Can Andean medicine coexist with biomedical healthcare? A comparison of two rural communities in Peru and Bolivia

ABSTRACT: BACKGROUND: It is commonly assumed that indigenous medical systems are strong in developing countries because biomedicine is physically inaccessible or financially not affordable. This paper compares the health-seeking behavior of households from rural Andean communities at a Peruvian and a Bolivian study site. The main research question was whether the increased presence of biomedicine led to a displacement of Andean indigenous medical practices or to coexistence of the two healing traditions. Methodology: Interviews were conducted between June 2006 and December 2008 with 18 households at each study site. Qualitative identification and analysis of households' therapeutic strategies and use of remedies was complemented by quantitative assessment of the incidence of culture-bound illnesses in local ethnobiological inventories. RESULTS: Our findings indicate that the health-seeking behavior of Andean households is independent of the degree of availability of biomedical facilities in terms of quality of services provided, physical accessibility, and financial affordability, except for specific practices such as childbirth. Preference for natural remedies over pharmaceuticals coexisted with biomedical healthcare that was both accessible and affordable. Furthermore, our results show that greater access to biomedicine does not lead to less prevalence of Andean indigenous medical knowledge, as represented by the levels of knowledge about culture-bound illnesses. CONCLUSIONS: The take-home lesson for health policy-makers from this study is that the main obstacle to improved use of biomedicine in resource-poor rural areas might not be infrastructural or economic alone. Rather, it may lie in lack of sufficient recognition by biomedical practitioners of the value and importance of indigenous medical systems. We propose that the implementation of health care in indigenous communities be designed as a process of joint development of complementary knowledge and practices from indigenous and biomedical health traditions.     

Environmental and socio‐economic factors related to urban bird communities

Urban fauna communities may be strongly influenced by environmental and socio‐economic factors, but the relative importance of these factors is poorly known. Most research on urban fauna has been conducted in large cities and it is unclear if the patterns found in these locations coincide with those from smaller human settlements. We examined the relative importance of environmental and socio‐economic factors in explaining variation in urban bird communities across 72 neighbourhoods in 18 regional towns in south‐eastern Australia. Native bird species richness varied from 6 to 32 across neighbourhoods and was higher in neighbourhoods with more nectar‐rich plants. Variation in bird species diversity across neighbourhoods was also strongly positively related to the density of nectar‐rich plants, but was higher also in neighbourhoods with higher socio‐economic status (reflecting higher levels of disposal income, education and home ownership). The density of native birds across neighbourhoods per season varied from 1 to 15 birds per hectare and was lower in neighbourhoods with a greater cover of impervious surfaces. The density of exotic birds (introduced to Australia) per season also varied across neighbourhoods (0–13 birds per hectare) and was lower in neighbourhoods with more nectar‐rich plants and higher in neighbourhoods with greater impervious surface cover. Our results demonstrated that the vegetation characteristics of household gardens, along streetscapes and in urban parklands had a strong influence on the richness and diversity of urban bird communities. The density of native and exotic birds varied primarily in response to changes in the built environment (measured through impervious surface cover). Socio‐economic factors had relatively little direct influence on urban birds, but neighbourhood socio‐economics may influence bird communities indirectly through the positive relationship between socio‐economic status and vegetation cover recorded in our study area.     

Positive and negative factors in defensive medicine: a questionnaire study of general practitioners.

