Dealing with dichotomies in health care: Case reports

ABSTRACT

Dichotomies with respect to medical orientations and public health have been common in the past and even in the present probably orchestrated by the traditional versus modern medical concepts that became eternal arena for disquiet in the healing world of many countries. In public health, the so-called technology tradition was especially dominant which assumed the power of technology and the paternalistic ‘managerial mode’ regarding disease control programs. Such a ‘managerial perversion’ has demolished the positivity of primary health care as well as the social determinants framework. It is important to consider cultural background, the belief systems and perceptions of the people in shaping the health behaviour of the people. We are presenting here two case reports on distinct scenarios in order to show the conceptual problems with respect to the notion of dichotomies and the linkages with health. These are based on our empirical explorations using qualitative methodologies. The first case is on non-communicable diseases in a tribal society in Kerala and the second one on utilization of Traditional Complementary and Alternative Medicine (TCAM) among palliative cancer patients from a district in Kerala. It is seen that as new problems emerge or when people struggle with diseases as presented in the two case reports, they tend to depend on the positivity of the deeply entrenched cultural artefacts in combination with modern systems and they tend to bridge the dichotomies rationally instead of viewing them retrograde. It is necessary to examine the reasons for engaging in such syncretic health behaviour which could be popular realizations on the positive and negative features of both health orientations. This approach of the people could be used effectively for managing such health problems in the community.

We have encountered problems in dealing with dichotomies in the past and even in the present, probably orchestrated by the traditional versus modern medical concepts that became the eternal arena for disquiet in the healing world of many countries. Such dichotomies and difficulties became more prominent during the coronavirus disease (COVID) pandemic.

The debates on ‘post-industrial societies’, ‘knowledge societies’, and so on, which depend on material production as a key to growth and human welfare, initially gave an impression of ‘end of ideology’, a phrase which is attributed to Daniel Bell and many others in the sixties.[1] They impudently assumed that the progress in the society is directly linked to the use of science and technology and also stated that the material culture is the most developed cultural form in the world. Knowledge societies, especially technology, are expected to aid decisions which can remove all forms of insecurities and risks, and this is also expected to help decisions which can take the societies forward.[2,3]

We do not need to restate in detail a universal assumption again, which is that societies that do not fall into the so-called post-industrial or modern/knowledge/information societies are termed as backward. However, it needs to be emphasised that domains such as health and especially human reproduction also fell into this framework in an obsequious style. In public health, the so-called technology tradition was especially dominant, which assumed power of technology and the paternalistic ‘managerial mode’ regarding disease control programs. Such a ‘managerial perversion’ has demolished the positivity of primary health care as well as the social determinants framework.

Evidently, knowledge need not be the only factor which influences the trajectory of societies as conceptualised by the dominant political and economic philosophy. The pandemic had further exposed the limitations of the so-called ‘knowledge society’. Although not openly admitted, there was complete maiming and helplessness written largely on the faces of Western leaders regarding the course of the pandemic. It took such societies backwards almost a century back when the world witnessed the influenza pandemic, and the preventive measures evolved during the smallpox epidemic and subsequent epidemics known as John Haygarth’s 18^th century rules of prevention (including contact tracing) had to be brought back. The incomplete knowledge of the COVID-19 infection played a major role in shaping our response to the disease. It shaped not only the worldviews of the people but even the official responses including preventive actions. A large proportion of such science could have been just guesses, assumptions, and hypothetical statements based on available understanding. Evidently, there were distinct dichotomies between knowledge regarding the infection and the responses, popular notions, and so on.[4]

It is now well accepted that cultural background, the belief systems, and perceptions of the people play important roles in shaping the health behaviour of the people. We present here two case reports on distinct scenarios in order to show the conceptual and operational dimensions with respect to the notion of dichotomies and the linkages with health.

Methodology

The case reports are based on our empirical explorations using qualitative methodologies. The first case is on non-communicable diseases in a tribal society in Kerala, and the second one on utilisation of Traditional Complementary and Alternative Medicine (TCAM) among palliative cancer patients from a district in Kerala. In both cases, the responses were elicited using in-depth interviews with carefully developed interview schedules and the researchers stayed in close contact with the respondents during the fieldwork.

