island of Madura. In contrast to
Afdhal and Welsch, she provides a view from below, showing how jamu is
interpreted within the Madurese understanding of the physiological processes
surrounding pregnancy and childbirth, which is dominated by (but cannot be
reduced to) the hot-cold opposition.
Niehof's paper shows a 'negative' context of Western pharmaceuticals on
Madura. Although Western drugs are available, Madurese women do not
perceive them as relevant for this area of health care.
Bledsoe and Goubaud address the 'inappropriate' use of Western medi-
cines as a cultural issue. Among the Mende of Sierra Leone indigenous beliefs
about illness and treatment provide the explanatory framework for interpret-
ing Western medicines. People appear to base their treatment decisions
largely on local notions of how a drug's shape, color and taste is related to its
effects. Consistency with traditional logic and the medicine's reputed success
in treating analogous illnesses are also important indicators for use. The
authors illustrate their argument by describing people's handling of three
common health complaints, fever, worms and 'blood problems', and a con-
cern for health maintenance. This cultural reinterpretation often leads to drug
use that is at odds with Western assumptions about appropriate use. The
authors point out various implications of their research for local and interna-
tional health planning.
INTRODUCTORY NOTE 177
In this paper I wish to point out how cultural differentials influenced the
formation of pharmacological systems in ancient Europe and medieval China.
Pharmacology, in a modern sense, is the science concerned with the reaction
of the living organism to stimuli exerted by chemical agents. 4 Although the
term 'pharmacology' represents a modern concept and was not introduced
prior to the seventeenth century,5 I shall extend it, with a slightly modified
definition, to an analysis of events that occurred many centuries earlier. The
term pharmacology, as I shall use it in this paper, refers to knowledge
concerned with the explanation of drug effects in the living organism by
linking certain drug properties to a pe,rceived physiology of the body.
A precondition for the emergence of pharmacological systems is an accu-
mulation of extensive pharmaceutical knowledge. In ancient China such
knowledge may have been developed and transmitted for a long time before it
was documented in literary form. The earliest texts on Chinese pharmaceutics
available today are also the earliest records known on Chinese drug lore.
They consist of prescriptions and appear to have been compiled around 200
B.C.; they were discovered in the famous Ma-wang-tui tombs near Ch'ang-
sha, Hunan province, in the early 1970s. Another three hundred years
elapsed before the first known Chinese herbal was compiled in the first
century A.D. Whereas the prescriptions had focused on illness and disease,
this herbal concentrated on a description of numerous individual substances.
The Shen-nung pen-ts'ao ching ('Shen-nung's Scripture on Materia Medica')
is said to have contained, in correspondence to the number of days in a solar
year - a total of 365 drug monographs. 6
Both the prescriptions of the Ma-wang-tui texts and the drug descriptions in
the Shen-nung pen-ts'ao ching are basically pragmatic; that is, although in
numerous instances we may hypothesize that criteria based on demonological
or magical reasoning supported the selection of a particular substance for the
treatment of a particular ailment, the texts themselves do not contain any
explicit references to such considerations. 7 The Shen-nung pen-ts'ao ching
lists names, places of origin, drug qualities, and indications; the Ma-wang-tui
prescriptions provide but indications and drug names, as well as references to
dosages and suitable pharmaceutical processing of raw drugs. The drug
182 P. U. UNSCHULD
qualities listed in the Shen-nung pen-ts'ao ching, i.e., various flavors and
thermo-qualities associated with individual substances, correspond to abstract
qualities (possibly of food) listed in the classics of the theory of the medicine
of systematic correspondence, that is, the Huang-ti nei-ching of the second
and first century B.C. However, a linkage of drug application with the
theoretical foundations of systematic correspondence was not attempted, in
China, until the 12th through the 14th century, during a period, that is, which
proved favorable to the union of the hitherto antagonistic traditions of
pharmaceutics on the one hand and of the medicine of systematic correspon-
dence (favoring the therapeutic technique of needling) on the other hand.
The socio-political and ideological context that kept these traditions apart for
more than a millennium and brought them together only one and a half
thousand years after their formation, has been described and analysed in
detail elsewhere, and need not be repeated here. H
Before we take a closer look at the 'pharmacology of systematic correspon-
dence' resulting from this union, I should like to trace corresponding develop-
ments in ancient Europe.
The origins of pharmaceutical literature were somewhat different here than
in China. The earliest European herbals known to us and transmitted. at least
in fragments, to the present time were compiled by Diokles of Karystos and
by Theophrastos of Eresos in the fourth century B. C. They. too. were part of
a much older tradition - the epic of Homer of the second millennium B.C.
provides the earliest European literary data on an application of therapeutic
drugs - but they appear to have emerged from an Aristotelian interest in
botany, that is, from a general interest in herbs and other plants, some of
which were known to possess therapeutic properties, and were described
accordingly.<i
A long series of herbals is known to have followed the works of Diokles and
Theophrastos, and prescriptions were recorded in some of the texts of the
'Corpus Hippocraticum' during the final four to five centuries B.C., until the
first European herbal was compiled that has come down to us in full length.
that is, the Materia Medica of Dioscurides of the first century A.D.
Similar to its Chinese contemporary, the Shen-nung pen-ts 'ao ching, the
Materia Medica of Dioscurides was pragmatically oriented and contained no
explicity theoretical pharmacology even though some of the drug qualities
referred to could easily have been employed as links to the physiology and
pathology of systematic correspondence dominating the 'Corpus Hippocrati-
cum'.
The step from an empirical justification of drug use to a theoretical or
'scientific' understanding of why drugs achieve certain effects in the living
organism was undertaken in Europe rather early. that is, in the second
century, by the Greek physician Galen of Pergamon who preferred to
practice in the capital of the Roman empire for many years of his life.
Galen and the Chinese scholars of the 12th through the 14th century had
ANCIENT EUROPE AND MEDIEVAL CHINA 183
In the following I wish to point out some basic differences between cognitive
tendencies in European culture and China. My hypothesis is that in the
history of European knowledge, for more than two thousand years, a ten-
dency may be identified, and appears to have dominated, to build cognitive
systems permeated by one homogeneous paradigm. This paradigm is prefer-
ably internally stringent and free of any internal antagonistic contradictions; it
claims truth but for itself, and cannot accept any other truth besides it. This
European attitude towards knowledge entails that all those concepts and
ideas cannot be accepted as knowledge, and cannot be accepted as 'true', that
cannot be integrated into a dominating cognitive system without apparent
contradictions. The tendency thus described applies both to knowledge
gained through transcendental revelation, i.e., religious knowledge, and to
knowledge gained through an observation of and hypothesizing about nature,
i.e., 'scientific' knowledge.
A rather different tendency, it seems to me, has influenced - to a significant
degree - the formation of knowledge in China for the past two and a half
millennia. In China, as in Europe, many authors, in the course of time, have
offered comprehensive and partial paradigms and world-views, contradicting
existing explanatory models. And, as in Europe, heated and lengthy debates
occurred in Chinese history on the 'truth' or 'adequacy' of conflicting para-
digms. However, in contrast to Europe, Chinese culture, be it in philosophy
or 'science', appears to have favored, after an initial phase of fierce confronta-
tion, an inclusion of various paradigms within one complex syncretic structure
of knowledge. This way, the former antagonists were each granted a certain
degree of - limited - truth, or at least a certain competence to solve some
specific issue. As a result, extremely complex and highly impressive cognitive
edifices emerged that could not be free of internal contradictions between
their integrated parts, but that may be called logical and contingent since all
184 P. U. UNSCHULD
Georg Harig has pointed out, in his studies on Galenic pharmacology in the
1970s, that Galen intended to construe a purely theoretical system of drug
effects, but, at the same time, was forced to take into account empirical
categories that had been associated with drug therapy and drug effects during
preceding centuries. II
Galen's starting point was the ancient European version of the paradigm of
systematic correspondence, that is, the so-called doctrine of the Four Humors
(corresponding to the doctrine of the Four Elements) with its notion of four
basic drug qualities, i.e., warm, cold, dry, and moist. The issue to which
Galen directed his attention was the replacement of time-honored empirical
descriptions of drug effects - such as 'draining pus', 'purging', 'eliminating
pain', or 'causing one to sleep', and many others - by scientific, that is,
theoretical criteria of categorization. These theoretical criteria were not to be
based, primarily, on a sensual perception of specific drug properties but on
the position of a drug within the system of the four basic drug qualities. 12
Of course, Galen was aware of the fact that a complete exchange of
'unscientific' , empirical criteria of drug evaluation with the 'scientific' catego-
ries derived from the doctrine of the four humors would have meant construc-
tion of a system of ideas so far removed from daily clinical reality that most
physicians could not have made any use of it. 13 The pharmacology construed,
finally, by Galen, and published in his De simplicium medicamentorum
temperamentis ac facultatibus, represents a quite sophisticated union between
theoretical claims and sensually perceptible reality. Galen created a system
that was sufficiently open to integrate any future results from empirical
observation; at the same time, from a theoretical perspective, it was suf-
ficiently homogeneous to remain free of internal contradictions. A survey of
the structural components of Galen's pharmacology may clarify this state-
ment.
The theoretical premise on which Galen built his system was rather simple.
(Table I)
The four humors, the four elements, and further fourfold categorizations,
such as annual seasons and body organs, were seen as corresponding to the
four basic qualities warm, cold, dry, and moist. All drugs were supposed to
contain these four basic qualities in varying proportions; that is, these basic
qualities are contained in all drugs in specific mixtures (krasis) and are,
therefore, responsible for the medicinal effects of these drugs. The medicinal
effects, in turn, represent an empirical category comprising altogether 17
groups that were adopted, by Galen, from the descriptive literature of former
186 P. U. UNSCHULD
TABLE I
The four basic drug qualities within the system of the Four Humors and Four Elements
TABLE II
The seventeen groups of drugs according to their effects
TABLE III
The secondary qualities of drugs
Empirical Theoretical
in the fifth century B.C. In contrast to the Greek development though, there
appear to have emerged, in China, almost simultaneously, two antagonistic
schools. One of them, the yinyang school, explained all coming into being, all
change, and all passing away through the dualism of two complementary
categories of all being; the second school propagated the so-called Five-
Phases doctrine which saw the sum of all phenomena, and all of their mutual
relationships, as resulting from interactions among five categories of all being.
The situation appears to have become even further complicated by the fact
that the yin yang school itself seems to have split into two sub-doctrines, one
of which held a two-fold sub-categorization while the other advocated a
three-fold sub-categorization of both yin and yang. 21
The complete range of Chinese concepts of systematic correspondence
included, therefore, patterns based on the numbers two, four, five, and six for
a categorization of all phenomena of perceived and assumed reality, and for
an explanation of the relationships and interactions among these phenomena.
TABLE IV
The pharmacological system of Galen
4 Basic
-
9 sensually ::::::::::=-
~
qualities 6 groups of 17 groups
+ perceivable pharmaco- of
2 Addi- taste ~ logical drug
tional qualities functions effects
qualities
TABLE V
Yinyang categorizations
1. The four-fold yinyang categorization 2. The six-fold yinyang categorization
yang-in-yang major-yang
Yang
maturity)
Yan~ minor-yang
yin-in-yang
(immaturity) ~ yang-brilliance
yin-in-yin major-yin
~ yang-in-yin Yi"~miOO'-~"
(maturity)
Yin
(immaturity) ceasmg-ym
190 P. U. UNSCHULD
Empirical!
Theoretical Empirical Theoretical Empirical Theoretical
Theoretical
......
'i:)
......
192
TABLE VII
The six-fold yinyang categorization of the locations, paths, and hours of drug effects
Lung Hand-major-yin 3- 5
Spleen Foot-major-yin 9- 11
Heart-enclos. network Hand-ceasing-yin 19 - 21
Yin
Liver Foot-ceasing-yin 1- 3
Heart Hand-minor-yin 11 - 13
Kidneys Foot-minor-yin 17 - 19
TABLE VIII
The five-fold categorization of drug qualities
reach the number six. Similar adaptations enabling linkages between basic
patterns of four, five, or six appear in this system quite regularly. Some
situations may require one to speak and think in terms of a sum of five depots
in the organism; other circumstances may demand a consideration of al-
together six depots. The acceptance of such alternatives is quite characteristic
of patterned knowledge; the choice between such alternatives would create
difficulties, however, for a scientist raised in the Western tradition and,
hence, obliged to demand a decision as to the existence of five or six
functional depot units in the organism.
As a final example of a categorization of drug qualities in the work of Wang
Hao-ku, a pattern of a five-fold categorization is reproduced in Table VIII. In
this pattern, the depots and the palaces are correlated with the flavor and
temperature qualities of drugs, and also with a four-fold sub-categorization of
the yinyang pattern. It should be pointed out that, for instance, 'warm' is
defined here as yang-in-yin, whereas it is categorized, in Table VI, as
yang-in-yang. Similar inconsistencies appear in the definition of other quali-
ties as well.
Considering all the patterns together now, the total structure of Wang
Hao-ku's pharmacological system may be illustrated graphically as follows in
Table IX; it represents a typical example of 'pattern science'.
With this structure, different patterns could be employed for explaining
different relationships between such pharmacological dimensions as drug
qualities and pharmacological functions, as well as locations, paths, and times
of drug effects. Additional yinyang and Five Phases patterns, not quoted
here, made possible, for instance, an integration of drug effects into the
course of the annual seasons with their corresponding climatic changes. All
these patterns may be called conting1ent with each other because all of them
are logically derived from the basic paradigm of systematic correspondence.
The dotted lines in Table IX indicate the kind of links between the individual
patterns as they appear, for instance, in Table VIII.
194 P. U. UNSCHULD
TABLE IX
The structure of the pharmacology of Wang Hao-ku
f-- pattern
of yinyang pattern
of two r--
systematic of six
0 0
0 0
0
correspondence
0
0 0
0 0
0 0
0
IMPLICATIONS
The realm of pharmaceutics is, like many other aspects of medicine and
health care, conditioned culturally. In this essay, I have pointed out but one
facet of cultural differences in pharmaceutics by contrasting Greek and
Chinese pharmacological systems. The comparison presented here may add
strength to the argument that one ought to be quite cautious in applying even
time-honored occidental epistemological concepts to non-Western cultures.
One may still speak of a 'system' in the case of both ancient European and
medieval Chinese pharmacology, because the term 'system' refers to but the
intellectual process of 'combining' or 'causing (here: ideas) to stand together'
(and that is what both Galen and Wang Hao-ku intended to do). But one
should be aware that not only the structures but the very nature of these
'systems' are entirely different. We should also be cautious, though, not to
separate, in this case Chinese and European, cultures too deeply. Chinese
and European/Western medicine have many levels, some of them being
surprisingly close to their cultural counterparts others being rather different.
Galen's pharmacology was complete and remained useful for one and a half
millennia. Wang Hao-ku represented, in the history of Chinese pharmacol-
ogy, but one author; others followed, partly adopting the contributions of
ANCIENT EUROPE AND MEDlEY AL CHINA 195
concepts for many years to come, but Chinese children passing through the
contemporary educational system and being raised, without exception, in a
society based on modern technology and science will become - irrevocably -
representatives of a culture that is distinctly different from a socio-cultural
environment that could keep the medicine and pharmacology of systematic
correspondence not only in use but also alive. Hence there is no question that
traditional Chinese medicine and pharmaceutics will continue to play an
important and useful role in future Chinese health care - as an alternative and
complement to so-called Western medicine - but I believe it is safe to expect
that future generations will become increasingly alienated from its theoretical
background.
NOTES
1. Artelt, W. Studien zur Geschichte der Begriffe 'Heilmittel'und 'Gift'. Ambrosius Barth
Verlag. Leipzig. 1937. Unschuld, P. U. Ma-wang-tui Materia Medica. A Comparative
Analysis of Early Chinese Pharmaceutical Knowledge. Zinbun: Memoirs of the Research
Institute for Humanistic Studies. Kyoto University 18. 11-63. 1982.
2. Unschuld, P. U. Medicine in China. A History of Ideas. p. lIS. University of California
Press. Berkeley, Los Angeles, London. 1985.
3. Unschuld, 1985, p. 259.
4. Domenjoz, R. Zur Geschichte der Pharmakologie. Antrittsvorlesung zur Ubernahme des
Lehrstuhls fUr Pharmakologie an der Rhein. Friedr. Wilhelm-Univ. Bonn. Dec. 13, 1958,
p.5.
5. Heischkel, E. Pharmakologie in der Goethezeit. Sudh. Arch. 42. 302-311. 1958.
6. Unschuld, P. U. Medicine in China. A History of Pharmaceutics. p. 17. University of
California Press. Berkeley, Los Angeles, London. 1986a.
7. Harper, D. The Wu Shih Erh Ping Fang. Translation and Prolegomena. Ph.D. thesis.
University Microfilm Services. Ann Arbor. 1983.
8. Unschuld, P. U. 1985, pp. 154 ff.
9. Jaeger, W. Diokles von Karystos. pp. 181-186. Walter de Gruyter & Co. Berlin. 1938.
Kudlien, F. Probleme urn Diokles von Karystos. Sudh.Arch. 47. 45~464. 1963.
10. For Galen, see Harig, G. Verhaltnis zwischen Primar- und Sekundarqualitaten in der
theoretischen Pharmakologie Galens. NTM Schriftenreihe 10. 64-81. 1973.
11. Harig, 1973, p. 66.
12. Harig, 1973, p. 67.
13. Harig, 1973, p. 66.
14. Harig, 1973, pp. 7~77.
IS. Harig, 1973, p. 69.
16. Harig, 1973, pp. 70--75.
17. Galen did not employ the term krasis for this intersection. It appears to me, though. that it
may be applicable here - with all necessary caution - in the sense of 'mixture of pharmaco-
logical functions'.
18. Unschuld, U. Traditional Chinese Pharmacology. An Analysis of its Development in the
Thirteenth Century. Isis 68.224-248. 1977.
19. Unschuld, P. U. Die Bedeutung der Ma-wang-tui Funde fUr die chinesische Medizin- und
Pharmaziegeschichte. Perspektiven der Pharmaziegeschichte (P. Dilg et at. eds.). pp.
389--417. Akademische Verlagsanstalt Graz. 1983.
ANCIENT EUROPE AND MEDlEY AL CHINA 197
20. This was the Shen-nung pen-ts'ao ching, mentioned above, of unknown authorship. Al-
though this work is generally attributed to the first century A.D., a definite date can be given
only for a later edition of it, prepared by Tao Hung-ching around the year 500. Cf.
Unschuld, P. U., 1986a.
21. Yamada, K. Kyii-ku hachi-fu setsu to sh6shiha no tachiba. T6h6 gakuh6 52. 199-242. 1980.
22. For detailed examples of such 'as well as' structures see Unschuld, P. U. Nan-ching. The
Classic of Difficult Issues. University of California Press. Berkeley. Los Angeles. London.
1986b.
23. Three of the following tables have been discussed. from a different perspective. in Unschuld,
U. 1977 already.
24. The Shen-nung pen-ts'ao ching defined drugs, for instance, as 'bitter and slightly sour'. Chu
Chen-heng (1281-1358), the last scholar contributing original ideas to the development of a
pharmacology of systematic correspondence', was the first, though, to correlate systematically
two or three flavor and temperature qualities to one single substance. This enabled him to
explain different effects of one single substance that could not be understood through the
common rigid correlation of one quality per substance only. See Unschuld, P. U. 1986a,
pp. I \7-118.
LINDA K. SUSSMAN
Medical beliefs and practices are clearly both products and integral parts of
the sociocultural systems in which they occur. Thus, much of medical anthro-
pology has been devoted to the understanding of traditional medical systems
within their sociocultural contexts.
Until the second half of this century, there was no distinct subdiscipline of
'medical anthropology' that focused upon matters of health, illness, and
healing in non-Western societies. The study of indigenous medical beliefs and
practices was, rather, usually conducted by general ethnographers and in
conjunction with research on 'primitiv,e' religion and magic. In these studies
the traditional healer was depicted as routinely engaging in ceremonies and
rituals to restore patients to states of spiritual, social, and psychological
harmony. Accompanying the focus on magic, religion, and ritual was an
emphasis on the supernatural aspects of traditional medical beliefs and the
importance that is placed on spiritual, psychological, and social, as well as
physical, well-being in traditional beliefs and practices (e.g., Evans-Pritchard
1937; Spencer 1941). Such studies usually emphasized those aspects of tradi-
tional medicine that differ from Western views of illness causation and
treatment (e.g., Fortune 1932; Evans-Pritchard 1937; Harley 1941; Carstairs
1955).
It is only recently that specialists in medical anthropology have attempted
to study the full range of medical beliefs and practices in non-Western
societies and with this trend it has become increasingly noted that 'naturally'
caused illness, requiring only 'natural', physical treatment, is, indeed, a
category of illness recognized by most peoples. There is a growing body of
literature that at least makes note of the enormous pharmacopoeias of some
cultures and the propensity of peoples to use relatively straightforward,
non-ritualized, physical treatment for some types of illness - especially those
that are common, minor, and short-term (e.g., Maclean 1971; Ahern 1975;
Kunstadter 1975; Spiro 1975; Lewis and Elvin-Lewis 1977; Ngubane 1977;
Janzen 1978; Nichter 1978; Sussman 1980; Feierman 1981; Janzen and Prins
1981; Mahaniah 1981; Bibeau 1982; Reid 1982; Etkin and Ross 1983; Welsch
1983; Etkin 1986).
Few societies today remain culturally isolated and free of the influence of
biomedicine. Societies in which biomedicine has been introduced and West-
ern countries to which immigrant groups have brought their own healing
systems have provided anthropologists with opportunities to study the ways in
which non-Western and Western medical beliefs and practices interact (e.g.,
199
S. van derGeest and S. R. Whyte (eels.), The Context ofMedicines in Developing Countries, 199-215.
1988 by Kluwer Academic Publishers.
200 L. K. SUSSMAN
Saunders 1958; Read 1966; Schwartz 1969; Maclean 1971; Landy 1974;
Woods 1977; Janzen 1978; Welsch 1983). Some researchers have focused on
the interactions between the indigenous and biomedical systems and have
found a number of relationships to occur when the two systems coexist. These
include competition, compartmentalization, and exploitation (Press 1969)
along with complementarity (Garrison 1977) and a hierarchy of resort
(Schwartz 1969). Moreover, as a result of the interaction, new medical roles-
'emergent roles' - may be created (Landy 1974). In short, it is common in
such societies for patients to have different expectations regarding the various
systems and either to choose different types of healing specialists for different
types of problems or to utilize them simultaneously, each to deal with a
different aspect or symptom of the same problem (Jahoda 1961; Benoist 1975;
Garrison 1977; Woods 1977). Moreover, individuals frequently have different
expectations concerning the medicines which they receive. A common pat-
tern is to expect biomedical pharmaceuticals to act quickly and traditional
herbal treatments to. act more slowly. Thus, there are distinctions in the ways
in which the different forms of treatment are used by patients (e.g., the length
of time a particular medication will be taken) and evaluated by them.
While most research on traditional healing has focused on healers or the
patients of healers, another relatively recent trend has been to conduct
household surveys, to focus on entire illness episodes as units of analysis
(e.g., Woods 1977; Janzen 1978; Kleinman 1980; Roberts 1981; Yoder 1981),
and to collect quantitative data on the utilization of practitioners and on
decision-making during illness episodes (Woods 1977; Nichter 1978; Klein-
man 1980; Young 1981). As a result there is a growing body of literature on
the treatment practices of individuals who have not consulted healing special-
ists for their illnesses, and it appears as if most illnesses are initially treated at
home and the majority of these never come to the attention of a medical
practitioner (see, e.g., Kleinman 1980). Herbal and over-the-counter West-
ern pharmaceuticals play major roles in self-treatment.
In this chapter I shall examine the utilization and cultural context and
meaning of both Western and local herbal pharmaceuticals on the Indian
Ocean island of Mauritius. Mauritius is a polyethnic society with a plural
medical system. It represents a type of society that has rarely been studied by
ethnographers in that all of the people and all of the healing systems arrived
on Mauritius in relatively recent times. The island was uninhabited until the
seventeenth century when the Dutch briefly settled there. However, it was
not until the 1720s that French traders and privateers, with their African and
Malagasy slaves, first established a permanent settlement on the island.
Indian indentured laborers and Indian Muslim traders arrived in the mid-
nineteenth century, and Chinese merchants (Hakka and Cantonese) arrived
USE OF PHARMACEUTICALS ON MAURITIUS 201
in the late nineteenth and early twentieth centuries. Today the majority of the
population (68%) is of Indian origin (Indo-Mauritian), 3% are of Chinese
origin (Sino-Mauritian), and 29% are of European origin and 'creoles' (of
African or mixed origin).
A wide range of healing resources are found on Mauritius. These include
biomedicine - in the form of Government Medical Service which provides
free medical care, dispensaries at sugar estates and other large industries,
private physicians and hospitals, and nurses and pharmacists - Ayurveda,
homeopathy, traditional Chinese medicine, professional Tamil herbalists,
folk herbalists, traditional midwives, specialized Creole healers, and sorcer-
ers. Religious specialists - Hindu maraz, Tamil poussari, Buddhist sisters,
Muslim miadee, and Christian clergymen and shrines - are also visited in
times of illneSs. In addition, a number of different types of pharmaceuticals
may be obtained directly by patients without resort to healing specialists. The
most widely distributed are biomedical pharmaceuticals, local herbal reme-
dies, and patent Chinese herbal remedies.
In order to determine how Mauritians conceptualize illness and utilize the
multiple healing systems, I conducted a 21-month field study which included
an island-wide survey of healers (including biomedical practitioners) and their
patients and a 14-month longitudinal study of medical beliefs and treatment-
seeking by 32 households (198 individuals) or approximately 10% of the
population of two adjacent villages in the rural southwest. In the survey of
healers and patients, I interviewed and observed 32 practitioners from eleven
different healing systems to discover the theoretical foundations and thera-
peutic procedures associated with the various healing systems. A sample of
patients of these practitioners was also interviewed concerning their symp-
toms, previous treatments sought for the illness, and general demographic
information such as sex, age, ethnic group, and occupation.
The household sample consisted of 60% Creoles and 40% Indo-
Mauritians. 1 Most respondents were manual laborers of low socio-economic
status with little formal education. In an initial interview I obtained informa-
tion on demographics, socio-economics, past and present health problems,
diet, beliefs about illness causation, and knowledge, opinions, and past use of
healing resources. Respondents were also asked which treatment(s) they
would choose for a list of forty ailments and symptoms. I then conducted
monthly follow-up interviews on th(~ nature and severity of all illnesses
experienced by household members since the last interview, the steps that
were taken to treat the illnesses, and the outcomes of the treatment. Addi-
tional data were collected on the knowledge of medicinal plants. (See Suss-
man 1983 for a more detailed discussion of methodology.)
202 L. K. SUSSMAN
UTILIZATION OF PHARMACEUTICALS
TABLE I
Treatment choices during longitudinal study
a The sum of this column is greater than 100% because multiple treatments were used for 19% of
the 456 illness episodes.
TABLE II
Use of pharmaceuticals during longitudinal study
(recall period one month)
a This represents the percentage of illness episodes treated by any of the three types of treatment
at any time during the episode. It does not equal the sum of the column since multiple treatments
may have been utilized.
in the choice between the biomedical and herbal systems of medicine but
rather in that between self-treatment by biomedicine and treatment either by
herbal medicine or biomedical practitioners.