OBJECTIVES--(a) To investigate defensive medical practices among general practitioners; (b) to compare any such practices with general practitioners'' understanding of certain aspects of the terms of service and medical negligence and practitioners'' concerns about the risk of being sued or having a complaint lodged. DESIGN--Postal questionnaire survey. Each questionnaire was followed by a reminder. SUBJECTS--500 systematically selected general practitioners on the membership list of the Medical Defence Union. MAIN OUTCOME MEASURES--Answers to questions on defensive medical practices, understanding of certain aspects of the terms of service and medical negligence, and concerns about the risk of being sued or having a complaint lodged. RESULTS--300 general practitioners returned the questionnaire (response rate 60%). 294 (98%) claimed to have made some practice changes as a result of the possibility of a patient complaining. Of the defensive medical practices adopted, the most common (over half of doctors stating likely or very likely) seemed to be increased diagnostic testing, increased referrals, increased follow up, and more detailed patient explanations and note taking. Respondents practised defensive medicine as a possible consequence of concerns about the risks of being sued or having a complaint lodged. This association was particularly strong for negative defensive practices. Defensive medical practice did not correlate with any misunderstanding about the law of negligence or the general practitioners'' terms of service. CONCLUSIONS--General practitioners are practising defensive medicine. Some defensive practices such as increased patient explanations or more detailed note taking are clearly beneficial. However, implementing the findings of the Wilson report may increase negative defensive medical practices.     

Effect of Women’s Perceptions and Household Practices on Children’s Waterborne Illness in a Low Income Community

An ecosystem approach to human health was adopted in a community-based study carried out in Bebnine, an underserved town in Lebanon. The objective of the study is to examine the association between women’s household practices and diarrhea among children in a setting where contaminated drinking water and intestinal diseases are common. A total of 280 women were randomly selected and interviewed using a structured questionnaire. Data were collected on 712 children between the ages of 6 and 14. The study instrument included determinants of diarrhea such as sociodemographic characteristics, water, sanitation, hygiene practices, gender variables, and behavioral risk factors. Multivariate regression analysis was employed to examine the association between water handling practices and diarrhea. The prevalence of diarrhea is 5%. Female children are more likely to suffer from diarrhea than male children (OR = 2.58; 95% CI: 1.19–5.62). Treatment of drinking water at the household level and the use of drinking water for cooking and the preparation of hot beverages are protective against diarrhea (OR = 0.15; 95% CI: 0.03–0.65). Female caretakers’ behaviors such as daily bathing and seeking medical care at times of illness are protective against diarrhea in children. The findings suggest that diarrhea is a gendered health problem. Female children, who are generally more involved in household activities than male children, are at higher risk of suffering from diarrhea. Female caretakers’ personal hygiene, household practices, and perceptions of diarrhea are additional risk factors. Intervention activities would be more effective if based on a better understanding of gender roles and household power relations.     

The Psychologizing of Chinese Healing Practices in the United States

This paper explores ways in which Chinese healing practices have undergone acculturation in the United States since the early 1970s. Reacting to what is perceived as biomedicine's focus on the physiological, those who describe themselves as favoring a holistic orientation often use the language of 'energy blockage' to explain illness, whether thought of as 'physical,' 'emotional,' or 'spiritual'. Acupuncture in particular has been appropriated as one modality with which to 'unblock' such conditions, leading to its being used by some practitioners in conjunction with more psychotherapeutic approaches which include valuing the verbalizing of feelings. Some non-Chinese practitioners in the United States, returning to older Chinese texts to develop 'an American acupuncture,' are reinserting diagnoses eliminated from Traditional Chinese Medicine (TCM) by the People's Republic of China as 'superstition'. The assumption has been that many such diagnostic categories refer to psychological or spiritual conditions, and therefore may be useful in those American contexts which favor this orientation. Among these categories are those drawn from traditions of demonology in Chinese medicine. What was once a religious category in China turns psychological in the American setting. At the same time, many who use these terms have, since the late 1960s, increasingly conflated the psychological and the religious, the latter being reframed as 'spiritual'. Thus, this indigenization of Chinese practices is a complex synthesis which can be described as simultaneously medical, psychotherapeutic, and religious.     

A house is more than a house: aesthetic politics in a Northeastern Thai railway settlement

This article examines debates over architectural aesthetics between residents of Thai railway communities, state urban planners, and NGO activists. It interrogates the designs, colours, objects, and materials these groups use as they attempt to upgrade these settlements as part of a participatory urban housing project. I argue that through aesthetic practices, residents, planners, and activists propose, debate, and enact distinct political and moral orders. Houses, real and imagined, reflect these actors’ provisional attempts to answer contentious questions about what constitutes a legitimate political actor and what it means to live a good life in contemporary Thailand. Aesthetic practices thus constitute a ‘politics in the making’ that offers a means for actors to debate lived configurations of the political while simultaneously intervening upon it.     

