Juniper Publishers-Exploring the phenomenon of ‘medical pluralism’: A case of Pakistani Muslim Community in the United Kingdom
Juniper Publishers- Open Access Journal of Social Sciences & Management studies
Introduction
Migration plays a key role in the spread,
transformation and propagation of medical practices and its knowledge.
When moving from a place to another, people do not only take their
belongings, but they also transport their values, beliefs and cultural
practices with them. This also includes medical and healing practices.
There are two popular opinions about the relation between migration and
medicine. Firstly, some anthropologists [1,2], suggest that migrants
often assimilate within the social culture of their host country and
tend to forget, reject or surpass their own traditional medical
practices. Perhaps, it is more likely to be observed in situations where
the culture and medical system of country overlooks the diversity of
values and beliefs possessed by its people. Contrarily, Gans [3], argues
that immigrants use their ethnic and traditional practices as a
psychological, social and political defence against the dominating
culture of the host society. In such situations, the medical practices
function as an ethnic marker or an identity of the minority population
of migrants [4-6]. In either case, one may find that there is not a
single state or society where every individual follows a uniform medical
practice. Usually, there exists ‘plurality’ in the choices of medical
practices at individual levels. The medical choices made by individuals
could depend upon factors such as their gender, religion, ethnic origin
or society.
This research aims to explore the medical choices
made by the female Pakistani migrants living in the United Kingdom (UK).
With an assumption that there are multiple medical options available to
migrants in the UK, the research evaluates the factors influencing
their medical choices. The purpose of this research is to gain an emic
understanding of the phenomenon of ‘medical pluralism’. Here, medical
pluralism refers to the co-existence of multiple medical systems
functioning in harmony with one another [7]. The study focused on women
for certain reasons: a. The Self-Rated Health (SRH) ratio suggests that
the health of women is three times worse than the health of men living
in Pakistan [8], and b. There are several studies suggesting Pakistan is
a masculine society where women do not get enough opportunities to make
decisions in health care [9-13]. For these reasons, the study focuses
on the opinions of Pakistani women about making choices in health care.
Nonetheless, this limits the scope of the study; thus, the finding
cannot be generalized to all the Pakistani migrants living in the UK.
The study is carried out on the Pakistani population who have
migrated to UK in the last fifteen years and settled in the capital
city of the country, London. According to the Census of 2011, the
population of Pakistani migrants in the UK is the third largest
population comprised of around 482,000 people [14]. London is a
home to about half of the international migrants in the UK and the
Pakistani population constitutes the second largest non-European
migrant community in UK [15]. The total population of Pakistanis
living in London represents one-fifth of the national Pakistani
population [16].
Methodology
The main data collection tool was in-depth interviews. In
total, there were ten participants interviewed in this study. All
interviews were semi-structured. Participants were identified
through snowball sampling. All the participants were first
wave female migrants, which mean that none of their parents
or ancestors migrated and settled in the UK. All the research
participants got married in Pakistan before moving to the UK.
Some participants moved to the UK soon after the marriage as
their spouse were already settled in London whereas few travelled
with their spouses after marriage for socio-economic reasons. The
age of the participants ranges from twenty-six years to forty-five
years; and the period of their stay in London range between three
to fifteen years.
Literature Review
Forms of Medicines
Medicine, conventionally, is categorized into two broad forms
namely biomedicine and traditional medicine. Biomedicine is
also referring to as ‘western’ medicine, ‘conventional’ medicine,
‘modern’ medicine and ‘allopathy’ [6]. Because of its global
recognition and usage, it is also called as ‘cosmopolitan medicine’.
It often constitutes the core component of health systems around
the world. Its advancement and progression have enabled the
world to restore health quality on a global basis. Conversely,
traditional medicine includes a broad range of regional and
cultural medical practices. It is also referred to as ‘complementary
and alternative medicine’ when used by non-indigenous people.
In the opinion of Kayne [6], traditional medicine can also be
referred as folk medicine. However, Csordas [4,5] and Brady [17],
refute that folk medicine is different from traditional medicine
on the fact that knowledge of folk medicine is transmitted orally
and often the healers are not trained. Traditional medicine, unlike
folk medicine, could function as a medical system officially and
professionally.
