Asked about how to prevent illness and other unpleasant events, most Buddhist villagers living in the Thandwe area, in Rakhine State, Myanmar, respond: ‘practising dana, thila, bawana’, that is, making donations and offerings, respecting the precepts and practising meditation, the three practices which form the core of the Buddha's teaching. Whereas to the question of what to do in case of illness, they generally answer: ‘I go to buy some medicines or to see a [biomedical] doctor.’ Interestingly, these answers locate prevention and cure on two different levels. The first pertains to religion, more precisely to Theravada Buddhism — with dana, thila, bawana protecting against illness by virtue of effecting improvements in karma and spiritual progression. The second pertains to medicine, which cures by acting on the biological, physiological, aspect of the illness.
It may not come as a surprise that these Buddhists see religious practices aimed at improving one's karma as the main way of preventing illness, given that karma is commonly seen as the main determinant of individual well-being. But why then not use Buddhism to cure as well? Does this suggest a limit to what Buddhism can do? If so, does this limitation have to do with the claim, often stated by those defending a supposedly orthodox approach to the doctrine, that Buddhism operates for otherworldly issues only and is not concerned with worldly and mundane preoccupations? In this sense, one could argue that prevention is more generic, having to do with the maintenance of the cosmic order, of which Buddhism is the main guarantor, while curing is a form of intervention within the mundane, an attempt to modify it, something Buddhism is not supposed to do. Or does the — claimed — preference for medicine over Buddhism in case of illness just to do with the fact that clinics and medicine shops are quite accessible (at least in terms of location) and that biomedical technologies and especially pharmaceutical drugs are supposedly very effective and eliminate symptoms more quickly? Or are these answers something my informants say to impress me (the ethnographer), given that both Buddhism and medicine are socially highly regarded?
Whatever the reasons behind these answers, close observation of daily life in Thandwe indicates how much these answers are only a partial reflection of reality. In fact, ‘Buddhist’ and ‘medical’ practices are often combined within preventive and curative processes — and they are also supplemented with other resources such as making offerings to planetary forces and guardian spirits, wearing amulets, reciting auspicious Buddhist formulas, respecting dietary rules, or consulting indigenous healers. If some of these practices are recognised by everyone as belonging to the medical or religious field, others are not; they are subject to multiple definitions shifting from medicine, to tradition to backward superstitions, depending on the interlocutor and the context of the communication.
To this range of preventative and curative practices is the added complexity of healers who combine multiple practices and often two or more therapeutic functions — acting simultaneously, for instance, as monks and herbalists, or as herbalists and exorcists. The heterogeneous if not hybrid identities they build in order to expand their field of action and increase their legitimacy and respectability,Footnote 1 makes us further question any clear-cut definition of therapeutic figures and blurs the boundaries between supposedly distinct traditions.
Such complexity reveals how much health and illness are expressions of order as well as disorder, within the body or in relation to the cosmos; this order and disorder may be simultaneously biological, physical, social, and moral, as expressed in the Buddhist notion of dhamma, the cosmic law, inherited from the Hindu notion of rta. This complexity also reveals a need to address all factors contributing to the order/disorder, hence the intent of ‘healing’, in the etymological sense of ‘making whole’. It also shows that practices people engage in for the purpose of healing often go beyond and cut across categories of medicine and religion, the worldly and otherworldly, cure and salvation, in that they merge the venerational, devotional, medical, and social as much as the spiritual and material, visible and invisible.Footnote 2 The medical, religious, social, and cosmological orders seem to be less distinct than the categorisation implied by these words would suggest.Footnote 3 I follow here Arjun Appadurai's lesson,Footnote 4 and consider that from an analytical perspective it would be more appropriate not to speak of religion and medicine as nouns but as adjectives, since most conceptions and practices have both medical and religious properties.
Helen Lambert highlights a long-standing trend in the humanities to use ‘healing’ to refer to all non-biomedical approaches to health and to reserve ‘medicine’ for biomedicine and more recently modernised versions of indigenous medicines.Footnote 5 She suggests that this distinctive use of the two words obscures more than it reveals, in that it stresses or even creates a gap between the two medicines. As I do not see these two words as mutually exclusive, I use both interchangeably: I use the term medicine to refer to what is locally recognised as a medical system (both biomedicine and indigenous medicine), but I also use the adjective medical to refer to anything that has medical properties even though it might not be seen as belonging to a formal medical system. I use healing to refer to both the intention and the process, as all practices are seen as contributing to ‘making whole’, by addressing all potential causal factors.
At the same time, the boundaries between traditions do not disappear — they indeed remain present in personal narratives and explanations — and the categories remain relevant in daily life. They indeed provide a guide for judgement and for action. Moreover, I propose that the efficacy of medical practices relies on the combination and crossing of categories, which is possible only if these categories exist.
The most commonly mentioned and more relevant categories for this study in Rakhine are those of Buddhism and medicine. I suggest that this is so because of the official recognition these traditions have received and the process of formalisation, institutionalisation, and essentialisation they have undergone and which set clear boundaries between them.