The use of biomedical practitioners is also associated with episodes result-
ing in greater disability. Data collected on treatment preferences for the list of
forty ailments and symptoms also supports this finding. While biomedical
USE OF PHARMACEUTICALS ON MAURITIUS 205
Many of the same illnesses accounted for the majority of those treated by
biomedical practitioners, herbalists, and self-treatment by herbs and biomedi-
cine (Table IV).
Gastro-intestinal disorders, coughs, colds, fever, and influenza accounted
for many of the illnesses treated by all of these resources. However, the data
from the longitudinal study on treatment utilization and on treatment prefer-
ences for the list of hypothetical illnesses along with informal observations all
indicate that patients do tend to prefer different types of treatment for a set of
specific illnesses.
Self-treatment by biomedical pharmaceuticals is generally preferred for
coughs, colds, fever, intestinal parasites, and headaches. Panadol is usually
bought at local general stores for fever, headaches, and colds while cough
syrups and parasite medication (e.g., Mintezol) is frequently bought at
pharmacies.
Self-treatment by herbs is usually preferred for gastro-intestinal disorders
and vomiting, while both treatment by home herbal remedies and by
biomedical specialists are preferred for rheumatism, hypertension, nerves
and palpitations, and diabetes. Commonly used remedies for indigestion
include seeds of Salvia sp., Linum usitatissimum, and Hordeum vulgare that
may be purchased at the general stores in addition to leaves of Mentha sp. and
Litsea glutinosa and roots of Cocos nucifera which are either cultivated in
backyard gardens or grow wild in the vicinity of the village. Eupatorium
ayapana is an herbal remedy for vomiting known by virtually all of the village
respondents, and camomille flowers are a well known remedy for vomiting in
infants. These species are cultivated in gardens. Cassia alata and Bryophyllum
pinnatum, remedies for hypertension and rheumatism, respectively, are like-
wise widely known and frequently raised in gardens. Herbal remedies for
diabetes and palpitations are less widely known and less readily available.
These consists of the leaves of Faujasia flexuosa, the heart of Ravenala
madagascariensis, and the roots of Bruguieria gymnorhiza and Rhizophora
mucronata for diabetes and the leaves and stems of Selaginella sp., Mimosa
pudica, and Potamogeton chamissoi for nerves and palpitations (Sussman
1980). These are usually bought from professional herbalists.
206 L. K. SUSSMAN
TABLE III
Characteristics of illnesses treated by herbal and biomedical pharmaceuticals
Illness type
Acute 62.8% 67.1% 0% 61.8% 6S.9% 78.4'10 a
Recurrent 14.0 16.3 SO.O 17.4 12.2 15.S
Chronic 23.3 16.6 SO.O 20.7 22.0 6.2
Duration
<7 days 46.7 42.9 0 31.5 SO.O 63.S b
1-2 weeks 3.3 13.9 0 15.5 3.6 11.8
2-3 weeks 0 6.4 0 8.0 0 3.5
>3 weeks 50.0 36.8 100.0 45.0 46.4 21.2
Disability
None 64.7 SO.4 SO.O 42.0 6S.6 69.0'
Mild 23.5 29.3 50.0 33.5 21.9 19.5
Moderate 0 11.1 0 14.2 0 5.8
Bedridden 11.8 9.3 0 10.4 12.5 5.8
# Resorts
One 55.8 74.2 0 69.0 58.5 73.2
Two 37.2 20.6 100.0 24.2 34.1 21.6
Three or more 7.0 5.2 0 6.9 7.3 5.2
Mean # re-
sorts 1.51 1.31 d 2.00 1.38 1.49 \.32
a X 2 = 13.12, df = 4, P < .02. Because of the small number of cases, herbalists are not included
in any of the statistical tests.
b X:'= 31.01, df = 6, P < .01.
e X2 = 25.09, df = 6, P < .(ll.
d t = 2.02, P < .05 for biomedical vs. herbal pharmaceuticals.
TABLE IV
Percentage of illness episodes treated by each type of treatment (ranked)
a This column includes 17R patients of herbalists who were observed during the survey of
practitioners.
h There were no cases of diabetes or palpitations/nerves during the longitudinal study.
Until the twentieth century there were few medical doctors and biomedical
facilities on Mauritius, especially in the rural areas (Colony of Mauritius
Annual Report on the Medical Department 1885; Population Census of
Mauritius 1881, 1901; Titmuss and Abel-Smith 1968). Moreover, although
the island is quite small, and there were roads and some railroads connecting
major towns and cities in the nineteenth century (Pike 1873), transportation
from rural areas to facilities in the major cities was slow (Twain 1897). Some
Mauritians recalled that in the 1930s and 1940s travel from the central
highlands to coastal areas in the southwest constituted a major day-long
voyage. Furthermore, village residents in the southwest reported that twenty
years ago there was only one bus per day to the capital and other highland
cities. There are still some villages in the district today to which there is no
bus service.
It is probable, therefore, that until the increase in the number of hospitals
and dispensaries and the improvement in public transportation and roads,
health problems were treated at home with herbs and the use of local
herbalist-healers. Today, a substantial percentage of illnesses are still treated
with herbs but biomedicine appears to have supplanted herbal medicine as
the treatment of choice for most illnesses. Biomedicine is used to treat a
greater variety of ailments. During the longitudinal study, some form of
biomedicine was used to treat 50 of the 54 different ailments or symptoms
reported while herbal medicine was used to treat only 18 of these. As noted
above, herbal remedies are generally preferred for chronic ailments and are
also used to treat some common, minor illnesses.
Village residents tended to be familiar with a relatively consistent but very
small set of herbal remedies. Out of a list of 110 medicinal plant species, the
uses of only 19 of these were known by the majority of village respondents.
Those that they knew and used most were for indigestion (Mentha sp., Cocos
nucifera roots), vomiting (Eupatorium ayapana), hypertension (Cassia alata ),
rheumatism (Bryophyllum pinnatum) , and coughs (Cymbopogon citratus).
Professional herbalists and Chinese pharmacists, as well as village resi-
dents, all believe that the use of herbal remedies is declining. I found a
considerable amount of individual household variation in the knowledge and
use of medicinal plants. However, in general, younger Mauritians tend to
prefer biomedicine. In comparing the knowledge of medicinal plants among
mothers and daughters, I found a mean loss of 38% from one generation to
the next. Factors that appear to be contributing to the popularity of biomedi-
cine include: (a) the widespread distribution of biomedical resources as
compared to the relatively localized concentration of herbal medical resour-
ces (i.e., professional herbalists, the small ranges of some of the indigenous
plant species, and also the declining availability of some of these species); (b)
the availability of free biomedical care; (c) the relative convenience of
USE OF PHARMACEUTICALS ON MAURITIUS 209
Given the lack of general diagnosticians and the apparent lack of symptoma-
tic guidelines for assigning causes to illness episodes, it seems that patients
faced with illness episodes would find it difficult to decide upon the general
etiological category to which to assign their illnesses. Given the lack of
correspondence between symptom and cause, Mauritians cannot classify their
illnesses by symptomatology and then choose an appropriate practitioner or
treatment. Nor is there a universally recognized specialist to whom they may
turn to diagnose the cause of their illness. This problem is solved by Mauri-
tians by designating the causes of illness and using the various types of healing
resources in a specific pattern in the quest for cure.
When asked the type of treatment they would use initially for the list of
forty symptoms and ailments, respondents most frequently chose government
biomedical facilities and self-treatment by herbs, patent medicines, and
miscellaneous techniques (e.g., change of diet, rubbing with alcohol). For all
of the ailments and symptoms listed, most individuals chose either biomedical
practitioners or self-treatment, which accounted for 80-97% of the treat-
ments chosen by each respondent. In no case did respondents indicate that
they would initially consult a priest, maraz, poussari, or sorcerer despite the
fact that the list included symptoms frequently associated with illnesses
caused by dead souls, fright, and sorcery such as convulsions, sudden para-
lysis, bizarre behavior, and loss of consciousness. All initial treatment choices
were appropriate only for illnesses of God.
Mauritians, thus, tend to classify all illness episodes initially as mala des
Bondieu and utilize treatments appropriate for such illnesses. There is,
therefore, a hierarchy of resort in which biomedicine and herbal medicine are
used first, as are the most accessible and least expensive types of treatment.
Self-treatment by herbs or biomedicine and treatment at the local govern-
ment dispensary are usually followed by treatment at pharmacies and by
private biomedical physicians. Patients tend to exhaust all of these resources
before suspecting that an illness is supernaturally caused, reclassifying it, and
consulting appropriate religious specialists or sorcerers. Indeed, one of the
major criteria for believing that an illness is caused by dead souls or sorcery is
that it does not respond to treatment appropriate for illnesses of God.
Therefore, by initially classifying all illnesses as illnesses of God, patients can
eliminate what is believed to be the most 'simple' cause of illness, they can
utilize some of the least expensive healing resources, and they can also obtain
information relevant to the appropriate classification of the illness (i.e.,
whether or not it responds to biomedicine or herbal medicine).
212 L. K. SUSSMAN
ACKNOWLEDGEMENTS
The field research and writing of this manuscript was supported in part by an
International Doctoral Research Fellowship from the Social Science Re-
search Council, a Dissertation Improvement Award from the National Sci-
ence Foundation, a postdoctoral traineeship in epidemiology from the
National Institute of Mental Health, a University Fellowship from Washing-
ton University, a Biomedical Research Support Grant from the Biomedical
Support Program, Division of Research Resources, National Institutes of
Health, and by a Grant-in-Aid of Research from the Society of Sigma Xi.
NOTES
1. The results reported here are generalizable only to rural Creoles and Hindu Indo-Mauritians.
Hence, my subsequent use of the term 'Mauritian' is here meant to refer only to this group.
However, informal observations and interviews with more urbanized Creoles, Hindu and
Muslim Indo-Mauritians, and Sino-Mauritians suggest that the conclusions reached in this
study are, indeed, applicable to Mauritius as a whole.
2. For this analysis, individuals who bought medicine at a pharmacy are included in the
self-treatment category although they may have asked a clerk to suggest a medicine to treat
their illness (e.g., a cough medicine or a medicine for parasites).
3. Individuals who consulted biomedical practitioners are considered here to have been treated
with Western pharmaceuticals because with very few exceptions all such patients expected and
were given some type of medication.
4. A change in level of resort here signifies a switch initiated by the patient either (a) from one
healing system or mode of treatment to another or (b) from one practitioner to another within
the same healing system. For example, all of the following would be counted as two levels of
resort: government dispensary to private doctor, pharmacy to private doctor, self-treatment
by herbs to self-treatment by patent Western medicine, private doctor to another private
doctor, and sorcerer to poussari. However, if the change of practitioner resulted from a
referral from one practitioner to another and represented the following by the patient of an
ongoing diagnostic and treatment process, a change in level of resort would not be recorded.
This situation usually occurred when patients were referred by the local dispensary to the
government hospital for diagnostic tests, consultations, and, in some cases, treatment (e.g.,
surgery).
USE OF PHARMACEUTICALS ON MAURITIUS 213
5. Since village respondents consulted herbalists on only two occasions, no conclusions can be
reached concerning the use of professional herbalists.
6. Homeopathic, Ayurvedic, and traditional Chinese practitioners, Buddhist sisters, and Muslim
miadee were unknown to the village respondents and are, therefore, not included in this
discussion.
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SUSAN REYNOLDS WHYTE
before Amin came to power.) Since some of the points I want to make seem
to have general relevance, I shall refer to other African examples as well.
WHAT IS MEDICINE?
In Bunyole, medicine was many things. The term could be applied to all kinds
of substances, both healing and harmful, which were thought to have an
inherent capacity to achieve an effect upon a person or thing. To transform an
ordinary dog into a good hunting dog, medicine (not training) had to be
given. To get a good cash crop, 'cotton medicine' (DDT) was sprayed on the
plants. In the Nyole language, one can speak of 'bicycle medicine' (the rubber
cement used to patch tires), sorcery medicine (obulesi bw'obulogo), as well as
curative 'hospital medicine' (obulesi bW'edwaliro) and African medicines
(obulesi bw'ehimali) in their various forms. On occasion Nyole distinguished
medicines according to their functions (protective, curative, offensive) or
according to their modes of preparation and application, rather as Bellman
(1975) reports that the Fala Kpelle do. But the point is that all this variety is
subsumed under the category of medicine.
Medicine seems to be a broad semantic category in many African lan-
guages. Among the Abron of the Ivory Coast, Alland notes the conflation of
magical items and medicines. The semantic class sino includes magical
devices and real medicine, either of which may be native or Western' (Alland
1970: 177-8). The Zinza of northwestern Tanzania include Western and
indigenous remedies together with protective and destructive substances in
the category of medicine (Bjerke n.d.: 93-94). Among the Zezuru of Zim-
babwe, the term for medicines (muti) can refer to 'any substance or technique
which is used to bring about change in the human condition, whether it be
aspirin or a love potion made out of pubic hairs and sweat' (Fry 1976: 23).
The Safwa of Tanzania conceive of medicines as capable of enhancing and
repairing relationships and conditions as well as spoiling them (Harwood
1970: 62-3). The Swahili word dawa seems to have the same breadth; note the
usage dawa ya viatu, 'shoe medicine', for the substance used to restore the
condition of skuffed shoes.
Medicine is a substance that transforms something - for better or worse.
How does it do so? In Nyole thought, medicine achieved its effects through
some power inherent in itself, without reference to morality, relationships or
intention. In this it differed from other major modes of transforming condi-
tions - curing through prayer, ritual and sacrifice, and harming through
cursing or the power of spirits.
A sorcerer could use medicines to harm anyone, whether related to him or
not, and even though his motives in doing so were immoral. The power of the
medicine might even work independently of his intentions. Medicine buried
to harm one person could be unwittingly 'jumped' by someone else, who then
fell ill instead. A love potion might make the object of desire run mad instead
POWER OF MEDICINES IN EAST AFRICA 219
TREATMENT BY MEDICINES
Venereal disease was quite common in Bunyole, and it was said that govern-
ment health facilities demanded that one name or even bring along for
treatment the sexual partner from whom one had contracted the disease. I do
not know what the actual policy was at the clinics, but treatment there was
widely perceived as a very delicate matter. A friend, who came asking us
whether we had medicine for gonnoll"hea, explained his difficulties. His wife
had been away for some time attending funeral ceremonies at her home. A
'guest' had kept him company in the meantime, and given him the disease.
His wife was due home, and he felt it would be indiscreet to go to the
dispensary with his 'guest', who was married to someone else. So he had
gotten a village injection and was looking for more medicine. (Apparently the
problems continued; some time later he confided that both he and his wife
had been given injections by a needle man because they both had gonnor-
hea.)
During the period of our fieldwork, Bunyole County was served by a health
centre at the county headquarters, first established as a dispensary in 1926.
The man in charge claimed that they sometimes had as many as five hundred
out-patients a day. The maternity and general wards were also heavily used.
In addition, two aid posts (later up-graded to dispensaries) also served the
needs of the county's 90,000 inhabitants. These were the major sources of
Western medications.
A person attending these facilities for treatment always took a bottle, for
patients were supposed to supply their own containers for liquid medicine.
From the point of view of local people, dispensaries provided three kinds of
medication: tablets (amakarenda) , medicine for drinking (obulesi bw'o-
hunywa), and injections (epishyo). Most people spoke of Western medicines
in terms of their forms rather than their ingredients. This did not necessarily
show naivite; it corresponded well with the cultural construction of local
medicines. Medicinal content was the secret of he or she who 'goes in the
bush' to gather the remedy. What was discussed was the way the medicine
was administered. On this dimension, Western medicine was far less differen-
tiated than African medicine, which could be used in bath water, smoked in a
pipe, rubbed into incisions, worn in amulets, inhaled under a make-shift
steam tent, smeared on various parts of the body or mixed with specified
kinds of food or drink (to mention only the varieties of medicines applied
directly to persons).
Curers, needle men and national health facilities all provided treatment
which may be characterized as symptomatic in nature. That is to say, they
administered medicines which were thought to affect the signs and symptoms
of a disorder, rather than to address its cause. The distinction between
symptomatic and etiological treatment was important in Nyole medical prac-
tice. The etiological level was dominant both in terms of the perception of
sickness and conception about treatment. This level had enormous ideologi-
cal importance; images of social identity were articulated and reproduced
222 S. R. WHYTE
through explaining and treating the causes of sickness in certain ways (Whyte
1981). But the point I want to make here is not so much the difference
between symptomatic and etiological levels, as the relation between them.
In practice, causal explanation and treatment were not usually thought to
be necessary if symptomatic measures proved effective. Concerning a certain
condition for instance, I was told that it used to be caused by a spirit but that
now people just got it cured at the dispensary. It was not invariably the case
that symptomatic relief obviated the need for rituals addressed to superna-
tural causes. It was often said that the symptoms would return or that another
misfortune would strike if identified causes were not dealt with. But there was
definitely a tendency to put off expensive, complicated rituals and uncomfort-
able confrontations if possible. What made it possible - in many cases - was
medication to relieve symptoms. An example will illustrate my point.
Samwiri had been married to Jani for some years, and they had three children. Early in 1971. the
middle child, a boy, fell very ill with what looked like pneumonia. Fearing for his life, we offered
to drive the child and his parents to the hospital in Tororo, 25 miles away. Samwiri agreed
immediately, but Samwiri's mother hesitated, pointing out that her grandson had already been
given an injection at the dispensary, which had not helped. She and the neighbors suspected that
Samwiri's father-in-law had cursed Jani to lose the children. His curse had been diagnosed in
connection with earlier troubles, and relations between him and Samwiri had been poor for some
time. He claimed that Samwiri had never visited him when he was in jail, never gave him gifts
though he had a steady job, had still not paid the last cow on Jani's bridewealth. and was
generally a bad son-in-law. Samwiri said openly that he disliked his wife's father. that he was
greedy, drank too much, and did not deserve the satisfaction of the goat he would receive for
removing the curse. Not to mention the matter of the cow.
That time Samwiri's wishes prevailed and the child was taken to the hospital for treatment. But
then the next child fell ill almost immediately. Jani's father sent a message saying that Samwiri
should come and make arrangements about how he could help the sick children (implying a curse
removal ceremony), but Samwiri refused saying, "I do not want to see that man". He accepted
our offer to drive this child to the hospital, but it was Jani's turn to refuse. With tears streaming
down her face as she held her feverish, trembling child, she declared that there would be no
medical treatment until Samwiri went to see her father to arrange for him to remove the curse.
In this case, Samwiri's motives for seeking Western medicines were surely not
simply that they were effective. In fact the opposite had been demonstrated;
an injection had failed to cure the one child, and even after his hospitalization
and recovery, sickness still threatened the lives of Samwiri's other children.
Samwiri insisted on Western medicine because he wanted to avoid what
Nyole custom required - that he go humbly to his father-in-law.
Much has been written of the efficacy of Western medicines and the
pragmatism of people who adopt what is seen to have such powerful effects
(Foster 1977: 530). But this view of 'the practical patient' may be a bit too
simple. Certainly people appreciate that Western medicines cure some symp-
toms. But there may be push as well as pull factors in their attraction. What
pushes people towards medicines are the dynamics and difficulties of the
non-medicinal solutions to health problems.
POWER OF MEDICINES IN EAST AFRICA 223
the 'social utility' of medicines which 'can be acquired and used without
becoming dependent on others' (personal communication).
One of the most striking characteristics of the Nyole medicine men was that
they so frequently had foreign experience and used exotic techniques. Often
they had spent years at distant places or as apprentices to people from
faraway. It was said that many of the men who served abroad in World War II
worked as medicine men when they n~turned to Bunyole. Muslims, a minority
in Bunyole, were thought to be powerful medicine men. They used medicines
first introduced by Arab and Swahili traders - especially 'prayers' (eduwa) ,
which consisted of Koranic texts dissolved in water for drinking or bathing
(also called kombe). The majority of those who bought such medicines were
Christians; it was not the religious content that interested them, but the
power of an exotic medicine. One medicine man sold Zandu, a medicine
manufactured in Bombay and 'useful in the treatment of one hundred
diseases', and bicarbonate of soda. Another sold special amulets made by a
technique he had learned in Tanzania.
The use of exotic substances and techniques was not only recognized, but
emphasized. The experts themselves contrasted their methods with 'the
Nyole way' and demonstrated their special 'gimmicks' with a certain amount
of pride. The exotic, extra-ordinary nature of this medicinal practice has
implications which can best be grasped by returning to the general contrast
between medicine and ritual.
Treatment by ritual, in which relationships were openly stated and acted
upon, also involved the manipulation of objects and substances. These items
had symbolic meaning which could be traced through various rituals. They
were usually common items known to everyone, such as spears, winnowing
trays, beer, staple food or domestic animals. In removing a curse, water was
poured or sprinkled on the cursed person or millet porridge, formed into balls
called ebigwasi, was given to the victim to eat. Ebigwasi were also eaten by
the living when any sacrifice was performed for the ancestors. But these
substances were not medicine; their efficacy was not inherent, but derived
from the beings and relationships activated in the ritual.
Medicine contains a power which is not public and social in the same sense.
Knowledge of it is restricted; its content tends to be secret. Its source is
outside of morally regulated human relationships. Conceiving of it as foreign
and difficult to obtain underlines these aspects. Even neighborhood herbalists
spoke of their modest fees as payment for 'going in the bush'. If we understand
the bush as the conceptual contrast to the familiar, domestic homestead, then
we can draw a cosmological parallel between the bush and the faraway places
from with other kinds of medicine come. They are both in symbolic opposi-
tion to what Lewis (1971) calls the 'central morality cult', the set of rituals and
226 s. R. WHYTE
relationships which define Nyole as kinsmen and moral persons. All medi-
cines, in a sense, come from outside, so that it may be misleading to make too
strong a contrast between Nyole medicine and foreign medicine, or between
African medicine and hospital medicine.
In thinking about the foreign nature of medicine, we must stress once again
the transactable nature of powerful substances. When power is not tied to
particular relationships, it becomes cosmopolitan in a way that kin-specific
powers never can be. It can be transacted over great distances, between
people who have different though overlapping, symbolic universes. The belief
in the innate power of certain substances, and the tendency to attribute
special capacities to more esoteric medicines create the basis for lively
experimentation and entrepreneurial activity.
There is a stereotype of the African medicine man as a local resident,
embedded in his own tribal culture, serving the needs of his neighbors by
manipulating the symbols with which they are familiar. The traditional healer
is 'a co-member of his patient's social group' whose treatment' ... reinforces
and gives legitimacy to time honored beliefs' (Green 1980: 499). While it is
true that Nyole diviners and medicine men addressed 'traditional' notions of
etiology, medicine men in particular were cosmoplotian and innovative,
rather than 'traditional' in their orientation. The successful medicine man
drew his clientele from a large area and a variety of ethnic groups. Out of 101
people who visited one well-known Nyole specialist for divination and treat-
ment, only 37 were Nyole. Some Nyole specialists travelled all over Eastern
Uganda.
Likewise Nyole sought out foreign experts, especially when the problem
was difficult and dangerous. For example, a man accused of having misappro-
priated funds from the cotton cooperative society sought medicine from a
specialist in Mbale, 35 miles away, to make the case against him die. The
specialist was a Ganda Muslim who had lived ten years in Nairobi; his wife,
who also treated people, dressed like a coastal Swahili.
Speaking of the importance of medicines, a Nyole acquaintance also
expressed their cosmopolitan character. 'Ministers and big men use medicine
men from Pemba and Kenya. Even the most religious people must go to
medicine men to protect themselves. No one can be safe without going to
them. Even Dr. Obote must do so'. Nyole saw the growing importance of
medicine as part of a general situation in Eastern Africa, where life was
dangerous and where improved communication had increased awareness of
and access to new kinds of foreign medicine, both Western and African.
Although Nyole had not been heavily involved in labor migration, they were
very much integrated in the cash economy and were in touch with other parts
of the country through road and railway. Cotton was the universal cash crop
and the primary source of income at the time fieldwork was carried out in
Bunyole; land was at a premium, and the power of senior males, who
controlled land, livestock, and rights in women, may well have been
POWER OF MEDICINES IN EAST AFRICA 227
enhanced after cotton was established at the time of the first world war. This
power was expressed and accepted through the interpretation of misfortune
in terms of cursing, clan spirits and ancestral ghosts. In this context, I believe
that medicines and medicine men had a particularly strong appeal to women
and younger men. Elsewhere I have elaborated on the attractions of medicine
men as diviners and their potential for challenging authority (Whyte forth-
coming).
Ivan IlIich (1977) uses the term 'pharmaceutical invasion' to describe the
flooding of Third World countries by multi-national drug companies. One
approach to this subject is to focus upon the companies themselves and their
aggressive marketing strategies. While this is extremely important, it is
insufficient from an anthropological point of view. We must also examine the
terrain being conquered, and the cultural and historical processes which form
the local context of the intrusion. In Africa, the power of foreign medicines
was already established long before Western pharmaceuticals began to circu-
late on a large scale. The increased use of medicinal substances in general
seems to have been partly a result of improved inter-regional communication
facilitated by colonialism.
One of the most famous anthropological studies of religion in Africa speaks
of a medicinal invasion among people who professed to have had very little in
the way of medicines in earlier times. In 1930, when Evans-Pritchard lived
among the Nuer, fetishes, 'medicines which talk', were being brought into
eastern Nuerland. He writes that: 'Fetishes are amoral in their action. They
are acquired in the first instance by purchase, though they may later be
inherited, for private ends and personal aggrandizement ... Nuer told me
that European administration has made it easier for men to acquire and
exercise these powers . . . new fetishes frequently appear, they become
well-known in one district and are unknown in others, and they wax and wane
in popularity' (Evans-Pritchard 1956: 100-103).
In the introduction to their anthology on witchcraft and sorcery in East
Africa, Middleton and Winter (1963) discuss the belief common in many
African societies that sorcery is increasing. They relate this to increases in
hostility, insecurity and anxiety, to an increasing conflict between African
traditional and modern individualistic norms, and to the fact that changes
have created situations and statuses for which there were no indigenous
precedents. Several of the articles in the collection report that sorcery
medicines and techniques were supposed to have originated outside the local
society. LeVine notes that Gusii sorcerers were usually trained by Luo
(Ibid.: 133) and Middleton speaks of a kind of medicine which Lugbara men
buy 'either in the Congo or in southern Uganda where Lugbara meet Congol-
ese as fellow labour migrants' (Ibid.: 265).
228 s. R. WHYTE
The perceived threat of new sorcery techniques was and is met by new
counter-medicines, whose efficacy is also associated with foreign provenance.
In addition to the steady individual diffusion of medicines, there have been
anti-sorcery movements which have swept over large areas. The medicines
administered in the Kamcape anti-sorcery movement in southern Tanzania
were said to have originated in Malawi (Willis 1968: 5) and Field (1940)
reports that people from the southern Gold Coast travelled to the Northern
Territories to bring back powerful anti-sorcery medicines for the new cults
being established everywhere.
More recently, several studies have established the receptivity of African
societies to all kinds of new medicines. Alland writes of the Abron: 'New
medicines are accepted from the outside at a startling rate. While the average
Abron tires of a therapeutic technique which does not produce rather imme-
diate effects, the Abron pharmacopaeia is open and in a state of constant
change' (Alland 1970: 120). Murray Last, writing about a Hausa area in
northern Nigeria, stresses the extremely eclectic nature of the medical scene,
which he describes as a 'non-system'. Healers often travel and work among
foreign communities. 'The value of their remedies lies in their very strange-
ness, in their not being part of a known system of medicine' (Last 1981: 389).