Sampling Methods: For case 1, purposive sampling was used to select the sample. Information from the PHC and the ward members were sought to select the tribal members with non-communicable diseases (CVD, Hypertension, Diabetes and Cancer). For case 2, cluster sampling was used to select the institutions mainly covering government institutions (GH, PHC and FHC) in a district of Kerala and palliative cancer patients registered in those institutions were selected. Apart from a cross-sectional survey among 182 palliative cancer patients using an interviews schedule, in-depth interviews were conducted with 30 such patients.

Case 1

As stated earlier, the first case is based on in-depth interviews with tribal community members in northern Kerala, one which retains the original tribal characteristics to a large extent but is constantly exposed to modern life style including modern medicine and government health services. As known, the tribal communities, historically, have faced socio-economic, political, and cultural barriers and injustice. It is against such a context that they come in contact with new diseases and official control measures.

Modernisation has affected the traditional practices of the tribes such as dietary practices, lifestyle choices, and physical activity levels. Consumption of staple foods like millet and leafy vegetables; over-consumption of alcohol, tobacco, and other substances; and the lack of physical activity contribute to the high burden of diseases The case report shows that the tribal community members interchangeably use the formal and informal artefacts to manage emerging non-communicable diseases (NCDs).

The community members trusted traditional health practices, but it was found that there is an inclination towards formal health care. The report shows critical conflicts between the internally evolved strategies within the tribal communities for addressing NCDs and the formal health system. These are extremely important for effective implementation of NCD control measures. It is important to recognise the deeply entrenched informal artefacts such as cultural beliefs and social structures, and they come in conflict with more formal artefacts such as the health services system.

The lack of sensitivity among healthcare workers also leads to cultural disconnect and feelings of alienation among the tribal community members. The dichotomies are reinforced by such conflicts and non-sensitivities. Despite such conflicts and the persistence of dichotomies, the positivity and the disappearing hesitancy towards modern health care are milestones in the trajectory of tribal societies.

Case 2

The second case report is based on in-depth interviews with palliative cancer patients in a district of Kerala. The case report highlights the substantial utilisation of TCAM among palliative cancer patients, with Ayurveda being a prominent modality. While participants reported satisfaction with TCAM, communication gaps with oncologists and financial constraints were notable challenges. The importance of culturally sensitive, patient-centered care, and the need for standardised guidelines and regulatory frameworks to ensure safe and informed TCAM integration into palliative cancer care is highlighted through this case report.

TCAM is primarily used by the participants to reduce chemotherapy side effects, boost immunity, and prevent cancer recurrence. While they reported satisfaction with TCAM, disclosure to oncologists remained low, indicating a gap in communication between patients and healthcare providers. TCAM practitioners were perceived to offer more mental support and relief compared to oncologists, which facilitated the preference for TCAM.

Cultural practices, beliefs, and dietary patterns influenced TCAM utilisation, emphasising the need for culturally sensitive healthcare approaches. The case report highlights the need for a comprehensive cancer care model with a patient-centred approach that respects individual beliefs and preferences while prioritising evidence-based care. This is essential for optimising outcomes for palliative cancer patients utilising TCAM.

Conclusions

It is possible to conclude on a positive note based on the two case reports. As mentioned, the pandemic no doubt questioned the technical, political, and economic assumptions of knowledge societies obliquely. As new problems emerge or when people struggle with diseases as presented in the two case reports, they tend to depend on the positivity of the deeply entrenched cultural artefacts in combination with modern systems and they tend to bridge the dichotomies rationally instead of viewing them retrograde. From a medical anthropological angle, this may be called as ‘cultural opportunism’. But it is necessary to examine the reasons for engaging in such syncretic health behaviour, which could be popular realisations on the positive and negative features of both health orientations. This approach of the people could be used effectively for managing such health problems in the community.

Implications for primary care physicians

Primary care physicians need to understand such a health behaviour among the people and view them positively by exploring the reasons for adopting the approach adopted. It is especially important with respect to cancer care and NCDs.

Ethical clearance

Ethical clearance for both the case reports was obtained from the Institutional Ethical Committee of the Ananthapuri Hospital and Research Institute, Thiruvananthapuram. Informed consent was obtained from the respondents.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.