2What are the specificities and realities of biomedicine in Southeast Asia? From the treatments and care associated with a given pathology to the requirements to practise for practitioners to the uses made of biomedical knowledge, this issue explores the different dimensions of care when delivered by actors who appropriate and then mobilise the (conceptual and empirical) tools of biomedicine. In what ways do practitioners use biomedical products (industrial drugs, medical imaging and surgical techniques)? How do the professionals create a dialogue between scientific knowledge and social or economic motivations? These cross-cutting questions shed light on biomedicalisation processes (which I will return to below) and on the ways in which global health policies concretely influence treatments and therapeutic practices.

3The contributions in this issue investigate the appropriation of biomedicine in Southeast Asia to uncover how care is provided in hospitals, private clinics and health centres and, more broadly, to explore what a ‘hospital’ is and what it means to be a doctor, patient or caregiver in this region of the world. The approaches presented are far from exhaustive, but they aim to contribute to an understanding of how biomedicine intervenes in the daily lives of patients and their families through an analysis of its current forms. What imaginaries and values does biomedicine carry with it today in Southeast Asia?

4The issue contains six articles and a memorial to Clark Cunningham, a pioneering ethnologist in the field of health. Three of the contributions focus on Indonesia. Peter van Eeuwijk looks at experiences of caring for older adults in North Sulawesi. Michaela Haug describes successful recoveries from brain tumours among the Dayak Benuaq in East Kalimantan. And Alicia Paramita Rebuelta-Cho investigates obstetric violence on Flores. Clémence Schantz’s contribution continues along similar lines with her study of the biomedicalisation of childbirth in Cambodia. And staying with Cambodia, Meriem M’zoughi’s research conducted in and around Phnom Penh explores the knowledges and practices of oncologists. The final article is a collective contribution by Phonevilay Viphonephom, Pascale Hancart Petitet, Didier Bertrand, Nicolas El Haïk-Wagner and Phimpha Paboriboune on the experiences of caregivers looking after children living with HIV/AIDS in Laos. The In Memoriam is written by Lorraine V. Aragon and Susan Long. In it, they highlight a leading article from Cunningham (1970) on the Thai ‘injection doctors’, which serves as a basis for discussion of their Indonesian and Japanese research areas.

5Following on from work conducted in the areas of the globalisation of therapeutic knowledge and the transnationalisation of health (Pordié 2011, 2013) on the ways in which biomedical logics travel (Cartwright et al. 2016: 338), this issue looks at the acquisition of (López García 2020) and transformations and variations in (Weisberg & Long 1984: 118) new significations that result from the circulation of biomedical knowledge, practices and technologies. Cultural appropriation is thus not approached here in the folklorist sense or in the sense of diffusion, acculturation or assimilation, which, according to Jason Baird Jackson (2021), are the processes most commonly associated with the notion of appropriation. While there may be an element of power relations present, the appropriation examined in these contributions is not about a dominant cultural group imposing (as Jackson’s definition of the assimilation process suggests) or stealing (which is how it is viewed in the folklorist approaches) certain objects or cultural traits from a dominated group, nor is it about a literal or figurative non-coercive exchange (which refers here to the definition of the notion of diffusion). The history of Western-derived medicine in Southeast Asia shows rather that the appropriation has been hybrid and that biomedicine has been transformed and adapted by local actors since its beginnings in the 19th century (Monnais & Cook 2012). This is also true for indigenous medicines, where some neo-traditional practitioners (Guillou 2009) use biomedical objects and/or techniques (medical imaging, test results, stethoscopes, industrial drugs, etc.) in their ritual, divinatory, diagnostic and/or therapeutic practices.