Formally introduced to Burma by the British colonisers in the latter half of the nineteenth century,Footnote 6 Western medicine has, since then, been supported by the Burmese state and developed into a national health system. A few years after achieving independence in 1948, the government also added indigenous medicine to this system, but in a modernised version which was largely reduced to herbal medicine, and from which astrology, mantras and exorcism were excluded. A similar essentialisation and redefinition of categories happened with Buddhism. In the eleventh century Theravada Buddhism was recognised as the national religion and since then it has spread nationwide. It is increasingly regulated, however, and subjected to purification processes aimed at separating it from ‘external’ elements — spirit cults, alchemy, astrology — which are deemed to have ‘contaminated’ Buddhism's original purity. It is thus through these political processes that medicine and religion have emerged as more visible and even dominant categories while their content has been essentialised.Footnote 7
This work aims to address several questions: First, why is a plurality of medical and healing practices needed? Second, why do the people of Rakhine in this study use this plurality the way they do? And third, to what extent is health-seeking shaped by the categorisation and hierarchisation between different resources often manifested in people's discourses?
As mentioned above, the way medical and health-seeking conceptions and practices are used by patients and healers alike reflects an intent to ‘heal’, so as to ‘make whole’, to address all the factors at stake in the preservation of the individual and cosmic order. Now, I argue that these different conceptions and practices differ in their capacity to help people dealing — cognitively, practically and emotionally — with health issues and illness along with related uncertainties. Their contributions — to what I suggest calling a ‘compound healing’ — are complementary and hierarchical. These different contributions — and hence the relations of complementarity and hierarchy which connect the different healing conceptions and practices — hold to a nexus of political, social, economic, cosmological, biological, environmental factors. This also means that these relationships shift from person to person depending on their position in the social space. Indeed, the efficacy of each healing practice and the way a person will implement it will depend also on an individual's position in society, social circle, values and past experiences, lifestyle, and access to certain resources. Finally, I maintain that it is because of these relations of complementarity and hierarchy, which are constantly re-created through the processes of health-making and health-seeking within a health governance system, that the overarching plurality is maintained.
It is useful here to resort to Pierre Bourdieu's model of field and types of capital.Footnote 8 Unlike most works that explain the decision-making process only through the availability of services and their cost (accessibility), Bourdieu's approach brings into the picture also the social capital (social relations) and the cultural capital (the ‘indigenous knowledge of therapies’) of both healers and patients, and stresses the relations of complementarity and hierarchy that exist between actors and between practices.
The field has to be studied in its integrality, as suggested by Arthur Kleinman, who states that ‘In every culture, illness, the responses to it, individuals experiencing, and treating it, and the social institutions relating to it are all systematically interconnected. […]’ and that for this reason the ‘health care system’ must be studied as a whole.Footnote 9 Only by considering this plurality as a whole, can one understand the positions these different components occupy vis-à-vis each another and appreciate how they enable people to cope with their health issues.
The study of medical practices and the disciplinary split
The coexistence and combining of diverse health-related conceptions and practices is well attested in the literature on Myanmar and other Asian countries. Various authors have described how this complexity has resulted from the encounter and blending of different religions and medical traditions (Chinese, Indian Ayurvedic, Arab-Islamic, Buddhist and, more recently, Western) that spread across the region through the processes of Sinicisation, Indianisation, Islamisation and colonisation and were intermixed with indigenous belief systems.Footnote 10 So commonplace and visible is this plurality in Asia that it has been through studies conducted in this region that the notion of ‘medical pluralism’ has been elaborated. However, such studies have rarely examined the whole spectrum of health-related concepts and practices available to a particular population and the ways this population use them. The main reason behind this gap is a certain disciplinary division within the field.
In Asia, indeed, different conceptions and practices related to health have been examined separately, split between religious studies, medical studies (notably medical anthropology and the history of medicine) and, to a certain extent, ritual studies. This separation has contributed to perpetuating the idea that some practices pertain only to religion and others to medicine.Footnote 11 This is all the more problematic given that the scholarly notions of religion and medicine do not always correspond to their informants’ perceptions. The strong emphasis initially placed on texts also contributed to widening this disciplinary gap while hindering the possibility of seeing how much these traditions are intertwined in daily life.Footnote 12 A further limitation arises from most of these studies being focused on just a few traditions, notably Buddhism and spirit cults for religious studies, and Western medicine and indigenous herbal medicine or, more rarely, shamanism and exorcism, for medical studies.
For Myanmar the absence of studies on the plurality of health-related practices is also a consequence of the decades of military dictatorship which hindered scholars from conducting long-term fieldwork with a holistic approach.Footnote 13 The only studies of this kind are those of Melford E. Spiro and Manning Nash, in the early 1960s, and both focused on Mandalay.Footnote 14 Till my work and a chapter Monique Skidmore wrote on medical pluralism, nothing comprehensive has been produced.Footnote 15 Although they remain partial, works developed in Buddhist studies and medical anthropology have nevertheless made significant contributions to the present study. It is, however, by combining these approaches that we can best access a more accurate understanding of the reality.