Perspectives On Tuberculosis Among Traditional Chinese Medical Practitioners In New York City’s Chinatown

This article discusses the perspectives of Chinatown’s traditional Chinese medical practitioners on tuberculosis among New York City’s Chinese laborers. The practice of traditional Chinese medicine (TCM) in the United States is neither regulated nor well understood. Some public health providers have expressed their concern that the use of TCM could prevent Chinese tuberculosis patients from receiving proper, biomedical treatment. Contrary to the suspicion of public health providers, the traditional Chinese medical practitioners in the context of New York City’s Chinatown provide diverse methods of health care, many being familiar with the biomedical explanation for tuberculosis. All TCM informants in this study stated that biomedicine is more effective than Chinese medicine in treating tuberculosis. TCM in tuberculosis therapy is said to complement biomedicine and to restore bodily balance and the general health of patients. This study discusses the political–economic context shaping the explanation and treatment of tuberculosis among traditional Chinese medical practitioners and broadens our understanding of the various contexts in which TCM and biomedicine can be integrated. Furthermore, it is suggested that an opportunity exists for tuberculosis control programs to incorporate TCM practitioners in the effort to control the disease within New York City.     

Conditions of life in the city: medicine and gendered relations in Maputo,Mozambique

How do material conditions, urban life strategies, and postcolonial medical infrastructures shape the practices of care available to patients and families in Maputo? How do global health interventions articulate with urban economies, colonial legacies, and gendered relations? Under what conditions is health made available in Mozambique's capital? This article explores these questions through the experiences of one young woman as she moves through clinical and city spaces and through changing familial and residential situations. Showing how health is shaped by gendered relations and material circumstances (or condições) as they are refracted through urban space, her experiences make clear that care both requires and creates complex material‐relational conditions rooted in clinic practice, urban forms, and gendered social and familial life. In the midst of complex medical regimes and rapidly changing urban spaces, these conditions constitute the ground on which women access medicine but also give rise to exclusions from forms of care produced by both biomedicine and social relations. Arguing for greater attention to the role of gender, urban space, economy, and exchange in theorizing health in situated urban and transnational spaces, this article advocates for accounts that go beyond biomedical and clinical framings of life, health, and well‐being and that centre relational accounts of life in the city.     

Identification of key concepts in biomedical literature using a modified Markov heuristic

MOTIVATION: The recent explosion of interest in mining the biomedical literature for associations between defined entities such as genes, diseases and drugs has made apparent the need for robust methods of identifying occurrences of these entities in biomedical text. Such concept-based indexing is strongly dependent on the availability of a comprehensive ontology or lexicon of biomedical terms. However, such ontologies are very difficult and expensive to construct, and often require extensive manual curation to render them suitable for use by automatic indexing programs. Furthermore, the use of statistically salient noun phrases as surrogates for curated terminology is not without difficulties, due to the lack of high-quality part-of-speech taggers specific to medical nomenclature. RESULTS: We describe a method of improving the quality of automatically extracted noun phrases by employing prior knowledge during the HMM training procedure for the tagger. This enhancement, when combined with appropriate training data, can greatly improve the quality and relevance of the extracted phrases, thereby enabling greater accuracy in downstream literature mining tasks.     

Quantitative assessment of the quality of medical care provided in five family practices before and after attachment of a family practice nurse.

The standards of patient care were maintained in five urban medical practices after the introduction of family practice nurses. Evaluations were achieved before and after their appointment by the indicator condition method. Minimal explicit criteria for the management of patients with 12 indicator conditions and by the use of 14 drugs were approved by an ad hoc peer group of community physicians. These cirteria were applied to the five practices by the use of a single-blind design and the abstraction of unaltered medical records. A standardized score for each practic e permitted comparison of scores for the management of indicator conditions and for the clinical use of drugs before and after attachment of the family practice nurses. For each of the indicator conditions and the drugs assessed in the five practices similar levels of adequacy were observed in the two study periods. These explicit (objective) audit resutls agreed with the implicit (subjective) assessments of the family practice nurses by their physician colleagues.     

