The Triumph of Praticalty: Tradition and Modernity in Health Care Utilization in Selected Asian Countries 9789812304704

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The Triumph of Practicality

The Institut e of Southea st Asian Studies was establish ed as an autonom ous orgamzat 10n m May 1968. It IS a reg10nal research centre for scholars and other spectaltst s concerne d w1th modern Southeas t Asta, particula rly the multdac eted problems of stab1hty and secunty, economiC developm ent, and poltttcal and sooal change. The Institute IS governed by a twenty-tw o-membe r Board of Trustees compnsm g nommee s from the Smgapor e Governm ent, the National Umvers1 ty of Smgapor e, the vanous Chambe rs of Commer ce, and profesSional and c1v1c orgamzat 1ons. A ten-man Executiv e Committ ee oversees day-to-da y operation s; It IS cha1red by the Director, the Institute' s ch1ef academic and admm1st rat1ve off1cer. The Social Issues in Southea st Asia (SISEA) programm e was establtshed at the Institute m 1986. It addresses Itself to the study of the nature and dynamic s of ethmc1ty , rehg1on~, urbamsm , and populatio n change m Southeas t Asta. These Issues are examme d w1th particula r attention to the lmphcatl on» for, and relevance to, an under,ta ndmg of problems of developm ent and of societal confltct and co-opera tion. SISEA IS gutded by a Regional Adv1,ory Board compnsm g semor scholars from the vanous Southeas t As1an countnes . At the Institute, SISEA c~me~ under the overall charge of the D1rector wh1le Its day-to-da y runmng IS the responslb lhty of the Co-ordm ator.

The Triumph of Practicality TRADITION AND MODERNITY IN HEALTH CARE UTILIZATION IN SELECTED ASIAN COUNTRIES

Edited by STELLA R. QUAH

National University of Singapore

I~BI!! Social Issues in Southeast Asia

&&llii il

INSTITUTE OF SOUTHEAST ASIAN STUDIES

Pubhshed by Insntute of Southeast Asian Studies Heng Mui Keng Terrace Pasir PanJang Smgapore 0511 All nghts reserved or No part of thi; puhhcano n may be reproduced , stored m a retneval system, mg, transmitte d m any form or by any means, electronic, mechanica l, photocopy recordmg or otherwise, without the pnor permission of the Institute of Southeast Asian Studies.

© I989 Institute of Southeast Asian Studies Catalogu ing in Publicati on Data The Tnumph of pracncahty tradition and modernity m health care utilization m selected A,wn countnes I edited by Stella R Quah. 1 Medical care-- Asia-- Unhzanon --Collecte d works 2 Folk medicine-- Asia--Coll ected works I Quah, Stella R 1l Institute of Southeast Astan Studie; (Smgapore ) 1989 RA303 T84 ISBN 981-3035-19-6 The re,ponsiht hty for facts and opmions expressed m tht' publtcatto n re,ts exclu;tvelv or wtth the authors and thetr Interpretat ions do not nece,sanly reflect the vtcws supporter' tts or Institute the of the pohcy

Tvpeset b:v The Fototype Busmess Pnnted m Srngapore by Krn Keong Pnntmg Co Pte Ltd

Contents

List of Tables List of Figures Contributors Preface

vii X

xii XV

The Triumph of Practicality

Stella R. Quah

2 Marriage of Convenience: Traditional and Modern Medicine in the People's Republic of China

Stella R. Quah and Li ]ing-wei 3

Traditional and Modern Medicine in Japan: Main Features

Kyoichi Sonoda

19

43

Contents

Vl

4 Stress-Copm g and T radmonal Health Care Utthzation m Japan Tsunetsugu Munakata

75

5 Receptlvtty to Tradtttonal Chmese and Modern Medtcme among Chinese Adolescents m Hong Kong Rance PL. Lee and Yuet-wah Cheung

6 The Best Bargam: Medical Opttons m Smgapore Stella R. Quah

101 122

7 Unhzatton ofTradltlonal and Modern Health Care Servtces m Thatland Santhat Sermsn

8 Confirmmg the T numph of Practtcahty Stella R Quah

160 180

List of Tables

1.1 2.1 3.1 3.2 3.3 3.4 3.5

Companson of lndrcators of Development of F1ve Selected Countnes Tradltlonal and Modern Health Serv1ces m Chma, 1949, 1981, and 1985~86 Numbers and Rat1os of Modern Medrcal Personnel m Japan, 1972~84 lnst1tut1ons Trainmg Modern Medrcal Personnel, 1986 Numbers and Ranos of Four Types of Tradltlonal Medrcme Practitioners m Japan, 1972~84 lnst1tut1ons Trammg Tradltlonal Medrcme Pract!tloners, 1986 Cost of Production of Modern and Trad1t1onal Med1cmes, 1982~84

14 29 45 46 48 49 51

urr

Trends m Producti on of Prescnbe d and Non-Pre scnbed Herbal MediCmes, 1976-84 Unltzatto n of Modern and T radltlona l MediCal 3.7 Resources for Selected Health Problems, Japan, 1985 Utiltzano n of Modern and Tradltlon al MediCal 3.8 Resources by Sex and Age, Japan, 1985 Utilizatio n of Modern and Trad1t10nal Medical 3.9 Resources by Urban and Rural Sectors, Japan, 1985 Trends m Unltzatlo n of Modern and Tradltlon al 3.10 MediCal Resources, Japan, 1955-85 Unhzano n of Tradition al Medtcme , Bunkyo Study, 1986 3.11 A3.1 Unlizatio n of Thirteen Types of Tradltlon al MediCal Resources by Respond ents' Sex, Age, and Educatio nal Level, Bunkyo Study, 1986 A3.2 Opmion s on Kanpo (Tradlt!onal Chmese Medtcme ) by Respond ents' Sex, Age, and Educatio nal Level, Bunkyo Study, 1986 A3.3 Acnon Taken When Affected by Two Health Problems, by Respond ents' Sex, Age, and Educatio nal Level, Bunkyo Study, 1986 Effectiveness of Instrume ntal Support and 4.1 Emotion al Support Correlat ion and Mulnple Regresston Analysts on the 4.2 Psycho-Soctal Backgro und of Folk Remedtes Unltzatto n m the Populati on of Tokyo Suburbs 5.1 AssoCiation between Each SoClo-Demographtc Factor and the Use of Chmese or Western Medtcal Care 5.2 Evaluati on of Chmese versus Western MediCal Care 5.3 Assocwt ton between Each SoClo-D emograp htc Factor and the Evaluati on of Chinese versus Western Medical Care Evaluati on on Dtsease Treatmen t by Reltgton and 5.4 Mother's Level of Educatio n 5.5 Evaluatio n on Tome Care by Sex, Age, and Father's Occupat ional Status 6.1 Modern Medical Servtces m Smgapor c, 1978 and 1986 3.6

52 54 56 58 59 61

64

71

72 79

94 108 110

112

112 114

125

Ltst of Tahb

6.2 6.3 6.4 6.5 7.1 7.2 7.3 7.4

Utthzanon of Modern Health Servtces m the Pub he Sector: Pattent Attendance, 1978 and 1986 Utthzatton of Tradtttonal Chmese Medtcme: Clime Attendance, 1978 and 1986 Companson of Unhzanon of Modern and Tradltlonal Health Servtces, 1978 and 1986 Four Most Common Types of Condltlons Treated by Modern and Tradttional Health Scrvtces, 1976-86 Governmen t Health Servtce Facthttes m Thatland, 1978 Health Servtces Utthzanon m Thatland, 1970 Number of Governmen t Health Servtce Faolltles m Thatland, 1970, 1981, and 1987 Health Servtces Utthzatton m Thatland, 1979 and 1985

lX

139 142 144 149 167 168 171 174

List of Figures

2.1 2.2 2.3 2.4 4.1 7.1 7.2

Orgamzatlon of National Health Services Three-Tier Network of Health Services in Rural China Departments and Orgamzatlons under the Mmistry of Pubhc Health, Chma, 1982 The Academy of Tradltlonal Chmese Medicme, Chma, 1982 Trends m the Rates for Receivmg MediCal Care for Mam Illnesses Relationship Patterns of Modern and Tradltlonal Health Practitioners and Patients An Expansion of Government and Modern Health ServiCes to the Population

27 28 37 39

77 165 172

Lrst of Frgure1

8.1

Influence of Pragmatic Acculturation and Access1b1hty of Modern Med1cal Servtces upon Dual Usage of Medical Resources

Xl

187

Contributors

Yuet-wah Cheung, Ph.D.,

IS a Lecturer m the Department of Sociology at the Chmese Umvers1ty of Hong Kong. H1s areas of spec1altzat10n are med1cal soc1ology and sooology of dev1ance. He has pub!tshed numerous arttcles m professional mternat1onal JOurnals such as Sacral Sczence &

Medzcme, Human Organzzatwn, Canadzan Cnmmology Forum, Socwlogzcal Focus, Medzcal Anthropology, Revzews m Anthropology, Aszan Profzle, and the Internatwnal Journal of Comparative and Applzed Cnminal ]ustzce, and contnbuted a number of chapters m books. His recent publication 1s Mzsswnary Medzcme m Chma A Study of Two Canadzan Protestant Mzsswns m Chma before 1937 (Lanham, Maryland: Umvers1ty Press of Amenca, 1988).

Contnbutors

xm

Rance P.L. Lee, Ph.D., Is

Profe~sor of Sociology, Dean of the Faculty of Sacral Science~, Chmese Umversity of Hong Kong; Director of the Institute of Sooal Studies of the Chmese Umversity of Hong Kong; and Secretary-Treasurer of the Research Committee on the Sociology of Health, International Sociological Association. His maJor areas of research mclude interaction between tradltlonal and modern health care systems, problems of high-density livmg, and stress-copmg strategies m Chinese culture. He has contnbuted over seventy papers in academtc Journals and as chapters m books. He Is also the author of many books, among whtch are Hong Kong Economtc, Socwl and Polmcal Studtes m Development (New York: M.E. Sharpe, 1979); Sacral Ltfe and Development m Hong Kong (Hong Kong: Chinese Umversity Press, 1981); The People's Commune and Rural Development (m Chmese) (Hong Kong: Chmese Umversity Press, 1981); and Stattsttcal Analysts m Socwl Research (m Chmese) (Wubei, Chma: People's Press, 1987); and the editor of Corruptwn and Irs Control m Hong Kong (Hong Kong: Chmese Umversity Press, 1981).

Li Jing-wei IS Professor and Director of the Chma Institute of Medical History and Medtcal Literature, Chma Academy of Traditional Chmese Medtcme; Deputy Director of the Sooety of History of Medtcme, Chmese Medical Assoctation; and Council Member of the Chinese Sooety of History of Science and Technology. His research mterests cover vanous aspects of the history of tradltlonal Chmese medicme, and he has wntten extensively on the history of Chmese medtcme. He IS the chief editor of "Fascicle on Medical History", Encyclopaedw of Tradmonal Chmese Medtcme (m Chmese) and Dtctwnary of Htstoncal Ftgures of Tradttwnal Chmese Medtcme (m Chmese); and co-author of A Complete Dtctwnar::.' of Tradttwnal Chmese Medtcme (m Chinese). Tsunetsugu Munakata, Ph.D., Is Director of the Division of Society and Culture Research, National Institute of Mental Health, Japan. His research mterests mclude medical sociology, health psychology, and transcultural analysis. He Is the author of, among many publications, Setshm Iryo no Shakmgaku [Sociology of mental health treatment] (Tokyo: Koubundo, 1984) and Koudoukagaku kara Mtta Kenko to Byokt [Behavioural science of health and Illness] (Tokyo: Medical Fnend Co., 1987); and

XlV

Contnbutors

the co-author (with T.S. Lebra et al.) of Japanese Culture and Behavwr, rev. ed. (Honolulu: Umvers1ty of Hawau Press, 1986).

