Therapeutic expectations

One set of cultural factors which is important in eventually constituting the clinical reality, are therapeutic expectations (Kleinman 1980). Patient as well as provider have certain expectations regarding etiquette, treatment style, and therapeutic objectives. These expectations can be very different from patient to provider, from patient to patient and from provider to provider (this also depends on the sector which the provider represents). Often problems in the therapeutic interaction arise when patient and provider have different expectations.

Patient expectations about etiquette vary according to the type of provider. A provider in the professional sector will be expected to be formal but polite, competent but secretive, meticulous but fast. The provider on the other hand will expect the patient to be very polite and aware of the status differences between them, attentive but ignorant, and, hopefully, compliant. Neither part is likely to expect the patient to ask a lot of questions. It is not common in Thai culture for a person of inferior status to ask questions or to admit incomprehension to a socially superior person. Conflict and confusion will arise if either part does not conform to common role expectations.

Treatment expectations are likely to be very different in the folk sector. Provider and patient are closer to each other in terms of social status. The provider may be a fellow villager as is the case with the informal injection provider in Ban. A possible diagnosis may even be discussed between the folk sector provider and the patient. And since the patient is also a paying customer, he or she is likely to exert some influence on diagnosis and treatment schedule. The etiquette in the folk sector is therefore one of less formality and more equality.

In the popular sector the interactions are taking place between equals and neither part needs to show any special respect or deference. The provider may be the neighbour who owns a small grocery store or a relative. In this type of self-medication the diagnosis is often made by the patient himself and the provider merely sells or supplies the wanted medicines.

The patient’s expectations concerning the style of treatment will also depend on the provider sector. In a professional setting a patient will expect to receive high technology care, while in a folk sector some biomedical equipment may be present but not to the same extent as in the professional sector. In the popular sector, the setting or style of treatment is not characterized by any high technology biomedical equipment or any sense of formality.

The therapeutic objectives may vary widely from patient to provider and from one sector to another. A patient may wish to recover as quickly as possible, to be legitimized in a certain sick role or to escape reality for a while. The professional provider on the other hand may wish to achieve a biomedical cure and/or to ensure patient satisfaction (see next chapter). A folk provider may wish to achieve patient satisfaction or to confirm his own social status in the community. In the popular sector therapeutic objectives range from profit and future business to helping a dear relative.

Perceptions of medicines

As mentioned earlier medicines are believed by villagers to be essential in health care. Thai people truly believe that there is “a pill for every ill”. Weisberg’s and the team’s observations on this subject are quite similar; “The appropriate drug or treatment may only be found through a process of trial and error: one reason village patients pop from one healer to another is to search for “the” cure, which is felt to be out there, somewhere, if one can only find it. Also, since an afflicted part of the body (or the entire body, if the illness invades the entire system) must be treated before the illness’ harmful effects become irreversible, speed is essential” (Weisberg 1984a: 177). The concept of speed is very important in explaining villagers’ treatment seeking behavior and preferences for certain routes of medication administration.

As pointed out by Weisberg, biomedicine fits nicely into such a framework of speed and a process of trial and error. Villagers expect biomedicine to correct imbalances among the body elements much faster than could be expected of herbs. Furthermore, biomedicine is available everywhere and in a form which is ready for immediate consumption. As described by Bledsoe and Goubaud in the reinterpretation of pharmaceuticals among the Mende in Sierra Leone, biomedicine has been reinterpreted and subsumed under some preexisting categories (Bledsoe and Goubaud 1988). Vitamins, for instance, are perceived as analogous to elements. Blood pressure is perceived to be a measurement of the “wind” (or air) element. And intravenous drips constitute a replacement of energy, almost like a complex tonic of the kind which is so popular in Thai culture (Weisberg 1984a: 177). In Ban intravenous drips are also used by young men to stock up on energy before they go abroad for work.