Traditional medicine in national health policies
Considering the popularity and demand, many states have
incorporated traditional medicine as part of national health
systems and policies [18,19]. The World Health Organisation
(WHO) reports that there are around 45 countries that already
involve traditional medicine in their national health policy while
51countries mentioned to be in the process of developing national
policies on traditional medicine [20]. Traditional medicine
can become a part of national health policy in two ways. First,
it can be ‘integrated’ in the national health system. This way,
biomedicine and traditional medicine both constitute the content
of the training and education of medical practitioners. Secondly,
biomedicine and traditional medicine can be treated as ‘parallel’
but separate forms of medicine under the national health care
system. Not always, the two forms of medicine exist in harmony
under the state regulation which open discussion on the relation
of biomedicine to traditional medicine.
Relation of traditional medicine to biomedicine
There are various opinions about the relation between
biomedicine and traditional medicine. According to Kleinman [21]
and Ernst [22], the modern medicine and traditional medicine
are binary opposites. These two forms of medicine constantly
struggle for hegemonic representation in the field of medicine.
During this struggle, till now, the traditional medicine is usually
marginalized due to its non-scientific nature whereas western
medicine is regarded as a learned system of medicine practised
by medical experts [22]. Similarly, Baer et al. [23], proposes that
biomedicine always enjoys supremacy and extra attention by state
comparisons to traditional medicine despite both are allotted
official status in national health policies. These opinions got
challenge with the emergence of the field of medical anthropology
and increasing interest of social scientists in the field of medicine.
The ethnographic studies of people brought a realization that, at
community level, both medical systems function in harmony; thus,
introducing the notion of ‘plural medical system’ [21,24].
Plural Medical System
Plural medical system, as mentioned, refers to a health system
where various forms of medicine operate but each function in
correspondence to another [7]. Ramsey [25], mentions that
plurality of medicine is not a new phenomenon. Even in the
eighteenth and nineteenth centuries, there were a variety of healers
practicing French medicine along with elite medical professionals.
Likewise, Kleinman [21], found out that a health system is based
upon the following three medical sectors: the professional sector,
the folk sector and the popular sector. Each sector treats health
problems differently. The professional sector consists of medical
practitioners whereas the folk sector is comprised of local healers.
The third sector, the popular sector, forms the largest sector which
includes lay and non-professional ways of healing an illness at
home or within the community.
The co-existence of three sectors explains that people do
not always seek medical advices from the medical system of the
country. It appears that the primary concern of people is to get
cured or healed rather considering the official status of a medicine.
As a result, people follow different kinds of medicine whereas the
state regulates a certain form of medicine. Medical pluralism,
on one hand, tends to respect the individual’s preferences by
offering a variety of medical choices. On the other hand, this pose
challenges to a state for the regulation of more than one medical
system.
There are certain refutations against the concept of medical
pluralism. Strathern and Stewart [26], claim that medical pluralism
is possible only if all the co-existing medical systems are equally
competitive. Nevertheless, it is not the case as biomedicine often
takes the central position in a health system whereas traditional
medicine complements or supports the function of biomedicine.
Ernst [22], argues that the idea of plural medical system overlooks
the extensive history and philosophy behind the hegemonic
interplay between the two systems. Also, the plurality in medicine
endangers to keep a check on various cultural and scientific
frameworks and practices on moral grounds. These arguments are
further explored in this study. An evaluation of the participant’s
responses in this study will help to deduce answers of the fore
mentioned refutations.
Pakistani Muslim Migrants in The United Kingdom
The United Kingdom (UK), a multi-ethnic country, is a home
of around 1.2 million Muslims. The Muslims constitute about 3
percent of the total population of the UK [27]. Most of the Muslims
are from South Asia specifically from Pakistan and Bangladesh.
At several occasions, such as the establishment of the British
Nationality Act 1948, labour shortage in 1960 and the formation of
New Common Wealth countries, the South Asians were welcomed
by the government of UK for migration. For this reason, one may
observe a high population of Pakistanis, Indians and Bangladeshis
living in the UK.
Medical choices available to Pakistani migrants in UK.
Pakistani migrants are privileged to rejoice the medical facilities
provided by the National Health Services (NHS) of UK. It is the
most common way of medical treatment that is employed by all
the participants of this study. It is identified, through interviews,
that every participant seeks medical advice and help from the
NHS; however, the level of dependency on the NHS, the time to
access NHS and the level of satisfaction of each participant with
NHS vary depending upon certain factors which are explored in
this study. The other medical options include herbal medicine and
folk remedies. None of the participant has tried any other form
of traditional medicine; but they have observed its usage among
relatives and other family members.