Stella R. Quah, Ph. D., 1s a Semor Lecturer m the Department of Sociology at the National University of Smgapore and Vice Chairperson of the Research Committee on the SoCiology of Health, International SoCiological AssoCiation. She has published papers m professional international Journals and chapters m books in the areas of soc1al policy, medical soc10logy, and sociOlogy of the fam1ly. Among her publications are Balancing Autonomy and Control: The Case of Professwnals m Smgapore (Cambridge: Center ·for InternatiOnal Studies, Massachusetts Institute of Technology, 1984) and Between Two Worlds. Modern Wwes in a Traditwnal Settmg (Singapore: Institute of Southeast As1an Studies, 1988). She 1s the co-author (w1th Jon S.T. Quah) of Fnends in Blue: The Pollee and the Publrc in Smgapore (Smgapore: Oxford University Press, 1987) and the co-comp1ler (with Jon ST. Quah) of Smgapore (Oxford: CLIO Press, 1988).

Santhat Sermsri, Ph.D., 1s Associate Professor and Dean of the Faculty of SoCial Sciences and Humamtles, Mah1dol Umversity, Bangkok, Thmland; and Board Member of the ASEAN Trammg Center for Primary Health Care Development m Bangkok. H1s research interests include health serviCes utilization, soc1al1mpact of health, and social demography. He is the co-author (with J.N. R1ley) of The Vanegated Thaz Medzcal System as a Context for Brrth Control Servzces (Bangkok: Institute for Population and SoCial Research, 1974); and the author of Impact of Rapid Urbanizatwn on Health Status zn Thailand (Bangkok: Project of Applied Soc1al Sciences to the Development of Population Activities and Family Plannmg, Mah1dol Umversity, 1986).

Kyoichi Sonoda, Ph.D., 1s Professor of SociOlogy in the School of Health Snences, Faculty of Med1cme at the University of Tokyo. He has published numerous papers on health and 1llness behaviour and attitudes m Japan, includmg the utilization of health services. Among h1s recent publications 1s Proceedzngs of the Second Aszan Conference on Health and Medrcal Socwlogy, wh1eh he edited Jomtly w1th E. Isomura and others (Tokyo: Japanese Society of Health and MediCal SoCiology, 1987).

Preface

The tdea for thts volume began takmg shape dunng the preparation for the sesston on tradltlonal and modern medtcme, whtch was one of the sessions orgamzed by the Research Committee on MediCal Sonology (now Sociology of Health) of the International Sonologtcal AssoCiation (ISA) as part of the XIth World Congress of Sociology held m New Delht m August 1984. I was mvtted by the Chairman of the Committee, Ray Ellmg, to orgamze that sesston. Three of the papers presented m the sesston, namely, the paper on Hong Kong, Sonoda's paper on Japan, and the paper on Chma, were selected for mcluston m thts volume. They appear here, revised and enlarged, as Chapters 5, 3, and 2, respectively. Thetr contnbutors, Rance Lee, Yuet-wah Cheung, Kymcht Sonoda, and Lt ]mg-wet, had worked extensively on the study of mediCal systems from

XVL

Preface

d1fferent perspectives and were ~peC!ally mv1ted to partiCipate m the ISA Congress. For the other chapters, I approached Tsunetsugu Munakata from Japan and Santhat Sermsri of Thailand, prompted by their valuable contnbunons to the study of medical systems in their respective countnes. Sonoda's chapter provides an overview of the lmk between traditional and modern med1cme in Japan wh1le Munakata centres on the more speCific area of mental health, which IS a very relevant aspect m the high-technology and rapid pace of life m Japan m the 1980s. One of the mam contnbunons of this book IS that 1t offers the views of socwl sCientists from the countnes stud1ed. Of course, we paid the pnce m terms of time. Indeed, as IS common m collaborative efforts, the bulk of the rev1s1on work was done by correspondence. However, m the spnng of 1988, I had the opportumty to go to BeiJing to fmalize the chapter on Chma. The mam a1m of this study 1s to present current documentation on the resilience of the tradltlonal medKme system m As1an nations undergomg rapid modermzat1on and to explore the reasons for people's persistent combmat10n of modern and tradltlonal mediCal resources m their everyday life. The mtended audience for this book 1s the growmg number of soCial sCientists mterested m mediCal systems, problems of modernization and tradltlon, and the process of modermzation and 1ts consequences m Asia. But the book will also offer useful mformanon, as a reference volume, to modern mediCal practitiOners and mediCal students, particularly those concerned w1th pubhc health and workmg m Asia. Fmally, I am mdebted to the kmd and valuable mspiratlon I received from the wntmgs of Professors Charles Leshe and Ray Ellmg and the 1deas I have been fortunate to obtam personally from both of them on vanous occasions over the years. I wish to express my appreciation to the s1x contributors for their kmd co-operation m puttmg together this volume. Without their goodwill and scholarly spmt this work could not have been possible.

August 1988

Stella R. Quah Smgapore

The Triumph of Practicality STELLA R OUAH

Until not too long ago, ethnographic descnptions of traditional healing practices were welcomed by experts as ancient jewels of human behaviour that had to be preserved m records before they became extinct. It was taken for granted that such tradltlonal ways of preventing or handling Illness would eventually disappear as people became enlightened by the concepts and effectiveness of modern medicme. However, as the query on how different communities deal with disease contmues and more evidence Is collected, the premiss on the extmction of traditional health practices can no longer be accepted (Leslie, 1976; Klemman, 1984). Indeed, the study of traditional ways to treat and cure disease has evolved from bemg the cunous subject of a few erudite scholars to the theme at the forefront of health care analysis by a wide range of

2

Stella R Quah

dtsctplines. Cost-beneftt analysts, geographtcal , soctologtcal, and anthropologtcal studtes suggest that tradltlonal heahng practices have survtved the competltton of modern medtcme. Studtes documentin g the survtval of traditional health practtces substannate the argument advanced by Gusfield (1973). He tdenttfted a set of stx fallaoes on the study of traditton and modermty, four of whtch are fully corrected by the evtdence from the dual utihzatton of tradltlonal and modern health servtces. These four fallactes are: "old tradtttons are dtsplaced by new changes"; "tradltlonal and modern forms are always m confhct"; "tradltlon and modernity are mutually exclusive systems"; and "moderntzat ton processes weaken tradltlons" (Gusfteld, 1973: 335-39). Thts book addresses the dual uttlizatton of tradtttonal and modern medtcal systems as tt takes place m soctettes undergomg raptd modermzatton, and seeks to document the premtss that tradtttonal practtces are not merely "survtvmg" but, rather, they are "established " tradmonal ways of healmg acttvely mteractmg wtth modern practices m health-relate d behaviour. By analysmg the sttuatton of ftve Astan nations at vanous stages of developmen t and wtth dtverse cultural settings, we will be able to compare the pervastvenes s of the dual use of systems of health care, and the accommoda tions that have taken place m recent years on the part of tradltlonal and modern medtcal systems to coextst and to meet the health needs of consumers m these countnes. Thts chapter dtscusses three aspects of relevance to the comparative analysts of the ftve countnes mcluded m thts study. The ftrst aspect deals with the defmmon of concepts and explams the approaches used in thts study. The second aspect concerns the revtew of the mam theoretical pronouncem ents m the social sctence literature explammg the "survival" of tradltlonal medicine and the correspondm g data on dual health care utthzatton. The thtrd aspect covers the main questions gutdmg this study and the reasons for the selectton of the ftve countnes.

Concepts and Approaches Soctal scientists studymg the survtval and developmen t of beliefs, attitudes, and behaviOur mvolving health and illness, have used a vanety of terms to refer to the same phenomena thus, unwtttmgly, creatmg confuston and hmtting the usefulness of comparative research. It appears

The Trrumph of Prawcalrt\

3

that Klemman (1984: 140) was echomg the concern of many researchers . we need to be preo~e when he advised that "when we generaltze at what level of abstraction, w1th what quahflcat10ns, for what range of practices and practit!Oners our generaltzations hold". Wh1le such deflmtional clarity is undoubtedly necessary, 1t 1s not sufficient m comparative research. To facilttate and 1mprove our efforts at cross-cultural research, we must "delmeate meamngful umt~ of companson" as Yoder (1982: 15) suggested. For these rea~ons, the efforts by Press (1980) at standardmng our termmology are rather timely. In th1s discussion, I shall adopt h1s defmltlon of the followmg relevant concepts: a medrcal system w1ll be understood as "a patterned, mterrelated body of values and deltberate practices governed by a smgle parad1gm of the meamng, 1dentiflcat10n, prevention and treatment of siCkness" where the term srckness "embraces both Illness and/or d1sease concepts"; the presence of more than one med1eal system m the same soc1ety constitute a plural medrcal confrguratwn; a folk medrcal system 1s that "based upon parad1gms wh1eh d1ffer from those of a dommant med1cal system of the same community or sooety"; and popular medrcme refers to "those beltefs and practices wh1eh, though compatible w1th the underlymg parad1gm of a med1eal system, are matenally or behav10rally d1vergent from offioal med1cal practice" (Press, 1980:

47-48). Cons1denng that the thrust of th1s study 1s the analysis of the coexistence of tradition and modermty in health care unltzation, two mmor adjustments m terminology are necessary for the sake of consistency and s1mpltficat1on. In th1s book, we shall label modern or Western med1eal system the system that Press calls "Western b1omed1cme" (1980: 50); and we w1ll equate tradrtwnal med1eal system with Press' "folk" med1eal system. Concernmg the approaches used m th1s collaborative effort, we have striven to av01d a methodologiCal straight jacket by exploring vanous perspectives for the analysis of available mformation. The d1vers1ty in authorship 1s reflected m the vanety of approaches taken to deal with our subject matter. Pnmary data sources such as surveys and case interviews have been used, as well as secondary data such as population statistiCs, off1oal documents, and findmgs from other stud1es. The approaches followed m the data analys1s proper range from statlstlcal computations to content analysis, to h1stoncal and ethnographic descnptlons.

Stella R Quah

4

Theoretrcal and Emprncal Trends

Two analytical dimensions are involved in this study. The first dimension concerns the concepts of tradltlon and modernity. The second dimension is a mamfestation of the first m the realm of health-related behaviour, namely, the dual unhzation of services from traditional and modern medical systems. Much has been sa1d about both dimensions separately and a review of the most Important of those Ideas in the soCiological literature will provide the conceptual background to the premisses of this study. One of the best-known perspectives on the process of modermzation IS provided by Eisenstadt (1973). He subscnbes to the widely accepted differences m basic prmciples of allocation whereby tradltlonal societies emphasize partJculansnc, diffuse, and ascnptive pnnCJples and modern soCieties follow universal, differentiated, and achievement-or iented prmciples. But, in h1s view, three dichotomies Illustrate what constitutes modermty in contrast to tradltlon, namely: hberty versus authonty; change versus stability and contmwty, and "~oCJal rationality" or "tcchmcal effiCiency" versus cultural onentat1ons "or values such as tradltlon, religious, mystical expenence" (1973: 4-5). These pnnC!ples emphasize a clear-cut separation between traditiOn and modermty and seem to fit one of the fallaCJes Identified by Gusfield (1973: 337), that Is, "tradlt!on and modernity are mutually exclusive systems". Nevertheless, Eisenstadt proceeds to discuss the Impact of modermzation on what he terms "the Impenal Aswn societies" characterized by "pluralistic elements" and a "weak sociopolltlcal order" and, m the course of h1s discussiOn, he brings up a pomt highly relevant to this study: the challenge of modernity was perceived and re;,ponded to by these civilizations m ways that were often m harmony or contmwty with codes prevalent m these soCieties and with patterns of social and cultural change that had developed m the tradltlonal histoncal framework of these Civilization;, (Eisenstadt, 1973· 259-60)

Wh1le h1s reference to 1mpenahsm and a weak socio-political order Is no longer accurate to descnbe Asian nations m the 1980s, the perceived harmony and contmu1ty to wh1ch Eisenstadt refers Is ~till current and applicable. In fact, the pnnC!pal underlymg assumption m this study Is that people m Third World nations do not see any conflict m usmg

