Various medical anthropologists have formulated various schemes or approaches that recognize the phenomenon of medical pluralism in complex societies. Based upon their cultural ecological settings, Dunn (1976) delineates three types of medical systems: (1) local medical systems, (2) regional medical systems, and (3) the cosmopolitan medical system. Local medical systems are folk or indigenous medical systems in foraging, horticultural or pastoral societies, or peasant communities in state societies. Regional medical systems are systems distributed over a relatively large area, such as Ayurveda and Unani medicine in India and Sri Lanka and traditional Chinese medicine. Cosmopolitan medicine refers to the world-wide system commonly referred to as Western medicine, regular medicine, allopathic medicine, scientific medicine, or biomedicine. Complex societies generally contain all three of these systems. In modern industrial or post-industrial societies, biomedicine— the dominant system—tends to exist in a competitive relationship with other systems such as chiropractic, naturopathy, Christian Science, evangelical faith healing, and various folk medical systems. It often seeks either to annihilate these systems or to restrict their scope of practice. In some instance, biomedicine seeks to absorb or co-opt them, particularly if the latter achieve increasing legitimacy.
Chrisman and Kleinman (1983) created a widely used model that delineates three overlapping sectors in health care systems. The popular sector consists of health care performed by patients themselves, their families, social networks, and communities. It includes a wide array of therapies, such as special diets, herbs, exercise, rest, baths, and massage, and, in the case of modern societies, articles such as over-the-counter drugs, vitamin supplements, humidifiers, and hot water bottles. Based on research in Taiwan, Kleinman estimates that 70-90% of the treatment episodes on the island occur in the popular sector. The folk sector encompasses various healers who function informally and often on a quasi-legal or even illegal basis. These include shamans, mediums, magicians, herbalists, bonesetters, and midwives. The professional subsector includes the practitioners and bureaucratic structures, such as clinics, hospitals, and associations, which are associated with both biomedicine and professionalized heterodox medical systems, such as Ayurvedic and Unani medicine in South Asia, herbalism and acupuncture in the People's Republic of China, and homeopathy, osteopathy, chiropractic, and naturopathy in Britain.
In keeping with Navarro's (1986, p. 1) assertion that classes as well as races, ethnic groups, and genders within capitalist societies "have different ideologies which appear in different forms of cultures," it may be argued that these social categories also construct different medical systems to coincide with their respective views of reality. In contrast to many medical anthropologists who observe that complex societies exhibit a pattern of medical pluralism, many neo-Marxian medical social scientists confine their attention to the dominant capital-intensive system of medicine and ignore or at best give fleeting attention to alternative medical systems. Critical medical anthropology (CMA), which builds on the work of the political economy of health, attempts to overcome these shortcomings (Singer & Baer, 1995). It asserts that patterns of medical pluralism tend to reflect hierarchical relations in the larger society. Patterns of hierarchy may be based upon class, caste, racial, ethnic, regional, religious, and gender distinctions. Medical pluralism flourishes in all socially stratified or state societies and tends to mirror the wide sphere of class and social relationships. National medical systems in the modern world tend to be "plural," rather than "pluralistic," in that bio-medicine enjoys a dominant status over heterodox and/or folk medical practices. In reality, plural medical systems may be described as "dominative" in that one medical system generally enjoys a preeminent status vis-à-vis other medical systems. While within the context of a dominative medical system one system attempts to exert, with the support of social elites, dominance over other medical systems, people are quite capable of "dual use" of distinct medical systems (Romanucci-Ross, 1977).
Medical pluralism in the modern world is characterized by a pattern in which biomedicine exerts dominance over alternative medical systems, whether they are professionalized or not. The dominant status of biomedicine is legitimized by laws that grant it a monopoly over certain medical practices, and limit or prohibit the practice of other types of healers. Nevertheless, biomedicine's dominance over rival medical systems has never been absolute. The state, which primarily serves the interests of the corporate class, must periodically make concessions to subordinate social groups in the interests of maintaining social order and the capitalist mode of production. As a result, certain heterodox practitioners, with the backing of clients and particularly influential patrons, have been able to obtain legitimation in the form of full practice rights (e.g., homeopathic physicians in Britain, osteopathic physicians in the United States, and Ayurvedic and Unani physicians in India) or limited practice rights (e.g., chiropractors, naturopaths, and chiropractors in North American societies, many European societies, as well as Australia and New Zealand). Lower social classes, racial and ethnic minorities, and women have utilized alternative medicine as a forum for challenging not only biomedical dominance but also, to a degree, the hegemony of the corporate class and its political allies.
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