National Health Services (NHS)
The NHS was established in 1948 with an ambition to
provide free medical services to every individual living in the
UK. This organisation regulates hospitals, general practitioners
(GP), pharmacies and other health care facilities. It is the prime
organisation that looks after the health concerns of the population
of the whole country. It promises to provide best services to its
people and encourage the staff to give compassionate care without
any discrimination. In general, every participant expressed an
admiration for the NHS [28]. Specially, because NHS services are
free of cost and the standards are maintained by the government
whereas medicine and healthcare in Pakistan is an out-of-pocket
expenditure as the system is poorly managed. Participants were
happy that they did not have to pay for consultation fees and most
of the procedures. In addition, none of the participant mentioned
that they felt discriminated or mistreated by any staff based on
their ethnicity, race, colour or nationality.
However, a concern raised by participants was the unavailability
of appointments at the GP. This concern was equally shared
by all the participants. Most of the participants think that the reason
for delayed care is the insufficient number of staffs resulting
unavailability of appointments in GP surgeries and long waiting
hours in emergency services at hospitals. The same issue is also
voiced by media and public. For instance, Campbell [29], informs
that with the shortage of staff, the burden on each employ increases;
consequently, they do not attend patients appropriately. The
Guardian news (Topping 2013) reported that there are around
300,000 unregulated or unqualified staff working under NHS employed
by GPs and Hospital managers on low wages to meet the
budget constraints and for gaining profits. As a result, the Care
Quality Commission identified that at least one in every ten patients
are denied respect and dignity whereas 20 percent of the
patients complain about a neglected health care and welfare [29].
Though “the NHS aspires to put patients at the heart of everything
it does” (NHS 2013:12); yet the public’s verdicts do not match the
core principle of the NHS. However, it should be emphasized that
the issue of unavailability of appointments is not related to the
participants being ‘Pakistani’ or ‘immigrants’ rather it’s a concern
raised by public and the government.
Complementary and Alternative Medicine (CAM) in NHS
As per the study, there are only two forms of CAM which are
registered and regulated by the NHS. The practice of chiropractic
is regulated by the General Chiropractic Council (GCC) while
osteopathy runs under the General Osteopathic Council (GOC).
Patients are also referred to the other forms of CAM such as
homeopathy, acupuncture and clinical hypnotherapy but such
practices are not supervised by the NHS. Nonetheless, the
practitioners are expected to hold set standards of qualifications
and should be affiliated with an independent regulatory
institution. NHS, on its official website under the section of CAM,
provides all the terms and conditions for the practitioners for
public consultancy. Furthermore, the White Government Paper
for the Regulation of Health Professionals in the 21st Century is
also available on the website of the General Regulatory Council for
Complementary Therapies (GRCCT).
Traditional Medicine as the First Choice of Medicine
A considerable number of the participants mentioned that
traditional medicine is their first choice of medicine. These
participants stated that they take biomedicine as a secondary
option for the following reasons.
i. Biomedicine is not prioritized because of its known sideeffects.
ii. Folk medicine specifically based on kitchen items like
spices and eatables are non-harmful as they are part of routine
life.
iii. There is an unexpected delay in arranging doctor’s
appointments and seeking medical advices whereas folk
and traditional medicines are quick. Following points A
and B, it was evident that there is a perception that, unlike
biomedicine, traditional medicine does not have adverse
effects, whereas there is lack of literature and enough studies
to claim traditional medicines as less or not harmful.
Limitations of CAM
The scientific revolution, in the early sixteenth century,
introduced advanced forms of medical and surgical practices
for the maintenance of quality of health. It is important to note
that not every westerner was aware of these forms of medicine;
rather it was popular amongst the elite and educated classes of the
society [30]. The rest of the population continued the medicine
which was traditional and indigenous to them. Hence, there were
people in both, the Western and the Eastern parts of the World,
unaware of the new forms of medical science and technology.
Later, the western knowledge and science of medicine sprung
in all over the world during the colonial period. The coloniser from
the West introduced the western medical sciences in colonies.
Simultaneously, the coloniser specifically the military and
administrators who lived in the colonies learnt about the medicine
indigenous to those societies. With the movement of colonial
power, these medicines also travelled across the western and
eastern blocks of the world [23]. Since, the knowledge and access
to the western medicine were limited to the elite class, military and
state officials; it received special attention. It underwent constant
research and advancement in the western world. Therefore, there
is no doubt that doctors and practitioners are more certain about
the uses and abuses of biomedicine and, it supports medical
treatment where traditional medicine fails to cure.