The Trtumph of Practtcaltty

5

both tradmonal and modern health servtces: they perceive the modern servtces as a complementary part of their traditional healing practices. Scholars mvolved m the study of modermzation of traditional societies refer to this phenomenon as the process of "d1ffus10n and acculturation" where "old and new elements are recombmed m ways that d1d not previously exist m either sooety" (Nash, 1984: 85). It IS common to find these concepts applied to the analysis of polltlcal and economic modernization of traditional societies (cf. Darlmg, 1979). Although the phenomena of diffusion and acculturation may indeed be mltlated m the economic and polittcal arenas, they tend to 'spill over' to other aspects of people's lives, mcludmg health-related activltles. Hence, these concepts help us to understand the dual utilization of modern and tradltlonal health services m countnes with a plural medtcal configuration. Movmg from the general conceptual aspects of tradlt!on and modernity to speofic studies on health-related behaviOur and attitudes, one fmds that most studies of medical systems have paid greater attention to the provmon of health servtces than to the utrlrzatwn of such servtces. There IS a great deal of mterest among scholars m the arrangements, deCisiOns, and coalltlons made at the national level for the provision of medtcal care to the population. Some of these researchers suggest the application of systems theory as the most comprehensive approach for that type of study (cf. Krause, 1977; Elling, 1980). Others prefer to focus on the dimensiOns of power and confltct among the healmg professions, to explam the preponderance of the modern medtcal system and the respective subordmanon of the traditional medical system (Zeller, 1979; Asuni, 1979; Ulin,'1979; Lee, 1982; Neumann, 1982; Taylor, 1984; Bibeau, 1979, 1985; Leslie, 1985; Barbie, 1986; Akerele; 1987). Yet another angle of analysis IS the economic perspective which deals with the costs and benefits of traditional versus modern systems of medicme within a nation state (see, for example, Dunlop, 1979; K1khela, B1beau, and Corin, 1979). There are comparatively fewer studies on the users of medical care and on the phenomenon of dual utilization of health services offered by traditional and modern medtcal systems. Interestmgly, the latter studies have a common thread: they agree on a mam explanatory argument for dual utilization whtch I would label as pragmatrc acculturatwn, a phenomenon found m nations with diverse health care resources and a plural medtcal configuration.

6

Stella R Quah

The concept "acculturatio n'' normally refers to an individual's or a group's "adoption of aspects of a culture that IS not their native one" (Hoult, 1974: 4). This "culture borrowmg" Is not just the "movement of thmgs among ~octetles" as some ethnographe rs emphasize; It also encompasse s patterns of behaviour and attitudes. Moreover, some mamfestatlons of this culture borrowmg may be termed pragmatiC acculturation when the borrowmg Is motivated by the desire to satisfy spectf!C needs. As Press (1980: 47) puts It succmctly: "Human mmds compartmen talize cultures mto a multitude of contextual and mdividual domams for flllmg a multitude of needs." Such Is the case when people combme health resources from different medical systems. The prevalence of pragmatic acculturatio n can be better appreciated when one considers that the daily lives of people m Third World countnes are immersed m a context of cultural diversity where tradition and modernity are closely mtertwmed. Indeed, food choices range from ancient staples to fast-food restaurants; entertamme nt involves traditional dances, Western movies, mternationa l sports, and the ommpresen t mass media; dressmg codes cover an interestmg and colourful range of possibilities from traditional religious attire to simple jeans and Tshirts for family outmgs; codes of conduct and language may vary too accordmg to the occasion, from mformal slang m one's group dialect at home or at the market-place , to the formal use of major language for business or offiCial purposes. Withm this context, It IS not surpnsing that m matters mvolvmg health and Illness the same pattern of diversity apphes. People perceive traditional and modern medical resources as part of their natural mosaic of choiCes, selectmg whatever alternatives they perceive as appropnate and useful to fulfil a particular health need. The outcome of such perception IS the person's pragmatic and conflict-free move between traditional and modern health services. If ever there 1s a sense of conflict, It is usually mtroduced by modern mediCal system practitioners who routmely try to discourage patients from combmmg resources from different medical systems m general but, especially, from usmg the serviCes offered by the traditional medical system. Numerous studies may be cited to Illustrate empmcally the pragmatiC acculturatio n argument, but a few examples will suffice. Kramer and Thomas (1982) found that among the rural population in Kenya, "the

The Tnumph of Pracucalzt)'

7

textbook dtstmctlons of 'reltg10n', 'medtcme' and 'law' are not relevant. These .. domains . . tended to be mterconnected or blended m everyday life" (1982: 159). The authors distmgutsh three related levels for the study of illness beliefs and behavtour, namely, allevtatton, eradtcatlon, and prevention. They found that people used tradtttonal medtcme at all three levels whtle modern medtcme servtces were used at the levels of alleviation and eradtcatlon but not at the level of prevention (1982: 168-69). The pattern of dual use reported by Kramer and Thomas could be found m many countnes; the overall ptcture of thetr fmdmgs shows that many people would expenence no conflict m resortmg to all of the followmg modern and tradmonal alternatives. buymg shop [over-the-counte r] medicmes to alleviate the pam of headaches, seekmg a mixture from a herbalist for a persistent stomachache, v1s1tmg a nyunyz expert for the eradication of a chrome headache, attendmg the health center for mJecttons that may cure bronchial pneumoma and consulnng a d1vmer for determmmg the ulnmate cause of a senes of mtsfortunes [mcludmg tllness] (Kramer and Thomas, 1982: 170)

From hts fteld-work in a rural area of Malaysta, Heggenhougen (1980) concluded that vtllagers referred dtfferent types of health complamts to health care providers m the modern and traditional medtcal systems. Rehgtous healers or had]ts were percetved by users as experts on affective aspects of illnesses that medtcal doctors would be unable to treat. A stmilar trend was reported m another study on the health practices of South Astan immtgrants m Britam by Bhopal (1986). Bhopal found that although these tmmigrants ltved withm a Western cultural milieu, their own cultural values permeated their deCisions on what health servtces to use for what purpose; they mamfested a strong dnve to seek the help of traditional healers for problems they considered outside the expertise of modern system physiCians. A fmal Illustration of the mfluence of pragmatic acculturation upon dual use of medtcal systems is provided by Anderson's (1987) study of a Cantonese village m the New Terntones of Hong Kong. Anderson observed that his Chinese mformants beheved strongly m their mdividual nght and obhgatlon to mamtam balance and harmony m their dally hves m order to be healthy or to recover from illness. The villagers'

8

Stella R Quah

cultural belief on the Importance of mamtammg "a harmomous balance" m hfe and on their nght to seek it, facilitated their perception of both modern and traditional medical services as potentially useful for that purpose; they did not see their mixed use of health services as mconsistent or conflictive. PragmatiC acculturation Is, thus, an Important factor m the explanation of dual use of traditional and modern health serviCes m soCieties with more than one medical system. However, pragmatiC acculturation Is not the only explanatory factor; It simply Identifies the existence of a conducive cultural mtlteu (that Is, where culture borrowmg Is accepted) for the mixed use of various mediCal systems. Wtthm thts mtlteu, another explanatory factor becomes rather relevant, namely, the accessrbrlrty of health serviCes. This more comprehensive line of explanation suggests that while pragmatiC acculturation Is conducive to the perception of dtverse mediCal systems as a umfied market of healmg options, the consumer's actual accessibility to the vanous types of health serviCes may determme hts or her fmal dec1s10n on what services to utilize. When Is a gtven health serviCe accesstble? The accessibility of health services, whether modern or traditional, may be seen as a contmuum rather than a dichotomy: from a situation where any consumer can use the serviCe without diffiCulties whenever the need arises, to a s1tuat10n where the service Is available to only a few members of the commumty under restrictive condtttons. To determme how accessible health services are, one may refer to five major components of accessibthty, that is, quantitative adequacy, geographical distnbution, cost (m terms of time and money), educat10n, and perceived accesstbtlity (Quah, 1977). The level of accesstbtlity of a gtven service, say maternal and chtld health clmics, increases wtth the number of such cltmcs, thetr widespread geographical dtstribution, and accordmg to how affordable Is the consultation fee, if any, and how much time the user is expected to mvest when gomg for a consultation. Education IS seen as a component of accessibility because, to utilize them successfully, different health services require different levels of educational sophistication on the part of the consumers. An Illiterate patient may be unable to use the computer screenmg services of some climes, or may fmd it difficult to explain to the doctor the intensity of pam or a dizzy spell whtle he or she may feel perfectly at home talking to the neighbourhood herbalist about the

The Trtumph of Prawcaltty

9

same symptoms. It 1s clear that the lower the educational sophistication required on the part of the potential user, the more accessible the health service is. The ftfth component, perceived accesslb!l!ty, 1s denved from the assumption that values and behefs regardmg health and illness affect the mdividual's perception of the accessibility of health services as well as h1s or her dec1sion to unhze such services. Perceived access1bihty may be defmed as "the md1v1dual's mterpretatlon of h1s chances to obtam a g1ven health care serviCe 1.e., the difficulty or easmess with which he thinks he could enter the health care system" (Quah, 1977: 333). Indeed, a health care serviCe may be conveniently located and even free of charge, but potential users may perceive 1t as maccesstble tf they see cultural or social barners such as language, social stigma, or soCial class dtstmcttons 1mpedmg thetr use of that servtce. In addition to cultural beliefs and access!btlity, there 1s a th1rd factor that, m my vtew, Improves considerably the probability that a person uses a gtven health service. That factor ts the person's subjective perception of the beneftts of usmg the servtce. One often observes people wtllmg to overcome great obstacles to get to a serv1ee that they see as the most effective solution to their health problem. A factory worker's faith m the free cl1mc's doctor may be weak compared w1th his fatth m hts home village's healer; the worker may be compelled to travel a long distance at great cost in order to get the healing serviCes of someone whose level of expertise he trusts. The opposite movement ts observed among farmers who happened to beheve that the modern medical system in the c1ty offers the most effective solution to thetr tllness. The combmed argument of pragmatiC acculturation, access!b!hty, and perceived benefits of use, appears to be a more comprehensive explanation of the dual utihzanon of med1eal systems than any of the three factors alone. The extstmg body of research findmgs on health serviCes utihzanon offers empirical support to thts argument. A few examples wtll illustrate th1s. In his study of the Bono community m Central Ghana, Warren (1979) reported that people perceived diseases as "naturally caused" and saw the modern med1cal services as an extension of the1r own traditional system; the1r use of both types of health serviCes was facilitated by the appropriate geographical distnbution of traditional healers and government clinics.