Last relates inventive and entrepreneurial uses of Islamic, Western and
various African medical elements to the disintegration of traditional medicine
as a system; the breakdown of kinship groups has forced individuals to rely
upon their own medical defences. He finds that people no longer 'know' what
the proper therapeutic response to sickness is, and in this atmosphere of
'not-knowing' secrecy and skepticism thrive. The foreign, little-known prove-
nance of medicines fits with the general uncertainty of the times.
An excellent example of the increasing use of medicines is to be found in
Keller's study of women's reliance upon love and luck medicines in a small,
mostly Tonga-speaking Zambian town. A woman in a socially and economi-
cally vulnerable situation may use medicines to get and keep a husband, to
prevent him beating her, to bring him directly home after work, to make him
help in the house and even - on the 30th of each month - to make him hand
over a sufficient portion of his pay! Keller says that the medicines, far from
being ethnic-specific, are of foreign origin. 'In fact, consistent with the
prevalent idea that foreign diviners or spirit mediums are more powerful than
local ones is the belief that exotic medicines are more potent than local ones'
(Keller 1978: 498). But the increased availability of medicines from other
ethnic groups, due to greater mobility, cannot alone explain the more com-
mon use of medicines today. Keller attributes it to women's greater isolation
in monogamous households, especially in towns, and to the loss of support of
older relatives. In the past, young women were given medicines by their
elders, but this was accompanied by instruction to both sexes on proper
behavior and by 'other institutional supports for marriage which do not
function today' (Ibid.: 504).
POWER OF MEDICINES IN EAST AFRICA 229
Thus, although the pharmaceutical invasion may be the work of the drug
companies, the capitalist system did not create the demand for foreign
medicines. That is based on the dynamic relationship between indigenous
concepts of medicines and of other sources of transformative power. Presu-
mably medicines are an ancient concept in Africa, and perhaps in their most
powerful forms they have often been seen as coming from beyond the
domestic circle of familiar culture. In the last hundred years or so, two
important kinds of changes have shifh!d the balance in the relation between
medicines and other powers. First, there has been a great increase in people's
experiences with 'otherness', entailing among other things the greater avail-
ability of foreign medicines in any locality. Second, the kinds of social
relationships in which spirit and kinship powers were embedded have them-
selves changed in various ways, increasing the attractions of medicines, for
some people at least.
Having suggested that there has been a change in the balance between
medicines and other powers within local society, I would like to leave the
local ethnographic scene to glance briefly at a conceptual development at the
national and international levels. I refer to the new consciousness of tradi-
tional medicine which can be seen in the media, in the pronouncements of
African governments and in the stated concerns of international agencies
dealing with health development. A pharmacological bias is evident here,
which parallels in its way the fascinatiton with medicines seen in many local
societies.
The medicine man is regaining his lost honor, according to an article in a
Tanzanian newspaper (Van Amelsvoort 1976: 55). But other articles made it
clear that in the new traditional medicine, the dross of superstition must be
separated from the gold of scientific truth: ' ... it must be understood that
the root or leaf of a tree with medicinal content cures a disease purely because
of the medicinal content and not because of the superstitious words that are
uttered when administering it or the taboos and paraphernalia that is asso-
ciated with its administration' (Ibid.: 70). Here African healing is being
measured by the standard of Western bio-medicine. Interest is focused on the
content of substances, not on symbols. and relationships. Medicine men are
seen as experts; they are the sources of healing medications, comparable to
Western specialists. Little attention is paid to the therapeutic community of
kinsmen and spirits, and there is no place here for etiological explanations
and therapeutic rituals.
Pharmacological research predominates in the steps taken by international
organizations to initiate research on African medicine and in most institutes
of traditional medicine (Bibeau 1979). At least some indigenous healers are
aware of this interest and may redefine their own practice accordingly. In
230 S. R. WHYTE
1982 and 1983, when I interviewed healers in Tanzania, a number had had
contact with the Traditional Medicine Research Unit in Dar es Salaam and
knew of the investigations of herbal medicines being carried out there. l Like
the Nyole medicine men, many of these practitioners tended to emphasize
medicinal therapy, sometimes combining elements of Western and African
medicine. One district organization of 'traditional healers' had established a
hospital for traditional medicine (hospitali ya dawa ya jadi) which was actually
a cooperative herbal apothecary. Healers brought roots, bark and leaves,
which were mixed, bottled and labelled with scientific-sounding names. This
organization was hoping to gain government support, and the form and
content of its practice fit well with the Western-derived model of 'traditional
medicine' mentioned above. African traditional medicine had been redefined
as African medicines. Relations to kin, community and spirits are quite
irrelevant to the application of powdered herbs with labels like Na 15 A. U.K.
In this case a government-supported model of healing, which emphasized
medicines, had been appropriated and used to shape the form that therapy
took.
Medicines are an area where Western and African conceptions of healing
seem to meet. Just as Western drugs are easily incorporated within the
African conception of therapeutic powers, African herbal ism can be made
acceptable to the bio-medical model. Because of this overlap, there is a
tendency to place a great deal of emphasis on the medicinal aspect of African
'traditional' healing, without properly appreciating either the breadth of the
African conception of medicines or the relation of medicines to other forms of
healing. This image of 'traditional' medicine is being propagated at a time
when other factors have contributed toward an emphasis on medicines in
relation to other types of powers. Thus the medicinal bias is over-determined.
CONCLUSION
ACKNOWLEDGEMENTS
I would like to thank Sjaak van der Geest and Robert Welsch for their helpful
comments on my plans and first draft for this article. The fieldwork on which
it was based, supported by the US National Institute of Mental Health, was
carried out together with Michael A. Whyte. He has contributed many
suggestions and useful criticisms to the paper, for which I thank him very
much.
NOTES
1. These interviews were part of a baseline study of the current treatment of mental health
problems, carried out in connection with the Tanzania Mental Health Programme which is
supported by the Danish International Development Agency and the World Health Organiza-
tion.
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Bellman, Beryl Larry
1975 Village of Curers and Assassins. The Hague & Paris: Mouton.
232 S. R. WHYTE
Bibeau, Giles
1979 The World Health Organization in Encounter with African Traditional Medicine. In
Ademuwagun et al. (eds.) African Therapeutic Systems. Waltham, Mass.: Crossroads
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Bjerke, Svein
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1976 Medical Anthropology and International Health Planning. Social Science & Medicine
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1980 Roles for African Traditional Healers in Mental Health Care. Medical Anthropology
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Illich, Ivan
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1978 Marriage and Medicine: Women's Search for Love and Luck. African Social Research
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Last, Murray
1981 The Importance of Knowing about Not-knowing. Social Science & Medicine l5B:
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Levine, Robert A.
1963 Witchcraft and Sorcery in a Gusii Community. In Middleton and Winter (eds.)
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Lewis, I. M.
1971 Ecstatic Religion. Harmondsworth: Penguin.
Middleton, John
1963 Witchcraft and Sorcery in Lugbara. In Middleton and Winter (eds.) Witchcraft and
Sorcery in East Africa. London: Routledge & Kegan Paul.
Middleton, John and Winter, E. H. (eds.).
1963 Witchcraft and Sorcery in East Africa. London: Routledge & Kegan Paul.
Nichter, Mark
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Parkin, David J.
1968 Medicines and Men of Influence. Man 3: 424-439.
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POWER OF MEDICINES IN EAST AFRICA 233
INTRODUCTION
235
S. van derGeestandS. R. Whyte (eds.) , The Context ofMedicines in Developing Countries, 235-252.
1988by Kluwer Academic Publishers.
236 A. NIEHOF
RESEARCH SETTING
According to the latest census (1980) the island Madura counted about 2.7
million inhabitants. Many more Madurese live outside Madura, especially in
mainland East Java. Conditions on the dry and infertile island have stimu-
lated a flow of emigration that has been going on for centuries. The island
Madura is administered by the governor of the province of East Java. The
Madurese are a distinct ethnic group with a language of their own. They are
known as devout Muslims, extravert and hardworking people, who do not
take an insult lightly.
Modern medical facilities have also been introduced in the Madurese
countryside. Spread all over the region, but usually near the sub-district
offices, there are 85 health centres. Madura counts 66 general practitioners,
12 dentists, and 205 nurses or midwives. In each of the four regency capitals
there is a small general hospital (ct. Provincial Health Services 1984). Madura's
main health problems are primarily due to its low standards of living: poor
sanitation and hygiene, prevalence of protein-energy malnutrition (in the
interior more than in the coastal areas), hypovitaminosis A, and nutritional
anaemia (ct. East Java Nutrition Studies 1977-1979). Compared to East Java
as a whole the health condition fo Madura's population is poor, as is the case
with the socio-economic situation in general.
The research on which this chapter is based took place in two villages in
central Madura: the first is a fishing village on the northern coast, the other an
agricultural village in the interior. Though differing in more aspects than main
means of subsistence,3 with respect to the present theme we did not find
significant differences. Apparently, medication and ritual surrounding preg-
nancy and childbirth strike a common chord in Madurese culture. Even the
fact that in the fishing village people have access to a health-centre and a
resident modern midwife, did not lead to fundamental differences in the way
people cope with the hazards of pregnancy and childbirth and did not
basically alter their views on the processes involved.
Islam is a factor of importance in Madurese society and Islamic elements
have been incorporated in Madurese rituals, including those surrounding
childbirth. But the people themselves do not distinguish between elements of
Islamic and non-Islamic origin. Islam is blended into 'how ordinary
people ... order and articulate categories, symbols and the relations be-
tween them in the pursuit of comprehending, expressing and formulating
social practice' (Ellen 1983: 54). In any case, the specific Islamic elements that
could be detected are not very prominent in the sphere on which this
discussion focusses. Pregnancy and childbirth are essentially a women's affair,
where formal Islam retreats in favour of Madurese custom, of which women
are the guardians (Niehof 1985: 218).
PREGNANCY AND CHILDBIRTH IN MADURA 237
The point of departure in Madurese thinking about health and illness is the
notion that the 'normal' state of being is one of balance or harmony in the
individual's relation to the natural and supernatural order (Jordaan 1985: 228
ff). This state of balance is intermediate between misfortune and well-being,
which are symbolically equated with respectively 'hotness' and 'coolness'.
Thus, the balance may be offset in two ways. While 'hotness' always has
negative implications, 'coolness' is essentially positive. Persons in special
conditions or with special attributes may be in such a 'cool' state. Examples
are: children who are born with a caul, or with a physical handicap, or people
who possess extraordinary talents or objects. In the next section we shall
demonstrate how the thinking in terms of 'hot' and 'cold' is applied more
specifically with regard to the processes of gestation and childbirth.
Here, it is important to note that the balance concept of health yields a
three-dimensional model, in which there are two states of imbalance: a
positive and a negative one. This contrasts with models built on an all too
narrow interpretation of binary oppositions (e.g. Hiroko Horikoshi 1980:
160-164). Because in such two-dimensional representations 'hotness' is con-
sidered a disturbance equated with illness, health has to be equated with
'coolness'. Disturbance of the balance may be brought about by all kinds of
circumstances: either by natural or supernatural factors, or, for instance, by
violating basic principles in the socio-cultural order.
For a person afflicted with illness or misfortune, there are several options
open in order to regain the state of balance. Home-remedies are the first
alternative to turn to, unless there is acute danger which calls for more drastic
action. Home-remedies include herbal drinks, ointments, purgatives, fumiga-
tion, bathing, massaging, cupping, and the like. Sometimes it is sufficient to
follow dietary restrictions. These kinds of remedies may be used for both
therapeutic and prophylactic purposes. Herbal drinks and poultices may be
home-made, bought from the vendor, or bought in the shop. There are two
kinds of vendors: a Javanese vendor who sells her medicines ready-made in
bottles, and a Madurese vendor who prepares the medicine in front of the
client from the ingredients she carries in a basket on her head. Preference for
the one or the other is a matter of personal taste, and depends on the kind of
remedy one is looking for. The village shops offer a variety of Indonesian-
made prefabricated jamu. Sometimes one can freely buy antibiotics at the
local market.
When self-treatment fails, or is expected to be ineffective, people seek
medical assistance from others. 'Outside' medical assistance (called etambha
lowar) ranges from the indigenous magico-medical specialists to the health-
center auxiliary or physician. In serious cases people may consider bringing
the patient to the hospital in town. The indigenous specialists are of two
kinds. First there is the dukon, a word that is used for a motley assembly of
238 A. NIEHOF
part - and full-time practitioners. Secondly, there is the kiyai, the religious
teacher who, by virtue of his religious knowledge and experience, is ascribed
healing powers. Although all Madurese dukon are Muslims, the main differ-
ence between the kiyai and the dukon is that the first is primarily a represen-
tative of the Islamic Faith, while the second represents custom and tradition,
however interwoven with Islam. The kiyai hardly ever uses herbal medicine,
while dukon generally do. There are many kinds of dukon (see Jordaan 1985:
161-174). The specialist in the field of pregnancy and childbirth is the dukon
rembi', who is always a woman.
The choice of a particular healer or a representative of modern health care
is based on a number of considerations. It largely depends on how the patient
and his relatives interpret the symptoms. If there is a pattern of general
misfortune or if one is convinced of the involvement of supernatural powers,
it is no use going to the health-center . In such cases there are kiyai and
certain kinds of dukon, dependent upon the circumstances at hand, to turn to.
On the other hand, in case of stab wounds, accidents and the like, a doctor or
a paramedic is consulted. Similarly, the doctor is considered more effective in
treating bodily disorders like gastro-enteritis. In the other cases, the course of
the illness and its duration will be closely watched when deciding on the
measures to be taken. As for 'outside' medical assistance, it is believed that
there should be a 'good fit' (juddhu) between healer and patient for the
therapy to be effective. Madurese are convinced that the results of exactly
identical treatments by equally gifted dukon (or doctors, for that matter)
differ according to this mysterious 'fit'. If a healer has proved to be juddhu, he
or she will be consulted by preference, even if this implies travelling. Inter-
estingly, the healer or doctor who is considered juddhu often does not live in
the same village, but at some distance. It follows that considerations of
geographical distance and costs play only a secondary role in the decision-
making process.
are said to achieve this end, are popular items in the shop (see also Afdhal
and Welsch, in this volume).
Most village women do not regard their menstrual cycle as consisting of
fertile and infertile days. And those who do, think they are most likely to
conceive on the days just before and just after menstruation, the 'safe period'
according to Western medicine. They believe the mid-period of the cycle to
be sterile. 4 These ideas are based on the association of dry with sterile and
moist or wet with fertile. The womb is thought to be driest in the middle of
the cycle. Just before menstruation it is thought to be moist and swollen with
blood, providing an ideal host environment for the seed. After menstruation
the womb is thought to be like an ope:n wound, facilitating penetration and
settling of the seed. During menstruation sexual intercourse is prohibited.
Violating this taboo is believed to result in the birth of a child suffering from
leprosy.
Pregnancy as a physiological event is viewed by the Madurese as a process,
not as a state. s For an understanding about how they conceptualize the
process, we have to take a closer look at some important classificatory
associations in Madurese thinking. These are the association of 'coolness'
with fecundity and growth, and of 'hotness' with infecundity, abortion, and
check of growth.
The Madurese say that the 'cool' drinks and jamu to induce conception
have three closely related but distinct properties: coagulation of the woman's
blood and the man's sperm, increased viscosity of the mixture to prevent easy
extrusion, and stimulation of fetal growth. 'Hot' food and medicines have
the opposite qualites: they liquify the mixture to prevent its adhesion to the
womb, they hamper or slow down fetal growth, and they are abortive
(Jordaan 1985: 210). This picture is surprisingly similar to the Malay version
as provided by Laderman (1983: 78): ' ... operating on the theory that
coolness is necessary for conception, some women drink "hot" medicines for
their supposed contraceptive qualities and some use them as an abortifacient.
The fetus is considered to be a clot of blood, and hot medicine is thought to
liquify the blood, and to make the womb uncongenial for the child.'
One aspect which can be discerned clearly in the ritual surrounding preg-
nancy and childbirth is that of transition. For the child, these processes imply
a transformation from an anonymous fetus, a mere clot of blood in the
beginning, to a member of society. This transformation is achieved gradually,
and is only completed when the baby, about forty days after birth, is taken
out of the house and shown to the neighbors for the first time.
For the mother pregnancy and childbirth imply gradual social isolation
before birth, and social re-integration thereafter. Especially for women who
are pregnant for the first time the accompanying ritual takes on the character
of a rite of passage. Interwoven in rite-of-passage symbolisms, are symbols
which are thought to avert danger and which point to well-being and fertility.
240 A. NIEHOF
Since Madurese women are very concerned about the regularity of their
menstruation, every pregnancy is dubious in the beginning. The fact that it is
common to take medicine if menstruation is not on time (the so-called jamu
te/at bulan, for instance), provides a way out when pregnancy is suspected and
unwanted. A similar attitude 6 is reported to prevail among women in two
Chinese communities in Malaysia: The ambiguity in folk beliefs about when
a developing fetus becomes human makes the period between a missed
menses and the positive identification of pregnancy a time in which menstrual
induction cannot be subjected to negative legal sanctions or labelled medi-
cally as abortion' (Ngin 1985: 40). In Madura, any woman who takes her body
seriously should start drinking herbal medicine some days or even a week
before menstruation is due. The herbal medicine should contain ingredients
that are classified as 'hot', such as vinegar, yeast, ginger, and the like. A woman
who is eagerly awaiting pregnancy should refrain from these measures.
When in spite of all medication the menstrual flow does not start, preg-
nancy becomes probable. If it is unwanted, the woman may look for more
drastic means, such as induced abortion by massage. In the area of research
this was done by some elderly women, who were known as illicit abortionists.
The local traditional midwives did not want to have anything to do with these
practices. If anything went wrong it was usually the modern midwife who was
called in. When massage fails to produce the desired effect, pregnancy has to
be accepted. The dukon rembi' will be called or visited for a first examination.
During the first months of pregnancy 'hot' food and drinks are forbidden. The
early months of pregnancy, called andhek, which refers to the ceasing of
menstruation, are accompanied by the familiar physical signs and complaints.
The whims of a woman's appetite in such circumstances (getting sick from one
type of food, while craving for particular snacks) are explicitly acknowledged.
The husband is expected to see to it that his wife gets what she wishes. It is the
only situation in which women are allowed, and even expected, to make
explicit demands on their husbands.
If a woman sticks to the dietary rules, her pregnancy should develop well.
Still, incidence of pregnancy wastage appeared to be quite high. In the
research area about 10% of all pregnancies resulted in miscarriage or stillbirth
(Niehof 1985: 229). After the immediate risk of abortion is over, during the
PREGNANCY AND CHILDBIRTH IN MADURA 241
second period of the pregnancy, which lasts from the third to the seventh
month, some women reported having a missed abortion which they called
ekakan sambhilang. The fetus is thought to have been consumed in the womb
by a malicious spirit which materializes as a snake-like creature. The womb
expels only blood and dead tissue, sometimes pieces of bone.
The most significant moment in the second period of the pregnancy is when
the movements of the baby are felt for the first time, because this means that
the soul or roh has entered. Usually then, an offering of food is sent to the
kiyai. In some parts of Madura a special ritual is staged for the occasion.
'Ensoulment' marks the fetus as a developing human being. From now on the
dukon rembi' will visit the pregnant women regularly. The course of action is
now focused on strengthening the baby. This implies that food and drinks
classified as 'cool' are preferred to those classified as 'hot'. The discontinuity
between the two periods is in the status of the fetus, deniable in the first
period, positively identified in the second. During the first period the woman
refrains from taking 'hot' food for fear of abortion, during the second period
she takes 'cool' food in order to promote the baby's growth.
When pregnancy has lasted for seven months there is another turning point
in the course of gestation. While in the first seven months attention is
focussed on the stability, position, and growth of the fetus, during the last
months of the pregnancy the overriding concern is to facilitate birth. This is
dramatically demonstrated by the fact that the expectant mother will now
abstain from 'cool' food and drinks, because these would stimulate the baby's
growth too much and impede a smooth delivery.
Besides the change in food and drink habits, the last period of gestation
shows an increase in behavioral rules for the expectant mother and father,
which fall into a pattern described in detail for South-East Asia as a whole
(Hart et al. 1965). Many of the rules are aimed at preventing a complicated
and prolonged delivery. One of the complications most feared is a retention
of the placenta. Other rules are to protect the expectant parents in their
vulnerable condition. The fact that the same type of rules apply, for example,
to persons on the verge of their first marriage and for newlyweds, is in
accordance with the perception of pregnancy and childbirth as a transition
process.
The last turning point in the course of gestation is ritually and ceremonially
emphasized. On a suitable day in the seventh month a ritual is held. It is
referred to as raso! pellet kandong, 'ritual for the massage of the belly'. In
conjunction with the actual massage treatment by the dukon rembi' several
activities are staged. The ritual should take place in the house of the expec-
tant mother (where the young couple will usually live, given the rule of
uxorilocality). The family of the expectant father has to be invited formally;
both families contribute food for the meal to be offered to the guests at the
end, money, and other attributes necessary for the ceremony. Usually, a kiyai
is invited to lead the recital of Islamic texts with the male guests.
242 A. NIEHOF
CHILDBIRTH
When the birth pangs announce that the moment of delivery is near, the
dukon is fetched. The woman in labor is placed on a mat in the inner room of
the house. She is put in a semi-upright position, head and shoulders leaning
against the wall, and is covered with a piece of cloth. A towel is put over her
shoulders. The dukon usually refrains from internal manipulation and deliv-
ers the baby more or less by the touch.
After the baby has been delivered safely, the dukon awaits the birth of the
placenta before cutting the umblical cord with a bamboo knife. The baby is
cleansed with kitchen soot and tamarind fruit, and carefully bathed. The
navel wound is treated with an embrocation of turmeric root and mashed
leaves, but sometimes only wetted with water heated in a potsherd held in the
fire. To promote the drying of the wound, ground coffee beans, or the
pulverized earthen nests made by a specific sort of wasp, are put on it as well.
Usually some kitchen soot is added. The wound is dressed with a sirih (Piper
betle L.) leaf, and all this is covered with a piece of cloth tightly wound around
the baby's waist. The baby is given some honey or coconut water; the
colostrum is thought unfit for the baby to drink. Then it is brought to the
father, who has to whisper the Islamic confession of faith in the baby's ear.
After that, the baby may rest. It is put to sleep on a bed between pillows, or
on an upturned rice winnow. A knife with a chalk-cross on it, and a native
broom, made of the nerves of coconut palm leaves,8 are put alongside, to
protect the child from evil spirits.
The placenta also receives careful treatment. It is regarded as one of the
baby's siblings. In case of twins with one placenta, it is cut in half. The
placenta is thought to be the material form of one of the four invisible
siblings, who accompany the baby at birth, and who will reappear before their
earthly companion at the end of his or her life. This belief in the four invisible
siblings is not only found in Madura, but all over the Indonesian archipelago.
In this article we will not elaborate the theme. 9 I mention it to point to the
importance of the placenta. The placenta is cleansed with the same ingre-
dients as the baby was washed with. It is salted, and seasoned with all kinds of
spices, both of the 'hot' and the 'cool' type. Then it is wrapped in white cloth,
and put into an earthenware jar together with some rice, maize, coins, a piece
PREGNANCY AND CHILDBIRTH IN MADURA 243
Because the baby is almost entirely dependent upon its mother's milk during
the first months of its existence, the mother has to take care that her supply is
sufficient and the milk is of good quality. This is one of the ends served by
regularly drinking jamu (jhamo in Madurese). There are, however, other
reasons as well. The mother's body should be freed from all contamination
and pollution, both internally and externally, and should regain its normal
shape. To these ends, she has to drink daily herbal potions, and is rubbed
with herbal ointments. Just as in pregnancy there are also specific behavioral
rules which should be observed.
As regards the last, these are based on two principles. In the first place the
mother and baby are thought to be in a state of transition which makes them
very vulnerable to supernatural evill forces. Secondly, they are not only
contaminated, but also contaminating. The mother should therefore confine
herself to the house and compound, and should not come near the kitchen or
participate in cooking and cleaning activities.
The application of ointments follows a simple basic pattern. The woman's
244 A. NIEHOF
body is thought to consist of two parts: from the waist up, and from the waist
down. The latter part is called pora baba, the 'lower sore'. It is regarded as a
sore wound, which has to heal by expelling the pollution. For this part of the
body the ointment, called parem, contains 'hot' ingredients. The so-called
parem baba is thus classified as 'hot', while the parem for the upper part
should be fragrant.
The parem baba is particularly meant to expel the lochia, the 'dirty blood',
from the body. This blood is supposed to consist of white and red blood.
Retention of the 'red dirty blood' will cause the mother to feel unwell and
look unhealthy, while it also enhances susceptibility for a quick next preg-
nancy. The consequences of retention of the dirty white blood are even more
unfavourable. This polluting substance is believed to disperse throughout the
body, causing the woman to become pale and thin, finally leading to death.
The lixivium of burnt coconut shell, which was usually administered in the
interior village to women after childbirth, serves the same purpose. So does
the jhamo of the 'hot' type. This shows again that the interpretation of the
hot-cold dichotomy should take into account the ascribed qualities of the
categories, in this case the supposed Jiquifying effect of 'hot' medicine. 10
Just as the extrusion of the lochia is thought to be stimulated by 'hot'
medicine, the flow of milk is thought to be stimulated by it as well. The supply
of milk should be kept up by drinking medicine of the 'bitter' type, the
so-called ababeddjha, which consists of an extract of particular leaves. In the
village in the interior it was known as jhamo ranronnan. This type of jhamo is
also thought to enhance femininity. It is never taken by men. The whole
complex of medication, rules, and practices to be followed during the post-
partum period is summarized in Diagram I (see p.245); in Diagram II (see
p.246ff.) are listed the names and the ingredients as well as the therapeutic
purposes of the main herbal drinks and ointments to be taken by pregnant
and post-parturient women.
During the period of forty days after childbirth, it is customary to visit
mother and child, bringing a gift in kind. Only female guests are expected.
Formerly, they were requested to hold their feet over a smouldering woodfire
which was kept burning in front of or on the front porch especially for this
purpose. This was to prevent the visitors from inflicting illness and adversity
upon the vulnerable baby. Nowadays, few people keep to this custom. When
there are guests, the young mother keeps in the background, letting her
relatives, or a neighbor do the honors. It is a relaxed social occasion, which
allows for leisurely gossiping.