7The contributions in this issue approach the concept of the appropriation of biomedicine as a two-way process, where subjects and objects can switch roles. Van Eeuwijk judiciously asks in his article who appropriates who? Is it people who appropriate biomedical knowledges and practices, or biomedicine that appropriates people’s bodies and health? For example, Haug shows how the Dayak Benuaq villagers became accustomed to surgery, how something that was strange and worrying for them turned into a source of attraction, fascination and wonder. By contrast, both Rebuelta-Cho and Schantz describe obstetric practices as a form of medical ‘colonisation’ that appropriates women’s bodies, even going so far as to suggest that the practices infringe human rights. Van Eeuwijk highlights the ambivalence of this two-way process in his study of older adults’ dependence on and subjection to pharmaceutical products. It is important to bear in mind here though that biomedicine can appear as a source of hope (as in the case studied by Haug). Finally, both Schantz and M’zoughi describe how professionals overcome the constraints inherent in their practices by adapting their knowledges and know-hows.

8The backdrop to all six articles is the idea that the appropriation of biomedicine is part of a third way that invites us to reflect on mediation (the interlinking of a number of objects and/or subjects) by going beyond it. Van Eeuwijk explains that nonmedical health professionals are situated at the intersection of care and cure, acting as the mediator and buffer between older adults and the biomedical professionals (and their pharmaceutical products). This is also how Viphonephom and her co-authors describe the role of caregivers. Positioned at the interface of the familial and institutional spheres, they act as intermediaries between the child and the biomedical management of their disease. Aragon and Long talk about a third approach to care that involves neither western nor traditional medicine, which Haug prefers to think of as a new creative path or creative combination that is situated outside the dichotomous ‘magic versus modernity’ school of thought. Creativity is also the focus of Schantz’s reflection when she talks about the adaptation of private infrastructures to attract Cambodian clients by Khmerising childbirth. Paradoxically, an alternative way emerges in Rebuelta-Cho’s article on women’s refusal to give birth in hospital as an individual form of empowerment. This middle way is also evidenced among Cambodian oncologists practising a ductile medicine that lies outside biomedical standards, in other words, a malleable, flexible, pliant medicine in which professionals manipulate and transform the tools and resources at their disposal without breaching or changing paradigm.

9This special issue of Moussons therefore invites a reflection on the contemporary forms of biomedicine in Southeast Asia. I will begin here by looking at the historical and social specificities of biomedicine and will then return to the local/global connection and the ‘situated’ nature of biomedical knowledges and practices. My intention is to outline the main themes running through the research on this region, which are all reflected in the contributions included here, addressing in particular health systems, the hospital, caregivers and certain diseases.

Biomedecine(s): Commodification and Expansion

10The term ‘biomedicine’ is used in reference to practices derived from scientific medicine of Western origin. This designation is preferred to ‘scientific medicine’, ‘cosmopolitan medicine’, ‘Western medicine’, ‘allopathic medicine’ (Engel 1980; Kleinman 1980; Leslie 1976; Mishler et al. 1981) and, above all, just ‘medicine’. As Gaines and Davis-Floyd (2004) pointed out, ‘medicine’ is perhaps the most problematic of these terms because it devalues all other forms of organised therapeutic practices by labelling them as nonmedical, ethnomedical or popular and thus excluding them from the medical field. This creates a dividing line and implies that, unlike ‘medicine’, some knowledges are based on (ineffective) beliefs (Gaines & Davis-Floyd 2004; Good 1994). Ever since Kleinman (1995) argued that ‘biomedicine’ highlights the institutional and global aspect of a profession that is no longer confined to the West and cosmopolitan centres, it has been the preferred option for most researchers.

The power of the RCT is reflected in the firm belief that biomedical practice must be informed by ‘evidence’ derived from RCTs or related scientific studies, a belief that gave rise to the evidence‐based medicine (EBM) movement. (Lock & Nguyen 2018: 112.)

13Biomedicalisation is therefore understood as a continuation of the medicalisation of society (Clarke et al. 2010). Medicalisation refers here to an extension of the jurisdiction of medicine, where something that was not previously considered to be in the medical domain becomes so. For example, nutrition (anorexia, obesity), addictions (alcohol, drugs) and the life cycle (birth, ageing) have become medical problems (Zola 1972).

