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Introduction

The Appropriation of Biomedicine in Southeast Asia

L’appropriation de la biomédecine en Asie du Sud-Est
Meriem M’zoughi
Traduction de Clare Ferguson
Cet article est une traduction de :
L’appropriation de la biomédecine en Asie du Sud-Est [fr]

Résumés

Des techniques chirurgicales aux traitements pharmaceutiques, en passant par l’usage des sciences biologiques ou cliniques : quelles sont les spécificités et les réalités contemporaines de la biomédecine en Asie du Sud-Est ? La diversité de ses formes invite à penser le caractère situé de savoirs et de pratiques qui visent à médicaliser et transformer les corps. Ce numéro interroge les dimensions du soin lorsque celui-ci est produit par des acteurs mobilisant, en se les appropriant, les outils conceptuels et empiriques de la médecine scientifique d’origine occidentale. Il aborde les expériences de soin des personnes âgées au nord de la Sulawesi, les vécus des aidants d’enfants vivant avec le VIH-sida au Laos, la guérison d’une tumeur du cerveau chez les Dayak Benuaq dans le Kalimantan oriental, les conditions d’exercice des oncologues cambodgiens ainsi que les violences obstétricales en Indonésie et au Cambodge. L’ensemble des contributions permettent d’analyser comment les traitements et les soins sont dispensés à l’hôpital, dans les cliniques privées et dans les centres de santé afin de questionner, plus largement, ce que signifie être médecin, patient, aidant ou femme dans cette région du monde. Loin d’être exhaustives, ces approches entendent contribuer à comprendre comment la biomédecine s’immisce-t-elle dans le quotidien des malades et des familles par l’analyse de ses formes actuelles et quels imaginaires et valeurs charrie-t-elle aujourd’hui en Asie du Sud-Est ?

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Texte intégral

  • 1 See definition below.

1This special issue of Moussons focuses on the diverse uses and forms of biomedicine (i.e. medical practices based on Western-derived scientific medicine1) in Southeast Asia. It extends and updates some of the analyses and reflections presented in 2010 in issue 15, ‘La santé: miroir des sociétés d’Asie du Sud-Est’ (health: a mirror on Southeast Asian societies).

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.

  • 2 Translated from French (‘adaptation locale “contextualisée” de savoirs médicaux’).

6In other words, biomedicine ‘is a malleable and mobile set of practices and ideas’ that are used in ways that are ‘unique to local situations’ (Cartwright et al. 2016: 338). It therefore always entails a ‘“contextualised” local adaptation of medical knowledge’2 (Micollier 2007: 31).

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.

  • 3 For a summary of the debates and criticisms relating to the term ‘biomedicine’ and the assertion of (...)

11The appellation ‘biomedicine’ was chosen to signal the new connection between the fields of biology and medicine3 that emerged in the 19th century with Louis Pasteur, Rudolf Virchow and Robert Koch and that was consolidated after the Second World War (Rabeharisoa 2009: 47). Playing an increasingly prominent role in the treatment of diseases, molecular biology redefined the relationship between the normal and the pathological. Disease was understood to result from biological perturbations (Kleinman 1995). This phenomenon correlated with a scientification (Rabeharisoa 2009: 47) and standardisation (Timmermans & Berg 2003) of the discipline that was linked to the use of randomised controlled trials (RCTs), which ultimately led to the emergence of what is now called evidence-based medicine (EBM). In other words:

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.)

  • 4 Randomisation refers to ‘the random allocation of patients selected to participate in a trial to an (...)

12In the first half of the 20th century, the development of controlled clinical trials met with some resistance and caused friction within the medical community, mainly because clinicians had to be persuaded to surrender their individual authority in favour of collective action. From the 1920s to the mid-1940s, the first multicentre trials in the United States raised a number of compatibility and methodological standardisation issues, as shown by the antisyphilis treatment studies (Löwy 1998). A turning point came at the end of the 1940s in England when a medical statistician, Austin Bradford Hill, proposed the first randomised double-blind study4. He also encouraged the use of statistical tools to monitor and control the progress of clinical trials and the consequences of treatments. These new methodological principles were introduced into cancer research (thus supporting the development of chemotherapies in the 1960s) and ultimately became the template for the majority of clinical trials for all diseases in the 1980s and 1990s. The scientification mentioned above contributed to a rationalisation of medical practices (Timmermans 2005) accompanied by a profound transformation of healthcare (Burri & Dumit 2007). Biomedicine draws not just on the biological sciences but also on neurosciences, physical sciences, chemical sciences and, above all, technologies. Clarke (in collaboration with others) in particular has focused on the links between the technosciences and biomedicine and on the ways in which these links are changing health, disease and care in the United States (Clarke et al. 2003).

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

  • 5 Translated from French (‘une institution aux frontières poreuses, perméable à son environnement to (...)

