Northern Thai health care alternatives

Sot. SCI. Mud. Vol. 16. pp. 1507 to 1517. 1982 Printed in Great Brttam. All rights reserved

NORTHERN PATIENT

THAI

0277-9536/82/161507-I Copyright 0 1982 Pergamon

HEALTH

ALTERNATIVES

CONTROL AND THE STRUCTURE MEDICAL PLURALISM DANIEL

Department

CARE

1$03.00/O Press Ltd

OF

H. WEISIERG

of Anthropology, 109 Davenport Hall, University of Illinois-Urbana-Champaign, 607 South Mathews Avenue, Urbana. IL 61801. U.S.A.

distinct features characterize village behavior in dealing with health care alternatives in Northern Thailand. First, the individual strives to preserve a secure social environment by controlhng the course and choice of treatment during an illness crisis. Second, there are two spheres of health care discernible beyond any division based solely on type of medical technology. or urban-rural or moderntraditional dichotomies. One sphere, ‘officially-sanctioned’, is socially distant from the patient and totally dependent on the support, and under the aegis of central authority; the other sphere, ‘locallysanctioned’, is socially close to the patient and dependent on the approval and support of only the local population. The nature of each sphere is dependent upon (1) the way in which practitioners are validated and sanctioned; (2) the internal organization of each practitioner group; and (3) the style of interaction between the practitioner and patient and his or her family. The variable success of patients in controlling the course of their treatment is demonstrated by the styles of interaction in the respective spheres. Attempts to manipulate the healer by influencing the context of healing, the amount and terms of payment for services rendered, and the type of therapy given are major parts of this control. The history of the local medical system suggests that patients in the research area became accustomed to these efforts to control quite early. Such attempts have been instrumental in shaping the present form of the medical system; therefore, a connection between those efforts to control the course of healing and the shape of the medical system is postulated and explored here. Abstract-Two

In rural Northern Thailand, social mechanisms for approaching and utilizing healers join with a medical system that affords a maximum of flexibility and a wide variety of alternatives. This paper explores the relationship of those social mechanisms to the shape of the medical system. It will demonstrate that: (1) the medical system is divided into two distinct yet interrelated spheres-one sanctioned by the central authority of the government, the other sanctioned by the local populace-and the populace contributes to molding the medical system; and (2) a primary influence on the medical system’ has been the tendency of villagers to preserve their physical and financial integrity by attempting to control their choice and course of treatment as much as possible. In taking this approach, 1 follow Friedson Cl, 23 who noted ‘client control’ through a lay referral system and detected a distinction between ‘dependent’ and ‘independent’ medical practice based on the relative reliance of practitioners on patient approval and goodwill. More recently. Janzen [3] analyzed ‘therapy management groups’ of kin and friends which guide a patient by defining the situation and alternatives on the basis of a perceived social and cognitive concensus. He noted that such groups and concepts must be rooted in a more inclusive social and ideational order. I concur. but suggest moving beyond lay referral and information management to include more direct devices at the disposal of patients and their kin. Glick [4] noted the relevance of ‘power’ as a concept in understanding the occurrence and treatment of supernaturally-induced illness. Though. as Glick ob-

served, the idea of power is variously defined and inevitably imprecise, it has possible uses for the analysis of medical systems. Long [S] has suggested that patient-physician interactions are characterized by the efforts of each party to maximize control over the situation and that such actions emphasize the physicians’ relative distance from the patients’ familiar social milieu. I shall show how the use of power-in the form of patient control-operates in a particular environment and how this affects the shape and standards of the medical alternatives available. The description of this Northern Thai medical system is determined by patients’ attempts to deal with the practitioners within the system: it is not solely dependent on any urban-rural or modern-traditional dichotomies, or any distinction based exclusively on particular therapeutic modes. Of course, the origins or characteristics of technology (modern or traditional) or relative distance from centers of social and economic power (urban or rural) are not irrelevant; but research [6] indicates that relying too much on these labels is not equal to discussing their influence on behavior. Inflexible use of these labels also results in some practitioners being categorized as ‘marginal’ on the basis of typologies. whereas their role is much better explained in terms of patient behavioral patterns. This paper does not seek to discount such characterizations as urban-rural or modern-traditional, but to emphasize instead the role of behavioral axioms in shaping the organization of the medical system. The unity of the medical system as it exists in Northern Thailand depends on the actions and perceptions of the patients utilizing it. I submit that while patients alone do not determine the

1507

1508

DASIEL

medical alternatives available. they do have an influence on their shape. their standards of practice. their effectiveness and in some cases, their very existence. Studies of the medical system in Thailand and Thai health behavior early centered on analysis of the social characteristics of the various healer groups and their constituent clients, and the compatibilities or dissonance of healing practices and patient beliefs [7]. Various researchers have emphasized the dissonance of modern (or Western) beliefs and traditional beliefs, and social roles as a guide to understanding Thai health behavior [S, 91. While recognizing cognitive and social gulfs, other observers have viewed the behavior of their subjects from the perspective of generalized principles of social organization and behavior. Where Cunningham [lo] emphasized ‘social distance’ as an impetus to attract or repel patients seeking care, Wray [I I] noted that willingness to engage the services of healers might depend on socio-economic status. distance to services (also noted by Day and Leoprapai [12]), and the level of ‘desperation’--or desire to get well at any cost. Riley and Santhat [13], calling the Thai medical system one in which patients select ‘freely among variegated alternatives’, saw the reputations of the individual practitioners, the nature of the medical problem, and socio-economic status an-d ‘desperation’ of the patient shaping behavior. Guiding principles remain to be formulated to account for the various actions and social devices of Thai health behavior, and the peculiar configuration of the Thai medical system. It is hoped that this paper will contribute to the discussion by emphasizing the role of patient control in the healing process, and its influence on the shape of the medical system. Selection of health care alternatives in the Northern Thai environment does not merely bring an ill individual in contact with a potential cure or curer. It also shapes the medical system by repeating certain styles of interaction between the patient and a wide variety of healers. The idiom of charting personal fate and the fate of kin dominates medical interactions, as well as those in other areas of social life. Efforts to control personal position and course of action in healing episodes are manifested in styles of interaction and elements influencing selection of healers. Choice is thus only one component in the individual’s arsenal for coping with the reality of illness. I do not deny that the opportunity for Northern Thai villagers to choose among a wide variety of health care alternatives with such alacrity and ease is in itself a decisive part of the system. The range of alternatives in this plural system is limited only by the individual’s knowledge and perceptions: such alternatives often lie outside the secure world of the village and district and are a.pproached always with caution

*Other than the names of major cities (e.g. Chiang Mai City, Bangkok), all place names and personal names in thts paper are pseudonyms. The ‘Practitioner Profiles’ and ‘Patient Cases’ are from the author’s fieldnotes gathered during an 18 month stay in the ‘Sri Muang’ area. Chiang Mai Prownce. Dialogues that appear in the case studies are translations of interviews recorded in the Northern Thai dialect. and in each case. the ‘interviewer’ is the author.

H.