Pluralism in Buddhist studies
One of the main concerns for the first anthropologists approaching Theravada Buddhism in the field was to understand how to conceive the relationship between Buddhism and the other traditions embraced by local populations, mainly spirit cults which these scholars, unlike local people, considered a form of religion. The majority of scholars working on Burma,Footnote 16 like scholars working on other Theravada societies,Footnote 17 have understood Buddhism and spirit cults to be part of a single religious system dominated by Buddhism, which provides the conceptual framework and system of values within which the other practices are integrated. If Gananath Obeyesekere and Thomas Kirsch stressed the different functionality between Buddhism, turned to other-worldly aims, and spirit cults, turned to worldly aims, Nash and Stanley J. Tambiah recognised that Buddhism itself is used for both aims. Tambiah and Nash's approach is particularly relevant for the present work because they include not only spirit cults but also other traditions such as astrology, alchemy and medicine. Moreover, they both argued for a coherence of the ‘system’. Nash, for instance, affirmed that the:
nat cult, the predictive, divinatory and medical systems are analytical categories divided by the recording anthropologist. To local people, they with Buddhism make a coherent whole, a set of beliefs and strategies to be invoked as instrumentalities [….] all practices — medicine, astrology, alchemy — aim at modifying the magical balance of the body.Footnote 18
The main exception to this general consensus is represented by Spiro, whose work has remained influential in the literature on Myanmar and has thus delayed, for this country, the paradigm shift.Footnote 19 Spiro considered Buddhism and what he called supernaturalism as being of two different religious systems. Buddhism, he argued, is a religion of salvation but that while becoming a religion for the masses, it started to be used also for worldly concerns; its doctrines have been gradually modified to justify this new use of Buddhism alongside supernaturalism-related practices.
Bénedicte Brac de la Perrière notes that the distinction between Buddhism and other worldly practices in the Burmese context (but historically certainly also in other Theravada countries) has also much to do with the purificatory campaigns led by the state.Footnote 20 These campaigns have been particularly strong in Myanmar, given that Buddhism has always been an instrument of political power the central government uses to dominate the peripheral ethnic states.
Pluralism in medical anthropology
A recognition of the coexistence of different medical traditions within a specific society — what Charles Leslie called ‘medical pluralism’Footnote 21 — and the analysis of the way people navigate and make use of this complexity, have long been at the core of the reflections developed. If overall scholarship on Theravada societies has been quite prolific, the core of scholarly reflections on issues of pluralism has nevertheless emerged elsewhere in Asia, in the Americas, and in Africa. Among the questions which have been addressed is the cognitive and conceptual coherence between the different medical traditions under study. In this regard Leslie and Allan Young speak of ‘Asian medical systems’, meaning by this that the ensemble of medical traditions available in Asian societies makes a coherent whole.Footnote 22 For Theravada countries, to my knowledge, only Spiro, Nash, Louis Golomb, Richard Pottier and Anne Y. Guillou, addressed this question and, except for Spiro, they all also conclude in favour of a certain coherence.Footnote 23 Like Nash, Golomb explains that the different magico-religious therapies employed by herbalists, exorcists, and others, form a coherent whole by arguing that all these therapies rely on ‘magical’ practices manipulating the supernatural forces which are responsible for the problems.
Since the 1990s and especially since the beginning of this century, attention has shifted to the political economy of medical pluralism. Numerous anthropologists, including Asianists, have vigorously argued that medical pluralism continues because the accessibility and hence use of mainstream health services is entangled with social forces, political interests, and economics.Footnote 24 Put differently, since biomedicine, which generally represents the main if not the only component of the official health system, is geared to only a tiny, rich and educated part of the population, these scholars consider medical pluralism as a way for people to bridge unequal access to health services. A similar position is taken by Skidmore, who attributes the fact that the Myanmarese resort to traditional healing practices to the inaccessibility and the poor quality of biomedical services.Footnote 25
If important reflections on pluralism have been developed in both Buddhist studies and in medical studies, none provides a comprehensive reflection on local realities. First, they do not consider the entire spectrum of healing and medical resources in a particular society, since they look only at what they consider to be medicine or religion, and only at one part of these. Second, they examine only one dimension, conceptual or structural/political, while I believe that a more accurate understanding of the dynamics of this field only comes from combining both these perspectives.
After a brief description of my fieldwork, I will present and examine the local medico-religious field starting with the conception of health and illness held by Rakhine Buddhists and continuing with practices which they employ to maintain and restore health, and end with an analysis of what I have presented.
Fieldwork
Data used for this study was gathered during multiple fieldwork trips conducted between 2005 and 2011 among the Buddhist population living in the Thandwe area in central Rakhine State.