Stella R Quah

10

In Buganda the modern mediCal system was mtroduced by the Bntlsh coloma! government and accepted by the local population as complementary to traditional health serviCes. However, modern health services d1d not reach large sectors of the population; people had to travel great d1stances to get to a modern clime. In contrast "traditional med1eme was always accessible"; fam1lies knew the tradinonal healers by name; and traditional remedies "were widely sold at bus parks, markets and wherever people congregated" (Zeller, 1979: 252). Descnbing the situation of the Yoruba community m N1gena, Asum (1979) mdicated that their behefs were flex1ble enough to see harmony rather than conflict between tradltlonal and modern med1cal systems. Yet, Asum's findmgs showed that people perceived different benefits m the use of tradttJOnal as compared w1th modern health services. The average person beheved that while modern medtcme can procure a cure, tt does not deal w1th the bas1c cause of h1s 1llnes;, which may be a curse, the vengeance of a god, the evil machmations of another person, etc The objective of the traditional healmg practice m th1s situation IS to counteract the baste cause, thereby making modern medicine effective and lastmg m Its curative effect [thus] the traditional system complements the modern system. (Asum, 1979. 180)

At the same time, the Yoruba mdtvlduals hvmg m urban centres had better access to modern health services than those m rural areas: the reverse was true concernmg tradltlonal healers. Asum observed that dual utlhzatton was common: fam!l1es would bnng tradltlonal remedies to thetr stck relattve at the hospttal; and they would move the sJCk person from a medJCa! doctor's chmc to a healer's home seekmg the most benefit from all avatlable spheres of mediCal expertise, even 1f that meant an arduous tnp to consult a well-known and respected healer. Yet another example of the combmed Impact of pragmatic acculturation, acces;,1b1hty, and percetved bencftts ts prov1ded by Ademuwagun (1979). In h1s study of the lgbo-Ora he reports that people perceived the tradmonal and modern systems "as mev1table partners m the tmprovement of thetr health condtnons, workmg complementan ly rather than contradlctonly . . They commute freely between the two [systems] m their efforts to solve their health problems" (1979: 159). On the other hand,

The Trtumph of Practtcaltt)'

11

Ademuwagun found that tradmonal medtcal serv1ces were used more frequently than modern serv1ces, gtven the greater accessibility of the former compared wtth the latter. The average consumer knew that healers spoke the same language, understood hts or her own fears, and cared about the same aspects of h1s or her health complamts; and tradmonal medical services were at the reach of the consumer m terms of cost and location. In contrast, modern health services were less accesstble: the consumer had to 'learn' how to use them; they would be more expensive; and 1t usually reqmred a tnp to the c1ty, whtch was not always convement or posstble. In her detailed analysts of health beliefs and health behaviour m Colombta, Pmeda (1985) reports fmdmgs along the same lmes: people were mclmed to select health servtces from the traditional and the modern systems accordmg to what they thought were the areas of expertise of each system. Yet, the accessibility of modern medtcal faCilities was much lower than that of tradltlonal servtces; cost is the mam barrier among the urban poor; and cost and dtstance are the key obstacles rural populations have to face to reach modern health services. The studtes by Btbeau (1985) on the Chmese and by Taylor (1984) on Bntam and the Umted States present data that provide further support to the combmed concepts of pragmatiC acculturation, accesstbtlity, and percetved benefits. In both studtes, the authors report dual utilization of tradmonal and modern medtcal services whenever the consumers' cultural md1eu was flextble enough to permit the coexistence of both systems and when consumers perceived the ex1stmg servtces as effective and access1ble. Discussmg the well-documented persistence of traditional medtcal systems m African countnes, Fabrega nghtly tdennftes two key questions for further study: "How and speCially why consumers use facets of dtfferent systems of medtcme" (1982: 248). As mdtcated earlier, these questions reflect the mam focus of the present study. I suggest that the explanatory argument mvolvmg pragmatic acculturation, accessibility, and percetved beneftts bnngs us closer to answer the why question. Ethnographtc descnpnons of each commumty wdl contmue to provtde us with culture-speCific answers to the how question. There 1s one more relevant pomt that emerges from the scanmng of research fmdmgs m the literature, namely, that there are two levels of

12

Stella R Quah

reality within a nation-state as far as medical systems are concerned. One IS the official level, representing the v1ews and policies of the dominant mediCal system, whereby boundanes are clearly demarcated between 'legitimate' and 'illegitimate' providers of health care services. Such boundanes imply an array of real and imagined confliCts between traditional and the modern mediCal systems that some Interest groups promote to prevent or delay any official attempt at mtegration. The other level of reality 1s that of the population at large, that is, consumers, as well as providers of traditional medical services. At this level, as descnbed earlier, the average person perceives all available medical services, modern and traditional, as potentially useful and chooses across alternatives motivated by a pragmatiC need of fmdmg the best solution to his or her health problems, w1thm the wide array of possJbJlttJes and gmded by his or her belief of how effective and accessible the services are. The providers of traditional healing serviCes may be seen as part of th1s second level of reality because there are mdications that they share the same pragmatiC perspective with the general publiC, that 1s, the belief that one should use whatever means available to overcome 1llness, whether modern or traditional, and that these two medical systems offer solutions for different types of illness. In most Third World countries, these two levels of reality are parallel: they coexist but do not meet. It appears that the modern mediCal establishment ignores the second level of reality for vanous reasons, not least of whiCh are: the lack of scientific testing of traditional medJCme claims and, correspondingly, the mediCal doctors' negative views on the effectiveness and safety of the services offered by the traditional healers; and the efforts of modern medicme to preserve its dommance.

Basrc Ouest1ons The precedent rev1ew of fmdmgs on health services utilization m countnes w1th traditional and modern med1cal systems has established that dual use of health services 1s prevalent; and that researchers are still unclear as to why people use both traditional and modern serviCes. Available fmdings also indicate that a formal mtegration with the traditional system would be complex and 1s resisted by the modern mediCal system (see, for example, Akerele, 1987; Barbee, 1986; Bibeau, 1985; Twumas1, 1982; Lee,

The Tnumph of Practrcalrty

13

1982; Koss, 1980; Ademuwagun, 1979; Quah, 1977); and that tradltlonal healers have often made attempts to adapt to or emulate modern health serv1ces (for example, Quah, 1977; Ulm, 1979; Zeller, 1979; Lee, 1982). Departmg from these fmdmgs, this book addresses three important questions snll unanswered. The first question focuses on the conceptual concern with understandmg people's cho1ces across cultures and the need to d1scover general trends, that 1s, "What are the promment patterns (1f any) of dual unhzanon of health serviCes?" The second question probes the 1mpact of changmg social condltlons and consumer preferences 10 Th1rd World countries, that 1s, "Does dual unhzat1on of mediCal serviCes d!mm!sh w1th modermzat10n?" The third research question refers to the coexistence of the two levels of reahty and deals w1th health pohcy formulation, namely, "What 1s the current role of the government with respect to the controversial collaboration or mtegratlon of modern and tradltlonal med1cal systems?" The flrSt question will be taken up 10 Chapter 8 where the s1milant1es and differences among the five nations (People's Republic of China, Hong Kong, Japan, Smgapore, and Thailand) will be compared and analysed to probe further the comb10ed explanatory argument of pragmatiC acculturation, access1b1hty, and perce1ved benefits of us10g health serviCes. The other two questions gmde the d1scuss1on 10 Chapters 2 to 7 where the situation of the five 10d!v1dual nations Is discussed and w1ll also serve as a frame of reference for the summary of the ma10 study fmdmgs 10 Chapter 8.

Why These Frve Natrons7 The pnnClpal cnterion for the selection of the five nations 10 th1s study was "umty m d1vers1ty". G1ven the nature of the subject under 10vesngatl0n, the countries mcluded had to be from the Th1rd World and had to meet the basK requirement of a plural mediCal configuration. At the same time, m order to probe the basK quest10ns gu1ding th1s study, it was necessary to select countnes at different stages of modermzatlon or socioeconomiC development and w1th d1fferent levels of cultural homogeneity. Furthermore, for the sake of expediency, it was necessary to work with a manageable number of countries. The five nations selected meet all these requirements. Wh1le all the five are As1an countries w1th tradltlonal

14

Stella R Quah

and modern med1cal systems, they are different m relevant respects as Illustrated m Table 1.1. In terms of sooo-econom1c development and modermzatton, roughly estimated by the md1cators m Table 1.1, the ftve countnes occupy d1fferent pomts m a contmuum. At one extreme 1s Japan, a h1ghly mdustnaltzed nat1on and one of the world's economiC g1ants. Japan 1s followed by Smgapore and Hong Kong, two nations undergomg rap1d mdustnaltzatlon with h1gh gross national product (GNP) per cap1ta, rather low mfant mortaltty rates, and h1gh ltfe expectancy. Next IS Tha1land, With Its growmg GNP but a lower !tfe expectancy, a h1gher mfant morta!tty rate, and w1th the burden of a large hmterland. Further down the contmuum IS Chma, w1th the lowest GNP per capita, the highest mfant mortahty rate, hfe

TABLE 1.1 Comparison of Indicators of Development of Five Selected Countries

Selected Countnes

Population Estimate Mtd-1986 (mt!hom) (1)

Infant Mortahty Rate (2)

Ltfe Expectancy at Bmh (years) (3)

Percentage Urban (4)

GNP per Captta 1983 (US$) (5)

---------

Chma Hong Kong Japan Smgapore Thatland

1,050.0 5.7 121.5 2.6 52.8

so 0 9.2 6.2 9.4 48 0

64 75 77 71 63

32 92 76 100 17

300 6,070 10,100 6,660 820

Source Population Reference Bureau (1986 ). Ito, dcfmltlom of the above mdtcatoro arc as follows. (1) Estimate:, based on a recent census, or on U.N. or offiCial country pubhcanom. (2) The annual number of deaths of cht!dren under age one year per 1,000 btrth,. (3) The average number of years a new-born mfant can expect to hve under current mortahty levels. (4) Percentage of the total population hvmg m areas termed urban by that country. (5) The gross national product (GNP) per cap1ta ftgures are fmal ftgures from the World Bank.

The Tnumph of Pracucallty

15

expectancy figures close to those of Thatland, and the second lowest level of urbamzatton after Thatland. The ftve countnes also dtffer concermng cultural homogenetty. Three of them, Chma, Japan, and Hong Kong, are nearly homogeneous as the large ma]onty of thetr populations belong to one ethmc group. Thatland is moderately heterogeneous: "85 per cent [of tts population] speak a dtalect of That and share other features of culture mcludmg Theravada Buddhtsm" (Bunge, 1981: 61). Smgapore ts a mulnethmc nation: tts population ts composed of three mam ethmc groups: Chmese (76.4 per cent); Malays (14.9 per cent), and Indtans (6.4 per cent); the remammg 2.3 per cent involves vanous small ethmc minonttes (Mmtstry of Commumcattons and InformatiOn, 1986: 7). The beneftts of comparing these culturally and economically dtverse nations wtll become more evtdent as the dtscusston progresses. But what ts clear at this pomt ts the Importance of testmg the conceptual premtsses on dual utilization of medtcal systems under dtfferent socto-structural condttions. As the preceding dtscusston mdtcates, the baste assumptton to be tested ts people's mclmatton to tgnore the offictal boundaries separatmg medtcal systems and to make use of whatever resources they consider useful to sattsfy thetr health needs; m other words, the tnumph of practtcaltty over theorettcal and formal distmctions.

REFERENCES Ademuwagun, Z.A. "Problem and Prospect of LegltimlZlng and Integratmg Aspects of Traditional Health Care Systems and Methods wtth Modern Medtcal Therapy: The Igbo-Ora Expenence". In Afncan Therapeutzc Systems, edtted by Z.A. Ademuwagun, ].A.A. Ayoade, I.E. Harnsson, and D.M. Warren, pp. 158-64. Walthan, MA: Afncan Studtes AssoCiation, 1979. Akerele, 0. "The Best of Both Worlds: Bnngmg Tradtttonal Medtcme Up to Date". Soczal Sczence & Medzczne 24, no. 2 (1987): 177-81 Anderson, E.N. "Illness, Health and Balance m Chmese Medtcme". Paper presented at the Annual Conference of the Assoctatlon for Astan Studtes, Apnl 1987, Boston. Asunt, T. "Modern Medtcme and Traditional MedKme". In Afrzcan Therapeutzc

16

Stella R Quah Systems, edtted by Z.A Ademuwagun, ].A.A. Ayoade, I.E. Harnsson, and D.M Warren, pp 176-81. Walthan, MA: Afncan Studtes Assoctatton, 1979.