23Many ethnographies attest to the fact that the hospital has become a key research space in the fields of health anthropology, history and human geography. It has been a major research object in sociology since the end of the 1950s, but approaches to it began to change at the turn of the century. It is now seen as ‘an institution with porous borders, which is permeable to its environment while maintaining its own logic’5 (Fortin & Knotova 2013: 13). The hospital is a microcosm of society (Zaman 2013), or rather a space where societal issues are condensed (Livingston 2012: 25; Van der Geest & Finkler 2004). It is no longer envisaged as a separate, independent, ex nihilo place of care with its own subculture, as King (1962: 399) conceived it, nor as an isolated and unique island, as Coser (1962: 3) claimed. On the contrary, the hospital is seen as a strange village that reflects the culture in which it is embedded (Livingston 2012; Zaman 2013).

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.

  • 6 Translated from French (‘espace de connectivité’).

26Based on a survey conducted within an international hospital in Thailand, Whittaker and Chee (2015: 296) revealed the intercultural differences and tensions that diversified the patients’ healthcare experiences according to their nationality, ethnicity, religion, social class and gender. For example, although there was no spatial segregation of users according to nationality, as is the case in some hospitals (Bochaton & Lefebvre 2009), Muslim Arab patients tended to cluster together (and incidentally also to be the subject of racist discourses) because they did not have the same circadian rhythm or diet as other patients. In addition, painkillers were found to be a constant subject of negotiation between Western patients and the Thai medical staff, with the Westerners complaining that the doses were not high enough. The hospital thus appears as a ‘space of connectivity’6 (Pordié 2013: 14), manifesting the transnationalisation of health (Pordié 2013; Kaspar 2019). In other words, it promotes the exchange of knowledges, know-how and interpersonal skills by bringing together individuals circulating beyond their national borders. It also contributes to the development of heterotopias (Bochaton & Lefebvre 2009). This concept, borrowed from Foucault (1984), refers to specific existing places (as opposed to utopias, which have no real place) within which a utopia can effectively be established. It crops up in several studies of the hospital (independently of medical tourism and Southeast Asia). For example, Street and Coleman drew on Hetherington’s (1997) use of the hospital to show that these institutions are both real and imaginary spaces, loaded with ambiguity and possessing a ‘paradoxical capacity to be simultaneously bounded and permeable, both sites of social control and spaces where alternative and transgressive social orders emerge and are contested’ (Street & Coleman 2012: 4).

  • 7 Fan criticised the supposedly universal definition of patient autonomy as it is conceived in the We (...)

27Descriptions of Southeast Asian hospitals are mixed, but despite the differences, they invite us to go beyond the Western conceptual framework and rethink healthcare experiences. Implicit here is the idea that the notions of autonomy, informed consent and the doctor/patient consultation do not make sense. The ternary relationship, or the doctor/family/patient triad, seems to be the norm when it comes to healthcare decisions in Southeast Asia. This was the finding of Matusitz and Spear for Thailand (2015) and M’zoughi (2020) for Cambodia. It has also been evidenced elsewhere in Asia, for example Ishikawa and Yamazaki (2005) deconstructed the binary Western doctor/patient commonplace in favour of a doctor/family/patient relationship as they observed it in Japan. They highlighted the importance of the caregiver’s role regardless of the patient’s age, social background or disease. They also noted that the therapeutic relationship was based on a family-centred model. This calls into question the principle of patient autonomy. In this respect, Fan7 showed that autonomy, as it is defined in the West, attributes the ultimate responsibility for a medical decision to the patient, whereas East Asian societies attribute this responsibility to the family based on the principle of family sovereignty (1997: 316): ‘when one member of the family becomes sick, it is the responsibility of the entire family to look after him... The family knows that the care of the sick member is a family matter’ (ibid.). Although Fan’s study focused on societies all steeped in Confucian philosophy (China, Japan, South Korea, Taiwan and Hong Kong), his remarks resonate with the research conducted in Southeast Asia (Matusitz & Spear 2015; M’zoughi 2020). For example, Thanh Thao (2001) suggested that the family emerges as a key institution and an integral component in the Vietnamese hospital care process. The fact that ‘caregiver’ does not exist as a professional category in Vietnam implies there is a specific intra-familial set-up in terms of logistics and personal care in the event of hospitalisation. The same is true for Cambodia and Myanmar (Fink 2019). These observations are extended in Viphonephom et al.’s article (this issue), which shows the challenges of the informal care burden associated with the caregiver’s role.

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

  • 8 Translated from French (‘une porte d’entrée pour mieux cerner les mécanismes d’imbrication entre l (...)

30Diseases—as a biomedical category (disease)—are the subject of specific studies that go beyond the hospital setting. Some diseases appear to be ‘a gateway to a better understanding of the mechanisms that interlink the global and the local’8 (Bureau 2010: 3). This is certainly the case for those considered by international agencies to be a global health issue, such as HIV/AIDS, malaria and influenza.

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).

  • 9 Translated from French (‘paysages thérapeutiques’).