Although this last stage of the gestation and childbirth process is referred to
as the forty-day period, actually the closing ceremony may take place when
the baby is between 38 and 42 days old. For the selection of the day of the
final ceremony the sex of the child is also taken into account: an odd number
of days after birth for a boy, an even number for a girl. The occasion is called
molang are, which could be translated as the 'turning point day'. The day
PREGNANCY AND CHILDBIRTH IN MADURA 245
DIAGRAM I
Treatment of the mother during forty-day period after childbirth
Common ingredients
Name of herbal Therapeutic purpose
drink or ointment Local name Scientific name
jhamo rang-rang ana' sentok Cinnamomum sintok BI. One of several 'hot' herbal potions commonly
(birth control jamul mose Carum copticum Benth. used for regulating the menses. It may be
sa'ang bunto' Piper cubeba L. regarded as the Madurese equivalent of the
cabbhi alas Piper retro/ractum Yahl. factory-made lama Telat Bulan (see text). In fact,
jhai Zingiber officinale Ros. it can also serve contraceptive or rather abortive
laos Alpinia galanga Sw. purposes (hence its name rang-rang ana').
jhamo cellep sere temmo ora' ? Piper betle L. These ingredients make up one of the 'cool'
('cool' jamu) konce pet Kaemp/eria rotunda Linn. herbal potions to be taken during the first months
konce koneng Gastrochilis panduralum Ridl. of gestation. Apart from its 'cooling'
jhinten ereng Nigella saliva L. effects, the herbal potion should have adhesive
aeng landhana kapor water from lixivated chalk. properties lest the ovum should be expelled too
easily. This herbal potion is taken for three
sennam ~Tamarindus indica L.
months and then replaced by herbs which belong
bluntas Pluchea indica Less.
to the hasic ingredients of 'cool' herbal potions,
paspasan Coccinia Cordi/olia GLGN.
like senllam. bluntas. paspasan
jhamo anga' jhai Zingiber officinale Ros. At about the sixth month of gestation women
('hot' jamul daun jerruk kerres Citrus spec. (unidentified) should avoid 'cool' herbal drinks lest the fetus
mcnya' nyeor Cocos nuci/era Linn. should grow too large, thus impeding a normal
delivery. To facilitate delivery one may take
herbal potions which contain both 'hot' and
lubricating suhstances, as is shown in the
composition,
jhamo marena laher 1. temmo labak Curcumalonga L. These herbal potions are taken during the forty
(post-partum jamu) daun bluntas Pluchea indica Less. days after parturition. In combination they serve a
accem Tamarindus indica L. three-fold purpose: to stimulate lactation, to clean
telor ajam egg (yolk) the body of 'dirty' blood and other polluting
buja salt substances, to restore or enhance the health of
aeng landana batok water from Iixivated ashes the mother.
of coconut
2. kaju konyenga1 Cinnamom spec.
bhabang pote Allium sativum Linn.
aeng landana water from lixivated kitchen
abu tomang soot
parem baba klabhet Trigonella foenum graecum Lam. A 'hot' type of herbal ointment, which is to be
('lower' ointment) kastore Hibiscus abelmoschus L. applied to the lower part of the body. Its main
klemba' Rheum officinale Baill. purpose is to expel the lochia and to prevent
kaju candana Santalus album Z. abdominal swellings.
kembang konanga Cananga odorata Hook & Thoms.
kembang ramo' flower (unidentified)
kencor Kaempferia galanga L.
sa'ang pote bunto' Piper cubeba L.
jhai Zingiber officinale Ros.
laos Alpinia galanga SW.
parem atas konanga Cananga odorata Hook & Thoms. This ointment, which is both fragrant and 'cool',
('upper' ointment) ghaddung Dioscorea hirsuta BI. is to be applied to the upper part of the mother's
klabhet Trigonella foenum gracecum Lam. body (including the face). Its main purpose is the
kastore Hibiscus abelmoschus L. stimulation of lactation.
masoje Massoia aromatica
pocok Saussurea lappa Clark.
klemba' Rheum officinale Baill.
kalabistu Andropogon muricatus Retz.
candana Santalum album L.
N
continued on p. 248
~
DIAGRAM II continued ~
Herbal drinks (jhamo) and/or ointments (parem) during gestation and the post-partum
ababeddjha kasembu'an Paederia foetida L. This is a herbal potion to stimulate lactation and
(a bitter drink) daun jabbau unidentified simultaneously promote the health of mother and
ga'saya'an Hydrocotyle asiatica L. child.
lang-alang Imperata arundinaceae Cyrill.
rebbha pena'an Ehretia microphylla Lamk.
daun kamoneng Murraya exotica L.
ner-menneran Phyllanthus nururi Linn.
daun bluntas Pluchea indica Less.
daun lambibing ?Stenochlaena palustris Bedd.
salangkeng Anisomeles ovata R. Br.
daun blimbing bulung A verrhoa bilimbi L.
jhamo ronronnan daun kasembu'an Paederia foetida L. To stimulate lactation.
(a lactative jamu) daun mangkamang Hyptis suaveolons Poit.
rebbha sebu ?Oplismus Burmanni R. Br.
daun ka'seka'an Euphorbia reniformis BI.
daun ner-menneran Phyllanthus nururi Linn.
daun prengtale Bambusa spec.
buwa koddu' moda Morinda citrifolia L.
daun lanas duri Agave vivipara L.
daun komangae Ocimum basilicum Linn.
konco'na daun Flacourtia Rukam Zoll. & Mor.
rokkem ngoda
jhamo paka' majha kelleng Terminalia chebula Retz. After molang are. the end of the post-partum
(an aphrodisiac) sonte Zing. offic. L. var. Hassk. period, the woman is allowed to resume sexual
ghante Ligusticum acutilobum S. & Z. intercourse. For that purpose she may take jhamo
jlabi Terminalia laurinoides T. & B. paka', an aphrodisiac herbal potion. This drink
concong pandan Rhus Semialata Murr. not only makes her vagina shrink, but also
cangkok Schima noronhae Rnw. prevents unpleasant odors.
majhakane Quercus infectora Olv.
pekok unidentified
samarantok Sindora sumatrana Miq.
kadabung Parkia intermedia Hassk.
klemba' Rheum officinale Baill.
masoji Massoia aromatica
prabas Tetranthera brawas BI.
katombhar Coriandrum sativum L.
jhinten ereng Nigella sativa L.
bidhara ghunong Strychnos Iigustrina BI.
konye' Cur. longa L. var. Hassk.
pocok Saussurea lappa C1ar.
addas Foenicum vulgare Gaertn.
palasare Alyxia stellata R. & S.
konce pet Kaempferia rotunda Linn.
~
\0
250 A. NIEHOF
The kiyai, who is also invited, leads the male guests in the singing about the
life of the Prophet. In the village in the interior, the bathed and dressed-up
baby is put on a tray with flowers and handed over to the men, who are sitting
together in the langgar. They hold the baby in turns, while singing and taking
a flower from the tray. Thus, it is welcomed into the community of believers.
Finally, everybody is given a meal. The dukon rembi' is rewarded for her
services in money and in kind. She is also given a chicken which is the same as
the one the pregnant woman held on her lap as a baby chicken at the occasion
of the 'ceremony of the massage of the belly'. The chicken is referred to as
rep-orep ('being alive'), to signify the fact that the baby has survived the first
critical weeks of its existence.
After the molang are ceremony, the baby may be carried out of the house.
It is shown to neighbors and relatives, and given coins. As the people say, in
this way they 'share in the coolness of the baby'. The mother is now
considered clean. She is supposed to take up her social duties and get to work
again. The couple may resume sexual intercourse. The process of transition is
completed.
NOTES
1. The author did fieldwork in Madura for two years, during the years 1978-79. The doctoral
dissertation based on this fieldwork was published in Leiden in 1985 (see References below).
The research was subsidized by the Indonesian Studies !>rogramme. A substantial part of the
data in the present article is taken from a study of Madurese traditi\lnal .nedicine by my
husband R. E. Jordaan, who conducted his, own field work in Madura during the same period
(see Jordaan 1985).
2. The rates for infant mortality and mortality of children under five, which were calculated on
the basis of Fertility Survey data from the two villages of research, were significantly higher
than comparable figures for rural East Java. Infant mortality rates for both sexes, computed
for the birth cohorts of 1967-76 were 197 and 191 (per thousand) in the two Madurese
villages, while the rural East Java figure is 121 per thousand live births for a comparable
period. Figures of children who died before reaching the age of five, of the birth cohorts
1957-72 were 296 and 317 per thousand live births in the Madurese villages, while the rural
East Java figure declines from 192 to 117 during about the same period. See Niehof 1985:
288-290.
3. The position of women and the level of fertility appeared to be strikingly different for the two
types of villages (cL Niehof 1985).
4. These ideas are not uncommon in Asia. See, for instance, Hunte (1985: 53) on indigenous
methods of fertility regulation in Afghanistan.
5. Manderson's (1981: 510) observation that 'Malays regard pregnancy as a hot state' does not
apply to the Madurese. As we shall see in the next section, in Madura the notions of hot and
cold are applied throughout the processes of gestation and childbirth in a differential manner,
252 A. NIEHOF
which refutes a static perception of pregnancy. Another researcher reporting on Malay birth
customs (Laderman 1983: 41) actually denies that the Malay view pregnancy as a persistently
hot state.
6. See also Browner (1985) on pregnancy control in Cali. Colombia, and Hunte (1985) on
indigenous fertility regulation in Afghanistan.
7. For a description of the ceremony see Niehof 1985: 232-235.
8. This broom is called panebbha (Indonesian sapu lidi). It features in many ceremonies and is
regarded to have an auspicious influence.
9. More information about the 'four invisible siblings' can be found at several places in Jordaan
1985.
to. Explanations such as that 'with parturition heat is lost and the woman moves to a state of
excess cold' (Manderson: 1981: 511), or that 'after child-birth a woman enters a "cold" state
because her body has been depleted of blood, the "hot" body fluid' (Laderman 1983: 41), do
not take these into account.
11. For a more detailed list of recipes of herbal medicine to be taken during gestation and the
postpartum period, see Jordaan 1985: Appendix E, pp. 332-342.
REFERENCES
Browner, C. H.
1985 'Traditional Techniques for Diagnosis, Treatment, and Control of Pregnancy in Cali,
Colombia', In Women's Medicine L. F. Newman (ed.), pp. 99-125, New Jersey:
Rutgers University Press.
East Java Nutrition Studies (Report I, II, III)
1977- SurabayaiAmsterdam: Universitas Airlangga/Koninklijk Instituut voor de Tropen.
79
Ellen, R. F.
1983 'Social Theory, Ethnography and the Understanding of Practical Islam in South-East
Asia', In M. F. Hooker (ed.), Islam in South-East Asia, pp. 50-92, Leiden: E. J. Brill.
Hart, D. V. et al.
1965 Southeast Asian Birth Customs. Three Studies in Human Reproduction. New Haven,
Conn.: Human Relations Area Files.
Hiroko Horikoshi-Roe
1980 'Asrama: An Islamic Psychiatric Institution in West Java'. Soc. Sci. & Med. 14B (3):
157-167.
Hunte, P. A.
1985 'Indigenous Methods of Fertility Regulation in Afghanistan'. In L. F. Newman (ed.),
Women's Medicine, pp. 43-77, New Jersey: Rutgers University Press.
Jordaan, R. E.
1985 Folk Medicine in Madura (Indonesia). Leiden: Ph.D. thesis.
Laderman, C.
1983 Wives and Midwives: Childbirth and Nutrition in Rural Malaysia. Berkeley: Univer-
sity of California Press.
Manderson, L.
1981 'Roasting, Smoking and Dieting in Response to Birth: Malay Confinement in Cross-
cultural Perspective'. Soc. Sci. & Med. 15B: 509-520.
Niehof, A.
1985 Women and Fertility in Madura. Leiden: Ph.D. thesis.
Ngin, Chor-Swang
1985 'Indigenous Fertility Regulation Methods Among Two Chinese Communities in Ma-
laysia'. In L. F. Newman (ed.), Women's Medicine, pp. 25--43, New Jersey: Rutgers
University Press.
CAROLINE H. BLEDSOE AND MONICA F. GOUBAUD
INTRODUCTION
PREVIOUS RESEARCH
BACKGROUND
Medications end up for sale on the street or in private drug stores and clinics
of private practitioners. A 'secondary' system of medical practice has arisen in
which medical personnel who work in major hospitals and clinics also set up
private practices in their own homes with these supplies and sell them at
discounted rates (see also van der Geest 1982a and 1982b).
For these reasons, a sick person is unlikely to find many Western pharma-
ceuticals at government hospitals or clinics. More likely sources are private
pharmacies owned by doctors who work in the major government hospitals,
locally trained nurses, licensed - and unlicensed - dispensers, shop keepers,
market women, and often illiterate and unlicensed drug salesmen who walk
or bicycle into rural villages with drugs bought from large stores in town.
(Mission hospitals, however, usually have better supplies than government
hospitals.) One man with no medical training reported that his wife, a nurse at a
local hospital, had her own 'private practice' and sold medicines out of her
home. If she was out of the house or busy when patients came, he himself would
diagnose the illnesses, sell the patients medicines, and advise them on dosages.
Despite the dearth of medicines in government hospitals, almost any
Western drug that gets into Sierra Leone can be purchased from these
alternative practitioners and dispensers, or over the counter in private phar-
macies. One Peace Corps volunteer reported that some of her students were
falling asleep during class. She finally confiscated some narcotic tablets from a
boy who had supplied them to his classmates, and found that they were a
variety that had been banned in the US. People also acquire drugs readily from
friends or relatives with unused supplies, who are frequently called upon for
advice. Even drugs that were acquired through controlled prescriptions are
easy to get through an acquaintance who decides not to complete a treatment,
but to save the rest of a prescribed dosage for his own or someone else's
future need. Such drugs, in fact, may be seen by people as more desirable to
try, because the initial requirement of a prescription made them more difficult
to obtain, and thus heightened their aura.
Many possibilities for inappropriate use of pharmaceuticals, then, do stem
simply from lack of information. For example, pills are usually sold without
containers or directions, other than those the salesman gives - often wrongly.
This occurs because practitioners acquire most drugs in large quantities,
whereas their customers can seldom afford to buy more than a few doses at a
time. Also, because of the general lack of containers in the area, a person
may put all his pills together in one jar or in a small bit of plastic, and soon
forget what the original purpose of each pill was said to be. When literate
Mende visit villages, they are frequently approached by residents with jars
containing different kinds of pills and asked to identify them. One teenage
school boy related that the way he generally dealt with this problem was by
asking what the sufferer's complaint was when he or she was given the pills.
When an elderly woman, for example, brought him some tablets to identify,
she recalled that she was not eating well when she was given the tablets at the
DISTRIBUTION OF PHARMACEUTICALS IN SIERRA LEONE 261
hospital clinic. Since eating well is an important attribute to the Mende, the
young man naturally concluded that the tablets must be intended to improve
her appetite, and told her so.
If widespread availability of medications and lack of knowledgeable survey-
ors lead to greater possibilities of interpretation, another factor compounds
the problem. Because imported pharmaceuticals are valued goods and are
seen as effective for a wide range of sicknesses, it is not surprising that
individuals strategically reinterpret and exploit the meaning of these valued
new elements. Injections, for example, are given for a wide range of mala-
dies, though they often have no physiological justification from a Western
perspective. They are widely touted by practitioners who play upon their
customers' beliefs in the power of injections in order to boost cash flows. Van
der Geest (1982b: 270) cites an even more apt example in Ghana, wherein a
young boy attempted to sell him some capsules which, the boy said, were for
piles. Later, to other customers (presumably Ghanaians), the boy cast the
same capsules as remedies for sexual impotence. It is clear that the boy had
sized up the likely worries of the two kinds of customers, and pitched his
efforts accordingly.
Our findings clearly point to such tendencies. Pill traders in Sierra Leone
develop a keen sense of who their potential customers are and of their likely
complaints. When traveling to rural villages, traders are apt to call out,
'Medicines for aches and pains!', whereas in an urban setting they will
advertise the same medicines to secondary school students as agents combat-
ting sleepiness and inability to concentrate. In general, they try to ask
customers' complaints, rather than wait for customers to ask if they have
certain kinds of pills. In this way, the traders draw attention to attributes of
the pills they do have that are culturally compatible with their customers'
perceptions of the causes of their afflictions.
Not only can the meaning of the medicines be manipulated: it can also be
hidden deliberately. Because medicines comprise the basis of many individu-
als' livings, accurate knowledge about cheap and effective pharmaceuticals
and remedies is not always transmitted to people. Employees of a mission
hospital periodically drove out to a rural village to give public talks on cheap
and simple malarial remedies involving chloroquin sequences, and to explain
WHO - recommended treatments for child diarrhea using boiled water, salt
and sugar. However, the local licensed government dispenser, who derived
most of his income from the private sales of medicines, realized he would lose
a good deal of money from the sale of painkillers and dysentery medicines if
such information were spread widely. Consequently, he successfully pres-
sured the town leaders to forbid the hospital employees to return. s
Besides the blatantly exploitative uses of medicines, even when the manu-
facturers' instructions and warnings are known, a major reason why the
Mende do not necessarily accept the rationales that outsiders present for how
the medicines work is that some of these alleged functions are contrary to the
262 C. H. BLEDSOE AND M. F. GOUBAUD
Mende logic of sickness and cures. That is, pharmaceuticals may be used
inappropriately because of how the Mende attempt to reinterpret outside
drugs with powerful, mysterious potentials into locally comprehensible cul-
tural categories. In such cases, we would predict that only if these medicines
are culturally reinterpreted will they be accepted. We turn, then, to this more
cognitive aspect of Mende views and uses of pharmaceuticals.
METHODOLOGIES
Most of the material for the study was collected in a town around 4,500 in
Eastern Sierra Leone. The population was predominantly Mende, although it
contained people belonging to several other ethnic groups. The methodolo-
gies employed in the study included making observations and conducting
interviews on local uses of Western medicines, common illnesses and their
etiology and treatment, the local health care delivery system, and the diag-
nosing and prescribing practices of drug sellers. Those interviewed included
local health practitioners such as store keepers, an itinerant drug salesman,
several hospital workers who had private practices, as well as laymen. At
times, formal interviews were conducted in the researcher's house; but she
also went to stores and clinics to obtain a sense of the contexts in which
illnesses were diagnosed and medicines dispensed. One of the most valuable
methods was simply walking through the town and asking questions when sick
people were observed and while medicines were being taken.
Besides these more open-ended methods, the investigator also constructed
a large plastic packet as an elicitation device that displayed locally available
pharmaceuticals. Several vertical and horizontal seams were sewn into the
plastic to create 30 pockets, each containing a pill, capsule, or other Western
preparation such as a small tin of Mentholatum. Included were antimalarials,
vitamins, analgesics, worm medications, digitalis, ephedrine compounds,
steroids, antibiotics, and so on. 6 The packet also contained a few drugs such
as a Contac cold capsule and a One-A-Day vitamin that were not available
locally. These provided variety in shapes, sizes, and color which might elicit
interesting responses.
The investigator then asked ten people if they had ever seen the medicines
before, and if so, how they or other people had used them: for what illnesses
or symptoms, in what kinds of dosages, and why those particular ones had
been chosen. She also asked individuals what else they would do or take for
the maladies they had mentioned, even if these remedies were not included in
the packet. A few people queried were illiterate, and one could speak no Krio
or English - the lingua franca of Sierra Leone. But most people interviewed
had at least a secondary school education, and several had been through three
years of Teacher Training college. One man had been sent to Nigeria by the
Sierra Leonean government for extensive training in hematology and later
worked for a mission hospital.
DISTRIBUTION OF PHARMACEUTICALS IN SIERRA LEONE 263
THE FINDINGS
for example, are powerful, they can also be a dangerous force. For some
illness conditions, injections are seen as fatal. One man conducting a survey
of child mortality found that women whose children were thought to be
suffering from yellow fever did not bring them to the hospital, for fear that
they would receive injections and die.
Pills and tablets are seen as less effective than injections, though their
potency is not to be underestimated. People usually chew pills thoroughly
before swallowing them, because they fear that the tablets will settle in the
stomach and cause pain. Moreover, people fear that the pills' effectiveness
will be reduced if swallowed whole, making them act very slowly, if at all.
Capsules are seen as among the strongest remedies that vendors of Western
medicines can offer. Capsules are preferred for the treatment of wounds
because the contents are in powdered form; people break the shells and pour
the powder on wounds or open sores. However, capsules are also swallowed
for a variety of ailments, and their perceived value is high. Said the head of an
under-fives' clinic for children:
The clinics we run do not have capsules [since antibiotics can be dispensed in other forms]. When
we go, they [patients' mothers] ask us, 'Did you bring capsules?' We say, 'No'. In fact, I tell them
that capsules cannot be swallowed by a young baby, so that means the [medicine] is out of our
list. So they just move up [go away].
When asked why the Mende like capsules so much, one young man replied
that the medicine must be powerful because the manufacturers took the
trouble to seal it tightly in plastic. He also pointed out that because Western
practitioners told patients the taste would be very unpleasant if they chewed it
first (and thus urged them to swallow the capsule quickly), this was also a sign
that it must be a powerful medicine.
Interestingly, the logic of this can be extended to remedies with which
people are unfamiliar. The investigator showed two people, independently, a
Contac cold capsule, which they had never seen, and asked them what they
noticed about it and what they thought it might be useful in treating. Both
drew attention to the fact that the capsule actually contained many smaller
capsules or plastic balls that contained the medicine. One man pointed out
further that because capsules are seen as powerful, then this form of capsule -
a capsule within a capsule - must be highly potent indeed. The two also drew
attention to the fact that these smaller balls were of three different colors.
Although both dismissed the Contac capsule as efficacious for open wounds
because the little balls would fall off, one of the two commented that people
would use the capsules for diarrhea (often attributed to worms) because of
the white medicine balls (white being associated with a bitter taste), and
perhaps for blood problems, because of the red balls.
Colors are critical attributes by which the Mende interpret the functions of
medications. White and red colors are important signifiers of certain kinds of
physiological effects, as the following section will amplify. One woman
DISTRIBUTION OF PHARMACEUTICALS IN SIERRA LEONE 265
The most important factors that governed people's choices of remedies for
specific ailments seemed to revolve around qualities such as shape, color,
taste, and consistency. These choices reveal that fundamental transforma-
tions in meaning have taken place as the Mende adopt certain pharmaceuti-
cals. Yet their choices often reveal remarkable consistency with traditional
interpretations of the causes and cures of various types of illnesses. To
illustrate this, we describe three maladies that people mentioned most fre-
quently and some of the Western pharmaceuticals they used to treat them.
Fever
Fever is a common Mende complaint. In Western etiology it is associated with
a host of illnesses, with malaria perhaps the most predominant cause. Many
people, particularly the well educated ones, understand that mosquitoes carry
malaria. But virtually everyone expressed a humoral theory of its ultimate
causation: exposure to excessive cold or wind is said to cause the chills that
precede high temperatures. Some people report malaria attacks after drink-
ing cold liquids, and politely refuse drinks that have been refridgerated.
Fever is also said to result from hard work, because sweat is produced, which
cools the body. Sweat is harmless during the warmth of the day, but if not
washed off thoroughly in the evening with warm water, it will cause fever
because of its cooling elements. (Hard work may also produce body aches
which the Mende associate with malaria.)
Because the body is said to be suffering from too much cold, traditional
remedies have been those that people believe will make the body warm.
Dressing warmly, of course, is the most immediate remedy, and one com-
monly sees small children as well as adults who are suffering from fever
bundled in heavy caps and layers of clothes.
Foods provide other fever remedies. Indeed, just as the Mende do not
rigidly separate traditional from Western medicines, neither do they neces-
sarily separate food and drink from medicine (see also Etkin and Ross 1982).
People say they eat rice, the staple food, to fill up the body, alleviate hunger,
and (for children) to grow. But they view the other foods such as sauces,
condiments, and palm oil that go with the rice as medicinal agents that help
maintain the body's health. A salient ingredient of West African food dishes
is spicy hot pepper. To Westerners, peppers are a type of food or condiment,
but the Mende insist that peppers have strong medicinal properties: they
produce heat in the body, which can combat fevers. During the 'cold season'
from November to February, some people add even more peppers to their
sauces, along with other traditional bitter remedies, using them prophylacti-
cally to give the body additional protective warmth.
DISTRIBUTION OF PHARMACEUTICALS IN SIERRA LEONE 267
Worms
The Mende say that worms and small organisms called fulu-haisia (literally,
living things') in the body can cause a multitude of conditions. 'Big worms'
that can often be seen in the stools cause diarrhea, vomiting, dysentery, and
cholera, with consequent weight loss and malnutrition, especially among
young children. Most diarrhea and vomiting, in fact, is attributed to worms,
making worm medicine a frequent accompaniment to a variety of remedy
sequences. People also attribute conditions such as kwashiorkor to worms,
because a child's skin may become light, which indicates to the Mende that
worms have been sucking the blood. Also the stomach becomes bloated
which suggests the presence of worms.
'Small worms (organisms)' that cannot be seen but can be felt are said to
cause conditions such as sore throats and coughs, including diseases such as
tuberculosis, because the scratchiness in the throat is said to result from the
worms crawling up and down as the sufferer breathes in and out.
Although the Mende believe that worms can be acquired from drinking
water that is visibly dirty, worms are said to thrive on 'sweet' things that the
sufferer has eaten, or even to spontaneously generate in the body, from too
many 'sweet' things. 'Sweet', here, implies either sugary sweet, such as
papaya, oranges or Western-inspired candy, or good tasting, such as chicken,
meat, etc.
In Mende logic, because fulu-haisia thrive on sweet things, they may be
killed in the body, or at least discouraged, by eating or drinking bitter things.
Tuberculosis, for example, may be treated by drinking the juice of bitter
limes or lemons, which trickles slowly down the afflicted throat. Intestinal
worms can be treated by eating extra helpings of peppers.
To help prevent worms, on the other hand, children should be given little
meat, chicken, eggs, or fish, all of which are considered 'sweet'. In Mende
logic, in fact, these 'sweet' protein foods should be the last things to feed a
child with kwashiorkor, because the worms that are said to cause this
condition would simply be encouraged to grow and spread. When asked,
however, why adults can eat 'sweet' foods that are considered harmful, one
man explained that adults willingly eat bitter things to counteract the effects
of the sweet foods. But children are too young to be coaxed to injest bitter
foods or medicines that would counteract the bad effects of sweet foods.
Western-trained medical workers in Sierra Leone report widespread non-
compliance with their recommendations about proper foods for kwashiorkor
patients. They complain that small children are commonly given little more
than bones to chew on, implying that adults do this out of greed. It is true that
meat is considered a lUXury rather than a necessity; thus, adults - particularly
men, who command the most privilege - deserve most of it. These appear to
be important factors in many kwashiorkor cases among Mende children,
although declining access to sources of animal protein is probably equally
DISTRIBUTION OF PHARMACEUTICALS IN SIERRA LEONE 269
important. But the Mende also say that bone marrow, which children are
commonly given, is one of the best parts of the meat; more importantly,
marrow is safe for young children because it is surrounded by solid bone
which fulu-haisia cannot penetrate.
Although the Mende traditionally used bitter peppers, leaves or roots to
treat cases of fulu-haisia, Western medicines that taste bitter are quite
acceptable alternatives. Therefore, although people do take pharmaceutical
worm medication that is sold expressly for the purpose, they may take as
worm antidotes any pills that are bitter. Indeed, it is likely that many people
actually avoid the large sugary worm tablets manufactured by Western
companies for children, preferring to use any pills that are bitter. And, as
with fever, the preferred pills for treating worms and diarrhea are white, not
because of the color per se, but because white is associated with bitter pills,
which kills worms. For sore throats, coughs, or tuberculosis, anything harsh
smelling such as Mentholatum or harsh tasting such as certain kinds of cough
drops are said also to kill worms.
Blood
The Mende say that blood is vital yet difficult, if not impossible, to replace. It
may be lost through injuries or debilitating sicknesses, which are said to make
the blood dirty or drain it. Blood is also lost during bouts with fulu-haisia,
which are said to suck it, or by having blood samples and donations drawn at
the hospital. The Mende view with great fear the attempts of hospital workers
to induce them to give blood. Hospital workers in Sierra Leone - as in much
of West Africa - report enormous difficulties in getting people to donate
blood, even for the use of close relatives who may be dying.