Therapeutic and Adverse Effects of Medicine
“...that’s the best thing about traditional medicine. Even if it
does not help you; it won’t harm you at all”.
The comment made by two of the participants, as mentioned
earlier, reflects that their preference of traditional medicine
relies on a belief that the medicine does not have any side effect.
There are several studies appreciating the therapeutic effects of
traditional medicine. For example, the therapeutic effects of herbal
medicine in treating cancer are well known [31,32]. Likewise,
acupuncture is useful in treating the side-effects of drugs such as
chemotherapy, anti-hypertensive and sedatives such as morphine
[33-35]. Thus, traditional medicine tends to show a therapeutic
effect in most of the cases; and so, it can be a preferable option for
most of the participants in this study.
There exists another perception wherein traditional medicine
does not have any adverse effect. Beside participants, literature
also claims that it is a shared belief that traditional medicine
does not have any side effects [36,37]. In addition, in most of the
cases, health care providers are also not well-informed about the
adverse-effects of traditional medicine used by their patients [38].
Perhaps, for this reason, the World Health Organisation (2000)
clearly instructs every health authority to investigate the use of
traditional medicine among patients and investigate the details
for its legitimacy. Indeed, WHO (2002, 2013) present that the
various programs are installed, and guidelines are published to
mentor the safe utilisation of CAM.
Fertilizer Application
The choices and personal preferences of participants in this
study to when to prefer CAM over biomedicine was dependant of
very intriguing factors.
i. For most of the participants, they prefer CAM for
themselves or their spouses but not children. Children are
vulnerable and have weak immune system therefore with
less information on the side effects of CAM, parents keep
biomedicine as their first choice. Nonetheless, there are
studies in medical research on the proven benefits of CAM
among pediatric patients [39-41]. In the context of the UK,
Posadzki et.al [18], reports that the literature review of the
utilisation of CAM suggests that almost half of the UK adults
have administrated CAM to their children with elevated level
of satisfaction.
ii. Though not always consciously; some of the responses
of the participants project that their choice of medicine
is associated with their personality type, personal and
collective identity. For instance, a person said, “I am actually
an ‘allopathic person’. I do not try homeopathy or something
else. I am kind of person who likes to stick with one thing that
suits me”. Identifying herself as ‘allopathic person’ indicates
personal association and faith in one form of the medicine
over others.
iii. A couple of participants kept their choice of medicine on
the availability of information. For every home remedy that
their parents suggest, they investigate. If they find enough
information than they prefer traditional or folk medicine
over biomedicine. By bringing the notion of knowledge and
research in the selection of medicine, the general assumption
of people that traditional medicine is practised blindly is
challenged.
iv. The choice of medicine also depends on an individual’s
role in the family especially for women. A few participants
found traditional and folk remedies very helpful in reducing
illnesses and keeping their finances low. A participant said
that “I am on the guard. I won’t let anyone catch an infection”.
To keep her family members healthy, she keeps learning and
investigating ways to avoid and cure illnesses at home.
Culture, Society and Medicine
A form of medicine, in this study, also came up as a
symbol of
identity for a group. When a group or a population stay closely tied to
any specific healing practise, it becomes their identity marker
[5, 6]. This argument was reflected when quite a few participants
mentioned that “traditional medicine is our culture. ‘Other’ people
neither believe in ‘our’ medicine nor do they understand ‘our’
illnesses”. The process in which people define themselves as part
of an ‘us’ in opposition to a ‘them’ or an ‘other’ is called as ethnic
identification [42]. People and communities take ownership of
their medicine which then gradually turns out to be an ethnic
marker for them.
However, the urge of maintaining an identity often becomes
in the formation of ethnic boundaries where a group stay collided
with the members of own community and separating own
community from the other community [43]. If medicine is a way
of creating an identity then simultaneously, it may function as a
boundary between ethnic groups. At this point, one may debate
on the ‘cosmopolitanism’ of biomedicine against the ‘idiosyncrasy’
of traditional medicine. This raises a question why do Pakistani
migrants not only rely on traditional medicines to uphold their
ethnic identity in Western countries such as the UK? Concurrently,
a question arises on the role of biomedicine in the promotion of
medical pluralism.
