Introduction

Medical systems in all human societies, regardless of whether they are indigenous or state-based, consist of a dyadic core consisting of a healer and a patient. Healers range from generalists, such as the shaman in indigenous societies or the proverbial family physician in modern societies, to specialists, such as the herbalist, bonesetter, midwife, or medium in preindustrial societies or the urologist, internist, or psychiatrist in modern societies. In contrast to indigenous societies, which tend to exhibit a more-or-less coherent medical system, state or complex societies exhibit the conflation of an array of medical systems—a phenomenon generally referred to by medical anthropologists, as well as medical sociologists and medical geographers, as medical pluralism. The medical system of a society consists of the totality of medical subsystems that coexist in a cooperative or competitive relationship with one another. Although much of the initial work that anthropologists conducted on medical pluralism occurred in African and Asian societies, Leslie (1976, p. 9) notes that "[e]ven in the United States, the medical system is composed of physicians, dentists, druggists, clinical psychologists, chiropractors, social workers, health food experts, masseurs, yoga teachers, spirit teachers, Chinese herbalists, and so on."

Medical pluralism is not a recent phenomenon but has its roots in increasing patterns of ranking and social stratification in human societies. Fabrega (1997) argues that, as opposed to foraging and village-level societies, chiefdoms and early state societies exhibit the beginnings of the "institution" or "system" of medicine which includes: (1) an elaborate corpus of medical knowledge which continues to embrace aspects of cosmology, religion, and morality; and (2) the beginnings of medical pluralism, manifested by the presence of a wide variety of healers, including general practitioners, priests, diviners, herbalists, bonesetters, and midwives who undergo systematic training or apprenticeships. He delineates two broad levels in the plural medical systems of early civilizations and empires: (1) an official, scholarly academic system oriented to the care of the elite; and (2) a wide array of less prestigious physicians and folk healers who treat subordinate segments of the society, such as craftspeople, artisans, soldiers, peasants, and slaves. The state plays an increasing role in medical care by hiring practitioners for the elites and providing free or nominal care for the poor, especially during famines and epidemics. The literate or "great" medical tradition includes the formation of a medical profession, the beginnings of clinical medicine, and the increasing commercialization of the healing endeavor.

With European expansion and colonialism, allopathic medicine, or what eventually evolved into biomedicine, came to supercede in prestige and influence even professionalized traditional medical systems. Third World societies are characterized by a broad spectrum of humoral and ritual curing systems. Some of these are associated with literate traditions, such as Hinduism, Islam, Confucianism, Buddhism, and Taoism, and have schools, professional associations, and hospitals. Even though the upper and middle classes resort to traditional medicine as a backup for the shortcomings of biomedicine and for divination, advice, and luck, it constitutes the principal form of health care for the masses. As Frankenberg (1980, p. 198) observes, "The societies in which medical pluralism flourishes are invariably class divided."

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