WEISBERG

and sometimes with trepidation. Nevertheless. they are approached: the world outside the village may be sometimes threatening. sometimes helpful. but it is known and understood and is part of a discernible pattern of life. THE SETTI\G

Baan Loom Doi. the research village. IS in Sri Muang District. Chiang Mai Province. within 200 km of the provincial capital*. Sri Muang Town is a political and economic center. the site of all district administrative offices. of major produce wholesalers and middlemen, and a number of retail establishments. Medical facilities include a full range of government health services, and private pharmacies and physicians’ clinics. Transportation is readily available and relatively inexpensive-buses and mini-buses run frequently all day and mini-buses may be engaged at any time to travel to Chiang Mai City hospitals. The asphalt main road allows all-weather access to the provincial capital. The village lies among the paddy fields 2 km from Sri Muang Town, within easy access to the road to Chiang Mai City, the pharmacies of Sri Muang. and all the local health care establishments. As in the rest of the district. the villagers’ major occupation is wetrice farming, but the advent of irrigation works and an expanded cash economy have fostered multiple cropping, and villagers also earn cash through other pursuits, such as illegal logging or acting as middlemen. The village has a large number of landless or those with insufficient land to supply their subsistence needs. Sixty per cent of the 197 households in the village must depend in some measure on a form of wage labor. And virtually all villagers must resort at one time or another to day labor or entrepreneurial activities. Thus, every villager is well-versed in the vagaries of a cash economy, and currency is a scarce commodity carefully husbanded. THE SHAPE

OF THE

MEDICAL

SYSTEM

This paper examines the medical system in a given district of Chiang Mai Province from the perspective of a single village. I do not cover all health care alternatives available in Thailand, but concentrate on those mentioned by villagers during interviews and then observed in the course of research. Exhaustive descriptions of types of healers in Thailand will not be attempted in this article: such a description is given in broad overview by Riley and Santhat [ 133, and Cunningham [14] who put the healers in context in his discussion of healing within a limited geographic area of North-Central Thailand. Any disagreements I have with those descriptions must await further analysis. and have no bearing on issues addressed here. It is beneficial to use broad strokes to characterize the separate therapeutic traditions involved. Healing traditions using herbal remedies and supernatural cures of Indian and local derivation are diverse, imparted from master to students. each of whom may in turn have a number of different teachers and thus (literally) a ‘mixed bag’ of cures, potions, and incantations. The use of both the herbal and supernatural

Northern Table

1. The medical

system

‘Officially-sanctioned’

Thai health

in Sri Muang’

district.

care alternatives Chiang

Hrulrrs

Mission

Thailand:

a local perspective

‘Locally-sanctioned’

Hospital

and

Herhuli.st.s~h~~ulcrs winy

Paramedic stations-district and in each hamlet* Midwiferv stations-district and in each hamlet*t Communicable disease control stations-urban and district rntitirs:

Specie1 u~~cncies: Maternity center-urban Tuberculosis control center-urban Mental health hospital-urban *Personnel may be one and the same. tSome midwives are also injection doctors: $Most contacts with patients are outside the “officially-sanctioned” .$Their role varies as to specific case and circumstances,

*The use of terms of address or reference for medical prac-. titioners in Thailand are often imprecise. The word rndo is commonly used with anyone who engages in healing, whatever their tramine - or .position. For instance. itinerant drug sellers or workers spraying D.D.T. for antimalarial purposes are often called mdo. Phciet, formally . . used when referring to M.D.‘s. is also applied in the case of p/t&t prc~jam rum/m or hamlet health officers, appointees of the district government who are invariably injection doctors. For the purposes of this paper. ‘doctor’ will simply be a term for any healer. i.e. mcio. In the few instances where M.D.‘s will be referred to specifically, physician will be used. Pharmacy and pharmacist are two words that must be used with caution. While registered pharmacists of course exist in Thailand. their number is small. And there are certainly not enough to adequately staff all pharmacies. even if this paper refers to the owner of a drug store and his staff. all trained outside of schools of pharmacy.

tcvhniyurs:

techniques*t

sup~vwot~rral ctwos:

Herbalists (may use supernatural cures): part-time herbalists full-time herbalists medicine preparers Practitioners using only supernatural cures: healers of maladies of bodily origin healers of maladies of spirit origin Spirit mediums Buddhist monks who heal Massage doctors Fortune doctors Village midwives

Hamlet health officers* Pharmacies: Physicians’ private clinics*

traditions in the same case are common since the line between humoral malady and spirit-induced ailment is often ambiguous. Thus exorcism of a rapacious spirit is often needed, and a healer commonly employs a number of therapies through a process of elimination to find the appropriate cure. Associated with these traditions are midwives and massage doctors. the former among the most numerous and utilized of healers in rural Northern Thailand. All these healers are local residents and any government attempts to organize them have been fruitless, particularly when registration and government control are involved. While these healers-and the injection doctors and pharmacists mentioned below-would covet certificates of training or some form of credentials. they do not want the accompanying government scrutiny. At any rate, they can ply their trades without such credentials. Bio-medicine-the techniques and medicines and institutions as associated with modern or Western

using hio-twdicul

sphere

Pharmaciesf Physicians private clinicsg ln.jection doctors* Midwives who employ bio-medical

Parurlt~dicfu~ilitirs:

Other official

Mai Province.

sphere

Hospitals:

Government hospitals-urban Private hospitals-urban (includes Herbal Medicine Hospital) Government hospital-district

1509

sphere.

medicine-was introduced to Thailand in the 19th century and in time became ‘official’ government medicine. Hospitals, medical schools and various associated personnel have been structured on roughly a Western model. Higher statuses are accorded such personnel because of roles as government functionaries. and because of their social class. While for each health provider classification there are boundaries of permissible activities, government personnel-particularly in rural areas-have considerable prerogatives in treating patients. though they tend to adhere to a paramedic-nurse-physician referral hierarchy in patient treatment. Patients in rural areas have more contact with nurses and midwives and male paramedics than any other government healers, though consultation with physicians is possible, and particularly coveted. Non-government personnel have successfully co-opted some of the biomedical technology. Sales personnel in pharmacies diagnose and treat ills with both herbal and biomedical concoctions. primarily the latter. Their ‘professional’ standing is unofficial and most of their sales (e.g. anti-biotics) are illegal [IS]. Likewise. nonlicensed injectionists range throughout rural areas dispensing anti-biotics and vitamin injections. pills and advice. All the accoutrements of their trade are freely, if illegally. available at pharmacies. It should be noted that bio-medical remedies are often available from government healers treating patients for personal profit during free hours, as noted below and implied in Table l*. On the basis of my research I have divided the practitioners in the medical system in Sri Muang into two spheres, one here called ‘locally-sanctioned’ and the other ‘officially-sanctioned’ (see Table 1). The distinction rests on three bases: (1) how a particular. healer is validated as a practitioner; (2) the form of organization within a healer group. including the method of training and the manner in which healers