The other important factor is the collective medical
experiences. The basic unit of Pakistani society is the family
rather an individual. It is the duty of the family to look after the
well-being of each other (Chaudhry, 1984). Also, as a religious
value, Muslims consider it as an obligation to help and support
those who are not keeping well. In such circumstance, the first
ones to extend their supports are elderly members of the families
and their experiences determine the choices of medicines. Also,
stories and experiences of illnesses and medical treatments, in
such collective societies, travel faster and farther. Most of the
participants mentioned that they seek medical advices from their
mothers and mothers-in-law back home as their experiences are
integral to decide a form of medicine.
Gender and The Choice of Medicine
The maintenance of health of citizens in a country depends
upon certain socio-economic and cultural factors. Some of the
factors include the extent of poverty, illiteracy, unemployment
and insufficient governmental initiatives in the health sector. All
these factors are interrelated, and collectively, form a web where
a person may find oneself trapped. These factors may affect men
and women both. However, in certain societies like Pakistan,
women face more challenges than men.
Positionality of a Woman in Pakistani Families
The Self-Rated Health (SRH) ratio between men and women
in Pakistan is amongst the worst ratio found globally [8]. The ratio
suggests that the health of women is three times worse than the
health of men living in Pakistan. As mentioned earlier, the culture
of Pakistan is collective. The values and needs of a family are prior
to the values and needs of an individual. Extended family systems
are common. Women, as daughter-in-law, live with family-in-laws
and look after the need of every member of the family. A woman
plays several roles in one time where her life is dedicated to the
wellbeing and health of her family members and relatives. She is
not autonomous and independent in making decisions [9]. Besides
gender differences, the difference of age constricts the autonomy
of a woman. Kadir et al. [13], informs that, in Pakistani societies,
the influence of mothers-in-law overshadows the decision of
husbands and male members of the family specifically in domestic
matters. With such complex family structures, Pakistani women
seek permission and opinions of other members of family while
making any decision, including health care.
Autonomy of Women in Decision Making Related to Health Care
In contradiction to the fore mentioned literature, the Pakistani
women who participated in the current study mentioned to take
decisions related to family matters on their own. Indeed, they
mentioned that their spouses and family members appreciate
their role in decision making since they remain occupied with
their work and matters outside the house. This imply some
underlying factors. To start with, all the participants belonged to
Karachi which is a highly urbanised metropolis of Pakistan. Urban
locations provide space and opportunities to women where they
exercise rights more easily in comparison to rural areas [44]. Even
though urban areas also pose certain fears and vulnerabilities due
to gender disparity; women enjoy recreational and social life more
than women in rural areas. This reason may explain the authority
of women in health-related matters. Another factor could be
migration to a western country. A sizeable number of studies
[45,46], suggest that migration plays a vital role in transforming
the socio-cultural including health behaviours of migrants. The
social behaviors mainly change when couples or families move
from a rural or a developing to an urban or a developed country
respectively. Perhaps, the purpose behind adapting new culture
could be adjustment in the host society; but it does transform
their health behaviors [47-49].
Conclusion
Medicine is not a novel need of the human being as it
has
always been in function to freed people from illnesses and diseases.
However, its form and politics is ever changing. With the advent of
each civilisation, there are some advancement in the approaches,
learning and practices of medicine. The social processes such as
migration have helped these civilisations to exchange, borrow and
appropriate medical knowledge and practices in their contexts.
This way medical field is getting pluralist. Nonetheless, the
disequilibrium of power between medical systems challenges
the idea of pluralism. Each medicine tries to seize its place in the
society and to overtake the hegemony of others. In current time,
biomedicine dominates the status of traditional medicine at state
level; however, both forms of medicine together are addressing the
medical needs and demands of people. Though medical pluralism
increases the medical choices and options for people; there are
certain consequences which need to be regulated either by global health
agencies such as the World Health Organisation or national
health systems. People living in the UK, including migrants, are
free to choose any form of medicine.
However, if medical pluralism is the liberty of selecting a
medicine; then unfortunately, there is not enough attention
and efforts at state level in developed countries like UK where
knowledge on CAM is equally available, well-researched and
confidently presented to people as biomedicine. There is no way
to determine individual’s choice of a medicine; therefore, the best
and safe practices is to expand information and knowledge on all
forms of medicines so that choices are made wisely and without
hesitation. This will also increase the affordability, accessibility
and satisfaction of individuals on healthcare services.
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