Family doctors and innovation in general practice

Family doctors have been presented with changes in government policies and incentives in a recent white paper on primary care. Little work has been done, however, to find out how general practitioners respond to such measures. The response of general practitioners to professional and economic incentives was examined in relation to the location of the practice and the characteristics of the practitioners in seven different areas of England. The areas represented urban, rural, affluent, and deprived communities. The overall response rate was 74%, but the response varied among the areas, being poorest (64%) in an inner city area. Practices were subdivided as innovative, traditional, or intermediate, according to whether they employed a nurse and participated in the cost rent scheme and the vocational training scheme. Innovative practices were defined as fulfilling two of these criteria and traditional practices as fulfilling none; the remainder were classed as intermediate. The results showed that these three types of practice had distinct strategies that were related to financial constraints and the local population. Innovative practices had more partners and were often located in rural or affluent suburban areas; traditional practices had fewer partners and were more common in urban and working class areas. Innovative practices seemed to be in the best position to increase their services, and hence their incomes, in response to the recent proposals in the white paper. Practices in areas of developmental difficulty (predominantly urban but not necessarily inner city areas) had been less able to respond to existing incentives and had a smaller margin available for developing their services.In view of the effect of local constraints of economics and population on the strategy of practices, concentrating resources for primary care in local budgets for working class and urban areas may be preferable to extending the system of charging fees for services provided by family doctors.     

Claiming respectable American motherhood: homebirth mothers, medical officials, and the state

Based on ethnographic research regarding public policy and grassroots organizing for midwifery in Virginia, this article explores how medical discourses around appropriate health care practices intersect with state discourses about what practices are considered "respectable" versus "pathological" for its citizens. In recent legislative debates about the legalization of direct-entry midwifery, medical officials have extended their criticism of midwifery and homebirth to mothers who resist state-sanctioned childbirth practices. This article examines how medical officials challenge the respectable mothering practices of homebirthers by linking them with women they deem pathological--child abusers, negligent mothers, and drug users--and placing them outside the cadre of "normal" American mothers who acknowledge the "logical" and "natural" superiority of biomedical childbirth practices. I also address homebirth mothers' responses, which assert that their political advocacy for midwives is a respectable mothering practice because they are responsible citizens who desire what they deem the best care for their children.     

Research ethics and the use of placebo: status of the debate in Canada

The question of the use of the placebo is one of the most controversial in the field of the ethics of research today. The use of the placebo remains the standard practice of biomedical research in spite of the fact that various revisions of the Helsinki Declaration have sought to limit its use. In Canada, the Tri-council policy statement: Ethical conduct for research involving humans adopted a very restrictive position with respect to the use of placebos, precisely defining the situations in which its use would meet the demands of ethical research. The positions taken by the various ethical decision-making bodies are, however, hardly shared by regulatory bodies such as the Food and drug administration (FDA), the Council for international organization of medical sciences (CIOMS) or the European agency for the evaluation of medicinal products (EMEA). This divergence of opinions reveals two quite different conceptions of what constitutes the ethical. In the case of decision-making bodies in the ethical field, it is clearly medicine's Hippocratic Oath which explains their reluctance to use placebos. The first responsibility of the doctor is to "do no harm" to his or her patient. This duty is inherent to the medical profession and as such is not grounded in the view of medicine as a contract for care. In the case of regulatory bodies, it is the vision of "medicine as contract" which is in view; and it is this notion that justifies the use of placebos once free and informed consent has been obtained. It is also worth noting that these regulatory bodies make frequent use of arguments based on utilitarian ends. In an unprecedented move, the World medical association published in October 2001 a clarification note about the use of placebos. An analysis of this text raises the question about its real meaning: clarification or concession?     

When is a patient's use of primary care services unwarranted? Some answers from physicians.