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DANIEL H. WEISBERG

interrelate and perhaps cooperate; and (3) the style of interaction between the healer and the patient and family. The categories of healers are independent of the personnel involved: a healer might be a government health service functionary by day and an independent practitioner by night, with no serious clashes between the roles. Let us begin with the first two factors mentioned above. ‘Locally-sanctioned’ sphere C’ulidurion. The term ‘locally-sanctioned’ sphere encompasses herbalists. all practitioners using supernatural powers (including spirit mediums). massage doctors. pharmacists and itinerant drug sellers. unlicensed injectionists. and midwives of various persuasions. In this sphere no credentials are awarded. no plaques adorn walls. Even if credentials are avaiiable. they carry the liability of registration with government agencies. something troublesome and to be avoided. A practitioner becomes recognized by establishing him- or herself as such. treating patients and allowing a reputation to grow. Patients and the population at large judge the efficiency and viability -as well as the demeanor-of the healer. and choose either to utilize or not to utilize the practitioner’s services again. The collective sanction of the community responds to unfortunate or unsavory experiences (as well as pleasant, successful ones), which can result in a cooling of the local population toward a healer and a general skepticism about his abilities. A healer serves at the pleasure of his patient; one who pushes his cures beyond conventional civility runs the risk of rejection, or the liability of excessive responsibility for the cure’s success. Any healer, in order to be respectable, has to practice an understandable form of care and must approach patients and families in a polite and palatable manner. He must become a known quantity in the village arena by fitting into a relevant category. Internul organixtion and twining. Within the ‘locally-sanctioned sphere, disparate practitioner types manage to co-exist in a state of benign competition. Jealousies are common in herbal and supernatural curing circles. and among pharmacists and injectionists. But relations are generally cordial. though practitioners stop short of sharing esoteric information and formulas. They endeavor not to poach on each other’s practices (a patient is free to call anyone he chooses and a practitioner must go if called at the risk of violating a commonly recognized role and thus losing credibility; this does not mean there are no ways to decline to treat a specific case), and in the field they assiduously avoid each other. A relationship has developed between pharmacists and injectionists. wherein the pharmacist is the supplier of drugs and source of information for the injectionists. They generally cooperate only to the extent that it is in their own mutual financial interest, though in several cases. the relationships are long-standing and close (one major injection doctor’s sister is married to the owner of Sri Muang’s largest pharmacy). Healers in this sphere learn initially through apprenticeship and later by trial and error. Those curing with supernatural power derive their power from affiliation with a long line of teachers (khruu or guru). Injection doctors learn their trade in a variety of

ways: most learn how to give injections in the armed services, some from working for an M.D. and a few from other injection doctors. Or. of course. they may already be government paramedics or nurses working in their off-hours. Pharmacists or drug store employees learn from working either as assistants in other drug stores or. more often. as salesmen for drug companies (they work for a number of different companies, learning the entire drug line of each). Injection doctors often search for training sessions. such as those for volunteer militia paramedics, which bestow glossy certificates likely to impress visitors more than local villagers. Monthly training and business sessions for pharmacists are sponsored by the drug store owners’ association in the province; training includes lectures by drug company representatives. registered pharmacists. and physicians. and treatment manuals and drug company brochures are routinely available. But injection doctors and pharmacists have to learn the details and variations in the applications of cures on their own. honing their perceptions. their memories and their intuitive skills. like any other healer in their sphere. Others, such as midwives. learn with an established practitioner until they are competent to handle cases on their own. Even then. midwives may collaborate with colleagues in a delivery. Herbalists and those using supernatural powers possess valuable esoteric information and thus will not collaborate or train together. Instead, they are expected to treat patients until their expertise emerges; whether it emerges or not depends on their belief in their own powers and knowledge. and their success is a measure of this. ‘Ojficially-sanctioned’ sphere Validorion. The ‘officially-sanctioned’ sphere of this medical system is dominated by a physician-centered and largely bio-medically-oriented core of practitioners who receive their accreditation and livelihood from the government. Male paramedics, sanitarians who report on public health and sanitary concerns, midwives, nurses and technicians officially treat the more routine ailments, or prepare patients for physicians. (Midwives, of course, will see childbirths through to completion. unless complications are expected.) This does not. however. preclude nurses or paramedics treating patients beyond those official limits, either during office hours (with or without the permission of a supervising physician), or during their leisure hours. Healers within this sphere are granted the trappings of viability and validity by central authority, without reference to opinion or expertise outside the government. Internal organization and training. Training is equally subject to central authority, The duties of all healers in this sphere are predetermined by their education and though there is some form of apprenticeship (internship, residency or practical field experience for paramedics) the credentials create the outlines of the role. Public recognition is not crucial, since the position of the healers is contingent upon the approval of omnipotent central authority. Stratification among healers in this sphere is severe and absolute. No healer in a lower strata would dare overstep the bounds of his or her allocated official role or violate the established order of the organization in direct

Northern Thai health care alternatives conflict with superiors. Healers compete, but must do so in a carefully defined way-as physicians do within a code of ethics-or indirectly and with great discretion. Many of these healers function in the locallysanctioned sphere for their own profit. and sometimes their official role enhances their reputation in the ‘locally-sanctioned’ sphere. CONTROL

OF THE HEALING

INFLUENCE

PROCESS:

ON THE SHAPE OF

THE MEDICAL

SYSTEM

This section of the paper demonstrates that the influence patients wield over the medical system shaped the two spheres in the past and continues to do so now. It suggests that at the heart of the villager’s health-restoring actions is a desire to control the course of treatment. The purpose of this control is to achieve a cure or amelioration of a condition without great loss of physical or financial integrity. The discussion will touch on four points: (I) the evolution of the medical system into the form described in the first section of this paper; (2) qualitative differences in the status of villagers and practitioners as evidenced by their interactions; (3) patient influence on healers through a number of social devices; and (4) the consistency of this view of Thai social behavior with other areas of life in the Sri Muang area. Histor!, qf the medical system in the Sri Muang area Medical practitioners in the Sri Muang area prior to the 1930s consisted of herbalists, those who employed supernatural devices (including fortune tellers, etc.). massage doctors. and midwives. It should be noted that spirit mediums. individuals who are the vehicle through which local spirits of note speak and act. and who often engage in healing, take a defucto role in dealing with patients even though they do not themselves apply the cures. Thus, the spirits and the mediums (in this sample. all women) share in the healing task. Midwives have always been prevalent and remain so. There are a large number of women who are eligible to help during childbirth, but few are recognized as being really skilled. Midwives remain one of the largest groups of healers in the area. Healers using supernatural powers still find great favor. while herbal curers have a diminished, though greatly changed, role. Thus. the patient has always had a large number of non-governmental alternatives to choose from. particularly in the area of self-treatment: many herbalists respond to a request for ‘kidney medicine’ or ‘stomach medicine’ by producing the concoction to be consumed at the patient’s leisure. The advent of pharmacies led to even greater opportunities for self-treatment. The first public health services were brought by hamlet health officers and appointed midwives, chosen by the district officials and headmen respectively (the former are now elected by the hamlet councils). Hamlet health officers were to observe and report health conditions. pinpointing remedial problems and potential epidemic conditions. This is still their function. though most. in fact. are injection doctors. The first of these hamlet health officers in Baan Loom Doi’s hamlet were herbal doctors who also practiced supernatural cures. Not until sometime in