Nonetheless, people do try to replace or purify blood. Traditionally, the
Mende have relied on certain foods and medicinal substances. Greens such as
spinach and potato leaves used in sauces are commonly used for these
purposes. However, palm oil is the favorite remedy for dirty or inadequate
blood. In fact, young children may be fed only soft rice and palm oil until well
into their second year: rice develops the body, while palm oil makes it
produce blood. Unfortunately, though, some of the foods that might be richest
in iron are seen as potent medicines that are too strong for a young child's
stomach. Although Western trained medical personnel try to urge mothers to
feed greens to their children, they report limited success in this.
Like the traditional Mende remedy, Western medicines that are red in
color are widely used to build or purify the blood. Hence, all the red
medicines in the display packet were said to be suitable for blood. These
included iron tablets, diuretics, pile tablets to relieve constipation, and folic
acid to promote healthy pregnancies. In fact, the man trained in hematology
in Nigeria for hospital work, now working as an independent drug seller,
expressed great interest in obtaining the investigator's bottle of One-A-Day
270 C. H. BLEDSOE AND M. F. GOUBAUD
vitamins, even after he was told there was no iron in the tablets, because he
knew how eagerly his customers would buy red medicines. When asked if
people would actually take pills of different colors, the salesman replied that
they probably would, but if they did not feel better after a day or two from the
effects of what they perceived as blood problems, they would probably
abandon these other pills. However, they would be more likely to stick to red
pills.
Besides these remedies in the packet, people pointed out that there are
other red remedies for blood problems. Blood tonics manufactured abroad
that are red or brown in color - undoubtedly, intentionally - are extremely
popular. Other blood remedies include red soft drinks and even orange-
colored drinks such as orange Fanta. A favorite remedy is Guiness Stout, a
beer that is deep reddish brown in color. Several of the Mende hospital
workers were said to recommend it 'for blood'. Such uses question standard
assumptions of the Westerner that what is a non-nutritious luxury item will be
viewed by local people in the same ways. The researcher commonly offered
Mende visitors soft drinks such as Coke, Sprite, and Fanta, However, one
man finally explained that although her guests chose politely among these,
most would really prefer Vimto, a bright red carbonated beverage, for health
reasons, or brown Guiness Stout, neither of which she bought because she
disliked their taste.
Health maintenance
Besides treating symptoms of diseases, the Mende are concerned with main-
taining a healthy body, and view foods such as greens and palm oil as useful
for this. They are also impressed by the health maintenance potentials of
Western medicines. Several different medicines can help maintain good
health. According to one old woman, small orange junior aspirin can give
good health and strength, and can be taken every day or whenever extra
strength is needed.
The Mende particularly value capsules for preventive medicine. As noted
above, they perceive capsules as highly potent. Moreover, capsules with
different plastic colors on either end are seen as particularly efficacious
because the two colors suggest that the capsules contain different kinds of
medicine. A secondary school graduate reported he took a 'red and black'
capsule, which he knew to be the antibiotic Ampicillin, after a hard day of
work on the farm, to prevent a sore body the next day and to wake refreshed
for the next day of work. They are also used on a more regular basis. A clinic
worker reported that because capsules are seen as a potent Western medi-
cine, they are highly valued as daily preventive medicines. Hence, people
with wealth often buy capsules - which usually happen to be antibiotics - and
take them once a day, like vitamins. The clinic worker explained:
DISTRIBUTION OF PHARMACEUTICALS IN SIERRA LEONE 271
Some [people], when they come to sell their coffee or cocoa, they buy these drugs ... as a sort
of [prevention] kit. They take it every morning, like antibiotics. They make it as something usual.
Every morning, when they are eating their food, they will take one. They feel it is prevention
against further sicknesses. In fact, some people say that is why you [white, foreign] people live
longer: because every day you eat (take) medicine ... They say every pumo; [White, foreign
person] has got a small stock of drugs which they use every day. This makes them active and
strong.
soon after taking eight pills of unknown origin during self-medication for an
illness. Another reported that his six-month-old daughter got sick with
malaria when she was taken with her mother to visit the mother's village. The
mother and the relatives gave her 'all sorts of tablets' and had the local
dresser inject her. She died, the father reported, probably because of all this
medication: not because of the malaria. Not surprisingly, children suffer
many of the more serious consequences of inappropriate uses of pharmaceuti-
cals. Several cases of toxic poisoning and death were reported among children
who were fed whole packages, or even bottles, of worm medicine. Nor are the
Mende alone in such mistakes. A hospital supervisor noted that the baby of a
local Lebanese merchant family had died because its mother had dosed it with
many different drugs on her shelf, attempting to cure it of what was initially a
minor ailment.
There may also be a large number of disguised cases of pharmacogenic
maladies. During an interview with a local nurse about the uses of Western
medicines, an elderly woman came in with her small grandson who was
suffering from a severe case of malaria. Perhaps because she was being
queried about the subject, the nurse probed the grandmother and discovered
that she had given the boy a large dose of worm medicine to cure his stomach
ache, but this had apparently made him sicker, further depressing his appetite
and weakening his resistance. This, in turn, intensified and prolonged his
malaria.
These findings have important implications for development professionals
and for medical practitioners seeking to apply their knowledge and introduce
pharmaceuticals into societies that have cultural assumptions that differ
widely from their own. However, the reinterpretation of pharmaceuticals has
implications for our own society, because practitioners may assume too
readily that they and their patients share understandings and assumptions
about illnesses and how medicines affect them. It is probable that people in all
societies engage to a greater or lesser extent in reinterpreting medications
they have borrowed from other people or especially from other societies. For
example, American patients' occasional 'noncompliance' with physicians'
treatment instructions have been a persistent concern to medical sociology. In
fact, a group of nurses at a US hospital, hearing the results of the Mende
study, declared that they repeatedly encountered patients in their own wards
who refused medications or asked for other kinds of treatments the nurses
were convinced had no medical basis.
Another public health problem that can result from the reinterpretation of
medicines is that the effectiveness of certain drugs for the outside world
depends on sparing yet thorough application. Nonessential use of antibiotics
as well as using antibiotics in dosages that are too small to effectively kill the
target bacteria encourage the development of resistant dangerous bacterial
strains, and lower the effectiveness of antibiotics, a problem of growing
international concern. 9
DISTRIBUTION OF PHARMACEUTICALS IN SIERRA LEONE 273
Paradoxically, it is easy to see the differences between our own and other
people's cultural beliefs when examining material items that are very different
from our own. But it is harder to appreciate the strength of those different
traditional beliefs when the materials they involve originate from our own
culture, and have been reinterpreted in another cultural setting. Such items or
ideas may be imbued with completely different assumptions and meanings,
but because of our familiarity with the objects, we fail to perceive this shift in
meaning that has taken place. Yet in the case of drugs, the potential conse-
quences of this reinterpretation are enormous.
ACKNOWLEDGEMENTS
We thank the following people for their assistance during the research as well
as helpful comments on earlier drafts: Hermann Dornieden-Miiller, Renata
Dornieden-Miiller, Evelyn Early, Sister Hilary Lyons, Carol MacCormack,
William Murphy, Robert Welsch, and Sjaak van der Geest.
A previous version of this paper appeared in Social Science and Medicine,
Vol. 21(3), pp. 273-282. We are grateful to the editors for permission to revise
and publish this version.
NOTES
3. Self-medication is usually the first and most common form of treatment, yet it is one of the
least studied. Research has focused on behaviors in clinical situations, whereas few systematic
observations have been made on the role and prevalence of self-medication by sick people: for
example, asking family members, friends, and neighbors for medical advice, and evaluating
the effects of self-treatment and therapy from different sources. See, however, Arya and
Bennet (1974), A. Young (1976), Taussig (1978), Cosminsky and Scrimshaw 1980, Kleinman
(1980), Nichter (1980), Ferguson (1981), J. Young (1981), Melrose (1982), Silverman et al.
(1982), van der Geest (1982a), Good (1977), and Kroeger (1983). Attention to self-medication
and the acquisition of pharmaceuticals in developing nations provides information on the
networks and resources for health care outside 'official' channels; the roles of innovators and
cultural interpreters that drug peddlers, 'injection doctors', and others play; and, so on.
4. For related discussions, see Simmons (1955), Gonzales (1966), Press (1971), and Logan
(1973).
5. However, hospital personnel themselves do not always adhere strictly to Western notions of
moral practice. The same hospital employees who were evicted from town created 'private
practices' out of the opportunities created by their jobs. When they arrived in a village. they
stipulated that patients pay an additional 20 cents as a 'service fee' for the expenses of running
the clinic and the vehicle that had brought them, all of which the mission hospital had already
paid for. They also prescribed more medicines than were necessary to patients, and over-
charged for their medicines, thus pocketing the profits. Although it can be argued that local
hospital personnel are poorly paid and need to make a bit of money through 'private practice'.
some become quite wealthy by local standards from the 'private practices' they create.
6. Although the investigator sometimes inserted the small paper container that came with the
medicine, usually the medicines had no labels on them, other than what was printed on
individual tablets by the manufacturer. But often it was not important what the package said
about how to use the pill; most people had been using pills without package labels, and usually
professed familiarity with the medicines displayed.
7. Maitai et al. (1981) report that chloroquin is responsible for over half the fatal poisonings in
Kenya.
8. We have not dealt here with the problem of drug 'dumping' by Western pharmaceutical
companies, in which drugs that are banned or limited in Western countries are sold abroad
with few or no warning labels (e.g., Silverman et al. 1982).
9. One example of this is when approximately 20,000 Mexicans died from typhoid because of the
bacteria's built up resistance to chloramphenicol, which had been used indiscriminately in the
area (see also Mintz 1979). Moreover. studies of the widespread use of antibiotics in animal
feed in the US have found that bacteria resistant to a particular drug in one animal can
transmit that resistance (through fecal and other contamination) to the same bacteria which
are drug sensitive in another animal (Schell 1984). This means that drug resistance IS
communicable in the same way as the infectious disease the drug is designed to cure.
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CAROL MACCORMACK AND ALIZON DRAPER
Jamaica has been in the forefront of the primary health care movement.
Before primary health care workers had been identified in the WHO/
UNICEF declaration of 1978 as essential for equitable health coverage,
Jamaica had trained Rural Medical Aides and deployed them with nurses in
small health centres all over the island. By 1981 D. Ashley had published an
important paper on the success of oral rehydration therapy for Jamaican
children with acute diarrhea (Ashley 1981). In the pediatric hospital in
Kingston the number of children admitted for intravenous rehydration
dropped dramatically as guardians with sick children were taught oral rehy-
dration skills in an outpatient clinic. Oral rehydration clinics have now been
extended to some parish hospitals and all categories of health workers should
be able to teach guardians the therapy.
METHODS
the ages of 20 and 29. Eighty-three percent had between 7 and 12 years of
school (39% had 10-12 years). Sick children ranged in age from infancy to 10;
72% were under the age of 24 months. We used housing as a proxy for social
class and found that 65% of the diarrhea children live in very crowded
conditions, in houses with twice as many residents as rooms in the house. In
the random sample of people interviewed in markets only 54% lived in very
crowded conditions.
TABLE I
Signs of serious diarrh,!a (multiple responses).
Criteria Number %
Frequent 155 21
Watery 89 12
Mucous 107 14
Blood 27 4
Vomit 125 17
Fever 107 15
Worms 16 2
Persistent 51 7
Cold symptoms' 34 5
Wasted (dry) 19 3
Other 6
Guardians were asked what they had done first to help their child. Most
tried to cope with the condition at home (Table 2). We assume that most
diarrheas are successfully managed at home, but in this sample of clinic
attenders we saw more seriously ill children. Only 1% gave the therapy
officially recommended in nurses' health talks: drinks made from packets of
Oral Rehydration Salts. Of the other remedies most are very good for a
mildly dehydrated child, and the water from the center of a coconut is an
excellent rehydration fluid. We were puzzled by the ten mothers (2%) who
said they used to give coconut water or mint tea, but now they gave 'salt
280 C. MACCORMACK AND A. DRAPER
water'. Strong salt solutions draw water into the gut, away from vital organs,
and can kill an already dehydrated child.
TABLE II
First treatment (multiple responses - some remedies used in combination)
Treatment Number %
Total 517 99
TABLE III
Second treatment mothers tried
Treatment Number %
Three mothers reported giving a different home drink of porridge and going to clinic or
hospital.
TABLE IV
Interval between onset of symptoms and this interview
Interval Number %
1 day 65 25
2 days 40 15
3 days 29 11
4 days 33 13
5 days 13 5
6 days 5 2
7-13 days 48 18
14-20 days 8 3
21-27 days 4
28-89 days 3
90 days or more 3 1
Not recorded 9 3
screening too many children to take case histories; (2) laboratory services
were overstretched given the health budget; or (3) 'faith' in Oral Rehydration
Salts as the new wonder drug for diarrhea.
- throat
_ Stomach: Vomiting
comes from here
_ large intestine
- small intestine
_ bag of faeces
_rectum
Fig. 1
it, and explain what happened when the child had diarrhea. Some made quite
detailed drawings (Figure I), but most were not very interested in the
digestive system. This was in marked contrast to a parallel study where we
asked women to draw their reproductive system and explain its function and
the action of contraceptives (MacCormack and Draper 1987). There was far
more emotional involvement with the reproductive system. Pregnancy pro-
duces a child that enables a woman to grow in social power, whereas diarrhea
produces only waste. However, both systems are similar in that people were
concerned that matter move freely through them. Constipation was a greater
concern than diarrhea, and some guardians used a laxative during diarrhea to
help the system flush out the 'bad do do' so the body could cleanse itself and
become healthy. Similarly, women do not like contraceptives that stopped or
diminished regular menstrual flow, so that they could not 'see their health'.
Some used alaxative to help clear out a burden of contraceptive pills
threatening to 'block them up'. Although a few women thought of the
reproductive and digestive systems as a single system, we concluded that most
thought of them as being in a metaphoric relationship with each other.
Diarrhea is referred to as 'running belly' in Jamaica, and as women drew,
they explained that 'the belly gets loose and the food comes through too fast'.
Most drew a round stomach (Figure 2) where food is ground. Some said
diarrhea resulted when food 'wasn't digested; it went through the belly
without being adequately ground'. But others said it 'gets ground up too soft
and runs out of the belly'. When we asked what caused diarrhea in a
ORAL REHYDRATION SALTS IN JAMAICA 283
+ - stomach
+ - belly. where
food is ground
Fig. 2
Part way through this diarrhea study we realized that some guardians were
understanding the nature of oral rehydration salts in a way that was not
intended by the health service. The study design was flexible enough to
include questions about 'salts' in the latter part of the study. Table VI gives
responses to an open-ended question about how the therapy worked. This
question was asked only to guardians sitting in a diarrhea out-patients clinic,
spooning rehydration fluid into their sick child immediately after hearing a
health talk from the nurse on oral rehydration therapy. If we consider 'puts
284 C. MACCORMACK AND A. DRAPER
TABLE V
Mother's explanation for cause of diarrhea: clinic and community samples compared
TABLE VI
The meaning of salt in oral rehydration salts
Meaning Number %
back strength or substance' and 'replaces fluid' as correct answers, less than a
third of the guardians were understanding the message that had just been
given to them.
When we realised the importance of such remarks as 'I used to give coconut
water but now 1 give salt water' , we began to ask systematically what mothers
thought was in the packets labelled Oral Rehydration Salts.
Guardians who thought of Oral Rehydration Salts as laxative salts ex-
plained that it 'cleans out the belly', it 'loosens her, and the runs out the cold
(mucous)', or 'cleans out the child to get rid of the germs'. Pharmacies gave
much shelf space to a wide range of laxative salts and a newspaper article
advised parents to give their children a mild preparation with Epsom Salts
(magnesium sulfate), Andrews Salts (magnesium sulfate) or Glaubers Salts
(sodium sulfate) rather than harsh castor oil. The idea of purging with salts
for a 'wash out' even in cholera therapy has been popular in Jamaica at least
ORAL REHYDRATION SALTS IN JAMAICA 285
since the last century when Mary Seacole treated cholera patients with
laxative salts and plenty of good food in the Caribbean, and in the Crimean
War (Seacole 1984).
For at least a century many Jamaicans have treated diarrhea in two stages:
first a 'wash out', then plenty of liquid and food, especially mint tea and foods
such as porridge and banana that 'make the do do firm'. Recently Oral
Rehydration Therapy took on, for many people, both functions at once. One
guardian explained 'it cleans her stomach, it prevents her from getting worse
by feeding her, it prevents her from getting too dry, it is like Andrews Salts,
not strong like Epsom Salts'. Others said 'it kills germs', 'stops vomiting', or
'makes his do do f.rm'. One said 'this new salt water makes them thirsty and
so they drink more which is good'.
We asked a sub-sample of guardians attending clinic with a sick child what
kind of salt the packets contained. Some did not know what kind it was, some
said it was like laxative salts, a few said it was the same as cooking salt and an
equal number said it was different but did not know how it differed. Two said
it was a special salt that 'helps to fight germs', and one said it was medicine
'like oxygen or glucose' (see Table VI).
We found it disconcerting to learn that some guardians stopped giving
children coconut water which is an adequate natural rehydration fluid con-
taining electrolytes and enough sugar to speed their absorption. We were
especially concerned to learn that the 'cost' of sitting in clinic for half a day to
be given only one packet of Oral Rehydration Salts was too expensive in time,
child care and transport, so mothers were buying look-alike packets of Epsom
Salts done up locally by pharmacies. But lest we conclude that the 'natural'
treatment with coconut water is 'good' folk knowledge which was led astray
by allopathic professional and commercial pharmacies, we must know how
guardians thought about 'natural' treatments. Four guardians said quite
explicitly that coconut water 'washed out the system beginning with the
stomach'.
What no one ever asks is what the child likes to drink when it is sick with
diarrhea. Most guardians said that the child likes breasmilk best. Coconut
water, or sweet lime juice or other fruit juices and sweet blackmint or
peppermint tea were also popular. Some mentioned Pepsicola or other
bottled soda drinks. One said quite explicitly that the child liked anything
better than the oral rehydration fluid. Might fruit flavourings be added to the
packets, as they are in Britain? What are breast feeding mothers to make of
the clinic nurse's message to 'resume half-strength milk feeds? Nurses were
quite explicit in warning guardians never to give traditional remedies again;
they must only use the packets mixed with water.
286 C. MACCORMACK AND A. DRAPER
ANTHROPOLOGICAL ANALYSIS
Economics
Much of the primary health care planning literature is concerned with scarcity
of essential drugs, and the equitable distribution of drugs that are available
(see for example WHO 1983, 1987; Mamdani and Walker 1985). These are
morally correct concerns, but they reflect an excessively 'top-down' perspec-
tive which ignores useful self-help remedies people already use. If Jamaicans
were encouraged to continue using coconut water, mint tea with sugar, and
other popular remedies for mild dehydration from diarrhea, Jamaica would
not have to use foreign exchange for packets imported from Switzerland. This
'essential drug' makes even less economic sense when we realize that the
Jamaican economy has been based on sugar production for centuries, and the
main ingredient in the imported packets is sugar.
Bilateral and international aid agencies have given much effort and money
to finance packet production and publicize their use. They are reluctant to let
private firms cash in on this created market. Therefore, many developing
countries only have packets that come into the country through aid agency
channels, and are distributed through the national health service. This re-
stricts supply and ignore costs to the guardian in travelling to a clinic and
waiting in a queue most of the day. In this Jamaica case study, 63% (165) of
guardians spent between 1 and 10 Jamaican dollars in transport to come to the
clinic, 57% (149) spent between 1 and 10 dollars on snack food as they
travelled and waited, and others lost their wage for the day or had to pay for a
minder to look after other children left at home. Given these costs there was
quite a good economic reason for the guardian to nip into a nearby shop and
buy a look-alike packet of Epsom Salts instead.
told never to use the traditional therapies they understood and could make at
home, and therefore were being made dependent upon medical services
provided by 'qualified' personnel who commanded secret knowledge. Nurses,
especially, enjoyed the power of 'gatekeepers' to the therapy, sometimes
berating the guardians in a verbal show of power.
REFERENCES
Ashley, D.
1981 'Oral Rehydration Therapy in the Management of Acute Gastroenteritis in Children in
Jamaica.' In Acute Enteric Infections in Children, ed. by T. Holme, 1. Holmgren, M.
Merson and R. Mollby, pp. 389-394. Elsevier/North Holland: Biomedical Press.
Elliot, K. and Cutting, W. A. M.
1980a 'Diarrhea Need Not Kill', Diarrhea Dialogue, Issue 1: 1
1980b 'Agents of Change' Diarrhea Dialogue, Issue 3: 1
1987 'Time for Action' Diarrhea Dialogue, Issue 28: 1
Hirschorn, N.
1980 'Issues in Oral Rehydration' Diarrh~:a Dialogue, Issue 1: 4.
MacCormack C. and Draper, A.
1986 'Social and Cognitive Aspects of Female Sexuality in Jamaica'. In The Cultural
Construction of Sexuality ed. by P. Caplan, pp. 143-165. London: Tavistock.
Mamdani, M. and Walker, G.
1985 Essential Drugs and Developing Countries: A Review and Selected Annotated Bibli-
ography. E. P. C. Publication No.8. London: London School of Hygiene and Tropical
Medicine.
Ross Institute
1983 Coping with Diarrhea. London: London School of Hygiene and Tropical Medicine.
288 C. MACCORMACK AND A. DRAPER
Seacole, M.
1984 The Wonderful Adventures of Mrs. Seacole in Many Lands (reprint). London: Falling
Wall Press.
World Health Organisation
1983 Report of a Workshop on Essential Drugs. Action Programme on Essential Drugs.
OAPf84.2 Geneva: WHO.
RICHARD BURGHART
The clinic of Sri Hari Narayan Misra Vaidya operates out of his household in
a small provincial town of northern Mithila. Vaidya Ji is Brahman by caste; and
his patriline have been vaidyas in the Bhojpur region of Western Bihar for
several generations. He was the first in his family to be sent for training at the
Ayurvedic Medical College in Patna, Bihar. Thus he is a product of both
ayurvedic traditions: the modern, professional one and a Brahmanical family
tradition. Following his graduation he set up practice in a village just across
the Bihar frontier in the Nepalese Tarai. Throughout the 1950s he built up a
clientele and, by his own account, incorporated within his practice the
pharmacopoeia and diagnostic procedures of Western bio-medicine. The
nearest hospital at that time was some thirty miles away, or nearly a day's
journey by bullock cart and train; hence his clinic was a popular one as a
primary medical resort for the peasants of the region. In the 1960s, however,
he began to react against Western medicine, developing his own Ayurvedic
patent medicines which he sought to market in the region. One particular
tonic, called abal pippli, was a sovereign remedy. In his sales campaign he
claimed that this medicine was like an arrow from Lord Ram's quiver -
capable of destroying all enemies. He also stressed to prospective buyers that
AN ANCIENT A YURVEDIC MEDICINE 291
his tonic was made from the herbs of the countryside, not from foreign
products; and in piques of pride he challenged Western-trained doctors, with
their foreign medicines, to come up with anything better. In the early 1970s,
in order to market his sovereign medicine more effectively, he quit the village
and re-located his clinic in the nearby market town.
Although Vaidya Ji has weeded most bio-medical products from his dispen-
sory, he still keeps two on hand: penicillin and coramine. The latter, of
course, is essential in cases of allergy to penicillin, but it would seem that its
use is more generally as a 'life-giving' medicine, capable of reviving from
near-death those who have collapsed from heart attacks and asthmatic at-
tacks. In fact, coramine was infrequently used. Penicillin injections, however,
were commonplace, being used in the treatment of serious infections, skin
ulcerations and for pulmonary tuberculosis and 'asthma' (including tropical
pulmonary eosinophilia. Vaidya Ji also applied penicillin externally in the
treatment of abscesses and conjunctivitis. This does not exhaust the range of
illnesses for which he believed it could be used, but it does exhaust much of
what I saw at his clinic.
The quality of penicillin was largely understood in terms of its ability to
heat and dry the body. Hence its efficacy in the treatment of certain pulmon-
ary illnesses. The lungs are thought to be a cool, damp organ and various
pulmonary illnesses, such as asthma, tuberculosis and 'cough' result from the
immoderate presence of these two qualities. The term 'asthma' includes
tropical pulmonary eosiniphilia, and the term 'cough might include an early
misdiagnosis of tuberculosis. In its advanced stages, however, pulmonary
tuberculosis would be recognized as a separate illness. As for 'coughs', there
are both hot, dry coughs (e.g. whooping cough) and cool, wet ones (e.g.
chronic bronchitis and pulmonary tuberculosis). It is only the latter kind
which concern us here. Penicillin, by virtue of its heating and drying qualities,
restores equilibrium, to overly wet and cool lungs; hence its efficacy in the
treatment of asthma, eosiniphila, tuberculosis and bronchitis.
In addition to its heating and drying qualities, penicillin was also thought to
possess an antiseptic power which was apparent in the procedures which
Vaidya Ji used in giving injections. He knew that boiling the syringe and
needle in water for fifteen minutes was standard practice among Western
doctors, but he adopted a different procedure. Attaching the hypodermic
needle to the syringe, he draws clean water from the neighborhood tubewell.
After rinsing both syringe and needle in the water, he breaks off the cap of the
distilled water ampoule, inserts the needle and draws up distilled water to
rinse again the inside of the syringe. After ejecting this water, he draws fresh,
distilled water into the syringe which he then ejects into the phial of penicillin
powder. After shaking the phial vigorously, he draws the liquid penicillin into
the syringe. Next several drops of penicillin are expressed onto a tuft of
cotton wool, which is rubbed on both the exterior of the needle as well as the
site of injection. Vaidya Ji explained to me that since penicillin was powerful
292 R. BURGHART
enough to destroy all illnesses in the body, it was also powerful enough to
purify the needle and syringe of contamination. From a Western, clinical
point of view one can see that penicillin takes on the antiseptic function of
alcohol. From a Hindu point of view penicillin takes on the purifying function
of Ganges water; that is, it is not only pure but it is also capable of purifying
all other waters, without itself becoming impure.
The power of penicillin was also seen to stem from its being injected
directly into the body, bypassing thereby the preliminary stages in the body's
assimilation of food. Here it must be explained that in ayurveda the body is
integrated by a seven-stage digestion process. The process begins in the
stomach, likened to a cooking pot, which digests the food, converting it to a
nourishing juice which is then transferred to the liver. In the liver the juice
undergoes a further 'digestion', transforming it into blood. The heart drives
the blood to the extremities of the body where it is digested further and
transformed into flesh. The flesh is subsequently transformed into fat, the fat
into bone, bone into marrow and marrow into 'seed'. The seed - that is semen
or menstrual blood - is the source not only of one's fecundity but also of one's
mental and physical energy. The progressive refinement of food entails the
production of a dross at each stage: excrement, urine, bile, etc. Health and
longevity entail as much the accumulation of energy as it does the elimination
of this dross.
To my knowledge, Vaidya Ji never prescribed penicillin tablets; the impli-
cation here is that the tablet form of medicine is 'cooked' in the stomach and
then transferred to the liver where it passes into the blood; and thence to the
heart from where it is pumped to the extremities of the body to nourish the
flesh. The first two stages of digestion last at least one full day; hence there is
considerable delay before the medicine can begin to combat the illness.
Injections, however, shortcut the entire process, although at the cost of
disenabling the body to assimilate the poweful and potentially dangerous
qualities of the drug. Hence the notion that weak, vulnerable people, and
especially infants, should be given tablets rather than injections. In practice,
however, even children who had not yet been fully weaned, received injec-
tions at his clinic.