35In addition to these approaches, there has been increasing research interest in diseases that until very recently were invisibilised in the so-called South, such as cancer. The majority of qualitative studies on the subject have been conducted in the fields of medical sciences and human and social sciences using structured interviews and questionnaires rather than ethnography. These studies have examined the lived experiences of patients in order, for example, to understand the factors influencing treatment decisions for women with breast cancer in the Philippines (Guzman et al. 2020) or to measure symptoms of distress in patients being treated for colorectal or breast cancer in Indonesia (Haryani et al. 2018). More broadly, these studies have aimed to capture the screening behaviour and awareness of a specific target population. What do the women in an HIV/AIDS centre in Laos (Sichanvh et al. 2014) or the residents of a rural area in the Philippines (Imoto et al. 2020) know about cancer? Most of the studies have investigated the lived experiences of women with cervical or breast cancer. This has also been the main focus of surveys that have tended to use less standardised methods, where the post-diagnosis lived experiences of women, for example, with cervical cancer in Indonesia (Nastiti et al. 2020) or breast cancer in Thailand provide an understanding of the diversity of the ‘therapeutic landscapes’9 in this region (Liamputtong & Suwankhong 2015).

  • 10 Translated from French (‘entre des aires de savoir et de pratique qui relèvent d’une conception “s (...)
  • 11 Translated from French (‘modalité de production de savoirs et savoir-faire “situés” autour [d’une (...)

36As exemplified by the representations of breast cancer found in Vietnam (Do & Whittaker 2020), the common factor in all the studies mentioned above is a ‘knowledges’-based approach. A number of the studies were inspired either directly or indirectly by Carsten’s perspective on the study of blood in Malaysia. She analysed how blood circulates ‘between areas of knowledge and practice that are “scientific” or “biomedical” in conception and areas that are seemingly more overtly shaped by culture—such as kinship, ethnicity and religion’10 (Carsten 2011: 5). In particular, she examined the interconnections between different fields of knowledge in order to study the polyvalent nature of blood. This can be seen as a ‘modality of production of “situated” knowledges and know-how around [a disease]’11 (Gobatto & Tijou Traoré 2011: 2), which is a subject M’zoughi discusses in her contribution (this issue). Given that the construction and transformation of knowledges is intrinsically linked to experience, some studies have focused on lay and scientific pragmatic knowledges as well as experiential knowledges (Simon et al. 2020) in order to question the categorical oppositions between different types of knowledges. From this perspective, the contributions to this thematic issue examine, by turns, the knowledges of caregivers, medical professionals and patients.

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Note de fin

1 See definition below.

2 Translated from French (‘adaptation locale “contextualisée” de savoirs médicaux’).

3 For a summary of the debates and criticisms relating to the term ‘biomedicine’ and the assertion of a pre-eminence of the biological in medical practice, see Cambrosio and Keating (2003).

4 Randomisation refers to ‘the random allocation of patients selected to participate in a trial to an experimental group and a control group, and double-blind treatment means that neither the patient nor the treating physician knows whether the patient is receiving [the drug] or a placebo’ (Löwy 1998: 124, translated from French (‘la répartition au hasard, des malades sélectionnés pour participer à l’essai entre un groupe expérimental et un groupe témoin, et le traitement en double aveugle : le malade et le médecin traitant ignoraient si le malade recevait [le médicament] ou un placebo’)).

5 Translated from French (‘une institution aux frontières poreuses, perméable à son environnement tout en ayant une logique propre’).

6 Translated from French (‘espace de connectivité’).

7 Fan criticised the supposedly universal definition of patient autonomy as it is conceived in the West (based on individual independence, self-determination and a subjective conception of the good). He showed that East Asian societies base the principle of autonomy on harmonious dependence, familial determination and an objective conception of the good (1997: 309).

8 Translated from French (‘une porte d’entrée pour mieux cerner les mécanismes d’imbrication entre le global et le local’).

9 Translated from French (‘paysages thérapeutiques’).

10 Translated from French (‘entre des aires de savoir et de pratique qui relèvent d’une conception “scientifique” ou “biomédicale”, et des aires qui sont, en apparence, plus ouvertement modelées par la culture—telles la parenté, l’ethnicité ou la religion’).

11 Translated from French (‘modalité de production de savoirs et savoir-faire “situés” autour [d’une maladie]’).

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Meriem M’zoughi, « The Appropriation of Biomedicine in Southeast Asia »Moussons [En ligne], 38 | 2021, mis en ligne le 25 novembre 2021, consulté le 30 novembre 2021. URL : http://journals.openedition.org/moussons/8490 ; DOI : https://doi.org/10.4000/moussons.8490

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Auteur

Meriem M’zoughi

Doctor of anthropology, attached to the research unit UMR 5600 Environnement Ville Société (Environment, City, Society). As part of her PhD study, she conducted an ethnographic survey within and outside of cancer services in Phnom Penh, Cambodia. Her research interests are medical practices, health behaviours and representations (medical and lay) of disease and the body in Cambodia.

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