1511

the 1930s were government health specialists versed in bio-medicine stationed in Sri Muang. By then, however, villagers had already been exposed to bio-meditine in a variety of forms: small pox vaccinations, the ministrations of a Christian missionary-trained lay preacher, and the services of Chiang Mai City hospitals, particularly the mission hospital. The most influential was the lay preacher, immensely popular because of his skill and because of the speed and efficacy of his cures. Trained by missionary physicians, he held no degree but had served as physician’s assistant in the Mission Hospital of Chiang Mai City. The following gives some of the flavor of his tenure in the Sri Muang area: PRAC’TlT!ONER PROFILE A: Dr Boonkhrit originally came to the Sri Muang area in the 1930s. a young man informally trained at a mission hospital and imbued with religious fervor. Unfamiliar with the local dialect, he nonetheless led a small settlement of fellow Christians with little friction and tended the ill throughout the district, including Baan Loom Doi. His interpersonal skills and the unique nature of his clinical talents won him admirers and patients, and bio-medicine a good reputation. Day and night. Dr Boonkhrit travelled by bicycle and on foot to inject and advise patients. And often his home served as a clinic: women in labor filled one of the bedrooms while an out-patient clinic was located in the front room. The nascent health station was staffed by a health worker, but his efforts in rural areas were eclipsed by Dr Boonkhrit’s activities. Both referred patients to the hospitals of Chiang Mai City. both knew enough to treat and inject on their own. but Dr Boonkhrit had been there first. and only he was available at all times. In addition. he performed minor surgery. and he was firmly embedded in local society as a landowner, religious leader, and headman of a village, Dr Boonkhrit’s working lifetime spanned a period which saw public health services expand greatly. but those services followed his initial work. Throughout all the changes in the medical system of the area. Dr Boonkhrit remained immensely popular by virtue of his skill and personality. Though a Christian, he regularly accepted payment conveyed through local quasi-Buddhist rituals of gratitude. and his death occasioned a lengthy nine-day wake vividly remembered by Baan Loom Doi residents who participated. Lay residents who lifetimes span Dr Boonkhrit’s tenure and previous practitioners point to his arrival as the demarcation between bio-medicine as a distant entity found only in the provincial capital, and bio-medicine as a readily available form of care in Sri Muang District itself.

For over a decade, this man and his injectionist cohorts (the next injection doctor came later, in the 1940s-then others followed) constituted effective biomedical care in the area. They were active and interested in their position in the community, unlike their official counterparts. There has been a continuity of healing roles found in the ‘locally-sanctioned’ sphere, as the entire system grew over time. Nowhere have the changes been smoother than in the transition from hamlet health officers versed in herbal cures to those trained in bio-medical cures. Below are profiles of two hamlet health officers illustrative of what has been a trend over the last 30 years. PRACTITIONER PROFILES B and C: Phra Kae. a monk at the major Buddhist temple in Sri Muang. was for a goodlv portion of his eighty years a hamlet health officer in the district. It is a post with little real responsibility. but its holders are invariably already established as legitimate healers, As a young man. Phra Kae had served as an ap-

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DANIEL

H. WEISBERG

Prentice to various healers (herbalists and those using supernatural cures) and after a stint in the army he intermixed healing with farming (having inherited a sizeable amount of land) before attaining the positton of hamlet health officer-official recognition for what was already a burgeonmg practice. Phra Kae was busy in al1 areas of healing. from delivering babies to treating infectious diseases, though most severe cases were sent to the hospitals of Chiang Mai City. His immense popularity is remembered to this day. and even in the temple where he has resided for fifteen years he has continued his renown as a monk-healerexorcist. As hamlet health officer he was a therapeutic and financial success. and enjoyed smooth entree into circles of political and economic power. This enhanced his position as landowner and member of a broad kin network. Phra Kae retired in the late 1950s and was quickly replaced by a local man well-versed in biomedical cures. That individual was in turn replaced by Dr Fung, who significantly resembles Phrae Kae. A local man with a sizeable plot of paddy, Dr Fung was drafted into the army and served in the medical corps. After his discharge he treated patients over a wide area. though most resided near his home. His success as an injection doctor coincided with burgeoning personal wealth. As a result, when the post of hamlet health officer came open. he seized the opportunity and used all his connections. kin and otherwlse,

to obtain the post. Becoming the hamlet health officer provided a further entrke to circles of political power. precisely as it had for Phra Kae. The social conventions surrounding the clinical habits of both men are also similar: treatment in the patient’s home open to the full view of kin and neighbors; payment often deferred (sometimes even replaced by ritual payment for indigent patients); practitioner behavior rri.=&ois patients and others in their social circles imbedded in a larger pattern of local social relations. Both practitioners found themselves in great demand and both involved themselves with local elites as well as local medical circles. But in each case. prowess at healing was well established before attainment of any sort of quasi-official position.

By the 1960s several other types of care were available in Sri Muang: a full-scale health center staffed by a physician (now a hospital. with two physicians on the staff), pharmacies offering most common pills and injectables and a group of government sanitarians and midwives. But as the above examples suggest, bio-medicine administered by healers in the ‘locallysanctioned’ sphere was utilized before government services became established. and the most dominant practitioner in the area was the injection doctor. Healers in the ‘officially-sanctioned’ sphere are separated from their patients by a gulf of social distance. Even when practitioners are popular. that gulf may persist; midwives who dispense birth control devices and help with prenatal care and delivery are not always at ease with their patients, this despite speaking the local dialect and perhaps even being locally born. Thus, even when social distance might be lessened by goodwill. a great deal of ambiguity emerges, as the following example illustrates. PRACTITIONER PROFILE D: Dr Chaokrung is a physrcian at the local district hospital. Having arrived only one year ago to serve a two-year stint as part of his obligatton to repay the government for his eduction. he has established himself in the hospital and in an after-hours private chntc. Junior to the other hospital physician. he nonetheless has proved more popular. Despite a background radically different from the villagers who make up the bulk of his patients (he is ethnic Chinese and from Bangkok). hts

easy-gomg manner is pleasing,to locals. They tend to prefer to see him in his private cllmc rather than attemptrng to see htm during hospital out-patient hours. something he finds a bit baffling since the treatment is esactly the same-or so he claims. Indeed. he often charges a hit more in hts clime than the hospital demands. Villagers see their behavior as very sensible. however; Dr Chaokrunr IS satd to be more attentive tn his clinic. a bit more Hex~ble and infinitely more accessible. Even more importantly. though he maintains status differences regardless of the place of treatment, they expect htm to be more dtligent and pattent m his clinic than in the hospital. He works quickly in both places. administering expected drugs at each visit. thoueh he does not charge excessive amounts on his own. Still. villagers confide that they often. but not alwavs. feel out of place when dealing with Dr Chaokrung. He 1s. after all. a man from Bangkok. highly educated. and if there 1s banter. it IS one-way. originating wtth him. not back and forth. as among equals-as it is with injection doctors. for instance. Villagers like him for the most part. they say. They often neglect to be candid with him but he is not surprisrd at this. Dr Chaokrung considers himself tolerant of thetr sometimes seemingly irrattonal behavtor. even when some of their requests and desires are not sensible. “After all.” he said. “if they want a saline iv.. I give It to them. It doesn’t really matter all that much.” His feelings are known to them since he does not bother to mask his casualness. but they say his medicine is good and effective. Often he is only vaguely aware of their attitudes and treats them with the same lighthearted sincerity he uses in all matters. In short. he operates his clinic differently from the way he carrtes out his hospital duties (at least from the perspecttve of his patient), but he is benignly indifferent to the opinions of patients. however flexible he is as a clinician.