Vaidya Ji also applied liquid penicillin externally to skin ulcerations, boils
and abscesses. He reasoned that if penicillin, administered intramuscularly,
was effective in destroying illness then it should be effective when applied
superficially to the infected areas and the surrounding tissue. Skin has the
power to absorb liquid penicillin, which it does through the pores into the hair
follicles and then into the flesh. In cases of serious infection Vaidya Ji would
give an injection then, with whatever penicillin remained in the syringe, he
re-moistened the tuft of cotton wool and dabbed it on the infected area.
Similarly a batch of penicillin might be made up in order to treat conjunctivi-
tis. A few drops administered in the corner of the eye morning and evening
would clear up the illness in the matter of a day or two. This external use of
AN ANCIENT A YURVEDIC MEDICINE 293
penicillin was a discovery for which Vaidya Ji took credit. He claimed that he
had extended the frontiers of medical knowledge beyond that known by
Western doctors.
Sri Patuh
Aba! Pippli is beneficial for everyone: children, youth, the elderly and pregnant women
When water drips from your nose and eyes, your head aches; your entire body is tight, a dry
cough pierces your throat and you have a fever of 98.5 to 99 F. then make use of Aba! pippli
together with several tu!si leaves [Ocimum basilicum] or with honey or tea or in hot milk or
water; otherwise in betel leaf or in anything at hand. Within only two hours whatever ailment,
pain, sickness, or distress that you feel will be far removed. If you complain of asthma or cough,
then take two or three doses daily of Abal Pippli with honey or Sitopaladi Cum [a cough
medicine] and at once -like the arrow of Ram [capable of killing all enemies]- it will restore you
to good health. This Pippli has been prepared from a mixture of gold, ground coral, ground borax
and mother-of-pearl ashes together with peepli ashes. Aba! Pippli can be taken at anytime by
anyone; it may also be taken with homeopathic, yunani. and English medicine. Women from
their third or fourth month of pregnancy, who take daily a portion in honey or hot cow's milk will
make their child strong. When you leave your village on a journey, take a few packets with you.
Consume a portion every day and your body will put on weight. Because this medicine contains
ashes of coral and mother-of-pearl, there is abundant calcium in each portion. This is a scientific
medicine which nourishes at the time of one's daily meal the unborn infant, small children and
adults. Abal Pipp!i is your very own medicine sold near at hand and available in shops.
Virtues: By means of this medicine small children will find rest from every kind of illness, such
as sudden fever, jaundice, diarrhea, vomiting, cough, whooping cough, pneumonia, malnutrition
(including rickets), illness at the time of cutting teeth, etc.
Dosage: Give a one-quarter dose to babies from one to three months old, a half portion from
three months to one year. From one to fifty years of age give a full portion three times daily. For
children medical opinion recommends that the medicine be mixed with honey or breastmilk and
given three times daily.
Note: Aba! Pippli has been praised by thousands of people and doctors. For you also this
medicine will perform a reliable service in removing the above-mentioned illnesses. In the
Rasayana Sala [the name of Vaidya Ji's clinic] even incurable illnesses receive medical treatment
and many people have benefited from this. The test of this has already taken place. The
Rasayana Sala has been serving the people for the last forty years, just as much as it continues to
serve them today.
Penicillin
Dose According to personal experience and the needs of the ill person.
Virtues This medicine is useful in hundreds of illnesses: in particular, urinary diseases, pneumo-
nia, blood-poisoning, inflammation of the bones and marrow, recurrent fever, ear inflammations,
puerperal fever, venereal disease, syphilis, rheumatic fever, boils and abscesses, skin diseases,
eye illnesses, encephalitis, gas gangrene, pulmonary infections, degenerate heart disease, broken
bones, smallpox, tuberculosis, and cough.
Caution This medicine is as dangerous as it is beneficial.
1. Always store in a cool place.
2. Always mix with distilled water or with normal saline.
3. Always use a syringe which has been boiled in water.
4. Clean one's hands before administering the injection.
Side-effects Loose bowels, vomiting, increase in fever, skin rashes, giddiness.
Remedy Stop penicillin treatment. Inject coramine or anthisan. Inject benadryl.
Warning Do not inject intravenously by mistake. Only inject intramuscularly.
ACKNOWLEDGEMENT
REFERENCES
INTRODUCTION
IS EFFICACY IMPORTANT?
DEFINITIONS OF EFFICACY
practices which are efficacious from the point of view of biomedical science;
and healing, which refers to practices which are efficacious from the point of
view of these people [being studied], [emphasis in the original]. While this
distinction helps to clarify some of the differences, it also implies that Western
biomedical and ethnomedical understandings of efficacy cannot be the same.
But of course they can be, and to ignore that advances the western stereo-
typed view that other medical systems are fundamentally 'irrational' and
based on the precepts of magic and religion rather than on empirical observa-
tion of the biological universe.
Similarly, in their consideration of whether and how indigenous treatments
are efficacious, Kleinman and Sung (1979: 8) conclude that biomedicine
successfully treats 'disease' (disorders of biological and physiological processes),
while indigenous medicines treat 'illness' (secondary, affective and subjective
reactions to disease). This view assumes that ethnomedicines have no biologi-
cal efficacy against 'disease', although a growing literature in ethnopharma-
cology attests to the fallacy of that presumption.
Plant use and other medical behaviors are effective if they effect or assist in
producing the requisite, culturally defined outcomes. By so doing, these
actions confirm shared beliefs about the nature of health and illness (Young
1976, 1977), in the same way that the expected outcomes of such western
practices as surgery and antibiotic therapy reaffirm belief in biomedicine. It
merits note that the failure of a medicine to produce cure or another requisite
outcome does not necessarily undermine one's faith in the medical system.
Among the Hausa, for example, this is taken as sign that the medicine and the
individual were not 'right' (suited) in that particular instance. As do their
biomedical counterparts, Hausa practitioners call on alternative diagnoses
and/or medicines when preventive and therapeutic efforts fail to yield desired
results.
Western biased interpretations obscure these key behavioral dimensions of
medical treatment. For the first, pharmacologic evaluations that determine
that plant medicines have outcomes different from those considered appropri-
ate by biomedicine are critical of ethnomedical practices. For the second, the
ostensible 'failure' of some treatments is generalized to all indigenous medi-
cines, and the subsequent resort to other diagnoses and treatments is de-
plored, at least as built-in rationale, if not as processual sham. Both of these
outlooks have the effect of trivializing non western ideologies and denying the
capacity of indigenous populations to observe and act on the outcome of their
behaviors.
One of the most formidable obstacles to full comprehension of efficacy and
other characteristics of indigenous medical systems is the failure to under-
stand healing as process.
302 N. L. ETKIN
INDIGENOUS PHARMACOPOEIAS
What do the content, size, internal consistency, variability, and potential for
change of a given pharmacopoeia mean? Does a large and varied herbal
pharmacopoeia reflect the skilled elaboration of a broad-based and effective
therapeutic regimen, a botanically rich environment, the occurrence and
symbolic rendering of many illnesses, the ability of a population to develop
numerous effective means of dealing with only a few diseases, a group's
dependence on many marginally effective medicines, or some constellation of
these (and other) circumstances? Studies of biologic taxonomies inform some
of these questions.
Taxonomies are generally considered to reflect how people structure their
knowledge of the physical universe, but the specific interpretation of those
classifications varies with philosophic or theoretical orientation. Morris (1984)
distinguishes among three predominant views in his discussion of folk classifi-
cations: (1) Levi-Strauss (1966) embodies the structuralist approach that
perceives folk taxonomies to be the outcome of a group's intellectual, non-
pragmatic interaction with their physical universe - a process through which
different aspects of culture are symbolically unified. (2) Born of a theoretical
tradition in Anglo-Saxon empiricism, ethnoscientists (e.g., Berlin et al. 1974)
similarly focus on classificatory terminology, seek universals, and view ethno-
taxonomies as intellectual, non-pragmatic perceptions of the biological world.
Where structuralists emphasize symbolic logic, ethnoscientists view form and
structure as the fundamental classificatory criteria. (3) Different from these
CULTURAL CONSTRUCTIONS OF EFFICACY 303
Plant selection
the nomadic Turkana (Kenya) use a yellow product from Vahlia viscosa for
jaundice, with both plant and illness termed 'longyang' (yellow) (Morgan
1981: 101). Analogously, for Hausa and other medicines, plants of phallic
shape are used as aphrodisiacs, Native Americans use red-sapped Sanguinaria
canadensis and red-rooted Phaseolus spp. as hemostatics and to treat blood
disorders, while plants with multi-lobed leaves are used in the treatment of
liver disease (Moerman 1977; Nabhan et al. 1980; Lewis and Elvin-Lewis
1977).
In other cases the physical attributes of a plant are associated with certain
uses. The Hausa avail themselves of strong smelling plants to contend with
witches and spirits (e.g., Allium spp., Zingiber officina Ie, Eugenia caryophyl-
lata), using the sweet smelling plants to appease them and the foul ones to
prevent their coming or to chase them away. Davis and Yost (1983) report
similar associations in the use of aromatic plants (Guatteria, Siparuma,
Reneaimia, and Philodendron spp.) by the Waorani (Ecuador). By another
association, Ficus iteophylla is used in Hausa medicines to prevent witches
from causing disease, the expectation being that the witch will be overcome
with a choking cough resulting in death, in the same way that this plant grows
on and kills other plants.
While western interpretations frequently dismiss such medical behaviors as
'merely symbolic', it is important to note that the mnemonic identification of
medicinal plants may be related to empirical observations of activity and
physiologic outcome. Delaveau (1981), for example, contends that the use of
red plant substances for skin disorders may advance healing in view of the
presence of red quinones which have antimicrobial and hemostatic activities.
The Doctrine of Signatures in any case cannot explain all uses of a given plant
- e.g., those yellow- and red-producing plants noted above are used as well
for other disorders in which the color association does not hold. The persist-
ent highlighting of this Doctrine and invoking sympathetic magic as explana-
tion may reflect more the inability of Western researchers to otherwise 'make
sense' of plant selection than it does the reason for that selection.
In other cases selection includes also, or instead, choice for a particular
activity. For example, Australian Aborigines distinguish at least two varieties
of Duboisia hopwoodii: the nonaromatic variety has as its principal alkaloid
toxic nornicotine and is used as a poison in animal trapping; the aromatic
variety (containing the aromatic metanicotine) contains nicotine as its princi-
pal alkaloid and its various uses are consistent with the properties of that
alkaloid (Watson et al. 1983). With different outcomes expected, in different
healing episodes or as part of a single healing process, a quid prepared from
the leaves and terminal stem of the aromatic variety is chewed as a stimulant
to mitigate the effects of physical stress, and in larger doses as an analgesic in
preparation for painful initiation rites. While Watson and co-workers propose
that these observations suggest that the criteria for selection are 'nicotine as
the major alkaloid, a low nornicotine content and the presence of metanico-
CULTURAL CONSTRUCTIONS OF EFFICACY 307
tine' (1983: 309), a more accurate interpretation is that the selection criteria
are the effects of the relative concentrations of these constituents: analgesia in
high dose and stimulation (due to the presence of high nicotine levels), the
absence of toxicity (low nornicotine concentration), and aromaticity (from
metanicotine). While the intent and outcomes of ethno- and biomedical
behaviors may be identical, the former cannot be explained with reference to
'alkaloids' and comparable language of biomedicine.
do not have any knowledge of the mechanisms of the occurrence of side effects'.
The value of an otherwise comprehensive study of the genus Tabernae-
montana L. (Apocynaceae) also is diminished by the authors' failure to
address the issue of indigenous expectations. One entire issue of the Journal
of Ethnopharmacology (1984, 10: 1) is devoted to this genus and includes
extensive information on taxonomy, geographic distribution, constituents,
and studies of pharmacologic activity. Also, ethnobotanic data are presented
in more detail than in many other works, and include the listing of plant parts
used, form of preparation, and disease/symptoms against which it is used. It is
implicit in this work that one can use these data to pursue questions of efficacy
using biomedical criteria, and that estimations of efficacy using indigenous
paradigms have no meaning. The 'ethnobotanic conclusions' (van Beek et al.
1984: 128-129) are in any case very tentatative, only summarizing by most
common use, general mode of preparation, and plant part used. One of the
authors' statements is particularly illustrative of the point I wish to make. In
stating that 'Of the medicinal uses reported, those which rely on antimicrobial
action are the most common' (emphasis added), the authors ignore that
peoples who employ these plants may not have concepts of germ, contagion,
and the like. Medicinal use may rely on something altogether different
(healing power, spirit propitiation, color, astringency). From the authors'
implication that medicines containing 'antimicrobials' are likely to be effec-
tive when used against 'infections' must we extrapolate to conclude that
peoples who do not share a biomedical understanding of infective processes
and antimicrobial activity cannot have developed medicines effective in
treating infectious diseases?
A similar criticism can be levied against Banerjee and Sen (1980: 296) who
conclude their survey of ferns used in various indigenous medical systems by
stating that there is 'considerable agreement between the observations re-
corded by us regarding the antibiotic activity of the pteridophytes and their
uses in folk medicine'. Medicinal use is drawn from secondary and tertiary
sources and is addressed summarily by noting that many of the disorders
against which pteridophytes are used are caused by viruses, bacteria, proto-
zoa, and helminths. Against a paucity of cultural information are juxtaposed
detailed botanical and pharmacologic data indicating the presence of antimi-
crobial activity in many of the species tested. Until the depth of detail is
matched in the behavioral realm (providing data on plant selection, prepara-
tion, administration, and intended outcome), Banerjee and Sen's conclusion
is unwarranted.
Chagnon's (1984) assessment of Rwanda ethnomedicines provides more
information regarding the particular symptoms or disorders in whose treat-
ment these plants are used, but such data are not combined with pharmaco-
logic data in any way that affords credibility to indigenous disease models and
therapeutic expectations.
Watson et al. (1983: 310) also presume a consistency between western and
CULTURAL CONSTRUCTIONS OF EFFICACY 311
toxins - or, for that matter, of any active constituents - is insufficient basis for
the evaluation of efficacy.
This is illustrated as well by biomedical criticism of the use of pungent
substances in the treatment of inflammations - e.g., the Hausa application of
such plants as Capsicum annum and Eugenia caryophyllata to treat eye and
skin disorders. The efficacy of such treatments can be understood on two
levels. First, the Hausa treatment of (eye or skin) inflammation should be
understood as a process, with one of the proximate expectations being some
evidence that the disease substance is surfacing and leaving the body -
reddening of the eye and skin inflammation confirm Hausa expectations that
healing is in process, while the biomedical understanding of this is only of
symptom exacerbation. Both the proximate effect and the ultimate effect -
relief of pain and irritation - also can be understood as consistent with the
principles of biomedicine: capsaicin (from Capsicum spp., chile pepper) and
eugenol (from Eugenia spp., clove) cause immediate inflammation of the
affected area, followed by long lasting local analgesia (Isaacs 1983; Anonym-
ous 1983).
Similarly, Turner's (1984) review of Native American uses of the Ranun-
culaceae notes that the widespread medicinal application of these plants has
been criticized in view of their containing the irritant and vesicant pro-
toanemonin. Particularly insofar as the Ranunculaceae are commonly em-
ployed in the form of poultices applied (externally) for wounds, boils, and
other skin disorders, and for respiratory disorders, the vesicant action of
these plants is inconsistent with western biomedical models of healing. A
closer reading of Turner's work shows that this can be understood on two
levels. First, we should not be surprised to learn that the irritant and
sometimes poisonous qualities of the Ranunculaceae are known to these
Native Americans - likely they are as keen observers of their actions as
Western practitioners pride themselves to be. Turner records that these
species were judiciously used to achieve the effects desired with minimal
harmful consequences and, although she does not detail the underlying
medical ideology and expected sequelae, it merits attention that the induce-
ment of irritation with resultant change in skin color and vesication can be
understood as being consistent with illness models that require tangible
evidence that 'something' happens to the body in the process of cure and/or
that healing involves physical evidence that disease entities surface and then
leave the body. On another level, one can 'confirm' the efficacy of these uses
of the Ranunculaceae in a way that is consistent with biomedical models of
healing. Specifically, Turner (1984) suggests that the efficacy of these plants in
treating skin disorders might be attributed to fluid being drawn from sur-
rounding tissues and blood flow increased to the affected area, and that the
effectiveness of these plants in treating respiratory illnesses might be ascribed
to the decongestant action of protoanemonin.
314 N. L. ETKIN
Side/secondary effects
Failure to differentiate (or show overlap) between indigenous and Western
biomedical meanings is illustrated as well by the poor differentiation between
primary and secondary effects and the ethnocentric view that biomedical
researchers bring to consideration of 'side effects'. For example, the pub-
CULTURAL CONSTRUCTIONS OF EFFICACY 315
substance (i.e., cocaine alkaloid) that is extracted during the chewing (Anto-
nil 1978; in: de Smet 1985). To the extent that knowledge and regulation of
dosage is important, this analgesia could be perceived as primary, not secon-
dary.
Abebe (1984: 43) suggests a similar dose regulating role for the 'side-
effects' of traditional medicines used in Ethiopia and notes that healers view
these outcomes as evidence of the therapeutic activity of the medicine. If such
pharmacologic activities are expected, then the Western researcher's designa-
tion of 'secondary' or 'side effect' is ill placed. Secondary by whose standard?
The Western biomedical model based in the germ theory of disease perceives
cure or symptom remission as the prime goal. Thus, other outcomes are aptly
'side' effects. That this is not necessarily consistent with other medical models
is important for considerations of efficacy. This categorization of 'side effects'
is frequently cause for devaluation of indigenous medicines.
In the same vein, Rodriguez and co-workers' (1982) interpretation of the
use of psycho tropics both offers a novel perspective on the significance of
these plants and underscores a tendency of western researchers to be at-
tracted by, and to exaggerate, the more 'exotic' features of cultures other
than their own. Rather than concentrate as so many others have on the
hallucinogenic and related qualities of psychotropic plants, Rodriguez et al.
have suggested that other activities better inform their use in indigenous
medicine. They note for some psychotropic species antimicrobial and other
antiparasitic effects, due in part to strong purgative and emetic activity; and
they suggest these as the principle criteria for selection, marshalling as
'evidence' repeated ceremonial reference to the 'cleansing' qualities of these
plants, and proposing that the psychotropic effects were used as dosage
indicators. Thus we can ponder the possibility that psycho activity was per-
ceived as 'side effect' to emesis, whereas the conventional view considers
diarrhea and vomiting as 'side effects' of psychotropic plant use.
Too little attention has been paid to the use of medicinal plants in more than
one context. Perhaps most significant among other uses is the role that some
medicinal plants play in indigenous dietaries (e.g., see Etkin 1986a, b). These
categories of use - medicine, food - are in many cases clearly distinguished
(although commonly interrelated through metaphors of nurturance, growth,
and the like), so that medicinals and foods have different meanings and are
prepared, applied, and consumed with different intended outcomes. How-
ever, to the extent that such plants are pharmacologically active, their
consumption in various contexts merits closer attention.
In Chinese medicine, seemingly more so than in the case of other medical
systems, diet is inextricably linked to both preventive and therapeutic dimen-
sions of medical care (e.g., Ahern 1975; Ho 1985; Anderson and Anderson
CULTURAL CONSTRUCTIONS OF EFFICACY 317
1975; Koo 1984). Studies of efficacy become increasingly complex as one must
both distinguish between and conflate the conceptual and functional catego-
ries of 'food' and 'medicine'. And the problem is further exacerbated by lack
of consensus regarding definition of such related terms as 'tonics', 'patching
medicines' (Gould Martin 1975), 'teas', 'health foods', 'tisanes', and 'medici-
nal foods'. Koo's (1984) discussion of the use of food in Chinese preventive
and curative medicines is a particularly exaggerated confusion of such con-
cepts.
Such confusion is illustrated as well in Morton's (1983) promotion of the
South African beverage 'Rooibos tea' (Aspalathus linearis) as a more
'healthy' substitutt: for 'conventional tea and coffee' in view of its being
caffeine free, low in tannins, high in ascorbic acid and (anti-cariogenic)
fluoride, containing the antispasmodic quercetin. Is this then a tea or coffee
'substitute', a food, a medicine, or something else altogether? While such
beverages may be or become conceptual near equivalents of 'tea' (and
perhaps coffee, for which 'tea' itself frequently serves as 'substitute') - witness
the great proliferation of 'herbal' teas available in increasing variety in urban
centers worldwide - they are explicitly and deliberately not functional equi-
valents. As regards definitional murkiness, Morton jumps into the fray to
suggest that since the 'healthful' character lies more in what is absent rather
than in what it contains, , ... it should not be classified as a medical infusion.
It is, rather, a salubrious beverage' (p. 169). Any progress toward definitional
clarity is rapidly dissolved in Morton's two closing sentences which describe
the potential for using Rooibos tea 'in gelatin desserts ... tarts ... cookies,
aspics ... and in meat sauces', and which conclude that 'The possibilities are
endless, thus greatly enlarging the potential role of rooibos tea in the diet of
infants, children and adults' (emphasis added).
The inclusion of pharmacologically active plants in diet is particularly
significant in view of the relatively larger quantities in which foods are
generally consumed relative to medicines, thus suggesting important implica-
tions for estimating effects based on relative dosages. For example, among
the 107 Hausa plants commonly used in the treatment of a variety of
gastro-intestinal disorders, most contain constituents that are likely to be
beneficial in the treatment of gastro-intestinal disorders (from the points of
view of both Hausa and western medicine), and half appear as well as
elements of diet (Etkin and Ross 1982; 1983). From a pharmacologic perspec-
tive, this suggests that narrowly directed studies of plant medicines that
neglect the consumption of botanicals in other contexts may significantly
underestimate the extent to which these species influence the occurrence and
expression of illness. (And from a nutritional perspective, knowledge of the
pharmacologic activity of dietary elements provides a broader base from
which to study dietary quality.)
Studies of indigenous medicinal plants and dietaries have been constrained
by a bioscientific perspective that circumscribes as appropriate inquiry for
318 N. L. ETKIN
CONCLUSION
NOTES
1. The prefix 'ethno-' and the term 'indigenous' are used throughout to designate understandings
- of health, disease, plants, etc. - other than those informed by the precepts of Western
science and biomedicine. This is to imply neither that Western biomedicine and other
medicines are always (or ever) categorically different, nor that one should understand by the
term 'ethnomedicine' (or 'indigenous medicine') a single, homogeneous system of knowledge
any more than one should understand Western biomedicine to be always and everywhere the
same regardless of the context in which it appears.
2. Such metaphors, as well as the use of dietary elements in the prevention and treatment of
illness, blur the distinctions between foods and medicine - e.g., see the discussion in this
chapter on the multicontextual use of plants [page 316].
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CULTURAL CONSTRUCTIONS OF EFFICACY 325
nomena were studied within the framework of religion (cf. Whyte n.d.),
belief system or politics. The most conspicuous examples are 'witchcraft',
'sorcery', and 'magic'. Most authors did not even regard these as 'medical'
and the term 'medical anthropology' was not coined until much later. When
medical anthropology as a separate field of study came into existence research
focused on 'indigenous' beliefs and practices. Around that time the term
'ethnomedicine' was coined referring exclusively to the study of non-Western
medicine. It is significant that the aspect of being 'ethnic' (cultural) was not
extended to Western medicine. This myopia continued when the distinction
between 'disease' and 'illness' was introduced. 'Disease', the Western scien-
tific definition of a health problem, was exempted from cultural questions;
'illness', on the other hand, tended 'to be viewed as a cultural category and as
a set of culturally related events' (Fabrega 1971: 167).
I am not saying that the Western-type public health programs in the
colonies and - later on - 'developing countries' entirely escaped the attention
of social scientists. I do however contend that Western medicine in the
non-Western world was not studied as a cultural phenomenon. Applied
anthropologists who carried out research for the benefit of public health
programs did not examine these programs but studied indigenous ideas and
practices which were seen as 'barriers' to the acceptance of Western medicine
(cf. Paul 1955; Foster 1976).
Only recently have medical anthropologist turned towards biomedicine as
an object for cultural research, both in non-Western and Western societies.
Hahn and Kleinman (1983: 305) have called the exploration of biomedicine 'a
new frontier in medical anthropology'. Studies of biomedicine in a non-
Western context often deal with themes such as medical pluralism, therapy
choice, and the cultural hegemony of biomedicine. It is significant that, in
spite of the interest in biomedicine as a cultural tradition open to anthropo-
logical research, anthropologists have hardly begun to look at 'the hard core'
of biomedicine: pharmaceuticals. Until very recently the delusion that biome-
dicine was 'beyond culture' still hovered around its therapeutic substances.
Now at last anthropologists are beginning to direct their unsettling questions
at what used to be entirely taken for granted, their medicines.
The contributions to this volume have been arranged aroung two broad
themes, transaction and meaning. The former comprises studies that stress
the more tangible events concerning drugs and view them in their social,
economic and political context. Contributions assembled under the latter
theme focus on more hidden aspects of pharmaceuticals: their symbolic value,
the way they are perceived by those involved in their transaction. The
distinction transaction versus meaning is artificial; both move together
PERSPECTIVES FOR RESEARCH AND APPLICATION 331
In this volume only scanty attention has been devoted to the context of
production and marketing. Afdhal and Welsch discuss the ambiguous cultural
convergence of the production of Indonesianjamu and Western pharmaceuti-
cals. Wolffers describes the activities of a self-styled drug manufacturer in Sri
Lanka and the marketing practices of drug representatives in two villages.
Ferguson too reports about drug representatives and explains that the phar-
maceutical self-help sector in EI Salvador has emerged under the commercial
pressure of the international industry.
On the ground research about the marketing of medicines is perhaps the
most conspicuous gap in studies analysing the role of pharmaceutical firms in
developing countries.
Prescription
The fact that the prescription (and the medicine!) and not something else (for
example the conversation) has become the focus of medical symbolism is no
coincidence. Prescribing reflects the curative thrust of Western medicine.
Moreover, as Melville and Johnson (1982: 181) remark, 'it is easy to pre-
scribe, it requires less thought 3 and effort than a carefully explained sugges-
334 S. VAN DER GEEST
tion about life style change'. And finally, there are clear time-saving (read:
financial) advantages to prescribing. It is more quickly finished than a discus-
sion of life problems and it is a subtle but effective device to announce the end
of the consultation and send the patient away to make room for the next
customer. But because prescribing is such a powerful symbol it is also likely to
be overused; overprescription seems an obvious consequence.
A second point raised by some authors is that physicians are not always well
informed about the most appropriate drugs (ct. Speight 1975). This is partly
due to the fact that many physicians in the Third World rely on information
materials provided by the industry, and these may be biased to suit the
industry's interests. 4 Senturias et al. (1984), who conducted a preliminary
survey among 135 physicians in Manila, report frequent prescription of
doubtful drugs for four common ailments. Similar observations were made by
Group DCP (1984) and Hardon (1987). Silverman et al. (1982: 91) quote
seven drug experts in the Third World who 'label much of the prescribing in
their countries as irrational'. They mention several types of 'irrational
prescribing' ,5 one of which is the preference for injections. This preference
has been widely reported, also in medical journals. Greenhalgh (1987)
provides quantitative data on injections in India and Kleinman (1980: 287-8)
in his Taiwan study suggests that this professional preference is based on a
mix of science, psychology and commerce:
As odd as it sounds. of the 300 cases we observed in the clinics (private and public) of
Western-style practitioners, fewer than one-fourth failed to receive injections of one sort or
another. There is a strong financial motive here ... If a practitioner gives the patient medicine to
take orally, he gets paid, but less than if he gives the patient an injection. Furthermore. givmg an
injection is giving the patient the message that you are offering him the best treatment you
possess. Consequently, almost all medicinal agents that can be given by injections are so
administered ... Many Western style doctors told me this was dangerous. quite unnecessary
practice. but one they could not relinquish given the 'realities' of clinical care in Taiwan. They
feared the loss of income and patients.