14According to Clarke and colleagues, biomedicalisation extends this trend by interconnecting five processes: 1) a new economic biopolitics where biomedical knowledge has a market value through the concepts of privatisation and commodification (2010: viii); 2) an increased focus on the health of populations, which must be evaluated and controlled through the concepts of risk and surveillance; 3) an expansion of technoscientific practices through treatments that are increasingly dependent on science and technology; 4) a transformation of the modalities of the production, management and consumption of biomedical knowledge, and 5) a transformation of human bodies and subjectivities on an individual and collective scale. While medicalisation is said to consist in exerting control over bodily phenomena (diseases, ailments, deformities, injuries, etc.), biomedicalisation is said to aim not at controlling but at transforming bodily phenomena (Clarke et al. 2010: 2).

15The contributions in this issue address head-on the question of the social and bodily transformations brought about by biomedicine. Van Eeuwijk discusses over-pharmaceuticalisation. M’zoughi describes the commercial strategies of pharmaceutical companies and examines the nonmedical factors that guide professionals’ practices. Schantz shows that episiotomy, perineorrhaphy (to create a tightened opening to the vagina) and caesarean sections are more socially than therapeutically motivated interventions. Like Rebulta-Cho, she analyses the transformation of women’s bodies through ‘mutilating’ and potentially ‘dangerous’ obstetric practices. The use of technologies (particularly imaging technologies) and other health services moves away from a therapeutic to a consumption logic insofar as care is privatised. As Van Eeuwijk, Schantz and M’zoughi suggest, the status of the user is thus itself transformed from a patient to a customer consuming biomedical products.

Socially Situated Knowledges and Practices

16So far, I have referred to ‘biomedicine’ in the singular, but this cognitive and professional field seems to exist only in the plural. This tendency to perceive a unity that does not exist is prompted by the biomedical paradigm itself (Berg & Mol 1998: 4), which implicitly advocates a universalisable truth and thus contributes to the development of monotypic and hegemonic thinking (Kleinman 1995: 25-27). However, when biomedical systems are studied and compared, they appear to be polymorphous and multitudinous, because ‘like religion, ethnicity, and other key social institutions’, they are ‘a medium through which the pluralities of social life are expressed and recreated’ (Kleinman 1995: 24). Hence why the starting point of Berg and Mol’s collective work is based on the idea that:

medicine is not a coherent whole. It is not a unity. It is, rather, an amalgam of thoughts, a mixture of habits, an assemblage of techniques. Medicine is a heterogeneous coalition of ways of handling bodies, studying pictures, making numbers, conducting conversations. Wherever you look, in hospitals, in clinics, in laboratories, in general practitioners’ offices there is multiplicity. There is multiplicity even inside medicine’s biomedical ‘core’. (Berg & Mol 1998: 3.)

17The multiplicity claimed by Berg and Mol differs from Kleinman’s plurality. According to Mol, ‘a body may be multiple without shifting into pluralism’ (2002: 151). Indeed, the idea that biomedicine is exerted on a single body has been abandoned in the most recent studies for a thinking aimed at highlighting the ‘many bodies shaped in medical practices’ (Berg & Mol 1998: 6-7). This remark implies that ‘what we think of as a single object may appear to be more than one’ (Mol 2002: vii). To use Mol’s example, an atheromatous plaque in the arterial wall is not ‘the same entity’ (Mol 2002: vii) as the problems raised in the consultation room by people with this condition, although the object is called atherosclerosis in both situations. Also, the drop in blood pressure due to stenosis is not the same as the loss of lumen in the blood vessels that shows up in X-ray images. Thus, biomedicine produces different and sometimes incompatible realities, as Smith (1981) showed when she demonstrated that a respiratory disorder and a lung X-ray (supposedly materialising the problem) did not necessarily correspond. Smith investigated the Black Lung movement, which emerged in 1968 in the West Virginian mining region of the United States and sought legal recognition for an occupational respiratory disease. People with respiratory disorders in this region were not recognised as ill because their X-rays showed no pathological signs, and vice versa. Smith therefore set about describing the differences in perception and the incongruities in the very definition of the disease among the various actors (medical professionals, miners, politicians). The two approaches—plurality and multiplicity—converge through the idea that biomedical knowledges and practices are rooted in contexts, whether historical, political, social, cultural and/or environmental. On the one hand, the vast majority of social scientists believe that no medicine is independent of its historical context. As a result, ‘the same therapeutic technologies—say, for example, particular pharmaceuticals or surgical equipment—are also perceived and employed in different ways in different worlds’ (Kleinman 1995: 24). Kleinman called this process the indigenisation of biomedicine (1995: 24), which he saw as the cultural counterpart of the globalisation of medical care. Similarly, Ovesen and Trankell stated that ‘Indigenization and globalization should be seen as two sides of the same coin, and the focus on one or the other notion is basically a question of perspective’ (Ovesen & Trankell 2010: 7). Indigenisation is a process that refers to both the expansion of biomedicine and the perceptions associated with it around the world:

One aspect is the diffusion of biomedicine, the process of application of various biomedical therapeutic technologies in different local contexts. The other aspect is local perceptions of such biomedical technologies, which are shaped by cultural ideas about health and illness, causation, diagnosis, and treatment. Such ideas are often at variance with those entertained by representatives of the biomedical culture of origin. (Ovesen & Trankell 2010: 8.)

18On the other hand, Berg and Mol argued that ‘Medicine’s social diversity, its regional variations, its embeddedness in different contexts’ (1998: 2) needs to be unpacked. This embeddedness in contexts is the perspective adopted by intersectional studies and (feminist) epistemologies of incomplete, biased and situated knowledge (Harding 1986; Haraway 1988). This perspective resonates with the thinking of Lock and Nguyen, who, in an extension of Lock’s (2015) research on local biology, introduced the notion of situated biologies (2018: 312). The authors argued that ‘assessments of individual biology are snapshots, situated in the time and space of a complex and shifting material reality, brought about by changing environments and sociocultural, political and economic exigencies’ (2018: 332). This means that the human body and the practices associated with it should be understood as the outcome of a historical process that is situated in a unique context in interaction with the biological, the political and the cultural. For this reason, Burri and Dumit worked on the assumption that ‘biomedical practices are situated in the context of the larger developments in science, medicine, and society’ (2007: 1). So-called biological differences are thus conceptualised situationally rather than intrinsically (Haraway 1988: 594), suggesting a new biological politics of the body (ibid.) in which the biological and the social are interlocked and understood in continuity. This approach is therefore biosocial in nature (Lock & Nguyen 2018), where human bodies as engaged agents (not resources) are active not passive (Haraway 1988). From this perspective, there is not a unity but a diversity within human evolution, where ‘certain biologies initially emerge locally, but then travel to become situated, and later modified in other locations’ (Lock & Nguyen 2018: 323).

Futures and Fragilities of Health Systems in Southeast Asia

19As Kleinman pointed out in 1995, the field of health, diseases and medicines is no longer at the margins of human and social science research. While Southeast Asia has long been the poor and quasi-exotic relation (Husson 2010: 5) compared with India and China when it comes to scholarly medical knowledge, this region of the world is now the object of increasing research interest. However, the weaknesses noted by Guillou and Micollier (2010) remain. Despite a definite and growing interest, which is evidenced by the number of recent scientific publications on the thematic of health in Southeast Asia, studies on this subject still appear to be more dynamic elsewhere, particularly on the African continent. This is perhaps one of the reasons why Schantz, M’zoughi and Viphonephom and co-authors draw on Africanist research in their respective articles.