Such are the kinds of practitioners past and present in the Sri Muang area. Their practices reflect the reality of the two spheres as outlined above and the manner in which the medical system developed as a whole.

I have maintained that village patients shape the medical system to a certain extent by exerting a degree of control over how and by whom they will be treated when ill. I contend that the configuration of the medical system-the two ‘spheres’-is continually fine-tuned by actions on the part of patients. of which choice is one. In any healing situation. the relationship between the healer and the patient and family is crucial. 111 individuals call upon a specialista healer--because he or she is apt to know something the lay person does not. Each selection of a healer. a hopeful attempt to alleviate a real or potential threat. is also a problematic event surrounded by unique intluences requiring consideration. A major criterion for selecting a healer is the definition of the ill state and the lay diagnosis of a specific malady [16. 173. This definition of illness or its attendant consequences [IX] is seen to be crucial in choosing this or that healer. In this view. the healer chosen will be the practitioner most likely to provide a cure. In the Northern Thai context. however. such considerations merely serve to narrow the range of the appropriate from the field of the possible. One could also point to such crucial factors as availability of funds and means of transportation, among others [19]. What 1 seek to define here is not the formula of choice. as others have done [20.21]. but the role choice plays in this plural system. Flourishing

Northern

Thai health

medical plurality in this sense is not seen as only a function of the blend of bio-medical and traditional therapies, or as the result of ideological frame of mind. Rather, the plurality is related to the freedom of choice that serves to place the patient in control of his environment, to give him options to strike what seems the best course for himself. The act of choosing among a variety of alternatives is one way patients can control what happens in a healing interaction. This act is not an unrestrained or loosely-organized affair; it is governed by social devices assiduously applied in a situation that represents a great physical and financial threat. Patient control: devices, patterns and correlates How might a patient control his healing episode? ‘Control’ might connote an ironclad capacity to determine, and ‘influence’ a much softer attempt to shape through suggestions and cajoling. Control as used in this paper encompasses a mixture of both, with the express intent of achieving a specific end, a swift and inexpensive cure without dire loss of funds, face or health. Such attempts are never totally successful, and in such a context. must be more dependent on influence than actual exercise of brute power. But even if the individual is in a situation where his power is extremely limited, events will encourage him to look after his own fate and fortune. Context. Three forms of control mark the manner in which village patients might affect treatment: context. payment, and components of treatment. Treatment in the patient’s home affords the greatest chance for patients, their kin, and neighbors to scrutinize and evaluate the manner in which the potential cure is being administered. Home is the patient’s world, the most secure bailiwick he or she has. and the outsider or stranger is automatically at a disadvantage there. The collective eye of at least part of the village will be upon the healer. and the rest will hear the story second-hand. If healing takes place outside the home in the village. or in another village. or in the market at a suitable place. the rituals and pleasantries of local life will still prevail. When it becomes necessary to enter ‘officially-sanctioned’ areas, however. the prerogatives of community scrutiny. as well as the rituals and pleasantries, disappear. Attempts are made to compensate and retain these prerogatives during ventures into the ‘officially-sanctioned’ sphere through the company of friends and relatives. But family and friends usually are excluded by institutional routines, their watchful eyes and support allowed only when special privileges are purchased (such as a private room in a hospital. which can be prohibitive in cost). Where institutional and bureaucratic prerogatives assume control, the individual is helpless to retail? his or her role as arbiter of the context within which he or she is to be treated. The iniportance of context is indicative of social distance in healing interactions. Problems associated with approaching and utilizing healers of greater status than the patient have been noted with particular reference to the Thai context in

Cunningham’s social distance *i.e. English. I;md.

work mentioned above. and great suggests a high degree of powerless-

the language

of medical

education

in Thai-

care alternatives

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ness on the part of patients. The high status of the practitioner, in that healer’s home territory, precludes many of the defensive social devices enumerated here. If unequal status is part of the context. the patient may often have no idea how to proceed. One such example that illustrates the nature of the village and non-village contexts is the case of ‘Mrs Songsaan’. PATIENT CASE A: Mrs Songsaan, a village woman in her forties. felt a stricture in her throat and took a variety of local remedies before the symptoms worsened. injection doctors consulted could not effect a cure. Subsequent trips to local and Chiang Mai City physicians and hospitals had no results (and cost a considerable amount of money), until a Chiang Mai City clinic physician recommended by neighbors performed an X-ray of her throat. finding a small growth. A stay in the University Hospital in Chiang Mai City (a teaching hospital that also doubles as the provincial public hospital) followed and she was treated by a variety of staff and students who performed a number of tests. During one morning incident several students discussed (in her presence) an operation on her throat. Mrs Songsaan, left out of this conversation, said to the interviewer that they spoke animatedly about how they would perform such an operation on her, peppering the conversation with “words of your language*. professor. words 1 did not understand at all.” Unsettled. she fled the hospital the next day. She said that the “big” doctor did not want them to operate. and she felt that the students wanted to experiment on her. At home in the village, Mrs. Songsaan and her family then embarked upon a course of treatment with spirit mediums, herbalists and injection doctors called in to attempt cures. The treatments took place in her home or in the home of a sister in Sri Muang Town. Each treatment seemed to revive her for a while. and she was comforted by the familiar faces of her family and the familiar surroundings. As the tumor grew, her decline was steady. and at times. rapid (while others in the family recognized that this was the problem. the word tumor was never used in her presence and they were continually reassuring her she would recover). Five months after the onset of her problem she died, in her home. surrounded by kin and friends. Payment. Herbalists and healers using supernatural cures, in accord with their patients, have realized that each attempted cure is problematic, depending on the degree to which it is appropriate to the illness. A healer must be reimbursed in a token manner to justify his time spent with a patient, but the agreed-upon price accrues to him only if he accomplishes a cureand the patient is the ultimate judge of success. Negotiations over payments may take one of two courses. A patient who is tied to a healer by multiple ties of kinship, acquaintanceship or financial dealings is more reluctant to bargain. fearing to upset the multiple relationship. Patients less acquainted with the healer are more direct and more apt to make their position. clear. though the phrases are wrapped in social niceties. On the other hand. a healer well acquainted with the patient may be more sympathetic to temporary indigence. as the case below suggests. PATIENT CASE B: Road building jobs during a slack agricultural season had tragic consequences for several Baan Loom Doi villagers. A careless dump truck driver, sleepy in the earl) morning. overturned his vehicle on a steep mountain road. A dozen villagers en route to work at the job site spilled out on the pavement. and three died. Others were taken to the University Hospital in Chiang Mai City. where the construction company paid all bills.