This practice shows that the transmission of medical concepts not only goes
from professional to layperson, a type of medicalization which De Swaan
(1983: 216) calls 'proto-professionalisation', but also in the opposite direc-
tion: doctors comply with their patients' expectations and ideas. This remark-
able phenomenon has been little noticed. 6 The view that drugs are an
essential element in any treatment is common not only among large groups of
patients/ but also among doctors. It may be enlightening to study this belief
as a symptom of doctor's compliance.
The opposite is also discussed in the literature: the lack of concern physi-
cians sometimes have for the conditions in which their patients live. This leads
to another kind of 'irrational prescribing', i.e. prescribing drugs which people
cannot buy. As a result patients may select just some of the prescribed drugs
that they can pay for and leave the others. Muller (1982: 45-61) rightly points
PERSPECTIVES FOR RESEARCH AND APPLICATION 335
out that even though such drugs are 'effective' they are not 'efficient'. For
economic reasons people are not able to use them. Some authors who refer to
the socio-psychological gap between prescribing doctors and poor patients are
Melrose 1982, Senturias et al. 1984, and Shatrughna n.d. 8
These observations are, of course, related to the fact that physicians
themselves have commercial interests in prescribing. This is the case if they
sell the medicines they prescribe or if they have connections with pharma-
ceutical distributors. What I have called 'irrational prescribing' above may be
irrational according to medical standards and also from the patients' point of
view, but 'rational' in other senses because it serves the physician's economic
interests. Kleinman (1980: 287) reports. that most doctors in Taiwan sell their
own medicines in order to receive the maximum profit from their prescrip-
tions. In such situations, overprescribing obviously yields considerable bene-
fits. Similarly, Melrose (1982: 86-89) gives striking examples of
overprescribing in North Yemen, Burkina Faso and Bangladesh, which she
refers to as 'sledge-hammer therapy'. Overprescribing seems to occur world-
wide, but there can be little doubt that it is least controlled in developing
countries.
It should be noted, that overprescription for economic reasons occurs not
only in commercial health services. 'Non-profit', usually church-related,
institutions often make considerable profits by selling medicines. Hospitals
and health centers with little or no government subsidy have often found that
the easiest way for them to obtain an income lies in the sale of drugs.
Overprescription of course is likely to ensue in such a situation (d. Barnett et
al. 1980: 495).
A last problem to be mentioned is that patients tend to imitate prescrip-
tions in self-medication. Overprescribing or otherwise irrational prescribing
by doctors may thus lead to dubious methods of self- medication. Hardon
(1987) reports this for the Philippines, Group DCP (1984) for Brazil, and
Greenhalgh (1987) for India.
Distribution
Drug distribution tends to be extremely complex in most developing coun-
tries. Comparison with distribution in the Western world is misleading. The
situation is often paradoxically marked by both shortage and abundance. The
shortage concerns essential drugs, cheap and useful; the abundance non-
essential drugs, usually expensive, often superfluous and sometimes harmful.
Moreover, prescription drugs tend to be readily available without a prescrip-
tion, even in countries that require a prescription for their purchase.
The most typical situation is that legal and illegal distribution are intert-
wined. Ferguson (this volume) speaks of a 'two-tier delivery system', but the
'illegal' practice is usually socially accepted and 'normal'. Parallelling this,
336 S. VAN DER GEEST
shop or a booth, others are mobile and travel from village to village.
Although it is generally recognized that illegal drug vendors are common in
the Third World, research about them is virtually non-existent. A host of
studies can be cited which briefly mention the drug vendor, 15 but I know only
four studies that more or less focus on them. Cunningham (1970) describes
the Thai 'injection doctor' as a mediator between popular and professional
medicine and provides case material on two injection doctors. One of them
had first worked as a 'doctor's assistant' in a government health center. Such
links are often reported 16 and it seems probable that some informal drug
providers started their careers while attached to a health institution, for
example, as a lowly ranked nurse, a laboratory assistant, a cleaner or a
porter. Two other studies by Kloos (1974) and Nordberg (1974) describe drug
vendors in Ethiopia. Kloos as a geographer is mainly interested in spatial and
economic aspects of their trade. Nordberg studies the types of pharmaceuti-
cals sold in 25 rural drug shops, the number of clients and the amount they
spent. Fassin (1985), who did research on markets in the capital of Senegal,
explains why the Senegalese society and the authorities tollerate the illicit
trade in medicines. One of his answers is that the society cannot do without
this informal distribution as the state's provisions are insufficient. Moreover,
the clandestine business produces attractive fringe benefits for various groups
of people among whom the police. Fassin also has interesting things to say
about the careers and 'training' of medicine vendors.
Little is known about the social context in which drug vendors operate and,'
as far as I am aware, there has hardly been any participant observation in
their shops (however, my investigation in South Cameroon, reported in this
volume, and Fassin's work in Senegal suggest that such research is quite
feasible). Even less is known about drug vendors' beliefs and medical know-
ledge or the financial aspects of their trade. 17 As a result, one finds contradic-
tory statements about drug vendors in the literature; some authors regard
them as extremely dangerous while others have suggested that they be given
some training and included in the formal health care system. It is high time we
had a clearer and more complete picture of this recent but very common
provider of popular health care. Two studies in this volume try to fill this gap:
Kloos et al. and Van der Geest.
Use of medicines
In Western society the use of medicines has been mainly studied from a
medico-centered perspective, as 'compliance' and 'non-compliance'. Only
recently is it beginning to be studied through a patient-centered approach, as
'self-regulation' (see for example Conrad 1985). In non-Western societies it
has never been very useful to regard patients' use or non-use of drugs as
non-compliance, although the majority of health workers in these countries
probably continue to do so. The role of doctor's prescription has been
marginal in most developing countries (despite the importance health care
PERSPECTIVES FOR RESEARCH AND APPLICATION 339
of drug consumption: the social control which is felt most acutely during
periods of sickness. Western pharmaceuticals can be bought privately (with
money that can be earned individually) and they allow a sick person to bypass
those who otherwise might have used his sickness to exert social pressure
upon him. Whyte (this volume) sees medicines as a 'liberating' force in
contrast with ritual and relational therapies that confirm the patient's place in
relation to others. It seems likely, therefore, that where self-medication with
Western medicines increases, the importance of the family-based 'therapy
management group' will diminish.
The common observation that people often prefer to purchase medicines
without consulting a physician (e.g. Alland 1970; Ferguson this volume)
should be seen in that light; doctors are no less agents of social control than
lineage elders. The urge to bypass others will be the greatest when the
sickness is embarrassing and threatens to impair a person's reputation, for
example in the case of venereal disease (see Kloos et al. this volume) or
induced abortion. Indeed the increase of venereal disease in Africa may well
have fueled the demand for Western drugs (oral communication S. Whyte),
and so may the growing practice of clandestine abortion.
'De-naturalization' also depends partly on the themes discussed above, but
even more so on the theme yet to be considered: the concept of drug efficacy.
De-naturalization of pharmaceuticals can only be achieved by stepping out-
side the context of pharmaceutical use in the study community, but it also
requires that the researcher step outside his own cultural context. Taking
medicines is not a natural act per se; it appears so to the social actors
concerned (and often to the researcher) because of their culturally imposed
premises. No matter how natural drug taking may initially seem it is always
supported by arbitrary cultural conventions. Ideas about when to take drugs
and what kinds of drugs are the correct ones or the most effective ones are
inevitably part of an individual's cultural heritage (it should be noted that this
is as true of the physician, whose cultural heritage includes his or her medical
training, as of the rural patient).
Moreover, underlying these ideas about medicine use are subconscious
symbolizations that can be elucidated only with great care. One of the most
important of these symbolizations is that medicine use affirms and legitimizes
the patient as being sick. Clearly, the symbolic aspects of pharmaceutical use
will differ from culture to culture and from situation to situation, but this
merely demonstrates the cultural arbitrariness of these underlying concepts
about medicines. It is thus the anthropologist's task to examine these concepts
and symbolizations in order to 'de-naturalize' patients' drug use. This brings
us to people's concepts of pharmaceuticals, perhaps the most important part
of the context of medicine use.
In spite of the keen interest in the cognitive and symbolic aspects of culture
that has long been present in anthropology (and is very much in vogue in
medical anthropology), people's concepts and ideas about pharmaceuticals
PERSPECTIVES FOR RESEARCH AND APPLICATION 341
this way, not the type of drug, but drug taking as a culturally defined act,
seems of primary importance.
A second note of caution is that we should beware of a too 'natural' view of
our own culture. In pharmaceutical anthropology this would imply an exclu-
sive interest in non-Western concepts about drugs and a neglect of drug
concepts in Western countries. There is, however, another more hidden form
of 'ethnocentrism': regarding only lay people's concepts as objects of anthro-
pological research and overlooking the 'culturalness' of professional ideas.
This bias underlies the original formulation of the 'disease-illness distinction'.
But the same ethnocentricism repeatedly appears in studies that accept
without question the pharmacological conclusions about the benefits or
dangers of pharmaceuticals. 24
An example of this bias can be found in Helman's (1984) otherwise
excellent introduction in medical anthropology. He provides 'exotic' exam-
ples of folk-concepts about anatomy, food, illness and medicines in Western
society, but hardly pays attention to the ideas of physicians. Kleinman (1980)
similarly presents 'colorful' descriptions of patient explanatory models of
physiology that conflict with those of the physicians. But while the patients'
models are closely scrutinized, those of the nurses and physicians are very
much taken for granted. The growing literature on overprescribing suggests
that their ideas about drugs merit anthropological research as well. A point
deserving special attention is the high preference for injections that has been
observed world-wide. This preference exists not only among lay people/
patients (cf. Wyatt 1985),25 but also among physicians, as we have seen when
we discussed drug prescription.
Efficacy
1. the attributes of the drug itself (such as taste, shape, colour and name); 2. those of the patient
receiving the drug (such as experience, education, personality, socio-cultural background); 3.
those of the person prescribing or dispensing the drug (such as personality, professional status or
sense of authority); and 4. the setting in which the drug is administered - the 'drug situation'
(such as a doctor's office, laboratory or social occasion).
particular diseases, ignoring the small probability that this particular illness is
the result of the previously identified pathogen for which the drug is known to
be effective. This is not to say that the placebo is completely neglected, but
that those conducting placebo research find themselves somehow at the fringe
of biomedicine.
One short remark should be made about the studies on placebo which have
appeared. The placebo effect in biomedical practice has been exclusively
studied in Western societies. The few existing observations of placebos in a
non-Western context apply entirely to indigenous medical practices. The
most classic examples are probably Levi-Strauss' (1963) essays 'The sorcerer
and his magic' and 'The effectiveness of symbols'. 29 The Ndembu ethno-
graphic work by Victor Turner has also frequently been cited for its presenta-
tion of efficacious therapeutic symbols (see for example Douglas 1975).
Non-Western healing practices have often been described as effective because
of their histrionic and persuasive character (such as singing, dancing, praying,
excorcism, trance, etc.) (cf. Rubenstein 1984). Thus, the effectiveness of
placebos, writes Moerman (1981: 257), is underrated in modern and over-
rated in 'primitive' medicine. The study of Western medicine's placebo in a
non-Western context constitutes a special challenge to medical anthropolo-
gists and others. It could improve the understanding of placebo in general.
There is a second aspect to the anthropological study of drug efficacy which
I will mention only briefly. Anthropologists have pointed out occasionally
that efficacy is not a concept that can be measured ojectively. Healing, like
beauty, is in the eye of the beholder, it is a cultural concept, that does not
lend itself easily to intercultural codification (cf. Hansluwka 1985).
The concept of 'health' (which is the desired result of a drug's efficacy)
tends to be inchoate even within local cultures. People, including medical
practitioners, find it easier to define illness (or disease) than to describe
health. And some societies may even lack an ideal construct of health that
corresponds closely to the meaning of 'health' in Western countries. Welsch
(1982), for example, makes this point for the Ningerum in Papua New
Guinea. Many anthropologists nevertheless have tried to provide a sketch of
what people in 'their' culture understand by health.30 Such sketches often
contrast sharply with narrow biomedical definitions. They emphasize that
'health' is a holistic concept, including not only the body but also psychic,
social, religious and even economic aspects, referring not only to the indivi-
dual, but also to his kin, his cattle, his natural environment and his businessY
There is, however, no apriori reason to assume that any society should have a
clear concept of health that can be understood in terms of a Weberian 'ideal
type'. Thus attempts to define what people understand as 'health' may be a
misguided and poorly advised endeavor.
Kleinman (1980: 311-74) who studied the efficacy of various medical
systems in Taiwan discusses the 'vexing yet basic question: What is healing?'
(p. 354):
346 S. VAN DER GEEST
Successful treatment (can mean) ... success in treating the female family member (s), rather
than the sick person ... (or) appropriately treating the fate or expelling the god or ghost
possessing the client .. .
PRACTICAL RELEVANCE
anthropology seems feasible only for those anthropologists who are able or
willing to close their eyes to a part of social reality.
Anthropologists are best at pointing out the mistakes that have already
been made. McElroy and Townsend (1979: 408) remark that anthropologists
are often called in too late. As a result they can give only 'a postmortem
analysis of what went wrong'. I would rather say, however, that anthropology
is 'postmortem discipline'. It is not called in too late, it prefers to arrive late.
Before things go wrong it does not offer much advice. It does little more than
describe the complexity of the problem. 33
Foster and Anderson (1978: 205-301) optimistically devote a hundred
pages to practical roles that anthropologists can fill in medicine. But it must
be reckoned to their credit that they do not let themselves be enticed to give
ready-for-use prescriptions. They summarize the anthropologist's role in
health development in four areas: (a) offering a holistic view; (b) emphasizing
cultural relativism: 'a willingness to look sympathetically on the cultural
forms of other societies and not judge them against the "normal" of our own'
(1978: 211); (c) warning against misunderstanding in cross-cultural communi-
cation; and (d) suggesting a more appropriate research methodology to
explore the problems encountered in medical programs. These four points
can be summed up in one: making health technicians more sensitive to
people's problems. I would not be surprised if some of the technicians lack
the sensitivity to get the message. They are instead looking for concrete
solutions. In a recent publication Foster (1987) has chastized the WHO for
the low standard of its behavioral research. His pessimism about present
applied health research implies however optimism about better possibilities.
Foster pleads among other things for more recognition of qualitative re-
search.
The major practical relevance of pharmaceutical anthropology is probably
its suspicion of solutions. Anthropologists are awkward consultants in deve-
lopment work and wavering critics of the industry. They are a nuisance to
policy makers who think that they have solved the problem, and they spoil the
pleasures of action groups.
To illustrate my point I will sum up a number of common solutions to the
problems of supply and use of pharmaceuticals in developing countries,
adding some anthropological comments to each. Solutions have been sug-
gested by many authors and organizations. Comprehensive overviews are
provided by Melrose (1982: 129-99), Beardshaw (1983), HAl (1982b) and
Medawar (1984). From these lists of solutions I consider only a few examples
and these have been chosen somewhat selectively, because they suit my
purpose.
The best known and most widely documented policy measure is the WHO's
(1977, 1983) proposal for essential drugs program. Briefly, the proposal
entails ensuring that populations in Third World countries have access to
essential drugs at reasonable prices. The plan was remarkable in two respects.
348 S. VAN DER GEEST
It was designed very late although it seems the most obvious solution one
could think of. Secondly, although it was unanimously applauded, only a
handful of countries have effectively implemented it. 34
A (more or less postmortem) anthropological analysis would stress at least
three points which (with local variations) can be derived from a contextual
description of the essential drugs program. They are: (1) the obstacles to
implementation raised by various groups with vested interests in the old
situation;35 (2) the 'irrational' preference for non-essential drugs among lay
users of medicines; and (3) the observation that public and private health care
are so intertwined (cf. Ferguson and van der Geest in this volume) that it is
impossible to introduce essential drugs in the public sector alone. An addi-
tional observation, no less pertinent, is that effective implementation of an
essential drugs scheme is unlikely to prevent harmful misuse of drugs.
Dubious lay practices of drug use will almost certainly continue after its
implementation, leading to 'inessential' and even harmful use of drugs which
are meant to be essential. 36
Another important initiative for improving access to useful drugs in deve-
loping countries has been an attempt to introduce essential drugs in conjunc-
tion with primary health care. Primary health care involves a comprehensive
program for better health, emphasizing the primal importance of prevention
and self-reliance. Drugs are thus introduced in a context discouraging their
use. I am not denying that this is a very sensible way of improving access to
medicines, but again some marginal notes from the anthropologist's point of
view seem in order.
By now we have overwhelming evidence that the basic idea of primary
health care, viz. self-reliance, is missing in most so-called 'primary health care
programs'. These programs are usually initiated by national or regional
authorities with the help of outside financing. The very start of such programs
implies a denial of their basic tenet. 'Development from below' is introduced
from above. The net result is often an increase in dependency instead of
self-reliance (cf. MacCormack and Draper in this volume). If medicines are
supplied through the program, they will add their momentum to the loss of
self-reliance, because medicines are the most desired and sought after pro-
ducts of Western medicine and they can only be obtained from outside the
community.
It is, however, not so certain that medicines will in fact become more
available through primary health care. Designers of primary health care often
had a far too harmonious picture of local communities. It is naive to expect
that communities have no conflicts and that their members will unanimously
work for common goals, particularly when they may find it hard to survive
privately. In actual practice individual members often see primary health care
as an opportunity to improve their own position, and use its supplies for
private consumption. One of the most desired supplies is, of course, medi-
cines. I have seen numerous unpublished evaluation reports mentioning this
PERSPECTIVES FOR RESEARCH AND APPLICATION 349
problem. I have also had quite a few conversations with planners and
fieldworkers confirming the disappearance of medicines from primary health
care facilities.
Another suggestion frequently offered is to improve the quality of the drug
distribution services that are already in existence, rather than starting entirely
new experiments. The four most common distributors of drugs, as we have
seen, are physicians (prescribing and selling), pharmacists, traditional health
practitioners and unqualified drug vendors. The improvement of the physi-
cian's role in drug distribution has, of course, been the most common
recommendation. One of the ways to achieve this would be providing them
with 'balanced drug information' and 'guidance on cost-effective treatments'
(Melrose 1982: 195). The improvement of the pharmacist's role has been
suggested by, among others, Gish and Feller (1979: 88) and Mitchell (1985).
The contribution to this volume by Logan makes a similar proposal. The idea
here is that pharmacy workers are often expected to advise clients on drug
use. Informing them about correct drug consumption and the dangers of drug
misuse could have a beneficial effect on the quality of drug use. It is evident
that this recommendation would be pointless without prior anthropological
investigation ;nto the actual practices going on in local pharmacies.
Another suggestion, that many will regard doubtfully, is the training of
indigenous healers to improve their knowledge about Western pharmaceuti-
cals and to enable them to prescribe and distribute these drugs more cor-
rectly. One author proposing this solution is Dunlop (1975). Numerous
commentators have recommended a general integration of traditional practi-
tioners into the formal health care system (because they 'are there already')
(Pillsbury 1979). This would certainly also include accepting their role in
prescribing and supplying drugs.
The idea of giving training to drug vendors is mentioned by Nordberg
(1974) and Buschkens and Slikkerveer (1982: 121) for Ethiopia, by Casey and
Richards (1984) for Nepal and by Sural (1985) for Bangladesh. Undoubt-
edly this idea will be rejected by a large number of health workers, who
regard the unqualified drug vendor as a serious health hazard in Third World
countries.
Although I sympathize with all the above suggestions, I want to draw
attention to one formidable factor that is likely to hinder the intended
measures quite seriously: the commercial one. Training will certainly be
helpful in so far as the problems derive from lack of information. But there
are indications that, from Western-trained physicians to unqualified vendors,
it is the commercial aspect of pharmaceuticals that leads most directly to
maldistribution, overprescription and misuse. Fieldwork at the spot should
reveal whether the commercial factor is likely to become an obstacle in
particular cases.
Another suggestion has been aimed directly against the commercialization
of medicines. Marxist oriented authors in particular have proposed that the
350 S. VAN DER GEEST
those who need their help least. A spokesman of the pharmaceutical industry
has, with anthropological wit, observed a similar paradox in Western society:
... those patients who might be thought most at risk of suffering poor treatment are probably
those least likely to be represented by the more active consumerists. Desirably or otherwise,
older, sicker and less-educated people probably want to be able to put their trust in their doctors
and avoid being confronted with too many difficult choices related to their treatments (Taylor
1983: 26).
Action and consumer groups in the industrial world have also pleaded for a
tighter control of the export of pharmaceuticals from their own country to the
Third World. One problem with this suggestion is easily recognised by
anyone: the multinational structure of the pharmaceutical industry makes it
easy to circumvent restriction on its export from one country. More informa-
tion about the conditions of drugs procurement in Third World countries will
probably teach activist groups that the political, commercial and medical
elites there, eventually determine what medicines are delivered, although it
must be admitted that their choices are heavily influenced by the industry.
'Solutions' which overlook the local elite factor are not likely to have much
effect at all.
The pharmaceutical industry has its own 'solutions'. One has been a
voluntary 'Code of Pharmaceutical Marketing Practices' (IFPMA 1981)
which, it claims, meets the complaints of its critics concerning misleading
advertising and other dubious marketing practices in the Third World. In
actual fact the code has been a successful attempt to prevent the imposition of
a harsher and 'involuntary' code composed by the international consumer
organization, Health Action International (HAl 1982).
One need not be an anthropologist to see that such a voluntary code is a
sham, to allow the continuation of old marketing practices in a more watchful
world. The code as such, therefore, does not call for anthropological com-
ment, but its content does, in particular the general thrust that the industry is
fully aware of its special responsibility, that it produces high quality medicines
and sincerely tries to safeguard optimal use of those medicines.
Research into the conditions of medicine distribution and use in developing
countries reveals that the industry cannot be serious when it says that its
products 'have full regard to the needs of public health'. Its optimistic
assessment of the use of its products seems unwarranted in most developing
countries. Although it purports to be concerned about public health, it is
uninterested in Third World conditions that encourage wrong use of its
medicines and subsequently cause serious health hazards. When the industry
is informed about these conditions it ignores or even denies them (for two
examples see Medawar and Freese 1982; Wolffers 1983). The industry at-
tempts to continue its business with the help of some 'myths' that vaguely
imply that conditions in the Third World are the same as in the industrialized
352 S. VAN DER GEEST
world of the West. Three of those myths are: (a) that the industry can
guarantee the safety of its products and the adequacy of its information; (b)
that it is able to withdraw misinformation about its drugs when necessary; and
(c) that prescription-drugs are purchased with a doctor's prescription.
It is not difficult for an anthropologist to show that in a particuar society
these claims are untenable. A description of the context in South Cameroon,
for example, reveals that drugs are taken in completely different ways than
prescribed by the industry and that those who do so have no possibility of
discovering this because the industry's information on correct use is not
available. My research also makes clear that misinformation about drugs is
wide-spread and that the industry can do very little about it. It finally shows
that prescription drugs can be obtained everywhere without a doctor's pre-
scription.
Pharmaceutical anthropology may not have many 'prescriptions for change'
but the above examples will underscore my claim that such analyses can be
useful in pointing out the weaknesses and contradictions in solution which are
being proposed. Furthermore, insights derived from anthropological field
research make one wary about the possibility of improving drugs use by
'talking to' the authorities. Anthropologists have pointed out that authorities
often have a direct interest in maintaining the existing conditions. Providing
information and suggestions to those who are the 'victims' of present circum-
stances seems a more realistic lever for change.
CONCLUSION
The primary purpose of this chapter was to present themes for anthropologi-
cal research on pharmaceuticals in developing countries by taking stock of
what has been done so far and suggesting new research that should be
undertaken to gain a deeper understanding of pharmaceuticals. The second
aim was to discuss the practical relevance of pharmaceutical anthropology.
The conclusion is that anthropological research on Western pharmaceuti-
cals in a non-Western context is still scarce. To date, the overwhelming
majority of studies have been undertaken from a biomedical or economic
point of view. Contextualization is hardly applied and the authors rarely
manage to 'de-naturalize' their own medical and pharmacological concepts.
At present, policies for the improvement of drug use in developing coun-
tries are being initiated while the cultural complexity of drug use is but poorly
understood. There is a greater-than-ever need for an anthropological analysis
that views pharmaceuticals in their 'natural' context and,at the same time,
divests them of their 'naturalness'. Such anthropological research should deal
with the social and cultural aspects of the entire life history of pharmaceuti-
cals, their production and marketing, their prescription, retail distribution
and consumption and their efficacy. During their 'lives' pharmaceuticals move
PERSPECTIVES FOR RESEARCH AND APPLICATION 353
from hand to hand and from head to head. Both the transaction and the
meaning of medicines deserve the anthropologist's attention.
This collection of studies makes a beginning by viewing medicines in their
cultural context. The authors show how medicines as commodities are pro-
duced, sold and consumed. They elucidate the roles of drug company sales-
men, pharmacists, street vendors and 'traditional' practitioners and finally
they describe how Western pharmaceuticals are understood in terms of local
medical cultures. Their findings are not only relevant for health care policy in
developing countries; they also provide us with a fresh perspective on the
cultural dimension of the use of medicines in the West.
NOTES
1. This chapter owes very much to Robert Welsch who commented extensively on its earlier
versions and provided numerous suggestons for change. I also thank my co-editor Susan
Whyte for her help and comments.
2. Some publications analysing the working of the multinational industry are: Beardshaw 1983;
Blum et al. 1983; Buhler 1982; Gish and Feller 1979; Haslemere Group n.d.; Heller 1977;
LaIl1977; Ledogar 1975; Melrose 1982; Muller 1982; Patel 1983; Turshen 1976; Unctad 1975
and 1982. Research on the biased drug information in developing countries was carried out
by (among others): Medawar and Frees,e 1982; Osifo 1983; Silverman 1976 and 1977;
Silverman et al. 1982a and 1982b.
3. Some doctors, I was told, may first prescribe a drug and then add a 'fitting disease' to it. As
some doctors know very few drugs this mt:thod greatly simplifies the diagnosis. Prescribing
reassures the patient and the doctor (oral communication, David Lee, Panama).
4. There is abundant literature on biased information by the industry. Some of the most
prominent publications are: Greenhalgh 1987; Medawar 1979; Melrose 1982; Osifo 1983;
Peters 1983; Rolt 1985; Silverman 1976; Silverman et al. 1982; Yudkin 1980.
5. The examples of 'irrational' prescribing cited by Silverman et al. (1982: 91-2) are:
- prescribing multiple hormones, multiple antibiotics, and similar combinations when only a
single drug is clinically indicated;
- prescribing any antibiotic in the treatment of 'flu' or the common cold;
- prescribing a newly-introduced drug solely on the grounds that it is new;
- declining to prescribe or dispense a high-quality, low-cost generic-name product in place of
a costly brand-name product - which mayor may not be of high quality - on the grounds
that 'the generic firms can't be trusted' (such prescribers and pharmacists are apparently
unaware that the generic and the brand-name versions may be made by the same firm);
- giving a drug by injection rather than by mouth because 'our people prefer it that way - we
belong to an "injection culture".' (Patients and physicians alike have been duped by
rumors and hush-hush campaigns suggesting that aspirin is too dangerous for most children
- 'You doctors in Europe and America do not seem to know this' - and should be replaced
with a costly and more hazardous substiltute, preferably given by injection.)