Rakhine is one of seven northwestern states in Myanmar. The massive mountain range Rakhine Yoma along its eastern border increases its political marginalisation by a centralised system of governance which both dominates and neglects peripheral areas inhabited by minority ethnic groups. The impacts on the local economy and development are enormous, with Rakhine being the second poorest state after Chin. Together with education, health is a long neglected sector, as in the other peripheral states.Footnote 26 Indeed, while the main Burmese cities such as Yangon, Mandalay and the new capital Naypyidaw host various private and public health services from small clinics to hospitals as well as pharmacies, remote areas rely on a limited number of largely unequipped health centres and (mostly unlicensed) medicine shops. Despite the low quality of government health services, they are often very costly, especially because patients are expected to pay almost in full for treatment (92 per cent in 2010, the highest in the world). Thein Sein, the former president who marked the transition to a semi-democratic government in 2011, has launched a reform of the health system and increased the state contribution to health, and yet the improvements remain minimal, especially in remote areas like Thandwe.Footnote 27
The city of Thandwe hosts a mixed ethnic population with substantial Muslim communities. However, in the rural areas and coastal villages where I focused my research most of the population is Buddhist. The majority are farmers or fishers, though some are employed in trading, the food industry and hotels. Thandwe has a public hospital located in the town and, under it, a network of rural health centres in the surrounding villages. The private sector is represented by services started by professionals who also work in the public service, most of which are based in Thandwe town. There is also one public and three private indigenous medical clinics, all based in the town. All these services are under-resourced, lacking in staff, equipment and medicine and they are able to provide only very basic services. Beside these medical practitioners belonging to the official context, Thandwe and the villages alike host a high number of traditional doctors, masseurs and bone-setters trained and working outside the official, formalised context and also monks, diviners, astrologers, and spirit mediums, who also offer services for those experiencing illness and other forms of misfortune.
Illness as a cosmic disorder
Rakhine villagers distinguish between yawga or natural illness, which they explain by relying on theories of indigenous medicine, and payawga or supernatural illness, which they explain through notions drawn from representations of the supernatural realm, largely shared among Southeast Asia societies, as well as from Buddhism.
Yawga is a physical or mental disorder produced by an imbalance in the elements of the body (Mahā bhūta, in Pāli, or dat in Burmese): air, fire, earth, and water. The principle of the four elements is drawn from Buddhist medicine and is thus attested in other indigenous medical traditions in Buddhist Southeast Asia.Footnote 28 A traditional healer explains that fire is the chief element of the four. On account of this, diseases are mainly classified as hot (apu yawga) or cold (aay yawga). According to my informants, yawga can be generated by one or more of the following factors:Footnote 29
• Kan: karma, or ‘action’. People understand karma in two ways. First, in a religious-moral sense, as the sum of all meritorious (kutho) and demeritorious (akutho) deeds people accomplish during their successive life cycles as well as the consequences of those actions. This karma determines the constitution of the person's body at birth in terms of elements and, hence, whether it is hot or cold in nature, which affects the general health of the person throughout her/his life. It is also the main cause of congenital or serious diseases such as cancers, HIV, etc. Finally, karma determines the gravity of the illness and the chances of recovery. Second, karma is understood in a more secular way, as actions and movements of the body (the posture, the actions of sitting, standing, or walking) that also impact on the body elements (air, water, fire, earth) and thus on health.
• Seik: the mind. When a person undergoes a shock, or is overwhelmed by worries, his/her mind can overheat (seik bu de) or break down (phiette). It will thus malfunction and eventually damage the physical body.
• Utu: climate and seasons. Climate and seasonal changes from hot to cold and vice versa easily impact people's health.
• Ahara: food. The ingestion of unsuitable food can have a negative impact on a person's health. Unsuitable food is conceived in terms of incompatibility between the food, hot or cold, and the person, hot or cold.
Besides these factors that my informants identify as part of indigenous medical aetiology, they also recognise — not without a certain resistance — another causal factor: gyo, or the planets. Individuals are affected by the positive/‘cold’ and negative/‘hot’ influence of planets throughout their lives. A doctor of indigenous medicine explains how planetary influence is related to karma:
the place and time of birth and hence the planets active at that moment are determined by the karma the individual is fated to be born with.Footnote 30 Moreover, when during his/her life a person enjoys a favorable planetary influence, he/she benefits from the positive effects of the meritorious deeds accomplished during past lives; likewise, when a person comes under an unfavorable planetary influence, he/she faces the negative effects of unmeritorious actions.Footnote 31
The five causal factors can act alone or in combination with each other thus reinforcing each other's action. This is particularly true in the case of karma: a person's good karma, and hence positive planetary landscape, acts as a barrier against the other factors, while negative karma with its corresponding planetary influence gives free rein to the other factors to harm the individual. Some informants explain that every illness, which has karma as its primary cause, is a misfortune (kan ma kaung bu, ‘to have a bad karma’) in the same manner as any other destabilising incident is believed to be caused by negative karma (such as a car accident or poor harvest).
The second kind of sickness is payawga, literally ‘external disturbance’, troubles caused by aggression (a-hpan) from vindictive and malevolent beings such as witches (son), sorcerers (auklan hsaya, ‘masters of the lower path’), and spirits (nat, tahsay, thaye or peikta). Witches generally create aggression by using the power of their minds or some cursed food, while sorcerers act through esoteric diagrams or spirits that they control by dispatching them to harm the person from afar, or through possession of their souls.Footnote 32 Even though anybody can be ‘attacked’, there are some factors that can facilitate this occurrence. Payawga is thus always a form of misfortune. This kind of disorder is often expressed by behavioural deviance, such as shouting or crying, mental confusion, or specific physiological symptoms such as a headache, the sensation of a bloated stomach, or blurred vision, but also through an assortment of social, relationship, or economic problems.
