Throughout the late 19th and 20th centuries, Biomedicine was massively exported into Third World countries. Sometimes it was borrowed and at others it was exported as a result of its colonialist imposition (Kleinman, 1980; Lock, 1993; Reynolds, 1976; Weisberg & Long, 1984). Still later, it was actively sought by developing countries as a feature of modernization. The modernizing process acts as an homogenizing funnel that channels "development" toward univariate points: in economics, capitalism; in production, industrialization; in health care, Bio-medicine. The three work in tandem, as the importation of Biomedicine means the investment of huge sums of money in the construction of large hospitals (the factories of health care), the training of staff, and the incorporation of expensive medical technologies. Such modern biomedical facilities usually serve the colonizers and the middle and upper classes of colonized populations and are largely inaccessible to the majority of the population.
As in the West, major improvements in health for these biomedically underserved majorities have primarily resulted not from Biomedicine but from public health initiatives to clean water and improve waste disposal and nutrition (McKeown, 1979)—improvements that many Third World communities still sorely lack.
When Biomedicine is transplanted, it is altered in significant ways in terms of clinical practices, nosologies, medical theory, concepts of self, and therapeutics (Farmer, 1992; Feldman, 1995; Gaines & Farmer, 1986; Hershel, 1992; Kleinman, 1980; Lock, 1980; Reynolds, 1976; Weisberg & Long, 1984). For example, pharmaceutical agents only available by physician prescription in the First World often take on a life of their own in Third World countries: traditional healers and midwives incorporate allopathic injections into their pharmacological repertoires; drugs are sold in pharmacies and on the streets without prescription. In a sense, people become their own diagnosticians and self-prescribe, without the biomedical establishment but also without a systematic way of dealing with the biological implications of their use of allopathic medicines (Nichter, 1989; Van Der Geest & Whyte, 1988).
Biomedicine's inaccessibilty and lack of cultural fit often ensure that practitioners in the developing world do not enjoy a monopoly on medical care; indigenous and professional healers from non-biomedical systems continue to serve large clienteles. In some areas, postmodernization is beginning to limit Biomedicine's reach, as literate and savvy non-biomedical healers, from shamans to curanderos to naturopaths, increasingly tap into and augment scientific evidence supporting the herbal, humanistic, and spiritual elements of their practices.
In all instances of culture contact, Biomedicine generally attempts to maintain its modern scientific status by co-opting and redefining knowledge, therapies, or therapeutic agents found in other traditions, professional or popular. Medical dialogues are transformed into biomedical monologues (Gaines & Hahn, 1985). In this way, Biomedicine continually revitalizes itself and reinforces its hegemonic status by expanding to incorporate elements from other modalities.
In the cultural arena of childbirth, for example, core challenges to the intense medicalization of birth came from birth activists in the 1970s who demanded "natural childbirth" in the hospital, meaning in this case that women gave birth without drugs or technological interventions. By the 1980s, Biomedicine had humanized its approach to birth, redecorating delivery rooms, allowing the presence of family members and friends, and offering epidural analgesia so that women could be both pain-free and "awake and aware." These humanistic reforms took the steam out of the natural childbirth movement by incorporating some of its recommendations. Yet at the same time, the technologization of birth increased: for example, the use of electronic fetal monitors has risen exponentially since the 1970s, as has the cesarean rate. Thus, Biomedicine reinforced its biopower over birth while at the same time allowing women a greater sense of agency and respect.
Analogously, pharmaceutical companies now move into indigenous areas, harvest local botanical specimens (often stealing them from local healers), sell them as vitamins or herbs, or mix them with drugs to create "nutraceuticals"; they then try to control the use of the ingredients they have taken, limiting or eliminating their availability to local populations. As with childbirth, this process of co-option continually revitalizes Biomedicine without giving status or credit to other medical systems and their distinctive ideologies of illness and healing.
Yet even in the West, Biomedicine does not hold a monopoly on healing. In Europe, homeopathic and natur-opathic medicines are part of institutionalized health care systems, as are forms of hydropathy (Maretzki, 1989; Maretzki & Seidler, 1985; Payer, 1989). In European,
Canadian, and some American pharmacies, naturopathic and homeopathic medicines are sold alongside biomedical pharmaceuticals. In the United States, Osteopathy and Chiropractic compete successfully in the professional health care arena (Coulehan, 1985; Gevitz, 1982; Oths, 1992), as does professional Chinese medicine in the Western states.
Around the world, the narrow funnel of modernization is opening to more expansive appreciations of what has been lost, what can be preserved or re-created, and what is still to be learned. It is increasingly clear that in the postmodern era, multiple medical knowledge systems can co-exist and come to complement each other. Biomedicine in all likelihood will continue to advance within its own parameters and to hold on to some status, if not its earlier hegemony, for decades to come. But, increasingly biomedical practitioners will have to respond to the existence and strengths of other ways to heal.
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