To explore physicians'' perceptions of what constitutes unwarranted use of their services, examples of patient-initiated encounters considered unwarranted were contributed by physicians and categorized as requests for unnecessary services, inappropriately timed encounters or inconsiderate requests. A random sample of family and general practitioners in Ontario was surveyed with a questionnaire derived from these examples. Although there was no unanimity, examples of missed appointments, requests for further, unnecessary investigations, consultations or admissions to hospital, duplication of services, visits prompted by a desire to obtain free samples of over-the-counter drugs, some out-of-hours calls, and visits of healthy workers to obtain notes regarding fitness for work were seen as unwarranted by 70% or more of the respondents.     

Pluralism and pragmatism: knowledge and practice of birth in Morocco

This article examines knowledge and practice surrounding birth in Morocco, using women's narratives of their recent birth experiences, observations of medical encounters, and statements about prescribed behaviors during pregnancy and birth, as well as the vocabulary used to refer to physiological processes, disease conditions, and social relationships. The analysis shows that the three major themes that define the traditional Moroccan ethnophysiology of birth--conceptions of hot and cold, the symbolism of blood, and the metaphors of openness and obstruction--are not inconsistent with the precepts of biomedicine and public health and do not in themselves constitute obstacles either to safe home births or the use of formal health services. Women integrate biomedical and local knowledge and practices and simultaneously seek care from "traditional" and "modern" practitioners, creatively combining elements in accordance with their situations and the means at their disposal. Birth narratives show the eclecticism and flexibility that characterize women's attitudes and behaviors regarding pregnancy and birth. Women's decisions are shaped by two overriding considerations: incertitude about what can happen during the last phase of a pregnancy and ambivalence toward the available alternatives for care, both of which reflect a realistic assessment of their situations. By showing how women make decisions in response to these considerations, this article seeks to clarify some of the links between beliefs and practices and to contribute to ongoing discussions regarding the relevance of local knowledge for patterns of health care.     

Practices of the Pregnant Self: Compliance With and Resistance To Prenatal Norms

A major challenge of medical anthropology is to assess howbiomedicine, as a vaguely-defined set of diverse texts,technologies, and practitioners, shapes the experience of selfand body. Through narrative analyses of in-depth, semi-structuredinterviews with 158 pregnant women in southern California, thispaper explores how the culture of biomedicine, encounteredformally at prenatal care check-ups and informally throughdiverse media, influences pregnant women's perceptions ofappropriate prenatal behavior. In the spirit of recent socialscientific work that draws on and challenges Foucauldian insightsto explore social relations in medicine, we posit a spectrum ofcompliance and resistance to biomedical norms upon whichindividual prenatal practices are assessed. We suggest thatpregnancy is, above all, characterized by a split subjectivity inwhich women straddle the authoritative and the subjugated, theobjective and the subjective, and the haptic as well as theoptic, in telling and often strategic ways. In so doing, weidentify the intersection between the disciplinary practices ofbiomedicine and the practices of pregnant women as a means offurnishing more fruitful insights into the oft-used term ``power'and its roles in constituting social relations in medicine.     

Poverty,sanitation, and Leptospira transmission pathways in residents from four Brazilian slums

Residents of urban slums suffer from a high burden of zoonotic diseases due to individual, socioeconomic, and environmental factors. We conducted a cross-sectional sero-survey in four urban slums in Salvador, Brazil, to characterize how poverty and sanitation contribute to the transmission of rat-borne leptospirosis. Sero-prevalence in the 1,318 participants ranged between 10.0 and 13.3%. We found that contact with environmental sources of contamination, rather than presence of rat reservoirs, is what leads to higher risk for residents living in areas with inadequate sanitation. Further, poorer residents may be exposed away from the household, and ongoing governmental interventions were not associated with lower transmission risk. Residents at higher risk were aware of their vulnerability, and their efforts improved the physical environment near their household, but did not reduce their infection chances. This study highlights the importance of understanding the socioeconomic and environmental determinants of risk, which ought to guide intervention efforts.