Hence, two kinds of illness can be distinguished: natural ones which may or may not have karmic and planetary implications and aggressions for which those implications are the rule. However, the line between the two is not always clear in that one illness can engender the other.Footnote 33
These different conceptions create a coherent whole in that they each respond to the logic of illness as a cosmic disorder — each of them expressing a specific disorder — but also because they are grounded in the explanatory power and value attributed to them within a system dominated by Buddhism and medicine. Buddhism is even attributed a higher position in that karma, a key Buddhist notion, holds an encompassing role among the different causal factors. Karma is considered as the unique and direct cause of certain normal, natural diseases, in particular the congenital and incurable ones. And when it is seen as co-acting with other factors, these are believed to be submitted to it. And even when karma is not the ultimate cause, it does influence the way the other factors affect the person who is unwell. Karma indeed determines the gravity, the seriousness of the disorder.
Another sign of the domination of Buddhism and the predominance of karma is that the action of factors which were not initially part of Buddhist medical theory has been reinterpreted in a way which makes it compatible to the law of karma. Hence, planets have been reinterpreted as forces mirroring karma.Footnote 34 Like other authors, Caterina Guenzi affirms that this conception is a sort of trick which allows authors of ancient astrological treatises as well as contemporary astrologers to combine in a unique coherent whole two explanatory systems of human destiny otherwise incompatible and hence to legitimise astrology. Similarly, in order not to contradict the law of karma, the actions of spirits, witches and the like have been subordinated to it.
More importantly, even when the different factors are articulated to karma, and hence are submitted to its workings, their importance is not reduced; taken alone the various medico-religious and traditional healing practices still complement each other in what they allow to explain and in the emotional comfort they are able to provide. Indeed, as some authors — mostly Indologists — have pointed out, different causal factors provide explanations at different levels of meaning and of human concern: natural, social, supernatural/invisible, existential.Footnote 35 Not only do different causal explanations address different human and social needs, but they also differ in the agency they provide to an individual regarding the possibility of acting on the illness, of mastering one's destiny. But karma is invisible and difficult to grasp and thus potentially unsatisfying as aetiology while planets are visible and predictable. By combining these two systems and conceiving the planets as the mirror of the karma, karma become manageable. This process brings to light the limits of Buddhism, since karma alone is unable to provide a satisfying way of mastering one's health, but at the same time it confirms Buddhism's superior position, since planets are inscribed within, and submitted to the karmic logic.Footnote 36
The only conceptions that are still quite disconnected from the rest, only marginally integrated in the local aetiological system are biomedical ones. In Myanmar, this lack of integration has less to do with the system's cognitive impediments than to the social gap and problematic relationship between medical professionals and patients, and the lack of communication which further hinders the transmission of biomedical knowledge. Yet when these concepts are integrated, they are articulated to the other traditional concepts, notably karma and astrology.Footnote 37
Maintaining health as a daily ritual
In Thandwe, many regular rituals contribute in some way to protect people from illness and other dangers. These same practices are then reiterated in moments of vulnerability such as during childhood, the post-partum period or when the karmic and planetary situation is adverse.
Buddhist devotions
Most laypeople start and end their day with devotional gestures performed at the domestic Buddhist altar. In a family it is often the mother or a daughter who performs these acts, women being held responsible for the family's well-being. These gestures include the offering of food, water, flowers, candles and incense to the Buddha, the ‘taking of refuge in the Three Jewels’, the recitation of the precepts and of protective formulas (payeik), prayers, and for some people, a moment of meditation.Footnote 38 To end their daily devotions, people share the merit they have acquired with all sentient beings by uttering a specific formula. A similar or simplified set of practices is performed at the village pagoda, but the regularity of these visits varies significantly among individuals.
These gestures are understood as a way to pay homage to the Buddha and his teachings, but they are also seen as a powerful means to improve one's present life — including in terms of health — and to prepare for an even better future. They do so by improving a person's karma and power (hpon), purifying her mind, and invoking the help of deities and other powerful beings.Footnote 39 Moreover, some of these practices also contribute to well-being in other ways. Reciting and following the precepts, for instance, supports social harmony, which in turn affects a person positively. Meditating is widely recognised to grant mental stability, calm and, to a certain extent, invulnerability to supernatural aggression. The sharing of merit practice is deemed to ‘help appease malevolent beings and neutralise the forces of nature and thus to protect people from harm’, as the abbot of the Myabin monastery explains.Footnote 40
Donations to monks
A second form of religious practice villagers perform regularly is the donation (ahlu, dana) to monks. Most families make daily food offerings to monks who come through the village carrying their alms bowls. Generally, it is a woman, or the mother of a given family, who does this as she is the one who cooks. In addition, families that can afford it go to the monastery once a month to offer a whole meal made up of their best dishes, to which they might add other gifts (ahlu): yellow robes, snacks, money. Collective offerings are also made on the occasion of larger ceremonies.
