New York; Oxford: Berghahn Books, 2017. xx, 220 pp. (Tables, graphs, map, B&W photos.) US$110.00, cloth. ISBN 978-1-78533-394-1.
The small Himalayan nation of Bhutan is most famed for its often-misrepresented policy of “Gross National Happiness”: the strategy of formulating government policies according to “its spiritual, environmental and social values, derived from Mahayana Buddhism, the predominant and guiding religion” (2). The Patient Multiple provides an invaluable, if occasionally frustrating, ethnographic examination of how these policies are playing out in the field of health care. The Bhutanese government operates two national systems: a “modern” biomedical network of referral hospitals and local clinics and a parallel, much smaller network of “traditional” medical facilities offering services based upon sowa rigpa, principles of Buddhist healing. Alongside these government-sponsored options, Bhutanese seek out a bewilderingly wide range of indigenous healing practices including “shamanistic rituals, bone-setting, religious ceremonies, oracle use, spirit possession, dietary behaviours and familial care” (5). Although many of these draw upon Buddhist ideas as well as folk beliefs and practices, they operate outside of the purview of the two government services. Taee thus groups them together under the label “alternative” medical practices. Taee conducted a year of fieldwork from 2011 to 2012 based in Thimphu, the capital and site of the largest biomedical and traditional medicine hospitals, and the small provincial town of Mongar in eastern Bhutan. Operating in the two national languages of English and Dzongkha, Taee observed more than 600 procedures at the hospitals and interviewed well over 150 practitioners in all three fields as well as many of their patients. While this impressive collection of data informs Taee’s general description, each chapter features one or two case studies following patients as they navigate their way between the medical options available to them when illness strikes.
Following a short introduction on the history of medical care in Bhutan and background to his fieldwork, Taee walks readers through the practical complexities of seeking care by relating the experiences of “Pema,” a woman suffering from chronic stomach pain and nose bleeds. Readers immediately gain a sense of the practical challenges of seeking health care at Thimphu’s hospitals (the expense of getting to hospital, long waits in crowded waiting areas, hurried consultations from the overworked medical staff) as well as the confusion and anxiety patients experience as they attempt to sort out the possible causes and curative resorts for their illnesses including, in Pema’s typical case, consultations with astrologers and other “alternative” practitioners unsanctioned by the government. The three fields of health care, Taee argues, not only represent multiple understandings of illnesses but distinct notions of the body and its relationship to greater social, political, and cosmological contexts. Made multiple, patients like Pema must seek coherence “in the face of ethical, institutional and knowledges differences between practices, conceptions of health and bodies” (186).
Chapter 2 presents a detailed study of the second health-care option the Bhutanese government offers its citizens: a network of sowa rigpa traditional medical facilities parallel to the much larger biomedical system. Originating in the practices of elite practitioners treating the monarchy, the system relies upon knowledge of the four major Buddhist medical texts and an array of mainly Tibetan pharmaceutical and medical treatments. The institutionalization and professionalization of sowa rigpa medicine has given rise to a situation in which many indigenous curative resorts (Taee’s “alternative” practices) have become stigmatized by both modern and traditional practitioners as useless or harmful. Taee notes differences in the ways biomedical and traditional specialists deal with their patients (for instance, while doctors commonly inform patients of their diagnoses, traditional practitioners limit themselves to ordering curative procedures). Major efforts have been made to systematize traditional diagnoses and procedures; unfortunately, these seem to have further emphasized the fundamentally different philosophy bases of the two services and encouraged competition rather than cooperation.
The next three chapters shift the focus back to Bhutanese individuals dealing with serious illnesses. Chapter 3 provides two case studies of parents seeking medical treatment for their children. While Bhutan’s two health systems are free to users, accessing them often entails heavy costs as families must pay for their own travel and maintenance while in hospital. Given that illness can have several possible causes, individuals and families who fall ill are faced with difficult choices of which type of medical provider to consult. “Patients and those who act as decision makers on their behalf are solely responsible for making their own healthcare decisions amongst the available options” (113), in effect being put in the position of first responders. Not surprisingly, people living in rural areas—which is to say, most of Bhutan—tend initially to frame illnesses in terms that are susceptible to local interventions by monks, astrologers, and healers—that is, illnesses deriving from spiritual agencies. The topic of alternative medicine occupies chapter 4. While Taee admits to limited knowledge, the array of practitioners, treatments, and explanations he surveys is fascinating, exotic, and dizzyingly complex. While apparently as sought after as ever, alternative practitioners are being impacted by changes in Bhutanese overall society, including occasional law suits from disgruntled clients or community members objecting to being accused of causing illness in others. The final brief ethnographic chapter focuses upon the material aspects of health care, in particular how patients and practitioners alike deal with the vulnerabilities in the supply of medicine to Bhutan from the global market.
Of considerable interest for academics, The Patient Multiple should be a must-read for medical practitioners working in Bhutan, both citizens and foreigners. Unfortunately, there are several obstacles beginning with the ridiculously high price for the volume. Of equal concern, the early chapters suffer from dissertation bloat: long digressions into the scholarly literature and belaboured repetition of key points and themes. I suspect that most readers uninitiated into current anthropological debates about ontology, the body, personhood, and the like will find Taee’s discussions of various multiplicities more confusing than helpful. Taee does an excellent job of analyzing the distinct ways practitioners in the modern, traditional, and alternative spheres envision and treat patients and their illnesses and how these alternatives in turn resonate with differing notions of ethics, community, and citizenship among other factors. Taee argues that this results in a subjective sense of multiplicity that patients work to overcome over the course of their treatments. His case studies, however, reveal people pragmatically drawing upon experts from all three domains as they seek relief. Indeed, most seem to have little trouble reconciling the different treatments they receive in terms of a single, usually spiritual explanation of the origin of their illness. This may change, of course, but for the time being the multiplicities Taee documents appear to be of much greater concern for practitioners in the two government services than for most Bhutanese.
John Barker
The University of British Columbia, Vancouver, Canada