20Included among the special issues on health in Southeast Asia that have been published over the past decade is one from The Lancet (Chongsuvivatwong et al. 2011) that focused on demographic and epidemiological questions. The contributions in this issue highlighted health and social disparities as well as challenges faced in the region, such as infection risks, a surge in non-transmissible diseases and the problem of controlling emerging epidemics. At the time of writing this introduction (May 2021), these remarks have proved cautionary as Southeast Asia faces a new rise in Covid-19 cases. The question raised by Liamputtong and Proyer in relation to Lai and Tan’s study of the evolution of SARS and H1N1 control measures between 2003 and 2009 in Singapore is therefore now more pressing than ever: How do Southeast Asian countries cope with these epidemics and pandemics?

21Liamputtong and colleagues contributed to an issue in the Austrian Journal of South-East Asian Studies that analysed new perspectives on public health. Their aim was to study the determinants of health or, more precisely, the biological, sociological, cultural, economic and environmental factors that influence and determine population health. Based on the premise that public policies are considered to have an impact on individual and collective health and wellbeing (Liamputtong et al. 2012), the authors looked, for example, at how the Thai authorities were communicating on health risks (Tuler et al. 2012) and at how women’s health was being improved in Laos and Vietnam (Schippers 2012). Environmental and health issues raise questions of governance and the ways in which decisions are implemented.

22In this regard, Asian health systems were the subject of an international conference in Singapore in 2013 (187 papers and posters, 283 participants from 34 nationalities). This gathering mainly addressed questions relating to governance, equity and the social, economic and health impacts of policies on populations (Phua et al. 2015). The presentations specifically on Southeast Asia included themes such as the consequences of introducing health insurance and its evolution in Thailand and Vietnam (Palmer et al. 2015; Hsu et al. 2015) and the Thai paediatric HIV/AIDS programme (Tulloch et al. 2015). The common thread running through all the papers was a tension between recent transformations in health systems and their capacity to withstand present and future challenges.

The Hospital: Between International Hotel and Domestic Space

24Descriptions of the hospital in Southeast Asia are situated between two extremes, broadly represented by the archaic hospital and the luxury hospital. In both cases, the establishments bear little resemblance to a classic Western representation. At one end of the spectrum, there is the camp hospital, where even the basic necessities (water, food, etc.) are sometimes not available, and at the other, there is the hotel hospital, which offers every possible comfort and is as luxurious as the most sumptuous palaces. The socioeconomic heterogeneity of the countries in the region has a bearing on this offer, although the dividing lines do not fully correspond because there is also a public/private divide at play. In other words, the institutions in the richest countries (Singapore, Malaysia, Thailand) have little in common with those in the countries with limited resources (Myanmar, Laos, Philippines). The intermediate countries (Cambodia, Indonesia, Vietnam) present more contrasting landscapes, particularly Vietnam, where the private sector is highly developed.

25This health mapping encourages high therapeutic mobility, a concept first studied from the medical tourism perspective but which has now been replaced in some studies by the medical travel perspective (Whittaker & Chee 2015; Kaspar 2019). Research studies on medical tourism examine the relationships between the tourism industry and the internationalisation of healthcare provision and structures (Bookman & Bookman 2007; Bochaton & Lefebvre 2008; Chee 2010). For these authors, the major transformations in architecture, design, organisation and services are leading to a radical overhaul and even possibly a renaissance of the hospital (Bochaton & Lefebvre 2008). These new forms of care can be mainly observed in Singapore, Malaysia and Thailand (Chee 2010; Wilson 2010). Mobility is often cross-border, as in the cases of Laotians travelling to Thailand (Bochaton 2015) and Indonesians to Malaysia (Smith 2015). This mobility applies not just to users but also to healthcare workers, as shown in Amrith’s (2017) study of the aspirations and experiences of Filipino nurses who migrate for work to Singapore.