Barbee, E.L. "Btomedtcal Reststance to Ethnomedtcme m Botswana". Sooal Scrence & Medrcme 22, no. 1 (1986)· 75-80 Bhopal, R.S. "The Inter-Relationship of Folk, Tradmonal and Western Medtcme wtthm an Asian Commumty m Bntam" Sacral Scrence & Medrcme 22, no. 1 (1986)· 99-105. Bibeau, G. "The World Health Orgamzatton m Encounter with Afncan Traditional Medtcmc: Theoretical Conceptions and Practical Strategtc,". In Afncan Therapeutrc Systems, edited by Z A. Ademuwagun, ] A.A. Ayoade, I.E. Harnsson, and D.M Warren, pp. 182-86. Walthan, MA: Afncan Studies Assoctatton, 1979 _ _ _ "From Chma to Afnca. The Same Impossible Synthesis between Traditional and Western Medicmes". Sacral Soence & Medrcme 21, no. 8 (1985): 937-43 Bunge, F.M., ed Thatland A Country Study Washmgton: Amencan Umversity, 1981. Darhng, F.C. The We.1termzatwn of A sra A Comparatrve Analym Cambndge, Mm,s.· Schenkman Pubh,hmg Co., 1979. Dunlop, D.W. "Alternative" to 'Modern' Health Dehvery Systems m Afnca. Pubhc Pohcy Issues of Tradmonal Health Sy,tem,". In Afncan TherajJeutrc S:vstem.1, edited by Z A Ademuwagun, J A A Ayoade, I.E. Harnsson, and DM. Warren, pp. 191-96. Walthan, MA. Afncan Studies A"ooatton, 1979 Eisemtadt, S N. Tradrtwn, Change and Modernrt\', New York. John Wdey & Sons, 1973. Ellmg, R.H Cros.1-Natwnal Study of Health S)·stems, Polrtrcal Economres and Health Care. New Brunswick, N ].· Tramactlon Books, 1980. Fabrega, H "A Commentary on Afncan Sy,tem" of Medicme" In Afncan Health and Healmg Systems Proceedmgs of a Symposrum, edited by P.S. Yoder, pp. 237-52. Los Angeles, CA. Cro,sroads Press, 1982. Gusfleld, ].R. "Tradition and Modermty. Misplaced Polanties m the Study of Socwl Change" In Socral Change Sources, Patterns and Consequence.\, edited bv A. Et:Iom and E. Etzlom-Halevy, pp. 33 3-41 2nd ed. New York. Ba,Ic Boob, 1lJ73

The Tnumph of Pracucalzty

17

Heggenhougen, H.K. 'The Unhzanon of Tradltlonal Medtcme - A Malaystan Example". Soczal Sczence & Medzczne 14B (1980). 39-44. Hoult, T.F. Dzctzonary of Modern Soczology. Totowa, N.].: Lzttlefteld, Adams, Co, 1974. Ktkhela, N., G. Btbeau, and E. Conn. "Steps toward a New System of Pubhc Health m Zatre". In Afncan Therapeutzc Systems, edtted by Z.A. Ademuwagun, JA A Ayoade, I.E Harnsson, and OM Warren, pp. 217-24. Walthan, MA: Afncan Studtes Assoctatton, 1979. Klemman, A. "Indtgenous Sy,tems of Healmg. Questtons for Professtonal, Popular and Folk Care". In Alternatzve Medzcznes Popular and Polzcy Perspectzves, edtted by J.W. Salmon, pp. 138-64. New York: Tavtstock Pubhcattons, 1984. Koss, ].0 "The Theraptst-Spmttst Trammg ProJect m Puerto Rtco: An Expenment to Relate the Tradtttonal Healmg System to the Pubhc Health System". Soczal Sczence & Medzczne 14B (1980): 267-78. Kramer, ] and A Thomas. "The Modes of Mamtammg Health m Ukambam, Kenya". In Afncan Health and Healzng Systems Proceedzngs of a Symposzum, edtted by P.S. Yoder, pp. 159-97. Los Angeles, CA. Crossroads Press, 1982. Krause, E.A. Power and Illness The Polztzcal Soczology of Health and Medzcal Care New York. Elsevter, 1977. Lee, R.P.L. "Comparative Studzes of Health Care Systems". Soczal Sczence & Medzczne 16 (1982): 629-42 Le,he, C. "What Caused Indta's Masstve Commumty Health Workers Scheme: A Soctology of Knowledge". Soczal Sczence & Medzczne 21, no. 8 (1985): 923-30. Leshe, C, ed. Aszan Medzcal Systems. Berkeley. Umverstty of Cahforma Press, 1976. Mtm,try of Commumcattons and Information Szngapore Fact:, and Pzctures 1986 Smgapore: Information Divtston, Mmi,try of Commumcattom and Information, 1986. Nash, M Unfznz.1hed Agenda The D:vnamzcs of Modernrzatron m Detdopmg Natwm. Boulder, Col We"tvtew Press, 1984 Neumann, A K. "Plannmg Health Care Programs m a Plurahsnc Medical Conte>..t The Cao,e of Ghana". In Afncan Health and Healmg Svstem 1 Proceedmgs of a ~\mposzum, edited by P.S Yoder, pp. 217-35. Los Angeles, CA Crossroad, Press, 1982

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Pmeda, V. Medzcma Tradzcwnal de Colombra Magza, Relzgwn and Curandensmo. Vol. II. Bogota: Umverstdad Naoonal de Colombta, 1985. Population Reference Bureau. 1986 World Populatwn Data Sheet. Washmgton: Population Reference Bureau, 1986. Press, I. "Problems m the Oefmttlon and Classtftcatlon of Medtcal Systems". Sacral Sczence & Medzcme 14B (1980): 45-57. Quah, S.R. "Accesstbthty of Modern and Tradttlonal Health Servtces m Smgapore". Sacral Sczence & Medzczne 11 (1977): 333-40. Taylor, R. "Alternative Medtcme and the Medtcal Encounter m Bntam and the Umted States". In Alternatzve Medzcznes Popular and Polzcy Perspectzves, edtted by ].W Salmon, pp. 191-228. New York: Tavtstock Pubhcatlons, 1984 Twumast, P.A. "Improvement of Health Care m Ghana. Present Perspectives". In Afrzcan Health and Healzng Systems Proceedzngs of a Symposzum, edtted by P.S. Yoder, pp. 199-215. Los Angeles, CA: Crossroads Press, 1982. Ulm, P.R. "The Tradmonal Healer of Botswana m a Changmg Sooety". In Afrzcan Therapeutzc Systems, edtted by Z.A. Ademuwagun, ].A.A. Ayoade, I E. Harnsson, and D.M Warren, pp. 243-47 Walthan, MA: Afncan Studtes Assoctatlon, 1979. Warren, D.M. "The Interpretation of Change m a Ghanatan Ethnomedtcal Study". In Afrzcan Therapeutzc Systems, edt ted by Z.A. Ademuwagun, ].A.A. Ayoade, I.E Harnsson, and OM. Warren, pp. 247-50. Walthan, MA: Afncan Studtes Assoctatlon, 1979. Yoder, PS. "Issues m the Study of Ethnomedical Systems m Afnca". In Afrzcan Health and Healzng Systems Proceedmgs of a Symposzum, edited by P.S. Yoder, pp. 1-20. Los Angeles, CA: Crossroads Press, 1982. Zeller, O.L "Traditional and We:,tern Medicine m Buganda: Coexi:,tence and Complement" In Afrzcan Therapeutzc S)stems, edited by Z.A Ademuwagun, ].A A Ayoade, I E. Harns:,on, and OM Warren, pp. 251-56. Walthan, MA: Afncan Studies Assoctatlon, 1979.

2 Marriage of Convenience: Traditional and Modern Medicine in the People's Republic of China STELLA R OUAH and Ll JING-WEI

Much has been wntten about the struggles and successes of the People's Repubhc of Chma (PRC) m prov1ding adequate health care to 1ts over one bilhon ottzens - a population of 1,015,410,000 m 1982 - scattered over approximately 9.6 m1lhon sq. km. of territory. Th1s chapter attempts to prov1de an updated look at the s1tuat1on from a pohcy perspective, namely, the outcome of about thtrty-e1ght years of an off1nal merger pohcy, or marnage of convemence, between the traditional and modern medtcal systems. The PRC 1s the only country that has Implemented a pohcy of integration of tradmonal and modern systems of medtcme, following a top-down approach consistently. In contrast, most developed and developmg nations present a situation where the offtc1al government pohcy 1s to promote

20

Stella R Quah and Lz ]mg-wez

and support the modern health care system m preference to (and often agamst) tradltlonal alternatives of health care while both traditional and modern medical systems are regularly combined by people m their everyday life. Accordmgly, the discussion of Chma's case m this chapter IS divided into four parts. The first part Is a bnef exammation of the h1stoncal background supportmg the offiCial mtegration of tradmonal Chmese med1cme and modern (also referred to as "Western") med1cme. The second section presents the most signifiCant features of the merger policy. The third section highlights the main current features of the combmed provision and utilization of traditional and modern medical services in Chma. The most salient fmdmgs are summanzed m the concludmg section.

Hlstoncal Prelude to the Merger Perhaps the best-document ed aspect of civilization m Asia IS the development of traditional Chmese mediCme. Nearly 10,000 books or manuscnpts on Chmese medical theory and therapeutic techmques have been preserved, the earliest of which date back to around 221 BC (Lm and Zhu, 1984: 6). This body of mediCal knowledge represents the accumulation of vanous tradltlons mcludmg the Zhong Y1 which refers to tradltlonal Chmese med1cme m the broadest sense; Tibetan (~); Mongolian ('t); Uyghur (ilft-'8-it); Zhuang (;!±); Korean (.¥Jl SU.f); and Da1 (1~) tradltlons, all of whiCh cover theory and therapeutics. H1stoncally, the government has played a very Important role m the development of traditional Chmese mediCme. Sh1 Huang (~-!Iii j_), the first Emperor of the Qmg dynasty (221-206 BC) ordered the burnmg of all books and the burymg of mtellectuals, but he spared medical books from that destruction. The rulers of successive dynasties promoted the compilation and preservation of mediCal literature from all corners of their empire as a symbol of cultural achievement. Emperor Gaozong (~ ~) of the Tang dynasty (AD 618-907) accepted the suggestion of Chinese physiCians and pharmacologist s to set up a team of some twenty physicians with the task of rev1ewmg the ex1stmg medical literature on herbs and compile drawmgs and speomens of herbs with the help of local authonties throughout the country. The outcome of their work was the Xm Xzu Ben Cao (#Jj-1f;f-.$) [Revised herbology], which was wntten and widely distnbuted m AD 659.

Marnage of Convemence m Chma

21

Dunng the Song dynasty (960-1280) the government set up the Bureau for the Recttflcanon of MediCal Books (~tiE -1-"thi) to proof-read, correct, and update the medtcal ltterature wntten before the Tang dynasty and to publish thetr work m pnnt. At the same ttme, the Offtcial Bureau for the Regulation of Drugs was establtshed to momtor the quahty and effectiveness of medtcmes sold to the pubhc. The work of this bureau was cructal m raising the social standmg of physictans and pharmacologists m addttton to safeguardmg the health of the population. The Importance of government poltcy was evident not only m tts posttive effects but also m tts negative consequences for the development of tradlt!onal Chinese med1eme. For example, in 1822, the lmpenal medical authonty declared that acupuncture and moxtbustion were not suttable to the emperor. The Department of Acupuncture and Moxtbustlon at the lmpenal Hospttal was closed permanently by tmperial order and the development of acupuncture suffered a senous set-back for a long ttme after that offioal move. The best Illustration of the strength of the government's mfluence m modern ttmes ts the long-standmg controversy on how to deal wtth two dtfferent mediCal systems, namely, tradinonal Chmese medicine and modern (or Western) medteme. A htstoncal analysis of the begmnmgs of tradttional Chinese medtcme mdtcate that some "medtcal ltterature" from the West and, particularly from India, "reached China as early as the fifth century" (Cai, 1988: 1) and that there was a strong Buddhist influence from "anctent lndta" m tradtttonal mediCal practices in Chma m the stxth and seventh centuries. Arabtan medicine reached China through Arab merchants m the thirteenth and fourteenth centunes (Cat, 1988: 2). But Western medtcme was more ftrmly introduced m Chma by missiOnaries such as Matteo RKct, N1eollo Longobardi, Julto Aleni, and Johann Adam Schall von Bell, all of whom reached Chma between 1597 and 1629, and "translated western books on astrology, water conservation and medtcme into Chinese" (Chen Hatfeng, 1984a: 16). However, from the begmnmg of the seventeenth century to the end of the nmeteenth century, Western mediCine was not more than an Intellectual cunostty m Chma, and the contradictions between the two medical systems did not go beyond academic discussion. There were very few Chinese doctors practising modern medicine at that ttme. Avatlable figures indiCate that there were "ISO mtsstonary physiCians" in 1887, "most of them Amencans, mcludmg 27 female physicians" (Cat, 1988: 3).

