Patterns of health seeking

Beyond the division of the Burmese medical system into government versus private and military versus civilian sectors, the medical system can be broken down into the categories shown in Table 11.1.

Table 11.1 Myanmar medical system

Government

Private

Military

Biomedicine

 

Private Companies

Hospitals, Cardiac, Cancer, Dental, Diagnostic, Pathology

Civilian

Biomedicine

Para-statal

groups

(USDA, MRC

MMCWA),

ministries

UN, INGOs, Local NGOs

Foreign doctors and volunteers

Traditional Medicine

 

Trans-National Health Providers

Emergency health, Reproductive health, Trauma services

     

Ayurvedic/Humoral Medicine

 
     

Traditional Medicine Practitioners

Lethe (midwives)

     

Buddhist Sects (gaing)

Bodaws, Weikza, Occult practices

     

Astrology

 
     

Magical Healers

Alchemy, Inn Saya, Dat Saya, Medaws, Payawga Saya

     

Other Healing Systems

Wa, Karen, Naga healers, etc.

From the starting point of the user, given this complexity and unevenness of coverage, quality and cost, it is not surprising that competing and contradictory logics govern the use of this medical system. Some families bypass this system altogether. These are the high-ranking military officers and their families who are able to use the military’s clinics, hospitals and diagnostic services, and hospitals in Singapore and Bangkok for complicated interventions and surgery. This is a trend also followed by the very small Burmese middle class. In border areas, it is common to cross into neighbouring countries to seek treatment.

Most Burmese, however, cannot leave the country and, for the majority rural population, the combination of poverty and the scarcity of trained medical personnel mean that local remedies and practitioners are the only options. As a general rule, decisions about illness are made within co-located families. In the first instance, Burmese most often seek symptomatic relief through dietary changes, pharmaceuticals and traditional medicines. In villages, the level of knowledge of traditional medicine is dependent on the personal interests of individual villagers. This knowledge has become very unevenly distributed with neighbouring villages having very different patterns of resort to health care. In some villages, elders pass traditional-medicine recipes to their children and they become unofficial consultants when illnesses occur.[10] In other villages, lacking such knowledge, the village shop stocks common pharmaceuticals that provide symptomatic relief, such as pain and anti-inflammatory medication.

When initial symptomatic relief fails, a gradual change through dietary modification is employed (this is often practised concurrently with other remedies). This homeopathic system is similar to Indian Ayurvedic[11] practices, but is a more gentle and altogether less systematic practice in Burma. The comprehensive nature of the Ayurvedic system has been largely lost in Burma with the decline of indigenous medical practitioners after British colonisation. Complicating this approach to health care is the simple fact that most Burmese are well aware of the need to include, for example, more protein and a greater variety of vegetables in their diet, but they are prevented from doing so due to food scarcity and poverty.

Biomedicine is increasingly the first medical system that Burmese turn to for disease treatment—with two provisos. The first is that the cost of biomedicine puts all but the simplest consultations and treatment regimes out of the range of most of the population. The second is the great fear of surgery in Burma, whereas other forms of bodily penetration such as the insertion of gold needles under the skin as a form of alchemical treatment, tattooing and, more recently, biomedical injections, are readily tolerated. The great appeal of biomedicine,[12] especially in the form of pharmaceutical injections, is the rapidity of symptomatic relief, which is often equated with magic, as the response can be so dramatic. This sensation is further enhanced by the comparison with the more gradual changes that occur through dietary and homeopathic healing systems. This logic has been extended by many Burmese to include the use of multivitamin and B-vitamin injections to counter some of the effects of malnourishment.

Most Burmese do not have such options. A great deal of illnesses fit into a range of ‘bad fortune’ that can include a spate of bad luck or a belief in being cursed, bewitched or under the power of various malevolent spirits. These illnesses are the domain of a veritable smorgasbord of occult healers, a significant number of whom are Buddhist monks. A common healing forum is the Burmese gain. A gain is a ‘term referring to a group of people organised around a founder’ (Tosa 2005:155). The gain founder is most often believed to be a wizard (weikza) possessing supernatural powers obtained through mastery of occult law and practices (Skidmore 2004:183–4). Gain membership and the proliferation of gain decreased after a law was issued during the Ne Win era banning monks from practising medicine and a separate law banning gain (Tosa 2002). The leadership (and revolutionary) potential of charismatic gain leaders and other individuals claiming occult mastery is a common theme in Burmese history (Houtman 2005:136). In fact, bronze statues of Saya San, a healer who led a rebellion against the British in the Ayeyarwady Delta in the 1930s, have been commissioned by the Department of Traditional Medicine and stand proudly outside traditional-medicine clinics and buildings. Such charismatic gain and other occult practitioners sit on the right of Table 11.1. Not everyone utilises these practitioners and urban dwellers rarely, if ever, move any further to the right of the table than consulting an astrologer, except for life-threatening illnesses.[13]

Life-threatening diseases such as cancer or HIV/AIDS provide clear evidence of the patterns of resort to healers used by Burmese people. A great many of the hundreds of patients the author has interviewed in Yangon in the past decade or so begin in the folk and traditional medicine traditions then start spending large amounts of money in the biomedical sector once their disease progresses to a debilitating stage. This includes, for example, bowel cancer that has necessitated surgery and then the use of a colostomy bag. Another example is HIV-positive patients whose disease has progressed to the stage of almost no immune function. These patients run out of money very quickly and that is the stage when they exit the biomedical sector.

This leaves dying patients with the options of faith, religion, miraculous cure or supernatural intervention. It also leaves these patients open to practices such as the drinking of mercury-infused juices, in the case of HIV/AIDS patients being treated by alchemists, which can cause a faster decline and further compromise a failing immune system. Palliative care then becomes necessary and families, religious institutions and a very small number of government services provide end-of-life care for patients (many of whom are dying from diseases that could have been cured or slowed if they had been treated adequately at a much earlier stage).

The use of, or engagement with, the health system then depends on a host of variables, the foremost of which are money and military or civilian status; but ethnicity, previous health experiences, exposure to biomedicine, fear of surgery, belief in magical and religious healers, belief in spiritism, the location of the patient and the severity and stage of illness or disease all play determining roles.

So far this chapter has described the outward composition of the medical system and the factors that govern access to and use of the system by Burmese patients. It has done so within the framework of national health policies and the complexity of providers. The other aspects of the healthcare system that are covered next are rarely considered core business by healthcare providers, but they are essential to an integrated understanding of Burmese healthcare needs.




[10] An exception to this rule appears to be knowledge of emmenagogues—medications taken to induce miscarriage or as a method of fertility regulation (Skidmore 2002).

[11] Ayurvedic medicine is an ancient philosophy of health care native to the Indian subcontinent, sometimes considered as a Hindu system of health care because it derives from the oral advice on living in the Hindu Vedas. It is used by millions of people in India, Nepal, Sri Lanka and increasingly in the West and is known widely as the world’s oldest continuously practised system of medicine. ‘Ayurveda’ translates roughly as ‘wisdom for living’ or ‘knowledge of long life’.

[12] Biomedicine, or ‘Western’ medicine, is called Ingleik medicine in Burma as it was most widely introduced by British colonisers.

[13] I have interviewed a very broad cross-section of Burmese people, including retired senior government ministers and opposition political party members and followers, who have been suffering terminal illnesses and have sought treatment from magical healers.