Familiar Medicine: Everyday Health Knowledge and Practice in Today's Vietnam

6. The Patterning of Medical Choice

161 6 The Patterning of Medical Choice I had an appointment with Anh today, but he is suddenly off to a family meeting somewhere in the delta [Hai Duong]. His uncle is sick and they’ve called him in to offer his opinion. Significant family or neighborhood illness like this is probably the situation where the idea of individuals making rational, isolated choices gets thrown into the sharpest relief. These family meetings are quite an event, in fact a bantering exchange of ideas where the full gamut of [extended] family and sometimes close neighbors’ opinions are canvassed , offered, or chipped in, where metaphors, maxims, and personal experience are liberally wheeled out to support arguments in favor of this or that course of action. The whole range of cultural constructions of health and illness get to play. Sons and daughters living “outside” or even in distant cities will be called back home and involved. Cousins, relatives, and neighbors with any medical experience are expected to come and contribute. Arguments get weighed and debated, opinions and people are engaged and criticized, until a course of action is decided upon that the mother will follow. A mother’s opinion can weigh heavily here, but the illness has effectively become family or even neighborhood property. (Field notes, Hanoi, January 1996) Choice of medical care is not a simple matter of complying with some universal rationality that prescribes precisely what needs to be done. Rather, it is a complex negotiation between systemic biomedical knowledge (as accessed from doctors and pharmacists) and the family’s own pool of knowledge, experience, and resources. Choosing which course to follow thus takes place within fraught and contested domains of social and familiar relationships, economic opportunity, local knowledge, and available local resources. This chapter will describe these factors and weigh their consequence. It begins by considering the broad patterning of choice in the actual cases researched in this study, alongside evidence from larger studies elsewhere in Vietnam, for what they can tell us about the role of family authority and local knowledge in determining access to antibiotics and other services. It goes on to discuss the types of relationships people establish with pharmacists and doctors, and the sorts of regularity and certainty supplied by them. It then considers the role of the market and the pricing structure of drugs and hospital care, for their influence on choices of medical care. From there, knowledge and practice related to identified symptoms is investigated for its role in determining choice and, crucially, the reliability and value of this kind of knowledge in determining antibiotic use. In the concluding discussion, questions of habitus are worked through for what they can reveal about the overall pattern of deciding to use medicines . In many ways, the preceding questions are seen as providing the context and workings of habitus: which perceptions and practices make you go for drugs, how extensive is the domain of practical logic, and how is it bounded—for example, by medical authority or poverty. In the background are many of the other basic questions we have been asking throughout: How effective is local knowledge at dealing with global commodities and rationalities? To what extent is globalizing commodity chaos effectively regulated or determined by local hierarchies of progressively expensive medical choices? How free and open is the market? Does it deliver cheap, reliable commodities for all? Or do uncertainty and fear over dodgy products determine the access that people with marginal income will have to antibiotic treatment? Choice, Self-Care, and Medicines People like to go to get examined, get the prescription, and take the medicine into our home [tai nha]. We really don’t want to get stuck at the hospital . (Thai Binh mother) As Ilona Kickbusch describes, “About ten years ago academics discovered the fact that people actually take care of themselves.”1 Self-care and coping within the family in highly medicalized societies have been estimated to account for between 50 and 95 percent of all illness.2 Many of the usual reasons for preferring self-treatment can be applied to Vietnam: the costs—both direct and indirect—of clinical consultations; the ability to 162 ✦ chapter 6 shop around and get a better deal; the convenience of “open all hours” pharmacies; the saving of embarrassment in revealing bodily secrets to others; the feeling of control and of taking action on one’s own behalf; and speedy relief.3 Elderly...