Numerous scholars, among whom Charles Leslie was perhaps the first, have shown how medical pluralism is the rule in virtually all societies today, so that competition among medical sectors is common (Leslie, 1980), often with major repercussions on the health of populations. This tendency is well illustrated by examining the availability and use of medicinal technologies. Beginning in the 1950s anthropologists showed concern about the effects of imported pharmaceuticals, notably antibiotics, on the health of people in developing countries, when it became clear that these powerful medications were being misapplied. Anthropologists also were interested in the impact of the availability of pharmaceuticals on the use of indigenous medicines.
It was quickly recognized that politics are inevitably implicated in the global transfer of drugs, but in addition that pharmaceuticals have not only biochemical properties but are also associated with culturally defined meanings. "We can speak of the biography of a drug: its production, distribution, marketing, interpretation and use," argue Van Der Geest and Reynolds Whyte (1988). Etkin (1988), in a similar vein, discusses the cultural construction of efficacy with respect to pharmaceuticals and suggests that healing should be understood as proces-sual in order to grasp the way in which a series of outcomes are usually considered important to efficacy, not all of them physical.
It has been shown repeatedly that the introduction of pharmaceuticals has had major impacts, many of them negative, in societies without a health sector that has a well-functioning and well-funded infrastructure. In El Salvador, for example, when the use of locally produced indigenous medicinals was largely replaced, due to the introduction of a commercial pharmaceutical sector, community breakdown was evident as well as individual dependence on brand name prescription medications (Ferguson, 1981). Van Der Geest and
Reynolds Whyte (1988) describe the formation of an informal sector for the purchase of pharmaceuticals, one that included smuggled medicines in the Cameroon. They argue that self-medication with products bought in the informal sector can be detrimental to health (not only to individuals but to populations as antibiotic-resistant bacteria multiply); that money is often wasted on useless medication but that, for certain medical problems, the availability of pharmaceuticals sold across the counter is better than nothing. In such instances a form of autonomy can be achieved by patients that would otherwise not be possible. Nichter (1989) shows how in South India over the past two decades use of herbal remedies has rapidly been overtaken by sales of commercial medications. He argues that biomedicine is equated with modernity and progress, and pharmaceuticals have in effect become fetishes imbued with power, as is the case elsewhere. Family members share medications with each other. But Nichter detects ambivalence at work as well, because danger and impurity are also associated with these new, foreign drugs.
Oral rehydration salts (ORS) have been widely promoted by WHO and other organizations to combat infant diarrhea, the major cause of infant mortality in areas where poverty is widespread. MacCormack and Draper (1988) write about how mothers in Jamaica were taught to use ORS imported from Switzerland in place of very effective mint teas or coconut water prepared at home. They note the irony of importing ORS at great expense when one of the two ingredients in the packages is sugar—the bedrock of the Jamaican economy. These authors go on to show how aid agencies actively promote the use of ORS as a medicine—as a quality-controlled chemical formula—when in fact all that the packages contain are sugar and salt. Mothers must walk for hours with their sick children to clinics to obtain this "medicine" rather than caring for the children at home. Nichter argues that in Sri Lanka, ORS have been introduced to that country as a "technical fix." He shows how purveyors of this technology draw on local beliefs about health and "strength" to assist in their marketing strategies (Nichter, 1989). Increased infant mortality has been documented in connection with the promotion of bottle-feeding in regions where poverty and unhygienic conditions are present (Van Esterik, 1989). Numerous anthropologists writing on the subject of the introduction of pharmaceuticals, bottle-feeding, and ORS to the "developing" world have pointed out that, increasingly, governments adopt a reductionistic approach to the health of populations—a medicalized technical fix—at the expense of dealing with public health and environmental issues. Global and capitalist interests are rarely concerned with preventive medicine, and local elites, including many members of the medical profession trained overseas, give priority to high-tech medicine over primary care.
When biomedical technologies are adopted in countries supposedly dedicated to the idea of development, the response from some sectors is often one of nationalism. The result is that even as new biomedical technologies are incorporated, usually unevenly across society, there is a renewal of interest in indigenous techniques and therapies, although efforts are very often made to have them rationalized and scientized. Public interest in indigenous technologies is usually fired up through appeals to nationalism and often also to naturalism (Adams, 2002; Farquhar, 1995; Leslie, 1989; Nichter, 1989).
The globalized distribution of pharmaceuticals has another dark side that anthropologists have recently begun to research. The experimental trials of contraceptives in Egypt prior to their approval by the Food and Drug Administration (FDA) in the United States (Morsy, 1998) is one telling example of the use that the bodies of peoples in Africa, the Caribbean, the Middle East, and South East Asia have been put to as experimental subjects in the interests of drug companies. The cost of drugs proven to be effective against HIV/AIDS and of crucial medications for other diseases including malaria and multi-drug resistant TB, and the impact of these marketing strategies on the everyday lives of people has also been documented by anthropologists (Farmer, 1999; Nguyen, 2001).
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