In Rakhine as elsewhere, these donations are regarded as a sign of homage toward respected individuals and also as a sign of gratitude and thanksgiving (kadaw) for the services monks provide.Footnote 41 However, offerings are also made for acquiring merit and blessing. Indeed, after receiving donations monks pronounce a formula of loving-kindness, expressing the wish that the donor be healthy, wealthy, and free from danger.Footnote 42
Calendar rituals and monks’ chanting
While all rituals in the annual Buddhist calendar are believed to contribute to the maintenance of societal and individual well-being, there are also rituals performed primarily for their protective function. These consist of the Payeik na and/or the Pahtan pwe, rituals centred around monks’ chanting of the Buddha's most apotropaic discourses. Monks perform these chants during some calendar ceremonies but also on the occasion of rites of passage and when a family, or a person, undergoes an unlucky period. All villagers affirm that this practice is meritorious and especially gives them peace of mind. Although it is undeniable that most people ignore the exact content of the texts which are chanted, as many scholars have pointed out,Footnote 43 I stress that they do know the general meaning. This, combined with the fact that they are the words of the Buddha, is enough to bring them benefits. Yet, there is also another dimension at stake which is seldom acknowledged in the literature. When attending these rituals, villagers always bring along several objects (bottles of water, pots of sand, leaves, cotton threads) to be consecrated. The power of Buddha's words is transmitted to the objects through the monks’ voices.Footnote 44 Villagers then use these objects as protective fences for the house and for the body: the sand and the leaves are spread around the house, the water is placed on the Buddha's altar to be drunk in case of need, the blessed thread is tied around wrists as bracelets as a protection for vulnerable individuals such as children and sick people.
Social harmony and respect for gender and other hierarchies
Respect for social hierarchies, notably those related to gender, is a crucial component of community life which is recognised as very relevant for the maintenance of social harmony and individual health. Men are considered superior to women in terms of their karma and power (hpon). This superiority is translated into and preserved through respect for conventions regarding bodily gestures, positions, and movements which prevent men from being polluted by women.Footnote 45
By disrespecting these rules, a middle-aged man from Lintha (a village in the Thandwe area) explains, a woman ‘falls into hell’ and a man's power and karma are severely reduced, exposing him to various forms of misfortune. Although villagers do not think of these as being religious or Buddhist norms, they still relate them to Buddhism by explaining them through the law of karma.
Protection from the supernatural
Another important aspect of the maintenance of individual health is the preservation of a good relationship with the spiritual realm through respect for specific norms and the performance of ritual offerings. Villagers distinguish two categories of ritual acts associated with two main categories of supernatural beings, the tutelary spirits and the harmful ones.
Nat are tutelary spirits that watch over places where people live, the house, the village, the city, or which they cross during their daily activities, such as the sea, the rice fields, the forest. By regularly honouring nat with alimentary offerings and through possession ceremonies led by professional mediums people try to maintain a harmonious relationship with them in order to benefit from their support and prevent their vengeance which could arise from neglect. For a long time Myanmar's military government considered these practices a form of superstition which did not fit the image of the modern Buddhist nation it wanted to display to the world. Thus the government has led purification campaigns aimed at eliminating these practices especially from tourist sites. This campaign, as well as the growing acceptance of a certain positivistic style of thought, has seen many people abandoning this practice of appeasing the spirits or at least denying their involvement in them.
Other practices relate to harmful supernatural entities such as wandering spirits, spirits haunting territories such as street corners, old houses and big trees, along with hungry ghosts, witches and sorcerers. Most people, especially women, refrain from going out alone at night, when most attacks happen. When they cross places they suspect to be haunted, villagers recite some payeik or other protective formulas hoping in this way to produce an ‘instant karma’ or ‘emergency karma’Footnote 46 or to get protection from some deities or from Buddha himself.Footnote 47 People also protect themselves by wearing amulets but they do so mainly when they know — usually through divination — that their karma is temporarily ‘low’ (nein de). The most common amulet is the lethpwe, a special form of protection provided by exorcists. It consists of a sheet of paper or metal inscribed with esoteric diagrams,Footnote 48in or sama, combinations of letters or numbers referring to Buddhist and astrological concepts further empowered by the recitation of a mantra or Buddhist formula. These sheets are rolled around a string the person then wears around their wrist or neck. These objects are believed to neutralise negative planetary, and thus karmic, influence and to keep harmful beings away, thanks to the power of the Buddhist authority embedded in them. Although most people affirm that Buddhism has nothing to do with exorcist practices, they all acknowledge that the efficacy of exorcism largely stems from the power issuing from Buddhist symbols and recitations, the power of which depends very much on the power of the exorcist himself. This power comes from the practice of meditation and respect for the precepts.
Divination
Another practice which plays a crucial role in maintaining health and preventing illness and other misfortunes is divination. Villagers consult diviners once or twice a year, generally on birthdays, the Myanmar New Year, and for special events such as births, weddings, travel or starting a new business.
In Rakhine, the most common divinatory practices are astrology and divination through the weikza (individuals who have exited samsara through esoteric practices and are thus almost omniscient) or the daywa, nat (deities of the Hindu-Buddhist pantheon) which diviners are able to contact with their mind. Diviners are able to read a person's astrological chart which is supposed to reflect their karma, their fortunes and misfortunes, and to devise strategies for them to benefit from positive moments and prevent negative ones.Footnote 49
Besides amulets, payeik gyo and lethpwe, the most common technique used by diviners is the yadaya, a process which helps prevent or to bring release from harm and misfortune by neutralising negative planetary forces and improving karma. There are many kinds of yadaya,Footnote 50 yet the most common is in the form of offerings made at the pagoda of objects, flowers, candles, etc., chosen according to astrological calculations, in particular on the basis of the symbolic association between days of the week, planets, letters, objects and cardinal points.Footnote 51
Despite the popularity of divination and astrology among villagers, most are reticent to admit that they resort to them and often initially deny doing so, as one explained: ‘I only follow the Buddha's way, this does not concern Buddhism; this is a worldly practice while Buddhism is only concerned with otherworldly aims’, ‘according to the Buddha, you do, you get; yadaya cannot help’. If Buddhism is the criteria used to discredit these practices it is also the one which helps make them more acceptable and diviners considered to live according to the Buddhist doctrine are more trusted and respected because meditation and respect for the Buddha increases the power of their divination and ensures their honesty.