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H. WEISBERG

Mr Tack, a man in his forties. suffered concussion and severe abrasions on his left thigh and shin. Alone on a cot in an overcrdwded ward (actually, the overcrowding was such he was placed in the hallway). he was miserable while recouperatmg in the hospital. Against the advice of the hospital staff, he went home; in the iillage he called upon the village injection doctor, Dr Krom. to change the dressings on his leg and treat him for potential infections. Everv day for several months Dr Krom went to Tack’s homk to -spend an hour changing the dressings (a long, laborious orocess); he also checked Tack’s condition and administered necessary anti-biotic injections. Dr Krom never missed a day and never mentioned payment. Since compensation from the company was in doubt (and was considered by the headman to be unlikely), Dr Krom and others knew Mr Taek would have no available cash for some time to come. It was commonly felt that delaying payment to Dr Krom was understandable. Though ritual obeisance at New Years’ (which would include nominal ritual gifts of tobacco and sweets) would be appropriate. the final payment would be delayed up to nine months or longer. The sum would not be decided by patient alone or the practitioner alone, but through a process of consuitation between the patient and his friends and relatives. The final amount would be in keeping with Mr Tack’s economic status, but large enough to show appreciation for Dr Krom’s time and for drugs used in injections. Neither Mr Taek or Dr Krom ever discussed the payment face-to-face. The first installment of the payment was to be given ritually in the next Thai New Year.

Injection doctors are not the only ones with whom patients can negotiate payment terms. Herbalists and spirit healers are flexible, and a pharmacist might lower prices or amounts of dosage to suit a patient’s budget. Even private clinic physicians are susceptible to pleas from indigent patients and tailor prices and services accordingly. Pati.ents can and do press their cases and they are often successful. This striving for economy has to be seen in the context of the patient’s desire for a swift and certain cure. The cheapest a’lternative might not seem the most efficacious. The ofttimes frenetic and peripatetic search for a cure is the result of perceived needs to maximize the chances of returning to the normal. well state. This leads the outside observer to conclude that heightened activity correlates with perceived severity. Driven the patient might be, but the ideological underpinnings are sound and the outlays of precious cash are wise from their perspective. Bargaining or negotiating over price of therapeutic services thus becomes extremely important, since the threat of severe illness drives the individual beyond the bounds of everyday prudence. Flexibility of payment in the ‘officially-sanctioned sphere is much more difficult to obtain. Even in public hospitals where charity treatment terms are possible, a long and humiliating interview with a social worker is necessary before one is accepted as needy. Private hospitals receive patients’ attempts to bargain with cynicism and sometimes indignation. This is not to say that in the ‘locally-sanctioned’ sphere there is no resistance to such negotiation. Especially as one deals with healers outside the ‘known’ geographic areas of life and interacts with those from geographically or socially distant places, manipulation of terms of payment is more cumbersome and difficult to arrange. No matter which sphere one is in, however. there are ways to manipulate payment terms, as demonstrated in the case below, where personal contacts

led to knowledge cious assets.

of procedures

that preserved

pre-

PATIENT CASE C: Mr Yim is a 6%year-old man who enjoys relatively good health. though he has had problems with kidney stones. Three years ago. he was diagnosed (by bio-medical means) as needing an operation to remove some stones. Uncertain about how to proceed m arranging surgery. despite detailed instructlons from a physician. he turned to a long-time patron in Sri Muang Town. This individual, a Chinese merchant’s daughter, had succored his eleven-year-old son (now twenty-two years old) when he had taken a fall in town while attempting a childhood prank. This woman had on her own initiative taken the boy to a local health station for emergency treatment and then returned the child to his village home. Repayment was not requested. nor was it appropriate. Instead. Mr Yim presented himself at the merchant’s abode one morning to thank his son’s benefactor with ritual obeisance. In the ensuing years, minor economic dealings. as well as favors+ usually small tasks requested by the patron-followed. and a mutually dependent and beneficial relationship emerged. So when Yim was faced with the prospect of surgery. he consulted this woman. She went with him to the University Hospital and. using her contacts. arranged for his operatron. Later she was advised by those contacts (among others. a cousin who was a nurse) to have him delay paying the charges for several months. thereby opening the way for the bureaucratic organization to “write off” the charges altogether. Such has indeed been the case. The relationship with this lady continues as before. Mr Yim claims that he would have had trouble dealing with the operation except for the help of his patron. and he might have had to postpone the operation despite the pain he was suffermg. Componenr parts ofrherapy. The ability to decide on particular services. to have them either included or omitted, is one of the more direct ways patients have of controlling the course of healing. The very act of selecting this or that healer is evidence of patients’ exercising this power. They also exercise this option by communicating their perceived needs to the healer. based on their own lay diagnosis. In the ‘locally-sanctioned’ sphere patients negotiate with the healer in order to obtain a certain service, or indicate they do not desire the proposed treatment by suggesting that the healer comes again at a different time. or that they will call him when a ‘real’ need arises. If a patient then decides to seek another healer. that is his or her privilege. Since the selection of a certain type of healer insures in part the type of therapy involved. the next step is to induce the healer to provide the specific service the patient feels will be the most helpful, based on prior experience or reputed efficacy. PATIENT CASE D: Dr Krom. the resident injection doctor of &an Loom Doi. deals with chronic problems as well as routine emergencies. Mr lit. ;I fifty-seven-year-old villager. is a thin. habitually weak man who often complains of fatigue and occasional aches in his joints and lower back. Though he has been to a number of hospitals. clinics and pharmacies to find some permanent relief, all the treatments have been to no avail. Accordingly. it has fallen to the closest practitioner_Dr Krom--to deal with the dayto-day problems of Mr Iit. Neither the patient nor his family knows precisely the cause of the problem. though they all feel that his often weakened condition is worthy of intermittent care to “keep up his strength”. Mr Iit himself feels this frequent treatment is essential to his being able to carry on with necessary activities of life. He is no longer engaged in agricultural pursuits of a dif?icult nature (nor IS

Northern Thai health care alternatives he, at his age, expected to), but he spends a great deal of time repairing equipment, preparing produce for market, and tending grandchildren. Everyday personal activities and an acceptable level of comfort are gauges to his perception of health. When that level is not sufficient, he sends a grandchild to request a visit from Dr Krom. On one such occasion. the doctor carried out a cursory examination, checking blood pressure, heart, lungs and intestines. He remarked that the real problem-one of several years’ duration now-was not being addressed by the treatments that he was asked to give. He continued his efforts to convince Mr Iit to go to Chiang Mai City for further treatment. Mr Iit, however, would hear none of it. He was quite humble in his dealings with Dr Krom but he was definitely single-minded: he wanted an injection of vitamins or something that would give him more energy. Dr Krom, never adverse to making a profit, was nonetheless aware that this case was difficult to treat. perhaps even completely beyond his capabilities. However. as a practitioner. he came when called and ultimately gave Mr Iit the injection he wanted. Mr Iit had listed patiently to Dr Krom’s comments, but each knew the injection would occur; equally, though, both were aware of the chronic nature of the condition afllicting Mr Iit. Both played out their roles, one demanding a certain service in a relatively direct manner, the other giving the treatment while not abdicating his mutually perceived role as medical advisor. During the entire research period of eighteen months, Mr Iit’s condition remained essentially unchanged, except for a cough that appeared on occasion. Despite the failure of attempts to restore Mr Iit to the robust health that be had enjoyed during his younger years, he maintains that he feels measurably more energetic and refreshed ‘after such injections, which are always dispensed at his insistence.