22

Stella R Quah and Lz ]zng-wez

The onset of the twentteth century wttnessed an mterestmg change. Dunng the ftrst decade, before the 1911 RevolutiOn, the number of doctors trained in Western medtcme mcreased and the achievements of Western medtcal treatment recetved pubhc attentton. Chmese doctors were gtven social recognition and placed m dominant posltlons m the official medtcal servtces whtch current Chmese histonans say catered only "to the tmpenal rulers and mvadmg tmpenahst armtes and dtplomattc offtcials" (Chen Haifeng, 1984a: 16). Western medtcme recetved the dectstve tmpetus from the Nationahst government after the 1911 Revolutton. The Chmese Medical Assonatton was formed m 1915 and the general offtctal attitude was clearly leanmg towards the adoptton of Western medtcme. The Nattonahst government estabhshed the ftrst Pubhc Health Affatrs Office m Bet]mg m 1925 and the Mmtstry of Public Health m 1928 as part of the pubhc health services mfrastructure patterned after the Umted States model (Chen Hatfeng, 1984a: 18). By 1932 there were 5,390 modern medtcme doctors m Chma, 87 per cent of them Chinese and 13 per cent foretgners; 1,422 nurses, 50 per cent of them Chmese; and 2,941 medtcal students (Chen Hatfeng,

1984a: 22). An open clash between the supporters of each medical system was provoked by the Central Health Commtsston's btl! to abohsh tradltlonal Chmese medtcme. The government's posltlon m thts btl! was actually based on the work of Yu Yunxtu (~'*'.LJJ), an erudtte medtcal scholar born m 1879. Yu studted Western medtcme m Osaka and, upon hts return to Chma learned tradltlonal Chmese medtcme and pharmacology. In h1s book entttled Gu Oat ]z Bzng Mzng Hou Su Yz (-;1;1\*-¥i-t11~JJ\L,J\). [Treatt~e on anuent medtcal termmology and mamfestattons of dtseases] he cnttuzed the "unsctenttftc" aspects of tradmonal Chmese medtcme. Hts book had a constderable tmpact upon academtc and offtual ctrcles. In 1929 Yu put forward a proposal to the Central Health Commtss10n advocatmg a "medtcal revolutton" whereby tradltlonal Chmese phystctans should be removed for the sake of the pubhc's health and welfare; the presence of tradltlonal medtcme, accordmg to Yu, prevented people from changmg thetr attttudes and acceptmg more developed health care methods. He suggested the banmng of tradltlonal medtcme schools and advertisements of tradltlonal medtcme m the mass medta; prohtbttmg tradltlonal Chmese phystctans from tssumg death certtftcates when the

Marnage of Convenzence zn Chzna

23

cause of death was a commumcable d1sease; g1vmg a spec1al ftfteen-year ltcence to practise to traditional Chmese phys1c1ans over f1fty years of age; and requ1rmg traditional Chmese phystc1ans below the age of ftfty to undergo trammg m modern medtcme w1thm a penod of ftve years The a1m of 10 order to obtain a ltcence to practise as modern doctors. medtcme Chmese tradltlonal of practice these steps was to ehmmate the Nationahst the 10 the course of fifty years. Yu's proposal was accepted by government and became Its mam polttlcal document and gUldelme for the ehmmatlon of tradltlonal Chmese medtcme. Th1s offic1al stand prompted an mtense poltt1cal struggle on the part of Chmese phys1c1ans who all along had contmued the1r struggle to prevent the Nationahst government from banning traditional Chmese medtcine altogether. Tradltlonal Chinese physicians opposed the proposal by bringing together the1r hitherto scattered organizations mto a "national congress" held m Shanghai on 17 March 1929. A movement involvmg 132 groups of tradltlonal Chmese phystclans from fifteen provmces was transformed mto the organization Umted Petttion Group to Bel]tng for the purpose of ftghtmg for the cancellation of the Central Health Commlsston's btl!. The Group's motto was that the promotion of traditional Chinese medtcme was an effective way to counteract foreign econom1c and cultural mvas1ons. The Group obtained considerable support at home and from overseas Chmese. In response, the Natlonahst government made some concessions dunng the followmg years, by setnng up committees to study tradmonal Chmese medtcine Within the Central Hall of National Medtcme, the Pubhc Health Offtce, and the Mimstry of Education. In 1931 the Natlonahst government set up the Central Academy of Tradltlonal Chmese Medicme m Nan]mg With branches m vanous provmces and promulgated a set of Regulations for Tradltlonal Chmese Medtcine. But, m sp1te of these concessions, the Nationalist government contmued the1r support for the modern medtcal system as these were the only steps taken and "no substantial changes were made w1th regard to the pohctes d1scnmmating agamst traditional medtcme" (Chen Hatfeng, 1984a: 23). Before the commumst revolution, the s1tuat1on remamed bastcally the same: the government favounng the modern med1cal system and tradltlonal Chmese phys1c1ans strugglmg to achieve offtc1al recognition and to av01d further legal d1scnmmat1on. The controversy contmued,

24

Stella R Quah and Lz ]mg-wez

not only m offioal and academiC circles but also among the common people. There was a declme m the number of young students of traditional Chmese medicme, and many middle-aged Chmese physicians moved mto other occupations; only the oldest or "last generation" of Chmese physteians was left.

The Merger While the NatiOnalist government was promoting the use of modern medteme among the people, Mao Zedong's revolutionary forces were engaged in a different endeavour. They had to cater to the health needs of their growmg Red Army under rather diffteult circumstances and the combmed use of tradmonal and modern medteme was advocated by Mao as a matter of practicality and efficient use of available resources. The posltlve results and experience obtained during the revolutionary civil war m the combmation of both types of medteme were mvaluable and deos1ve for the health policy later adopted by the commumst government. Between 1928 and 1949 the Red Army actively made use of both Western and traditional Chinese medicine. The firSt "med1cme depot" of the Red Army was a cargo of "25 to 30 tons of herbal medicme" captured m May 1928 m the county of Yongxmg. In November that year, Mao "urged hospitals to combine Chmese med1cme with western medteme m treatmg disease" (Chen Ha1feng, 1984a: 25). Following the Western system, pharmaceutical plants were set up to produce "glucose, sulfamlam1de, anesthetics, vaccmes and serum" (1984a: 38); the Central Military Revolutionary Committee set up a comprehensive network of health orgamzations comprismg operation teams and hospitals as well as ep1demte prevention committees m every company (1984a: 40-41); and the treatment of the wounded included "relay stretcher teams" to minimize the time lapsed before operation or treatment, "plastic bandages, regular change of dressmg, and delayed sutunng" (1984a: 42). The foundation for a combmed system of health care was thus established before the creation of the PRC on 1 October 1949. The followmg year, on 7 August 1950, Chairman Mao opened the FirSt National Health Conference with the declaration Umte new and old medtcal personnel from all sectors of both traditional Chmese and Western medtcme to form a consohdated umted

Marnage of Convenrence m Chma

25

front and struggle for the development of the great people's health serviCe. (Chen Hmfeng, 1984a: 45)

Four "gutd10g pnnc1ples" of national health pohcy were established between 1950 and 1952, three of them at the F1rst Nanonal Health Conference and the other by Prem1er Zhou Enla1. These pnnciples were: to serve "the peasants, workers and sold1ers"; to give "pnonty to preventive over curative med1c10e"; to foster "umty between practltloners of trad!nonal Ch10ese med1c10e and practltloners of western mediCine"; and to make "health work a pnmary focus for mass movements" (L10 and Zhu, 1984: 2). Thus, the presentation of the merger as a patnotlC duty and the full support of the pohncal leadership beh10d the implementation of the merger ensured 1ts success. Although there are no available figures on the use of tradltlonal Ch10ese med1c10e dunng the Nanonahst reg1me, the anoent roots of tradltlonal Ch10ese med!Cme 10 the population allow us to assume that the Nanonahst government's preference for modern med1one d1d not reflect people's cho1ces 10 health care and that tradltlonal remed1es and procedures cont10ued to be used by people 10 the1r dally lives. The commumst government's d1rect1ves for merger and collaboration were then d1rected mostly at the practitioners of both systems of med1c10e, particularly the modern doctors who had been the benef!oanes of the prev10us regime's poliCy of separation. Apart from the pohtlcal ga10s of pleas10g the large majonty of the Ch10ese population, the pragmat1c aspect of thts pohcy of merger is evident when one analyses the figure on health care pracnnoners avatlable in 1949 when the Commumst Party took over. There were that year 38,000 modern doctors, 276,000 tradltlonal Ch10ese physiCians, and 363,400 practitioners of both trad1t1onal and modern med1e10e (Chen Zhongwu, 1984: 80). That 1s, only 5.6 per cent of all med1eal personnel were dedicated exclusively to modern med1c10e and the majonty (53.6 per cent) were hkely products of the Nationalist pohcy forc10g tradinonal Chmese physicians below fifty years of age to be retra10ed 10 Western med1cme as 10d1cated earl1er. Even 1f the new government had wanted to rely solely on modern mediCine, the number of doctors available was JUSt too small to prov1de modern health care to a large and needy population. In 1949 the adult mortahty rate was 25 per 1,000 of the populanon; the

26

Stella R Quah and Lz ]mg-wez

mfant morta!tty rate was 200 per 1,000; and the average !tfe expectancy was thtrty-flve years (Lm and Zhu, 1984: 4). Undoubtedly, then, there were strong pragmatic reasons for the commumst government's formulation and dec1s1ve tmplementatton of the merger policy. Frwts of a Marnage of Conventence

It 1s not unusual for a new polltlcal regtme, particularly a revolutionary one, to promise sweepmg reforms and take radtcal poltcy measures. But the polltlcal htstory of most countries 1s littered wtth unfimshed programmes and broken prombes. It 1s because of thts pattern that the PRC 'tands out as a umque case of perseverence and success m Its health care poltcy. Over the past decades smce the communist revolution, the policy of merger of tradltlonal and modern systems of medtcme has been Implemented consistently despite many problems faced over the years. The outcome m the 1980s could be satd to be successfultf the yardstiCk 1s not a direct companson wtth the htgh technology medtcme of Western mdustnaltzed nations but, rather, an assessment of the accessibility of pnmary health care serviCes to the population. Indeed, one of the Important aspects of accesstbiltty to health care serviCes 1s cost. China has stnven to provtde free medtcal services as far as posstble. Accordmgly, there are three mam types of medtcal schemes: (1) the "state-run free mediCal system" covenng ctvtl servants, teachers, and medtcal practltloners, whether m acttve serviCe or retired, requires only a nommal fee of 0.10 rmb yuan (about US$0.03) per vtslt and their famtly members may get reimbursement of up to 50 per cent of the total cost at designated cltmcs m some regtons; (2) the "enterpnse-run free medtcare system for staff and workers" covenng all employees of "factones or businesses run by the state, Cities or counties" as well as up to 50 per cent of the medtcal expenditure mcurred by family members; and (3) the "co-operative medtcare program" covering about 70 per cent of the total population !tving in rural communes. Thts scheme has two versions, namely, the "collective program" and the "co-operative program" proper. The "collective program" refers to the health serviCes run collectIvely by the bngade or commune, whiCh can be used free of charge "by every member of the community". The "co-operative program" on the other hand, 1s a scheme whereby members of the commune pay "one to

Marnage of Convenrence m Chma

27

two rmb yuan annual membership fee" (about US$0.28) wh!Ch entitles them to free mediCal care (L1u, 1985: 98-99). The basiC md1cators of health status m the population have Improved considerably smce 1949. For example, m 1982 the adult mortality rate declmed to 6.6 per 1,000 of the population; the mfant mortahty rate in urban areas was 13 per 1,000 hve births and m rural areas 22 per 1,000; and the average hfe expectancy had mcreased to sixty-nine years. One of the mam reasons for these Improvements 1s the orgamzanon of the health services nat1on-w1de both m Its admmlstrative and medICal aspects. At the national level, health pohcy and the prov1s1on and admmlstranon of health services are co-ordmated by the Mmistry of Health and three other regional-level organs as illustrated in Figure 2.1. The medical departments at each level set up and adm1mster hospitals and health fac!hties m urban and rural areas mcludmg "mediCal cooperatives and JOint cl1mcs and the supervision of 'barefoot doctors'" (Chen Zhongwu, 1984: 81). Rural medical services are managed through rural pubhc health bureaux using a comprehensive "three-tier" network of health care services. As F1gure 2.2 Illustrates, the three ners of the network mvolve counties, townships, and bngades. Accordmg to official figures for 1981, there were 4,118 county hospitals throughout the twenty-two provmces of the

FIGURE 2.1 Organization of National Health Services MINISTRY OF PUBLIC HEALTH

II PROVINCIAL AND AUTONOMOUS REGIONAL PUBLIC HEALTH DEPARTMENTS (Reg1onal and Mun1c1pal)

II CITY OR PREFECTURAL PUBLIC HEALTH BUREAUX

II COUNTY AND URBAN DISTRICT PUBLIC HEALTH BUREAUX (Autonomous County Health Bureaux)

Source Adapted from F1gure 4.1 m Chen Zhongwu (1984: 81).