Protecting the body
The only two practices that are strictly focused on the physical body and its elements which aim to preserve the balance between hot and cold are dietary rules and rules concerning appropriate times for taking showers and baths. People should avoid eating food which is too hot or too cold, in general and also according to their own bodily structure and health condition, and should refrain from having showers during the coldest times of the day, that is, before sunrise and after sunset.
In contrast to practices that people associate strictly with indigenous medicine, those belonging to biomedicine, such as immunisation, taking vitamins, and using condoms, are seldom mentioned in conversations about reducing vulnerability to disease, and their use is quite limited. The notion of prevention as promoted by biomedical science, preventing specific diseases by acting on the physical body, seems quite alien to local people. To them, if a disorder ends up manifesting itself in the body, its origin is elsewhere and often involves a plurality of factors.Footnote 52
However, both the people's general lack of understanding of and unwillingness to accept such important disease prevention methods are largely related to the shortcomings of Rakhine's health system and to the problematic relationship between its staff and the villagers. For instance, one woman explained that ‘the nurses rarely go to look for those who do not come to get the vaccination, and if they do, they scold [the villagers] for not coming.’ This attitude has certainly increased resistance against vaccinations and reinforced people's mistrust in public health programmes. Indeed these programmes have long been considered instruments of control and an expression of false paternalism on the part of the Myanmar government and, before it, the British colonisers.Footnote 53
According to Rakhine villagers, the practices they engage in on a regular basis contribute, each in its own way, to protecting them from the risk of illness and other forms of misfortune at the same time as they help them reduce uncertainty concerning their vulnerability to illness. Buddhist methods play a dominant role here. By improving a person's karma and personal power and granting the preservation of positive relations with both human and supernatural entities, they guarantee a wide range of forms of protection in both the short and long-term. Moreover, the Buddhist belief that good deeds will result in good rewards is an essential source of hope for a better future and helps people to cope with their difficulties. Buddhism is also dominant in providing people with a system of values to orient their actions, indicating what is good, reliable, and trustworthy. Yet, Buddhist practices are limited in their capacity to overcome specific problems and uncertainty related to the near future. Hence it is necessary to resort to other practices which are more focused on the short term and on specific kinds of protection. In particular, divination plays a significant role in revealing the factors involved in ill health and in determining the status of karma and the planets, and, if needed, how to act on them. This provides people with a sense of control and agency. However, although para-Buddhist practices are necessary, they still remain inscribed in the Buddhist logic because their efficacy is considered to depend on the afflicted person's karma. Indeed, divination, for instance, can only be effective if the events to be avoided are not the consequence of a particularly bad act the person has committed in one of his/her lives. The efficacy of these practices is guaranteed only if, in the current life, the person behaves according to Buddhist morality.
Restoring health: The process of health-seeking
When it happens that despite the multiplicity of preventive practices in which they engage on a regular basis, people fall sick, they try to find both a reason for and a solution to their problem by resorting to a variable number of practices. Although every health-seeking process is unique, I wish to present a case study to illustrate the complexity which health-seeking processes often entail, and to introduce a broader analysis of this complexity and of the choices people make.
The case of Aye Tan Shin
Aye Tan Shin is a woman living in Lintha.Footnote 54 She resides in a little hut in a compound where she works as a gardener. Her adoptive family lives in Watankwai, the village just nearby. In 2009, when this episode happened, she was 32 years old.
One afternoon in March, Aye Tan Shin was struck by strong abdominal pains which persisted for one week, and, since she was already in town, she decided to appeal to the Thandwe Hospital. The doctors diagnosed indigestion and prescribed medicines in addition to dietary restrictions that permitted rice only. As the treatment failed to cure her, she wondered whether the symptoms resulted from a previous incident where she had urinated under a tree in her garden and consequently dreamt of an ugly figure, which she thought was a bad spirit that was living in the tree, standing behind her. Due to the failure of medicines the family then turned to the village monk, the most popular astrologer in the area and the one Aye Than Shin's family always resorts to. Based on the horoscope readings the monk identified bad karmic and planetary influences affecting her and hence prescribed a reparative offering of rice and water to be made near the street in front of Aye Tan Shin's house. Despite the offering, the symptoms persisted and thus after four days they consulted Ma Shan Aye, a famous divination master living in Giaiktaw, a village near Lintha. Ma Shan Aye made some astrological calculations and mentally contacted a weikza. The weikza informed her that the woman's karma and planets were not favourable and that she had been tormented by a spirit for almost two weeks. The spirit wanted an offering of eggs, rice, and beef to be made that evening near the house. Moreover the divination master gave Aye Than Shin some consecrated candles, incense sticks, and bottles of water and advised her to meditate every morning at 5.