6. Two examples of doctors' compliance are reported by Sich from Korea. She describes how
she was induced by a woman in labor to do a cesarian section, although this was against the
medical criteria she adhered to. The other example was an old man with a common cold who
made a doctor comply with his request to give him an injection of Kanamycin (Hinderling
and Sich 1985: 8). Doctors' compliance to patients' demands is particularly prone to occur
when doctors compete for clients on a free market basis.Wolffers' contribution to this
volume provides a case in point. Sri Lanka traditional practitioners use Western medicines in
354 S. VAN DER GEEST
order not to lose patients. A Dutch study (Krol 1985) has shown that general practitioners
frequently refer patients to a specialist because the patients want it. Referring children to a
pediatrician happens in 46% of all cases on request of the parents. Helman (1978) makes the
point that physicians in Britain sometimes use concepts that closely parallel the concepts of
their patients rather than those of their medical training.
7. Haak (1987) reports from two Brazilian villages that 48 out of 62 households were of the
opinion that every consultation with a doctor should end with a presecription.
8. A typical example of harmful overprescribing is reported by Hardon (1987: 281) in the
following case occuring in a Filipino village:
Emma complains. Her child has diarrhoea. And she consulted a private doctor. She wants
the best she can get for her child. The doctor prescribed five medicines. She cannot buy them,
as her husband is jobless this month. She has borrowed money from relatives .... I ask her
how severe the diarrhoea is. I categorise it as simple diarrhoea: according to the recommen-
dations in the Primary Health Care manuals oral rehydration is the best therapy. The doctor
prescribed: a drug to prevent vomiting, an antidiarrhoeal. an antibiotic, a multi-vitamin, and
an analgesic. Total price: 120 peso (one week salary).
9. For studies discussing therapeutic practices by pharmacists see for example: De Walt 1977;
Dressler 1982; Ferguson 1981; Group DCP 1984; Haak 1987; Igun 1987; Kloos et al. (this
volume); K. Logan (this volume); Mitchell 1983 and 1985; Nichter 1983; Sussman 1981;
Weisberg 1982.
10. The following studies refer to the role of unqualified personnel in licensed pharmacies:
Ferguson (this volume); Haak 1987; Igun 1987; Jayasena 1985; Unschuld 1976; Van der
Geest 1985; Weisberg 1982; Wolffers 1987b.
11. Some studies reffering to informal private practices by health personnel are: Bledsoe and
Goubaud 1985; Janzen 1978; Lasker 1981; Maclean 1974; Nichter 1978; and 1983; Thomas
1975; Van der Geest 1982b and 1985; Wolffers (this volume).
12. Studies referring to the distribution of Western drugs by non-Western healers do so only
briefly. Some examples are: Alexander and Shivaswamy 1971; Alger 1974; Bhatia et al. 1975;
Brown 1963; De Walt 1977; Dobkin de Rios n.d.; Dressler 1982; Fabrega and Silver 1973;
Golomb 1985; Messenger 1959; Minocha 1980; Nichter 1983; Taylor 1976; and Waxler 1984.
A more substantial discussion is found in Burghart (this volume) and Wolffers (this volume
and 1987a).
13. Anne Laurentin told me in 1979 that during her work as a physician in Burkina Faso and the
Central African Republic she sometimes ran out of drugs, especially antibiotics. She then
informed the local chief who often managed to bring in a trader with the required drug. Not
infrequently the drugs were in bottles with hand-written labels. which made it impossible to
check them.
14. For a more elaborate discussion of illegal drug sale, see Fassin 1985 and Van der Geest
1982a.
15. Some studies referring to drug vendors are: Bagshawe et al. 1974; Bledsoe and Goubaud
1985; Buschkens and Slikkerveer 1982; Dressler 1982; Fabrega and Silver 1973; Janzen 1978
and 1979; Kleinman 1980; Kloos 1974; McEvoy 1976; Nichter 1983; Nordberg 1974, Schul-
pen and Swinkels 1980; Thomas 1970; Unschuld 1976; Van der Geest 1987. Some publica-
tions that mention the administration of injections by vendors are Cosminsky and Scrimshaw
1980; Cunningham 1970; Ferguson 1981; Maclean 1974; Taylor et al. 1968; Van der Most van
Spijk 1982; Whyte 1982 and this volume.
16. Authors who mention a - sometimes peripheral- medical background of drug vendors are:
Buschkens and Slikkerveer 1982: 54; Cominsky and Scrimshaw 1980: 271; Igun 1987;
Maclean 1974: 107; Taylor 1976: 298; Van der Most van Spijk 1982: 47. The Underwoods
(1981) give the example of an 'injection doctor' in South Yemen who had spent one month as
PERSPECTIVES FOR RESEARCH AND APPLICATION 355
a hospital cleaner. In Ghana I heard about a hospital gate keeper who trained himself by
'checking' and studying the patients' prescriptions. After some time he set up a private
practice of his own in a village at some distance from the hospital.
17. The observation concerning pharmaceutical companies' primary interest in profits may apply
equally to many drug vendors, who seem to be little hindered by knowledge of the dangers of
wrong drug use. Ferguson (this volume) writes that the owners of two pharmacy shops in El
Salvador 'engaged in their own forms of dumping', and Last (1981: 392) makes mention of
vendors who 'extended normally specific illness terms to cover arbitrarily a wider range of
symptoms in order more easily to sell off a specific remedy'. I witnessed similar practices
during research in South Cameroon.
18. Some publications which discuss self-medication in a non-Western context are: Abosede
1984; Greenhalgh 1987; Haak 1987; Hardon 1987; K. Logan 1983; Kleinman 1980: 179-202;
Nitschke et al. 1981; Ohnuki-Tierney 1981; Parker et al. 1979; Van der Geest 1987; J.C.
Young 1981: 104-8; and various contribution to this volume. An overview of literature on
self-medication is provided by Kroeger 1983.
19. See also Kleinman 1980; Lewis 1975; and Welsch 1982. An early study focusing on the role of
the family in treatment involvement is Boswell's (1965) research in a Zambian hospital.
20. Re-conceptualization of Western ideas and practices was mentioned very early by Paul
(1955) in the introduction to his classic study. Few researchers, however, have taken up his
call for further study in this field.
21. 'Translation' from professional to layperson also takes place within Western culture. Blum-
hagen (1982) for example shows how patients in the USA translate bodily sensations into
medical terms as 'hypertension'. Helman (1984) quotes some British studies which describe
lay perceptions of physiology and disease that are partly derived from professional theory.
They use its terminology and yet differ sharply from it. Kleinmans's (1980) Explanatory
Model is an attempt to account for such 'translations'. It would be short-sighted to see only
the translations from Western to non-Western, and from professional to non-professional.
Translations in the opposite direction are equally common, but seldom recognized. Cultural
anthropology, in spite of its emic claims, could be regarded as a continuous attempt to
understand foreign phenomena in Western terms. By the same token, medicine reformulates
lay experiences into professional language.
22. In the meantime Logan's study had been reprinted in Landy (1977) and Logan and Hunt
(1978). A revised version of the article by Bledsoe and Goubaud is found in this volume.
23. The 'construction' of culture by anthropologists has been a recurrent theme in recent
anthropological self-reflection. Goody (1977) has suggested that the dichotomous view of
cognitive aspects of human cultures (advanced versus primitive, modern versus traditional,
logico-empirical versus mythopotic, etc.) should be regarded as an ethnocentric attempt by
the Western academic to express the 'we-they experience'. Hobsbawm and Ranger (1983)
have collected essays in which it is argued that 'tradition' is not simply there, but is 'invented'
by dominat social groups, often for very practical purposes, for example in a colonial context.
The idea of 'tradition' often produced a platform for symbolic forms and ceremonies to
legitimize political power. From there it is only a small step to 'Culture as camouflage'
(Schrijvers 1983), hiding social and economic oppression behind cultural phrases and images.
24. See also Etkin (this volume) on the concept of efficacy in non-Western pharmaceuticals on
this latter point.
25. Mburu (1973: 94) writes about the Kenyan situation: 'Cognitive orientation towards the use
of injection is so intense ... that many people regardless of their educational level think it is
the only valid type of modern therapy'. Studies mentioning the popularity of injections
abound; see for example Bledsoe and Goubaud 1985; Burghart (this volume); Cunningham
1970; Igun 1987; Kleinman 1980; Nichter 1980.
26. The placebo effect can be - negatively - understood as the total drug effect minus the
pharmacological effect of the drug.
356 S. VAN DER GEEST
27. The concept 'nocebo' ('I shall harm') is sometimes used to indicate a negative placebo effect,
for example by Herzhaft (1969). Illich (1977: 121-2) uses the term to describe the process of
'social iatrogenesis'. Medical procedures, according to Illich, have a nocebo effect when
'instead of mobilizing his self-healing powers, they transform the sick man into a limp and
mystical voyeur of his own treatment'. For an ethnographic account of 'voodoo death' see
Lewis 1987.
28. In a WHO discussion Polunin (1982: 20) has said that 'reliance on the placebo effect ... is
characteristic of charlatans'. Some 'hard' biomedical statements on placebo are also quoted
by Brody (1983). As Lisbeth Sachs pointed out to me, the fact that the placebo has not been
included in the WHO's list of essential drugs epitomizes biomedicine's suspicion of it
(personal communication). In some countries, however, vitamins are included as placebos.
29. Laderman (1987) has criticized the somewhat apocryphal status of the shaman's words cited
in Levi-Strauss' latter article. Levi-Strauss never witnessed the events nor heard the words
which were to become the classic anthropological example of symbolic healing. His argument
is entirely based on a text transcibed by others.
30. It is remarkable, however, that anthropologists rarely present indigenous terms used by their
informants to describe those experiences which the ethnographer believes should be trans-
lated as 'health'. An exception is Ohnuki-Tierney's (1981: 34) analysis of the Ainu term ramu
pirika which literally means 'soul-beautiful', and, according to the author, refers to the
essential unity of body and mind in the Ainu concept of health.
31. Publications that stress a holistic view of health in various non-Western cultures are (to
mention only a few): Fabrega and Silver 1973; Morley and Wallis 1979: passim: Hinderling
1981 and Katz 1982. Some anthropological observations are tinged with a dose of romantic-
ism, reflecting the desire for 'lost values' in their own culture. A typical example of such a
romanticizing view is the following quotation from Katz (1982: 34) about the Kung Bushmen
in Southern Africa:
Healing seeks to establish health and growth on physical, psychological, social and spiritual
levels; it involves work on the individual, the group, and surrounding environment and
cosmos. Healing pervades Kung culture as a fundamental integrating and enhancing force.
The well-known WHO definition of health comes close to it: 'A state of complete physical,
mental and social well-being'. This definition has been widely criticized as too static, too soft,
too broad and too idealistic (for an overview of the comments see Hansluwka 1985). Lewis
(1976: 100(2), who worked as a physician and anthropologist among the Gnau in Papua New
Guinea, rejects the holistic definition, at least for illness: ' ... illness is a misfortune sensed
by the sick person in ways which other misfortunes, like his house burning down, are not'.
Lewis suggests that this must be a 'universal recognition'.
32. For more discussion on emic concepts of the efficacy of medical treatment and on the
difficulties of comparison, see Levi-Strauss 1963; Thomas 1973: 242-51; A. Young 1977:
Foster and Anderson 1978: 123-6.
33. Heggenhougen (1985: 133) criticizes anthropologists for their passive attitude in health
development:
Anthropologists should not only show why something should not be done in a certain way but
should make suggestions for alternative approaches ... We must persist in presenting a
broader definition of progress and development and in cautioning impatient developers to
consider the socio-cultural, economic, and health ramifications a program may have. But a
concern for complexities should not prevent action altogether.
34. About 40 countries report that they have implemented an essential drugs program( 1987). but
I regard most of these programs as little effective; doctors are still able to prescribe
'non-essential' drugs and patient continue purchasing them in the private sector. The
PERSPECTIVES FOR RESEARCH AND APPLICATION 357
publications on essential drugs are numerous. Most of them are from a medical-
pharmacological, economic and political point of view. Extensive bibliographies are provided
by Bannenberg 1985, Mamdani and Walker 1985 and WHO 1985.
35. Observations about the obstruction of essential drugs programs now abound, but - under-
standably - precise and 'hard' data on this ~ensitive issue are difficult to come by. One of the
first observations is by Lall and Bibile (1978) in Sri Lanka. Descriptions of Bangladesh's
attempts to reorganize drug supply are manfold (see e.g. Rolt 1985). In a note about three
East African countries Korn (1984: 35) is outspoken and vague at the same time:
It is a strange experience speaking to the doctors in Eastern Africa. You will not find one you
would suspect of accepting bribes or of excessive prescribing, let alone one who would admit
to such practices. However, the national import statistics, the shelves of the pharmacy stores,
and the rarely available records of the international drug companies will convince you that
you are dealing with JekyllfHydes who are likely to raise silent and obstinate political
pressure against any attempted drug policy in their country.
The philisophical and political platform for a national drug policy existed in Tanzania. The
economic disaster situation would also help to justify to the population a restrictive drug list.
Anyone would agree that some essential drugs would be better than no drugs at all. Nothing
but the implementation was lacking in Tanzania (Korn 1984: 36).
36. A collection of papers (Sterky 1985) on esst~ntial drugs, published by the Dag Hammarskjold
Foundation in Uppsala, Sweden, illustrates this point. Concepts like 'rational use' of
medicines and 'needs', why take a prominent place in many of the papers, are only used in a
biomedical sense. A more cultural definition of 'rational' and 'need' would have made the
discussion far more complex!
37. Some countries seem to be an exception to this 'rule'. It is reported that Botswana and
Zimbabwe, for example, have an efficient public system of drug distribution which leaves few
opportunities for informal private trade in medicines (various oral communications).
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LIST OF CONTRIBUTORS
Solomon Belay
City Council Pharmacies, Addis Ababa, Ethiopia
Caroline H. Bledsoe
Department of Anthropology, Northwestern University, Evanston, Illinois
60208, USA
Richard Burghart
Department of Anthropology, School of Oriental & African Studies,
University of London, Malet Street, London WCl 7HP, UK
Alizon Draper
London School of Hygiene & Tropical Medicine, University of London,
Keppel Street, London WCl 7HT, UK
Nina Etkin
Department of Anthropology, University of Minnesota, 215 Ford Hall, 224
Church Street S.E., Minneapolis, Minnesota 55455, USA
Anne Ferguson
Bean/Cowpea CRSP Management Office, 200 Center for International
Programs, Michigan State University, East Lansing, Michigan 48824, USA
Berhanu Getahun
Department of Geography, Addis Ababa University, P.O. Box 31609,
Addis Ababa, Ethiopia
Monica F. Goubaud
Department of Anthropology, University of New Mexico, Albuquerque,
New Mexico 87131, USA
367
S. van derGeest and S. R. Whyte (eds.). The Context ofMedicines in Developing Countrles, 367-369.
1988 by Kluwer Academic Publishers.
368 LIST OF CONTRIBUTORS
Nuria Homedes
School of Public Health, University of Texas, Austin, Texas 78712-1088,
USA
Helmut Kloos
Department of Geography, Addis Ababa University, P.O. Box 31609,
Addis Ababa, Ethiopia
Charles Leslie
Center for Science and Culture, University of Delaware, Newark, Dela-
ware 19716, USA
Kathleen Logan
International Studies Program, University of Alabama at Birmingham, 338
Ullman Building, Birmingham, Alabama 35294, USA
Carol MacCormack
London School of Hygiene & Tropical Medicine, University of London,
Keppel Street, London WC1 7HT, UK
Anke Niehof
Netherlands Ministry of Foreign Affairs.
Home address: Galileistraat 3, 2561 SX The Hague, The Netherlands
Linda K. Sussman
Department of Psychiatry, Medical School, Washington University, P.O.
Box 8134, S1. Louis, Missouri 63110, USA
Asregid Teferi
Department of Geography, Addis Ababa University, P.O. Box 31609,
Addis Ababa, Ethiopia
Antonio Ugalde
Department of Sociology, University of Texas, Austin, Texas 78712-1088,
USA
Paul U. Unschuld
Institut fur Geschichte der Medizin der Ludwig-Maximilians-UniversiHit,
Lessingstrasse 2, 8000 Munich 2, West Germany
Robert L. Welsch
Department of Anthropology, Northwestern University, Evanston, Illinois
60201, USA
Ivan Wolffers
Freelance Primary Health Care and Health Education Consultant, Mid-
dellaan 11, 3721 PG Bilthoven, The Netherlands
INDEX OF NAMES
371
372 INDEX OF NAMES
Cosminsky, S. 22, 27, 36, 274, 354 Feller, L.L. 19-20, 37, 147, 349, 353
Court, E.W. 309 Ferguson, A.E. 15,47,58-59, 147,274,
Croom, E.M. 303 335-336, 340, 346, 348, 354-355
Cross Beras, J. 76 Fernando, J. 50
Cunningham, C.E. ix, 47, 67, 220, 338, Field, M.J. 228
354- 355 Finerman, R.D. 300
Cutting, W.A.M. 277 Foege, W.H. 38'
Fortune, R.F. 199
Dafni, A. et al., 304-305 Foster, G.M. 222,255,330,347,356
Davis, E.W. 303,306,308,315 Fraser, H.S. 90
De Guevarra, C.C. 42 Freese, B. 351
Delaveau, P. 306 Freij, L. et al., 82
DelVecchio Good, M.J. 342 Friedman, P.S. 82
De Smet, P.A.G.M. 314-316 Fry, P. 218
Desta, A., 102
De Swaan, A. 334 Gagon, J.F. 101
De Walt, K.M. 108, 110, 125,354 Garrison, V. 200
Dharma, A.P. 169 Gebre-Medhin, M. 82
Diamond, S. 329 Gedebou, M. 94
Diesfeld, H.J. 318 Geertz, C. 167
Disengomoka, I. et al., 308 Geest, S. van der see Van der Geest
Dobkin de Rios, M. 354 Gereffi, G. x, 59
Dodge, R.W. 94 Geschiere, P.L. 133, 144
Domenjoz, R. 196 Gie1, R. 102
Dominguez, X. 307 Gilman, R. 82
Dotsenko, A.P. 82 Gimlette, J.D. 169
Douglas, J.D. 133 Giovanni, G. 332
Douglas, M. 345 Gish, O. 19-20,37, 147,349,353
Draper, A. 4, 177,282,346,348 Gobezie, A. 82
Dressler, W. W. 354 Golomb, L. 354
Dubos, R. 38,41 Gonzalez, N.S. 223, 274, 337
Dukes, M.N.G. 119 Good, B. 254, 274
Dunlop, D.W. 57, 349 Good, CH. et al., 47
Durham, W.H. 41 Good, M.J. see DelVecchio
Goody, J. 355
Echols, J.M. 168 Goubaud, M.F. 7-8, 176,217,342,346,
Edgerton, R.B. et al., 118, 125 354-355
Ellen, R.F. 236 Gould Martin, K. 317
Elling, R. 299 Green, E.C. 226, 307
Elliot, K. 277 Greenhalgh, T. 47,334-335,353,355
Elvin-Lewis, M.P.F. 199,306,311,315 Griffenhagen, G. 118
Eoff, G.M. 57 Grisiola, S. 311
Erasmus, CH. 111, 119 Gunaratne, V.T.H. 256-257
Etkin, N.L. 7, 177, 199,266,299,307, Gupta, B. 289
316-317,343
Evans, P. 19-20,38 Haak, H. 354-355
Evans-Pritchard, E.E. 199, 227 Hahn, R.A. 330, 344
Hailu, B. 81
Fabrega, H. Jr. 107-108, 125, 329-330, Hansluwka, H.E. 345, 356
337, 354, 356 Haragewoin, M.D. 82
Fassin, D. 338, 354 Hardon, A.P. 47, 57-58, 334-335, 354-355
Feierman, S. 199, 299 Harlan, J.R. 303
INDEX OF NAMES 373
377
378 INDEX OF SUBJECTS
informal sale of drugs vii, IS, 17, 59, 84-5, Jamaica 121,177,277-87,342
111, 135-6, 139-44, ISO, 152, 157, 164, Jamu Iboe 154
169,202,205,220,235,237,237,251. Jamu industry 149--70
253, 255, 260--2, 333, 337-8, 349--50, Jamu Jago 152, 154, 160, 163, 168
354-5 Jamu medicine x, xii, 17,339
informal sector 133, 135-6, 139--41 - packaged- 10,17,149--51,158,161,
information on drug use 29--31, 42, 53, 92, 237-8, 250-1
95-6, 100, 114-5, 117,119, 124-5, 138, - ready-to-drink 150
145, 152, 158, 253, 331-2, 334, 336, - relation to Western medicine 10
349,352-3 - use in pregnancy and childbirth 10,
(see also advertisements; advice on use 176, 239--40, 243--9, 251 Jamu Pasuka
of drugs by relatives; intructions; Ambon 154
inserts; media broadcasts) Japan x, 20
injection doctors ix, 22, 43, 83--5, 87-8, 98, jargon, biomedical 31
102, 220, 338, 354 jaundice 305-6
injections vii, ix, 32-3, 35-6, 38, 47, 70-1. Java 149--70, 251
73, 84, 89, 96, 98--9, 118, 135, 138, jhamo, see jamu
140, 334, 337, 343, 353, 355
- compared to tablets in India 292 Kamcape anti-sorcery movement 228
- death from- in Sierra Leone 263--4 kaopectate, 119, 121
- heating qualities of - in India 257 kaloin pectin ointment 51
- Mende views and use of- 261,263, Kamba 341
271-2 Kanamycin 353
- penicillin - by Ayurvedic doctors 177, kebele, see urban dwellers' associations
290-7 keftegna, 91-3, 102
- penicillin - by Nyole needle men 220-1 Kenya 306, 341
(see also health risks) Kerala 47
innovation of culture 55 key informants 110
insanity 210 Khmer medicine 308
insecticides 42 knowledge
inserts 22,30-1,39, 138 - of household remedies 122
instructions about drug use 6, 94, 102, - of traditional medicine ISO, 157
259--61,265,272,274, 290 Koranic texts as medicines 225
(see also information about medicines) Korea 353
integration of western and alternative Kossopharm 91
medical practitioners, see articulation Kung bushmen 356
of formal and informal medicine kwashiorkor 268
Inter-American Development Bank 59
interweaving of formal and informal 141-5 Laboratorio Lopez 30
(see also articulation) labour pains 53
intestinal helminths 42, 53 Latin America 20, 29, 41, 57-9, 63, 68, 111
intoxication 314 laws, see legislation
intravenous rehydration 277-8 lay health reporting systems 86
iodine 154 laxative xii, 136--8
Iran 342 - Indian - 312
iron tablets 269 - Jamaican treatment for diarrhea 279,
Islam 236, 238 282,284-5
Islamic medicine 228 - Mende treatment for malaria 254, 267
Israel folk medicine 304-5 lead poisoning 124
Italy 20 legal cases, medicines for- 223
Italian indigenous healers 311 legislation
Ivory Coast 218, 341 - on drug distribution 50, 136, 141, 144
386 INDEX OF SUBJECTS
peddlers of drugs, see informal sale of pharmacy clients, case histories of - 96-100
drugs pharmacy owners 30, 32-3, 42, 50
pedralyte 28, 30 pharmacy personei 30-4, 37, 40, 47. 51,
penacine 98 84, 95, 98, 99, 102, 354
penicillin 11, 39, 89, 95, 98, 177,220, pharmacogenic maladies 271-2
255-6, 263, 289--97, 342 pharmacology
- dangers of 295 - analyses 303
- power of- 291-2,5 - bias 229, 318
- qualities of - 291-2 - Chinese, medieval 179--97
pepper 89 - definition of - 181
Pepto-Bismol 121 - European. ancient 179--97
perception - Galenic 185-7. 190. 193
- of disease 81, 90 - historic textual sources on - 179,
- of use of drugs 99, 102 181-2, 187
personnel in medical institutions 35, 142-3. - origins in China 181-3
21-2. 29, 93. 116, 260, 262. 274. 336, - origins in Europe 181
338, 354 - research 229--30
Pfizer 30 - Wang Hao-Ku. of 189--196
pharmacopeias, indigenous- xi. 302-8 Pharmacopeias
pharmaceutical anthropology ix, 3, 5. 179 - cultural nature of - 318
pharmaceutical firms 19-46. 125, 134. 141, - indigenous - 302-8
146, 154-5. 158-9,277,331,333,351. - literature on - 199
355 Philippines 57-8, 332, 335, 354
- multinational- ix-xii. 273-4 phlebotomy 308
- national- 38 physicians 15, 26. 28-9, 39-40. 43, 47.
(see also manufacturers) 49--51,57,59-65,68-9, 110, 114, 123,
pharmaceutical industry 15. 19-46. 142. 125, 146, 150. 157, 169.201-3.205,
144-5.332 211-2, 236-7. 259-60, 286. 332. 336.
- multinational- 19-21. 29, 30. 36, 340, 343-4, 349, 353, 357
38-40, 42, 50, 59. 331, 353, 357 - and manufacturing medicines 154
pharmaceutical invasion 9, 19-46, 175-6, - and traditional medicine 156-7. 167.
227,229 170
- economic consequences of - 19--21. 331 - compulsory service by - 60
pharmaceutical pluralism 10. 250 - patient relationship 116, 335, 339
pharmaceutical, definition of- 5 - private - 111-2, 118, 120-2. 157
pharmaceutics physiology, Western paradigms of 318
- and culture 179-97 pile tablets 269
- cognitive basis of - 179--81 pilfering of medicines 62
pharmacies xii. 17, 19--46.50-1.59--77. pills, see tablets
107-25, 133-4. 139--43, 154, 158. 202, Piperazine 43
205, 207. 2Jl-2, 260, 284-5. 290. 355 placebo 343-5, 355-6
- communal- 16, 64 - and commerce 344
- government 16, 81 placenta 241-3
- wholesale - 33. 34, 35, 36 plant medicines xi, 17
pharmacists 15, 16, 135-6. 141-6, 150. 201. - qualities of - 303-8
208, 253. 332-3, 353 (see also herbal medicines)
- as health care practitioner 107-25. plants
113-7.336.354 - descriptive or functional names of-
- diagnosis by 107, 124 304
-pro-141,146 - selection of - 303-8
- professional organization 110 - smell of - 306
- training of- 116-7. 124 P.L.M. 30, 39
INDEX OF SUBJECTS 389
vomiting 96, 205, 207, 268, 316 worms 156, 176, 268-9
Voodoo death 344, 356 - medications for 96, 98, 136, 262, 265,
272
water wounds 89, 307
- consumption 82
- supply 37 yellow fever 264
Waorini 306 Yemen
Western medicine 330 - North 335
Whateroga 53 - South 354
Whitfield ointment 51 yin-yang doctrine 180, 184, 189-94
WHO xi, 20, 86,132,134,261,347,356 Yomesan 91
- Essential Drugs Programme 9 Yunani medicine 296
WHO/UNICEF declaration of 1978 278
wholesale of medicines 17, 135-6 Zaire 119
(see also pharmacies, wholesale) Zambia 228, 355
witch 5 zar, see possession
witchcraft 36, 39, 176,268-9,330 Zezuru 218
woggesha 85 Zimbabwe 218, 357
women 16, 110--1 Zinza 218
World Bank 59 Zuni 307