28

Stella R Quah and Lr ]mg-wer

FIGURE 2.2

Three-Tier Network of Health Services in Rural China AUTONOMOUS COUNTY HEALTH BUREAU [County hosp1tal, trad1t1onal Ch1nese mediCine hospital, ant1-ep1demlc stat1on, maternal and child health stat1on. drug 1nspect1on station, health cont1nuat1on school, and prevent1ve clin1cs for spec1al disease-,]

II TOWNSHIP GOVERNMENT (People's Commune) [Rural or commune hosp1tal, clin1cs or health care centres 1n enterprises, schools, and government bod1es]

II RURAL PRODUCTION BRIGADE (Villagers' Committee) [Bngade cl1n1cs or co-operative med1cal stat1ons]

Source Adapted from F1gure 4 13 m Chen Zhongwu (1984· 104).

country, prov1d10g 448,633 beds; 55,400 commune hospitals offenng a total of 775,000 beds; and 610,079 bngade cl101cs or co-operative medical stations with 1,396,452 barefoot doctors (Chen Zhongwu, 1984: 105). Cons1denng the 1981 total population of about 1,015 million, these figures amount to one county hospital bed for every 2,263 persons; one commune hospital bed for every 1,310 persons; and one barefoot doctor for every 727 persons. As these are rural health serviCes, the actual ratios may be better 1f one excludes the urban population, wh1ch 1s approximately 32 per cent of the total populatiOn (Population Reference Bureau, 1986). Further details of the ImplementatiOn of the merger policy 1s provided 10 Table 2.1 by some features of the modern and traditional health care services available 10 Ch10a today. It IS noteworthy that although the population has more than doubled 10 the span of four decades, and the percentage of the national budget dedicated to health Is modest, 10fant and adult mortality rates have declmed, and the number of health care services and personnel has mcreased. It appears that the strategy of makmg full use of md1genous or traditiOnal health practitiOners and remedies to complement modern mediCal faolmes and personnel has worked and pa1d well m Chma.

TABLE 2.1 in China, 1949, 1981, and 1985-86 Services Traditional and Modern Health Features Total population (m!lhons) Infant mortahty rate (per 1,000) Nanonal health budget (btlhon yuan) Percentage of nattonal budget allocated to health Number of general (city) hospitals Number of tradltlonal Chmese med1cme hospitals Number of merged practtttonersf Number of tradltlonal Chmese phys1c1ansh Number of semor doctors of Western med1cmeh Number of Juntor doctors of Western med1oneh Average number of tradlt!onal Chmese phys1c1ans m tradlt!onal Chmese med1cme hosp1talse Average number of modern doctors m tradlt!onal Chmese med1cme hosp1talse

1949

5ooa 200d n a. n.a 1, 140a n.a. 363,400" 276,000 38,000 49,000 na n.a

1981 1,0 15b 17.5J 32 74e

2.94%e 6,670a 878a 1,396,452" n.a. n.a. n.a

77 75

1985-86* 1,050(

soc

64.28e 2.81 %e

3:: IOl --< --


HO

8,100 3,360 7, 725 ) 7,2 s) 32,624 2,440 l,lJlJS

29 46 R'iS 64S 26

80

Somcn Comrtied from Mmtstry of Health and Welfare (1986b, l98t)C, and

llJ86d).

Japan'\ Mam Feature:,

47

decided to examme agam 1ts 1976 pronouncement. The most important reason, the MHW has sa1d, 1s the need to rationalize the cost of med1cal care. In their View, excludmg herbal remedies from health msurance w1ll bnng the MHW closer to that goal. In any case, excludmg herbal prescnpnons from msurance payments m1ght be difficult because of the strong populanty of traditiOnal med1cme among the Japanese. Th1s bnngs me to the descnptlon of the mam features of the traditional mediCal system. The Traditional Med1cal System

A bnef look at the supply aspect of traditional medJc:!l services reveals that available statistics do not mclude a category for "traditional practitioner" or the equivalent to a general practitioner m modern med!Cme. Instead, four categones of "speCialists" are used m offiCial statistiCS. "massage and related arts", "acupuncture", "moxibustiOn", and "bone-settmg". Moreover, com1dermg that a substantial number of Visually handicapped persons take up the practice of one of these areas of traditional mediCine, the offKwl figures are presented m terms of number of "blmd" and "sighted" practltloners. Table 3.3 illustrates the supply of these four categone" of traditional practitioners from 1972 to 1984. The mam weakness of these f1gures 1s, of course, that they may overlap That 1s, as It happens m other countnes, one practitioner may practise more than one "speC!ahty". Nevertheless, these statJ,.,tJcs do reveal two mterestmg features of the traditional mediCal system. The first feature of mterest '" the s1ze of these groups. The largest number of traditional practitioners are those speC!almng m massage, acupressure, and related arts. In 1984 there were 71.5 of these practitiOners per 100,000 population. Acupuncture and moxibustion are the second largest "PeClahnes w1th 43.9 acupunctunsts and 42.8 moxibustion practitioner" per 100,000 population m 1984. The smallest group IS the bone-setters, of whom there were only 14 per 100,000 population m 1984. If supply responds to demand, as economists argue, then the most popular type of traditiOnal med1cme m Japan may be sa1d to be massage and acupressure, followed by acupuncture. A second mtere,tmg feature IS the pattern of growth of these traditional med1cme areas. Companng the number of practitioners across

48

Kymchr Sonoda

TABLE 3.3 Numbers and Ratios of Four Types of Traditional Medicine Practitioners in Japan, 1972-84 Number Index

Rate (ratio per 100,000 population)

--------

Year

Stghted Persons

Blmd Persons

-----------

Massage and related arts

Acupuncture

Moxthustlon

Bone-settmg

Total

-----

1972 1975 1980 1984

32,658 36,201 42,380 48,099

35,614 38,029 37,679 37,925

68,272 74,230 80,059 86,024

100.0 108.7 117.3 126.0

71.5

1972 1975 1980 1984

20,916 22,923 28,154 33,562

16,780 18,213 18,744 19,232

37,696 41 '136 46,898 52,794

100.0 109.1 124.4 140.1

43.9

1972 1975 1980 1984

20,778 22,873 27,992 33,3 39

15,560 16,854 17,541 18,092

36,338 39,727 45,533 51,4 33

100.0 1093 125.3 141.5

42.8

1972 1975 1980 1984

8,661 9,889 12,916 16,779

8,691 9,925 12,973 16,779

100.0 114.2 149 3 193.1

14 0

30 36 57

Source Complied from Mmtstry of Health and Welfare (1986b).

the span of twelve years, it 1s clear that all categones of practitioners expenenced an mcrease. There were 68,272 massage and acupressure experts m 1972; th1s number went up to 86,024 m 1984, growmg by approximately 26 per cent. Wht!e smaller m stze, the number of acupunctunsts and mox1bust1on experts grew by 40.1 per cent and 41.5 per cent respectively over the same penod. lnterestmgly, bone-settmg may be less popular than the other types of traditional mediCme, but this group almost doubled m stze w1th a 93.1 per cent increase from 1972 to 1984. Th1s general pattern of growth may be seen as a clear s1gn of the population's mcreased mterest m tradltlonal med1cme. It is useful to

49

Japan's Mam Feature'

keep m mmd that the available frgures do not mclude other types of traditional healers such as rehg10us healers, spmt mediUms, and the !Ike, and 1t ts rather dtfftcult to determme their number natlon-wtde. Another angle of the supply of traditional practltloners 1s offered m '1:'1ble 3.4 whtch provtdes the number of mstttuttons and students m the same four traditional mediCme areas. The ftgures are presented accordmg to the number of stghted and blmd students. In 1986 there were ftfty-etght mst1tut10ns trammg 1,756 students m the tradltlonal arts of therapeutic massage and acupressure; fifty-four schools of acupuncture wtth 1,748 students; ftfty-four schools of moxtbustlon wtth 1,748 students; and twenty-one msntunons teachmg bone-settmg to 1,050 students. In all four types of tradmonal medtcme trammg centres, the number of blmd students 1s considerably lower than that of stghted students. Currently, there are no blmd students m mstltutlons teachmg bone-settmg. Thts situation IS an mterestmg departure from past trends suggested by the

TABLE 3.4 Institutions Training Traditional Medicine Practitioners, 1986 Type Massage and related arts Stghted ;,tudents Blmd :,tudent:, Total Acupuncture Sighted students Blmd :,tudent:, Total

Number of Institutions

Number of Students

35 23 58

1,276 480 1,756

37 17

1,383 365 1,748

54

Moxibustion Sighted students Blmd students Total

54

1,383 365 1,748

Bone-settmg*

21

1,050

37 17

* All the trammg centres are for sighted student;,.

Source' Complied from Mmbtry of Health and Welfare (1986b, 1986c)

50

Kvorchr Sonoda

figures on the number of practtsmg tradltlonal healers (Table 3.3). In 1984 the proportion of blmd practitioners was as follows: m massage and related arts, 44 per cent; m acupuncture, 36 per cent; and m moxibustion, 35 per cent. In contrast, the proportion of blmd students bemg tramed m massage and acupressure 1s only 27.3 per cent; m acupuncture, 20.1 per cent; and m mox1bust10n, also 20.1 per cent. The general1mpress10n that these tradltlonal healmg act1v1t1es are proper of blmd persons 1s bound to change m the future. Dual Ut1l1zat1on of Med1cal Serv1ces

The situation of dual utilization of modern and traditional health serVICes m Japan may be sketched w1th a reasonable level of confidence from f1gures collected by the MHW as well as from a vanety of stud1es conducted by soc1al sc1ent1sts and the mediCal profession. Most of these stud1es are based on surveys of the practices and attitudes of vanous subpopulat10ns. Perhaps the descnptlon of dual uttlizat1on may begm w1th the use of herbal remed1es. As md1cated earlier, s1xty types of herbal med1cmes have been added to the modern medtCmes that doctors can prescnbe under the coverage of health msurance. On the other hand, people may still buy "over-the-counter" med1ones, modern and tradltlonal. A companson of the production, m mdlion yen, of prescnbed and nonprescnbed medtCmes m Table 3.5 g1ves an md1cat1on of the demand for modern and tradltlonal med1cme both as prescnptlons as well as for self-medication, from 1982 to 1984. The total production of med1cmes m Japan has mcreased, not only m relative terms - due to the fluctuation of the yen - but also m real terms. More Importantly, the amount of money mvested m the production of non-prescnption mediCines was lower for all three years than the amount mvested m prescnpt1on med1cmes. Yet, the cost of non-prescnption modern med1cmes was m the range of 14 per cent of the total cost of modern drugs, wh!le the production of non-prescnpt10n herbal med1cmes was h1gher. It amounted to 32.8 per cent of the total production of herbal med1cmes m 1982 and decreased slightly to 27.2 per cent of total production m 1984. A companson of drugs production w1thm each category of med1cmes,

Japan's Mam

51

Feature~

TABLE 3.5 Cost of Production of Modern and Traditional Medicines, 1982-84 (In mlihon yen)

1982 total drug Non-preocnhcd drug

Pre~cnbed

1983 total Prescnbcd drug Non-prescnhed drug

1984 total Pre.,cnbed drug Non-prc~cnbed

drug

ll1tal Drug Productton

Herbal Medtcme

Ratto

3,980,232 3,406,516 573,717

58,279 39,129 19,149

15 11

4,032,057 3,438,567 593,490

53,650 37,491 16,159

11 2.7

4,026,985 3,429,482 597,503

71,413 51,969 19,444

1.8 1.5 33

n

1.3

Source Complied from Mnmtry of Health and Welfare (1985).

namely, prcscnbed and non-prescnbed, 111d1cates that modern medtcmes predommate. Thts should not be surpns111g as modern med1c111es are also 111 very htgh demand m other mdustriahzed countnes. Although one of the maJor economic powers, Japan ts an Astan nation. One would have expected to fmd a level of expendtture 111 herbal med1c111e production htgher than the mere 1.8 per cent of total production, whtch was the ftgure for 1984. In any case, herbal preparations represent a htgher proportion of all non-prescnbed med1c111es than of all prescnbed medtcines: 3.3 per cent 111 1982, 2.7 per cent 111 1983, and aga111 3.3 per cent m 1984. A more detailed ptcture of thts companson is provided 111 Table 3.6. Thts table covers the period 1976 to 1984. As the regulations allowmg doctors to prescnbe herbal med1c111es began 111 1976, Table 3.6 shows the posstble 111fluence of such a pohcy upon two aspects: dtrectly on the production of herbal med1c111es, 111d1rectly upon the practice of selfmedication. In terms of productiOn, the 111crease was impresstve: from 96,000 mtllion yen m 1976 to 714,000 mtlhon yen in 1984. Self-medtcatton ts the use of medtcmes wtthout a doctor's prescnptton.