Six of the grocery shops in the village Ban sell medicines. The number of medicines sold vary from 3 in one shop to 50 in the biggest shop. The shopkeepers buy their supplies from drug stores in the nearby district town. None of the shops sell injectables or syringes, nor do they sell IV fluid. As will be seen later, these shops are often people’s first treatment resort for trivial symptoms. Most people know exactly what medicines they want to purchase, If they do not, the shopkeepers, who have no medical or pharmaceutical training, will try to advise them. Sometimes the shopkeepers use their experience with other clients as a basis for giving advice, sometimes they read the package inserts of the pharmaceuticals.

Table 8
Best selling drugs in grocery shops

The following allopathic drugs were the 14 best selling items for the six shops taken together:

Referring to earlier discussion about the lower tolerance level for pain, it is interesting to notice that 1,218 pain-killer tablets or powders were sold during one week in the village, more than any other type of medicine. These medicines were probably also consumed as people normally buy only the amount needed for immediate consumption. It was also rare for people to be storing medicines at home.

The amount of pain-killers sold is the equivalent of all inhabitants in Ban, even babies, taking at least one pain-killer per week. This is a rather high consumption of pain-killers, given that there were no special disease factors at work. It would seem that Thai people in this village, and certainly also in the slum area, regard pain-killers as a regular feature of their daily lives.

The above listed drugs and two cough syrups and a worm medicine (Brown Mixture, Baby Cough Syrup, and Hexin Tapeworm Drug) were presented during a number of focus group discussions and the participants were asked to classify them. The women in the focus groups grouped the medicines according to symptoms. For instance Mag-77 and Admag M for stomach pains, Ravifort and Thiamine as vitamins, Heromycin for abscesses and Tiffy, Nutacold, Pyrana for colds. The main difference between the various focus groups’ classifications seemed to be whether the pain-killers such as Bura, Buadhai, and Tamjai were grouped separately for pain or together with the cold medicines, Yachut was some times grouped with the pain-killers; in other cases the women said the therapeutic effect depended on the specific type of Yachut and this is not evident from appearance.

The syringe and needle were also presented to the focus groups. The women agreed that injections could be used for all symptoms. There were different opinions as to how many times syringes and needles could be used.

In general, medicines were not perceived as being potentially dangerous if taken in moderation, Weisberg has made the same observation: “They (the villagers, AR) find no danger in seeing an injection doctor, a physician, and a druggist within 24 hours and receiving drugs from each” (Weisberg 1984: 178). Drugs, injections and IV fluid can in fact make one’s blood better. However, pain-killers such as Tamjai and Buadhai were recognized to be powerful and addictive. These drugs would also make one’s blood bad (like Yachut) and could be the cause of peptic ulcers and convulsions. Some women stated that they could actually feel these strong medicines working inside their bodies and that they would make them sweat.

The villagers feel that one should use medicines only as long as symptoms are present. One should stop taking medicines as soon as symptoms abate. “Otherwise, one would create an imbalance among the elements and court further illness and physical disaster” (ibid: 179).

Interestingly, some women stated that when they buy “shop-medicine”, they have to eat a lot of it to recover. The survey data showed that when people buy medicine in the grocery shops, they normally buy only one type of medicine. When they go to private doctors, they often end up with 4 different types of pills. Maybe the respondents meant that they would have to eat more of the same type of medicine if it was from a shop to achieve the same effect as a treatment schedule from a professional provider. The villagers were also asked if the power of a drug varied according to the healer. In other words, would a specific pain-killer be as effective if it was bought in a shop as if it was dispensed by a doctor or another type of provider. To this they always answered that there would be no difference in the effect of the drug. But the villagers do feel that a professional provider would choose a more effective/appropriate drug or a more effective combination of drugs than healers in the two other sectors.

When asked about the advantages and disadvantages of the different routes of administration of medicines, the majority of women agreed that pills, capsules and liquids work in the same way. They are digested in the stomach and later absorbed by the body. Injections, however, are more powerful and quick because they go directly into the blood where the medicine will “run in the blood vessels”. AH the observed injections in the health centre were given in the buttocks, not intravenously, but that did not seem to affect people’s perception of the way injections work.

Injections are not perceived as being any more risky than oral medicine except in cases of allergic reactions. Some people feel that injections should not be given to children, because children are less strong than adults.