Beyond Medical Plurality in Bhutan

For decades, biomedical science under the scientific paradigm has obscured healing methods in other knowledge frameworks, especially of local and traditional medicine. Some scholars[1] argue that biomedicine creates representations of illnesses, and the way in which medicine combines rational and irrational elements directs attention to the body with concern for moral dimensions of sickness and suffering without giving analysis to the role of cultural factors webbed in illness experience and medical practice. The argument has led to a more open view of ‘medical plurality’, giving more space to local or traditional medicine as a part of the healing practices and illness experience within human cultures. As a result, contemporary healing practices in many countries interestingly incorporate the concept of medical plurality into their healthcare systems. Bhutan is one of the countries that engages biomedical practice and traditional medical knowledge in the state-run healthcare service and organizational structure, i.e. the state-run hospitals centralized and funded by the Bhutanese government.

The Patient Multiple begins from this point, discussing the healthcare services and the incorporation of biomedical practice and traditional medical knowledge as a structural context. It is a well thought-out book that attempts to place the concept of medical plurality and especially ‘multiplicity’ in a more complex situation in Bhutan today. In my opinion, the book has contributed to medical anthropological studies and anthropological frameworks and methodology in two ways: 1) the book does not only explain how the healthcare systems in Bhutan today integrate biomedicine and traditional medicine effectively, it also engages what the author calls ‘alternative practices’ which include shamanistic, ritual, bone-setting, religious ceremonies, oracle usage, spirit procession, dietary behaviours, and familial care into the analytical framework of The Patient Multiple. The author chooses the term ‘alternative’ to emphasize that the mentioned practices should be differentiated from local and traditional ones which are set against the institutional and modern medical practices, and to tease out the otherness embedded in the healthcare systems; 2) By focusing on patients and its multiplicity, the book offers a new perspective to actors-oriented analysis and their decision-making regarding their practice and cares. The analysis does not look at patients as passive or isolated agents. Rather, it engages them with other social, economic, and political factors and influences that converge in a patient’s decision-making process. It introduces the reader to ‘an understanding of the Bhutanese patients as socially multiple, defined by a praxis of multiplicity’ in various healing practices (p. 15).

Analytical material is drawn from the author's fieldwork in Thimphu, the capital of Bhutan, and Mongar, the largest and most influential urban centre, known as a gateway between the eastern and central regions. The author spent 12 months conducting ethnographic research with patients and their family members, doctors, healthcare staff, and alternative healers. His fieldwork of anthropological method generates rich data through formal and informal interviews with over 400 patients, 150 healthcare staffs, and administrative officers. He also sat in 600 traditional and modern medicine consultations, as well as other treatment and clinical sessions. The result of the ethnographic research has shown how the author documented the crossover of patients between biomedical, traditional, and ‘alternative practices’.

The book is comprised of five chapters, written in rich ethnographic style and anthropological analyses. Chapter One defines the term ‘patient multiple’, ‘a multi-subjectivity person who has different healths and bodies that are engaged in a diverse array of [curing] practices’ (p. 64). The use of the patient multiple framework helps situate patients as nexuses of decision-making in the healthcare-seeking process within the three healthcare options in Bhutan. Chapter Two explores the traditional medicine services and how its patients are created within the organizational structure of these services. It contends how the traditional medicine system is incorporated into a state healthcare project, and how that led to a new type of ‘bio-traditional citizenship’. Chapter Three applies the notion of ‘appropriateness’ to understand the decision-making of Bhutanese patients: when, why, and in which contexts they use the different types of healthcare services. By giving two case studies, Taee illustrates both personal and social influences that affect patients’ decision-making, and the emerging ethics of appropriate healthcare seeking behaviours. Chapter Four focuses on how alternative practices affect a patient’s experience of illness. Exemplifying Ja Né, a disease category treated by alternative healers, the chapter shows the different logic in Bhutanese cultural context that is not relevant to those outlined by biomedical or traditional practices. Chapter Five explores the effects of medical materiality on patients. By medical materiality, Taee refers to ‘things’ that adopt a healing identity and become active non-human subjects that exert influence on patients. The conclusion of this book emphasizes that patients are capable of understanding and layering the different modes of practices, as well as the healing processes and bodies that arise from different narratives of healthcare seeking.

[1] For example Byron Good, Medicine, Rationality and Experience: An Anthropological Perspective, Cambridge: Cambridge University Press, 1994.

English language edited by: Tzy Jiun Tan, New York University Abu Dhabi