V1

N

TABLE 3.6 Trends in Production of Prescribed and Non-Prescribed Herbal Medicines, 1976-84 (In 100 mdhon yen) Ratto

Number

Year

Total

Prescnbed Herbal Mcdtcmco

1976 1977 1978 1979 1980 1981 1982 1983 1984

96 161 214 274 335 476 583 537 714

27 37 68 114 154 295 391 375 520

Non-Prescnbed Herbal Medtcmes 69 124 146 160 181 181 192 161 194

Total

Prescnbed Herbal Medtcmes

Non-Prescnbed Herbal Medtcmes

1000 100.0 100.0 100.0 1000 100.0 100.0 100.0 1000

28.1 23.0 31.8 41.6 46.0 62.0 67.1 70.0 72.8

71.9 77.0 68 2 58 4 54 0 38 0 32.9 30 0 27 2

Source Complied from Mmtstry of Health and Welfare (1985).

Z' 0

r;

2"'

VJ

0 ;3 0

>:>...

"'

Japan's Mam Features

53

Hence, non-prescnptlon med1cmes are understood to be used for selfmedication. The policy had a clear impact on people's need to selfmedicate, if one may mfer this from the production figures. Wh1le m 1976 most (71.9 per cent) of the herbal preparations were non-prescnbed and only 28.1 per cent were prescnpt1ons, there was a steady reversal of this situation m the followmg year~. By 1984, 72.8 per cent of the herbal med1cmes produced were prescnbed medicmes and only 27.2 per cent were non-prescnbed. If one can get a herbal remedy from the doctor and It IS pa1d for by h1s or her health msurance, then there 1s no need to spend one's own pocket money on these medJCmes. It was preCisely because of this mclmat1on on the part of the public and the correspondmg mcrease m the cost of herbal remedies production that the government has recently deoded to rev1ew this policy and cut costs. A more d1rect v1ew of dual utilization of services may be found m Table 3. 7. Th1s table presents the fmdmgs from a national survey on health and health practices conducted by the MHW m 1985. The survey collected mformat1on on services utilization accordmg to the type of health complamt, followmg the fourteen-category mternat10nal classJfJCatJon of d1seases. Table 3. 7 presents mne of those categones. Accordmg to this survey, the overwhelmmg maJonty of the respondents, that IS, between 73 and 99.5 per cent, use modern medical serviCes when affected by any one of the health problems md1cated. However, the proportion of those usmg traditional medical serviCes or self-medication vane~ accordmg to the d1sea~e m question. The largest proportiOn of respondents (12.0 per cent) md1catmg preference for traditional medJCme IS found among those who suffered from diseases of the musculoskeletal system and connective tissue, followed by people suffenng from mJunes or p01sonmg (7.4 per cent). The pattern of self-medication 1s somewhat different. Reported cases of self-medication m this survey are lower than expected. Nevertheless, the h1ghest proportion of cases usmg self-mediCation (non-prescnptlon med1cmes) IS found among people suffenng from upper respiratory track mfecnom (24.9 per cent), general problems of the re~p1ratory system 04.7 per cent), and mJunes and p01sonmg (14.5 per cent). The national survey figures are also presented m terms of the gender and age of the respondents m T.'!hle 3.8. It IS mterestmg to note that there are no s1gmflcant difference~ between males and females m their

TABLE 3.7 Utilization of Modern and Traditional Medical Resources for Selected Health Problems, Japan, 1985 (In percentages) Hosp1tal Chmc --------

Total

Subtotal

Med!Cal Care as In-Panent

1000

92.0

58

83 0

Infectwus and parasltlc d1seases

1000

86 7

61

III Endocnne, nutnnonal and metabohc d1seases, and 1mmumty d1sorders

1000

99.5

1000

Med1cal Care as Out-Panent

Dental Care

Massage, Acupuncture, Mox1busnon, Bone-Settmg

NonPre>cnbed Drugs

Others

NonTreatment

52

06

02

80 6

12 7

06

68

927

02

02

99 3

81

91 3

03

03

1000

97 0

38

93 1

18

04

02

100.0

99 2

45

94 7

05

02

01

1000

99 5

19

91/

02

0 3

----

Total

(Dwbetes Melhtus) VI D1seases of the nervous system and sense organs VII D1seases of the Clrculatory sy>tem (H ypertens1 ve d1sease)

32

19

06

06

06

06

0 1

14 7

11

0 3

02

24 9

15

0

0 3

66

02

0 1

38

10

04

s

20

02

1000

98 3

24 7

73.6

100.0

83 9

4 1

79 8

1000

72 9

0 5

724

IX Diseases of the digestive system

1000

92 8

6 1

66 7

(Diseases of tooth and supportrng n-,•;ues of teeth)

1000

98 6

(Gatnc and duodenal ulcer)

1000

96 9

61

90 8

31

XII Disea'ieS of the skrn and -;ubcutaneous tissue

100 0

91 8

04

91 4

82

XIII Disease of the musculoskeletal system and connective nsue

1000

82 8

32

79.6

1000

76 0

10 0

65 4

(Cerebrovascular disease) VIII Disea-;es of the respiratory sy'item (Acute upper respiratory rnfectron)

XVII Injury and pm-;onrng

20 0

1.4

98 6

Source Comp1led from Mm1stry of Health and Welfare (1986a)

12 0

05

s

74

14

\Jl

0\

TABLE 3.8 Utilization of Modern and Traditional Medical Resources by Sex and Age, Japan, 1985 (In percentage:,) Hosp1tal Chmc

Total

Total

Subtotal

Med1cal Care as ln-Patlent

100.0

92.0

'58

Male Female

1000 100.0

91.8

0-4 5-14 15-24 25-34 35-44 45-54 55-64 65-74 )! 75

100.0 100.0 100.0 100.0 1000 1000 100.0 1000 100.0

86.5 83.6 85 6 81.6 86.9 91.4 94 4 96.7 96 4

92.2

MedKal Care as Out-Patient

Dental Care

Mas:,agc, Acupuncture, Mox1bust1on, Bone-Settmg

83.0

32

1.9

67 5.1

82.2

1.6

80 2 72.9 70.7 68.4 737 83 4 86.5 90 4 86 3

2.9

53 4.5 5. 3 5.2 6.3 5.3 10.0

83 6

2.8

35

48 78 9.5 88 8.0

2.8

16 10 01

Source Complied from Mm1stry of Health and Welfare (l986a)

NonPre~

(/)

0

;:l

0

>=>...

I'>

Age

20-29

779 84.6

00 3.4 1.5 5.0 5.1 0.0

9.1 13 8 24.2 15.0 15.4 15 4

2.8 2.4 25

16.7 12.0 20.0

90.9

18

82 8

1.7

74.2 80.0 79.5 84.6

1.5 2.6 2.6 7.7

80 6 85.6 77.5

2.9 24 2.5

36.4 41.4 36.4 23.1 23.7 38.5

61.8 56.9 62.1 74.4 73.7 53.8

31.4 30 6 39.2

65 7 66.9 58.3

Herbal Medicme Provided by a Hospital or Chmc Often

Sometimes

Krkou Method

None

Often

Sometime;

None

---------

U)tal

6.7

29.2

64 1

00

0.7

99 3

Sex Male Female

49 8.0

26.2 31.5

68.9 60.5

0.0 0.0

0.0 1.2

100.0 98.8

Age 20-29 30-39 40-49 50-59 60-69 70 years and over

00 34 45 5.0 15.4 231

327 34 5 33 3 25.0 23.1 15.4

67.3 62.1 62.1 70.0 61.5 61 5

0.0 00 0.0 00 0.0 0.0

0.0 17 1.5 0.0 0.0 0.0

1000 98.3 98.5 100.0 100.0 100.0

Years of school completed Jumor high ochool Semor high school College, umversity

11.1 8.3 3.3

25.0 28.8 31 7

63 9 62.4 65.0

0.0 0.0 0.0

0.0 0.8 08

100.0 99.2 99 2

., .,

'-...

'tr

-

;:I

"'

.,::;:: 5

.,~ ;::

--< ~

~

'J

0\

Co

APPENDIX TABLE A3.1 (Contznued) Magnetic Therapy

Zen Sttung Medttatlon ---~--

Total Sex Male Female

Often

Sometimes

None

Often

Sometimes

None

0.0

1.4

98 6

2.5

6.0

91.5

Z\ 0

;:;

0.0 0.0

1.6 12

98.4 98.8

2.5 2.5

6.6 5.6

91.0 92.0

;:: Vl

0

;::!

0

k l:l

Age 20-29 30-39 40-49 50-59 60-69 70 years and over

0.0 0.0 00 0.0 0.0 0.0

1.8 17 1.5 2.5 00 00

98.2 98.3 98.5 97.5 1000 100.0

0.0 0.0 4.5 5.0 2.6 3.8

1.8 8.6 6.1 7.5 7.7 3.8

98.2 91.4 89.4 87.5 89.7 92.3

Years of school completed Jumor htgh school Semor htgh school College, umverstty

00 0.0 0.0

2.8 00 2.5

97.2 1000 97.5

28 4.0 08

11.1 4.8 58

86.1 91 2 93 3

Yoga Often

Sometimes

Tw Cht Chuan None

Often

Sometime;,

None

---------------

Tble 6.1, that 1~, 1978 and 1986. The reason for selectmg these years 1s s1mply availability of data. Indeed, the ut1ltzat10n of modern health services m the publtc sector and the use of servtces prov1ded by the SCPA are well documented before 1978; but the earltest available systematic ftgures on patient attendance at the

TABLE 6.2 Services in the Public Sector: Health Utilization of Modern 1978 and 1986 Attendance, Patient

1986

1978 Modern Health Servtces

Number

Rate per 1,000 Pop.

Number

Rate per 1,000 Pop.

-----

>---]

;:J-

"'to s;

~

2,586,200

Total population

2,353,600

Hospttal admtsstons Speoahst cltmcs attendance Acctdent & Emergency attendance

209,130 1,209,544 297,402

88 9 513 9 126 4

220,739 1,163,370 165,952

85 4 449.8 141.5

Pnmary health care attendance Government out-patient c!tmcs Maternal and cht!d health servtces School health servtces

3,930,841 2,922,263 989,342 19,236

1,670.1 1,241 6 420.3 82

3,183,645 2,344,081 765,919 73,645

1,2 31 0 906 4 296.2 28.5

OJ

"' ;:;"'

~

;:;

(/)

;:;

~

'0-=