28Ovesen and Trankell reported that health decisions in Khmer society appear to be a family affair and are commonly taken after deliberations have taken place between the relatives (2010: 233). This is precisely what Haug describes here in her article. Sometimes these deliberations take place in the absence of the person concerned, and the family decides on their behalf with the patient not necessarily even knowing their medical diagnosis and/or prognosis. A number of studies have analysed what is and is not said (including Viphonephom et al.s’ paper in this issue) within families or within doctor/family/patient communications. These communicational modalities have been studied, for example, in terms of ‘soft truth’ (Bennett 1999) and paternalism (Claramita et al. 2011). They seem to be underpinned in some contexts by a strong relational ambiguity between doctors and users and/or between doctors and healthcare managers, as highlighted by Van Eeuwijk (this issue). Smith (2015) summarised the ambivalence of the imaginary around biomedicine after the Aceh conflict in Indonesia as well as the fears and aspirations it gave rise to. This type of ambiguity was also found to be present in Cambodia (Guillou 2009) and seems to persist today. One of the reasons for this is health spending. In both Cambodia and Myanmar, ‘if the money runs out, the patient’s recovery is put at stake’ (Fink 2019: 646). In Cambodia, this contributes to the general criticism of doctors, who are seen by the population as authoritarian, unempathetic and venal. Each of the contributions in this issue contains evidence of inhospitality, dehumanisation and/or structural violences within public health services.

29More broadly, when a country’s social security system is fragile or nonexistent, the commodification or market value associated with health (Nichter 1996) often goes hand in hand with a ‘medical poverty trap’ (Annear 2010: 1). The biomedical expenses that plague users’ healthcare experiences can lead to a depletion of their savings and an accumulation of loans and household debt. Among others, Lincoln (2014) has analysed the medical stratification within Vietnamese hospitals. She described the health consequences of inequalities between the public and private sectors by demonstrating the different forms of medical privileges and exclusions based on economics, ethnicity and citizenship.

Studying Diseases for a Better Understanding of the Local/Global Link

31The H1N1 and H5N1 influenzas have raised the previously mentioned issues of health safety and governance in Vietnam, Singapore and Indonesia (Porter 2013a; Yu-Hung Lai 2014; Lowe 2019). They have also provided an opportunity to re-examine interspecies relationships (Porter 2013b) through the ‘one health’ concept, a holistic approach to human, animal and environmental health. In this domain, zoonoses (Dufour & Keck 2012) are the object of increased attention, and influenzas, just like tuberculosis, are helping us to understand ‘how zoonotic risk is framed and managed in a global arena of concern for emerging infectious diseases’ (Lainé 2018: 159).

32The ways in which malaria is managed in Cambodia (Bourdier 2016) and Thailand (Lyttleton 2016) reveal the limitations of global health policies. Bourdier described the tensions and inconsistencies permeating Cambodia’s public health and antimalaria programme. He criticised the authorities’ disjointed and unsustainable strategy, showing that it increased rather than reduced health inequalities.

33HIV/AIDS is also approached from the public health angle (Bourdier 2006), with the literature covering a range of micro and macro focuses at local, national and global levels. Bureau’s (2010) analysis of the participation of HIV-positive individuals in associated health programmes revealed how a globalised norm was applied locally. Researchers have also looked at people considered to be in a vulnerable situation or whose behaviours are deemed to be risky, such as the homosexual community in Indonesia (Boellstorff 2009), street children in Cambodia (Guillou 2009) and karaoke hostesses in Phnom Penh (Hancart Petitet 2010). HIV/AIDS allows us to tackle questions of sexuality, gender and reproductive health by highlighting the fine line between the biomedicalisation of life and the biomedicalisation of diseases. Hancart Petitet has demonstrated this in several of her studies. She described, for example, how transnational maternal and child health programmes were implemented in Cambodia and the effects they produced (2017). She also analysed ‘the frictions that emerge when science and medicine interact with social life’ (2014: 238) in her study of a clinical trial of drugs that were contraindicated in the case of pregnancy, which was conducted on a sample of women with HIV/AIDS.

34This perspective is incorporated within a rich body of work on the disconnects between the conceptual frameworks of biomedicine (or of global health policies) and the societies concerned. For example, a study of the life history and diagnosis of a woman with paranoid schizophrenia in Indonesia revealed ‘the tensions between local understandings and methods of care and transnational psychiatric framings of mental illness’ (Narny et al. 2019: 491).