Special agencies in the ‘officially-sanctioned’ sphere would seem to be ideal for this purpose, but they cannot always be induced to provide the desired service. ‘Officially-sanctioned’ healers often communicate little with patients. As with negotiation of payment, the villager is not always successful in making healers treat him according to his wishes. In the proper context, the patient might be able to receive the treatment he desires in a way that leaves him the ultimate arbiter of the situation. Obviously, the ‘locally-sanctioned sphere is a more advantageous context from the perspective of the patient. The following case underscores how a patient might manipulate a variety of therapies and assorted bits of medical knowledge to achieve amelioration of a condition. Medical knowledge is portable and transferable. This case emphasizes that fact, as well as the influence of context. PATIENT CASE E: Mrs Phloi. a relatively wealthy fiftyyear-old woman. was suffering from a “bloated feeling” in her face and arms and was extremely fatigued. She also had lower back pain and “red eye”*. This lady regularly uses an injection doctor, Dr Muang. who has been in Sri Muang for a number of years, having moved in from a neighboring province. His visit of the previous evening was followed the next day by Dr Salery. an injection doctor who is also a headman. called in by a headman nephew of Mrs Phloi. Both Dr Muang and Dr Salery had prescribed medicine for her. After taking both medicines in succession and receiving no relief from her symptoms, she then took several medicines that family members had heard about for backache. along with a pain reliever once prescribed by a *A dangerous pressure emanating from within the body that sometimes evidences itself as bloodshot eyes.

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former head paramedic at the local health station. In a follow-up interview she attributed her cure to medicine brought her by her family and she noted that the medicine Dr Salery had prescribed was useful for her husband’s backache. It was the medicine first prescribed many years ago by that since-departed health worker and this time purchased for her in a local pharmacy that cured her. In the following conversation, it is interesting to note that villagers are quite candid about healers, and about their own ability to judge and use medication. INTERVIEWER: Is he (Dr Muann) a herbal doctor? PATIENT: No, he’s not.. He has-treated my daughter for nosebleed and we gave the same medicine to my son-inlaw but it did not help his sore back. Another daughter was cured of a swollen face (using the same medicine). INTERVIEWER: And he did not give you the correct medicine for your present problem? PATIENTS SISTER No. I: (emphatically) No, not at all! INTERVIEWER: But Dr Muang is quite popular isn’t he? PATIENTS SISTER No. 2: Sure, when we have pains in our legs, arm or ear, he does a pretty good job of treating us. If the symptoms call for a shot, he injects, and if not, he doesn’t. Some of these doctors will give you a shot for just everything.. . Dr Muang speaks rather well and politely. PATIENT: If they (other doctors) come and inject right away, it might be necessary so it is all right. But if a doctor does not inject, we don’t use a lot of money. PATIENTS SISTER No. 2: Dr Muang does not want a lot of money-when he comes he just gives medicine (i.e. gives pills rather than injections). . INTERVIEWER: When he came to see you that afternoon, where did Dr Muang say the illness originated in your body? PATIENT: He didn’t say that it originated here or there in the body; he just said it was an illness that had returned. INTERVIEWER: So. he came to examine YOUand then gave you medicine, right? PATIENT: Yes, he gave me medicine and said that the illness was an eye ailment and he said he could not give me an injection. Dr Salery said he could not inject either, so both doctors agreed on that. So, while Dr Muang’s medicine (i.e. one of the medicines suggested by him) cured me of the pain, I think the illness subsided with the one my family bought in the pharmacy. They say that if your mouth is dry. that calls for that medicine. I’ve taken it and it’s correct and it works. I feel fine. One should note that Mrs Phloi, in concert with friends and family, manipulated the practitioners involved and used information about cures to achieve what she deemed to be the proper end-that is, to match a particular .cure with the appropriate illness. Correlates in other facets of social ltfe. Northern Thai villagers live within a labyrinth of relationships, some more familiar than others. but all recognized for their importance to the maintenance of life. Economic success has been deemed by villagers to be more likely, whatever the endeavor, outside the purview of government, and rather in the cushion of those relationships. Distant officially-sanctioned control is thus often viewed as a liability. The possibility of becoming a government official with a secure sinecure is a dream for many, a reality only for a few. Whole centers of marketing and enterprise flourish independently of central authority. Just as the impetus for local irrigation works came from within the community. so it is in other areas of agriculture and commerce. Commodities gathered or grown are

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DANIEL

H.

traded or sold without reliance on the authorities. Trading in livestock goes on as it always has. sometimes between villages quite remote from one another. and sometimes between town and city and village. all with only minimal government scrutiny. Livestock dealers in the village apply for commercial licenses only when detection by the government is considered inevitable. Any activity considered necessary for the well-being of the individual villager is carried out without regard for central authority. Illegal logging, a staple of many villagers who rely on wage labor, is a prime example. The entire range of social relations at the village level depends almost solely on locally-controlled standards. Marriage, divorce, and the resolution of domestic discord and local disagreements are handled at the village level using local standards. Only rarely do such issues reach district authorities. Even joint projects, such as maintenance of the local Buddhist temple, are generally done without referring to central religious authority. Recourse to other than local control is a last resort fraught with dangers and unknown consequences in that it automatically robs villagers of complete control over their lives and fortunes. The assertion here is that these efforts to husband local control are, in effect, very often efforts to retain personal control over a number of situations and circumstances. Only one’s kin, one’s neighbors and one’s own self can be relied upon to handle important matters with sufficient care and attention. Many of the efforts described here are defensive in nature, contrived to allow the individual to preserve the integrity of his social and economic world. When one releases control, one is subjected to the desires and caprices of others, and it seems inevitable that personal damage will ensue. These issues have not been foreign to Thai and Southeast Asian ethnography. Dealing with extrafamilial and extra-village entities has always been a major dilemma of Thai village life. Historical evidence suggests that villagers were left largely to their own devices as long as they satisfied minimal demands of ruling entities [22]. Heine-Geldern [23] found the political world of Southeast Asia to be envisioned as power centers embodied in the sacred body of the kingship from which influence and control radiated. The limits of influence from any single center were considered indeterminate. perhaps to be gauged only through experience. Governance emanated from power centers, alternating with periods when the village would remain relatively untroubled. The idiom of the world as divided into power centers, the strength of which diminishes with distance from those centers, has relevance for this discussion. The familiar environs of home and family are secure and individual influence is bounded by one’s networks of kin, friends and acquaintances. Whereas one’s influence has limits within a field of social activity, the power of others may be either dangerous or benign. Mulder [24], commenting on Thai social life, claims that the Thai perceive the power of others in terms of a dichotomy of decha, or amoral, non-benevolent power, and k~runnu or benevolent, warm and nurturing influence. While such dichotomies are difficult to support absolutely, some basis for this view can be found in the health behavior discussed in this paper, Villagers deli-

WEISBERG

nitely do divide their world into those aspects that are known. predictable and helpful and those aspects that are possibly hostile or at least indifferent to one’s welfare. Those entities closer to the village geographically and socially tend to be more known and safer but such a village-non-village dichotomy is not absolute. Within the village. hostilities and divisive issues abound. along kin and class lines. Benefits sometimes accrue from contact with that outside world. but there is no certainty of this and one must be on guard. In a village milieu where life and well-being are fragile. any upset may have longterm consequences. Although kin and neighbors serve as a cushion against the unfortunate. the impact of a calamity is felt for quite a long period of time. Accordingly, villagers consider their relationshipsslowly and carefully-especially those with authority figures. most of whom are outside the village [25]. Northern Thai have long been identified as being extremely “pragmatic” in this regard. always maneuvering to place themselves in the most advantageous position by a mixture of cajoling. negotiation and shrewd judgements [26-281. Inherent in this ‘shrewdness’. then, is a recognition of the double-edged nature of relationships: helpful. and threatening. While some commentators have attempted to formulate elaborate theories of non-involvement [29], this caginess might better be viewed as a cogent recognition of the potential threats in their world against which one must guard, using all the social and communicative devices available. CONCLUSION

This paper has discussed the manner in which village patients affect the organization of the medical care system available to them. It was suggested that the primary impetus of villagers is to control the course of their treatment as much as possible. They do so by judicious choice of healer, bargaining over amount or terms of payment, selection of healing context and environment. and negotiation about which component parts of therapy will be employed. The cumulative effect of this behavior has been to foster a medical system that might be seen as divided into two separate spheres characterized by respective sources of validation, means of training, relations between fellow healers, and the nature of relationships with patients. Such behavior and social organization have been shown to be harmonious with other facets of Thai social behavior and social organization. Ac~norvlrdyrments-Data upon which this paper is based were gathered in Chiang Mai Privince. Thailand (1977-1979) under the sponsorship of the National Research Council of Thailand. and with the financial support of a Fulbright-Hays Doctoral Fellowship. I am indebted to the staff of the Social Science Research Center (now Institute of Social Science Research). Chiang Mai University, especially Professor Prasert Bhanchand. and Professor Somphong Shevasunt. I am grateful to the late Somboon Vacharotai. M.D.. then the Director-General of the Department of Health. Ministry of Public Welfare. for his many kindnesses. I am grateful to Clark E. Cunningham of the University of Illinois for his comments on several drafts of this paper. My thanks also go to Edward M. Bruner of the University

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Northern Thai health care alternatives of Illinois and the late James C. Young of East Carolina University for their comments on an earlier draft presented at the 79th Annual Meeting of the American Anthropological Association in Washington, DC, December, 1980.

REFERENCES

I. Freidson E. Client control and medical practice. Am. J. Sot. 59, 374. 1960. 2. Freidson E. Doctoring Together. Elsevier, New York, 1975. 3. Janzen J. M. The Quesr for Therapy in Lower Zaire. University of California Press, Berkeley, 1978. 4. Glick L. B. Medicine as an ethnographic category: the Gimi of New Guinea Ethnology 6. 31. 1967. 5. Long S. 0. The ins and outs of doctor-patient relations in Japan. Am. J. Chinese Med. 8, 37, 1980. 6. These difficulties are reviewed in Press I. Problems in the definition and classification of medical systems. SOC.Sci. Med. 14B. 45. 1980. Problems specific to Asia are discussed in Leslie C. Introduction. In Asian Medical Systems (Edited by Leslie C.). University of California Press, Berkeley, 1976. Also relevant to this discussion is Dunn F. L. Traditional Asian medicine and cosmopolitan medicine as adaptive systems. In Asian Medical Svsrems (Edited bv Leslie C.) Universitv of California.Press. Berkeley, i976. 7. Hanks L. M. et al. Diphtheria immunization in a Thai community. In Health. Culture and Community (Edited by Paul B.). Russell Sage Foundation, New York, 1955. 8. Bryant J. Health and the Developing World. Cornell University Press, Ithaca. 1969. 9. Boesch E. E. Communication between doctors and patients in Thailand, part I: survey of the problem and analysis of consultations. Socio-Psychological Research Center on Development Planning, University of the Saar. Saarbrucken. West Germany, 1972. 10. Cunningham C. E. Thai injection doctors. Sot. Sci. Med. 4, I. 1970. 11. Wray J. D. Health care and the community: a view of Southeast Asia. paper presented at Quaker International Conference in Southeast Asia, Davao City, Philippines. 1973. 12. Day F. A. and Leoprapai B. Pattern of health utilization in upcountry Thailand: a report of the research project on “the effect of location of family planning/ health facility use”. Institute for Population and Social Research, Mahidol University, Bangkok, 1977. 13. Riley J. N. and Santhat S. The variegated Thai medical system as a context for birth control services. Working

Paper No. 6. Institute for Population and Social Research. Mahidol University, Bangkok, 1974. 14. In addition to Clark E. Cunningham’s paper on Thai injection doctors, there is a preKminary_ paper read at the Xlth Pacific Science Congress, Tokyo. 1966. Also of interest is an unpublished interim research report, mimeographed. 1966. 15. Thutiyapho P. et al. Research report on the use of medicine by the population (raingaan kuun wijai Gang kaan chdi yaa khdwng chumchon). Project on Public Health Services Development, School of Pharmacy. Chulalongkorn University, Bangkok, 1976 (in Thai). 16. Erasmus C. J. Changing folk beliefs and the relativity of empirical knowledge. Southwest J. Anthrop. 8, 41 I. 1952. 17. Foster Cl. M. Disease etiologies in non-western medical systems. Am. Anthrop. 78, 773. 1976. 18. Gould H. The implications of technological change for folk and scientific medicine. Am. Anthrop. 59, 507, 1957.

19. Colson A. The differential use of medical resources in developing countries. J. HIth sot. Behal;. 12, 226, 1971. 20 Woods C. Alternative curing strategies in a changing medical situation. Med. Anthrop. 1, 25, 1977. Choice in a Mexican Village. 21 Young J. C. Medicul Rutgers University Press. New Brunswick, New Jersey, 1981. 22 Steinberg D. J. (Ed.) In Search of Southeast Asiu: A Modern History. Oxford University Press. Kuala Lumpur, 1972. 23 von Heine-Geldern R. Conceptions of Srure und Kinyship in Sonrheusr Asiu. Cornell University Data Paper. Ithaca. 1956. 24 Mulder N. Everyday Life in Thailand: An Jnrerpretunon. Duang Kamol Press, Bangkok, 1979. 25. Phillips H. P. Thai Peasant Personality: The Patterning of Interpersonal

Behavior

in the Village

uf Bang

Chan.

University of California Press, Berkeley. 1965. 26. Kingshill K. Ku Dueng. The Red Tomb: A Village Stud!, in Northern Thailund. 2nd Edition. Bangkok Christian College. Bangkok. 1965. Chunge und Prusunr Choice 27. Moerman M. Agrictrlrnrul in u Thui Villuye. University of California Press. Berkeley, 1968. 28. Potter J. M. Thai Prusunr Sociul Srrrrcrrrrc. University of Chicago Press. Chicago. 1976. 29. This argument, known as the ‘loosely structured’ model of Thai social structure is well investigated (along with its opposing ‘tightly structured’ counterpart) in Evers, H.-D. (Ed.) Loosely Structured Social Systems:

Thai/and

in Comparative

Perspective.

South-

east Asia Studies. Cultural Report Series 17. Yale University. New Haven, CT, 1969.