The same afternoon, at her home, Aye Than Shin was possessed twice by the spirit and in that state she shouted, cried, opened her blouse showing off her breasts, and kicked her sister. At 6.30 p.m. Aye Than Shin's sister went outside to make the offerings and then returned to sprinkle consecrated water on her. The spirit left.
The next day, Aye Tan Shin felt better but soon she had low blood pressure, headaches, and pain in her abdomen. She continued to eat light food and to take biomedical drugs as prescribed by the doctors, but she also tried some ready-made herbal medicine she purchased from the small shop close to her house. These efforts being futile, she formulated a new hypothesis based on another previous incident where, after eating a fruit given to her by a neighbour, she had vomited. She now suspected that the food was bewitched. Under the advice of the monk, she and her family decided to seek help from an exorcist living in the remote village of Teiodo. The master started his consultation by invoking the Buddha's and the weikza's help and by reading Aye Tan Shin's horoscope, which indicated that the current troubles had been caused by a witch. The master invoked the witch inside the victim's body and ordered her to bow three times first to the Buddha and then to him. He forced her to promise she would never again attack Aye Than Shin and ordered her to go away. Then he gave Aye Than Shin some consecrated water to drink and provided her with a protective silver sheet inscribed with esoteric symbols. Right when Aye Than Shin's consultation session with the master ended she felt as if she had awakened from a dream. Her sisters commented that it was the witch who had controlled her mind and body from the time she ate the fruit until the witch had been removed from her body. Unfortunately her troubles weren't over. In the coming weeks Aye Than Shin kept coughing and suffered often from fever. Another sister explained this by saying that: ‘My sister is going through an unlucky period; her karma is temporarily low.’
Dealing with (supposed) natural disease
In most cases the symptoms are ambiguous and it is thus difficult to know the nature of the disease and to identify the factors involved. People generally — and Aye Than Shin was not an exception to this — take these symptoms as signs of a natural disease caused by some food they have ingested, by the weather, or simply by a natural variation of the body's elements, and treat it as such. The idea of the possible involvement of karma, the planets, or supernatural factors emerges only if the other treatments fail. In that case, other procedures are resorted to.
In case of minor problems, of chronic diseases, and whenever a specialist is not available, not accessible, or not deemed necessary, people resort to self-medication. This includes home-made remedies (hsaymido, ‘quick fire remedies’Footnote 55), such as betel leaf for treating headache, and, like in the case of Aye Tan Shin, the purchase of medicines in shops. Both biomedical products and manufactured products from the indigenous pharmacopeia are sold in most general and specialist shops, including pharmacies. Licensed shops exist only in towns and cities, while the rest of the country relies on unlicensed shops or shops that have a license for several goods but not for medicines. Herbal medicines in the form of powders, a single ingredient or combined ingredients, are sold in specialist shops that exist in most markets around the country. Nowadays, most people first resort to biomedical products, which, as opposed to herbal products, relieve the symptoms very fast. Yet, many people avoid or resist these products as far as possible given that they have the disadvantage of producing side effects. In fact, there are a certain number of symptoms which people prefer to address with indigenous medicine, notably joint pain, digestive, skin and blood problems, and the majority of chronic diseases. Indigenous medicine is considered particularly appropriate for these diseases first because it is deemed to be free from side effects and thus appropriate for long-term use and, second because it is said to completely erase the sickness, to myet phyat/pyet, to ‘cut/break the root of the sickness’. Anyway, the two systems are not seen as being mutually exclusive and are often combined in practice.
If, in many cases, self-medication through medicines purchased in shops is successful in solving the problem the person is suffering from, it can also worsen it. In fact, this practice entails several risks users are not always aware of: risks derived from the loose character of quality and safety controls and, for biomedical products, risks related to the way the products are sold and purchased. Such products are often sold in single doses, without the original box that indicates the registration number and the expiration date and without the leaflet and usually without instructions or warnings.
Although self-medication is very common there are several occasions where people prefer to consult a specialist, yet not everybody can afford to do so. When symptoms do not diminish through self-medication or when more serious illnesses such as acute diarrhoea or strong abdominal pain occur, people usually consult a biomedical specialist, be this a doctor or a nurse. Overall, biomedicine is appreciated for its modern technologies that allow to ‘see and act inside the body in a very precise way’, as a villager from Myabin put it. Additionally, Rakhine villagers tend to consult doctors for injuries that require surgery. As for specialists in indigenous medicine, they are usually appealed to in cases of chronic diseases, menstrual disorders, paralysis and some forms of cancers, for treatment of which this type of medicine is considered particularly effective. These are all in addition to instances where biomedical practices fail.
Access to these specialists, and to biomedical specialists in particular, is not always easy and even when it is, the inadequacy of the service and the dynamics of the encounter are likely to reduce the chance of the treatment being successful. All my informants complained that local biomedical services are highly inadequate. In the Thandwe Hospital the majority of doctors are general practitioners, while specialists are very rare. The services they can provide include simple operations, basic tests, and X-rays. For more complex procedures such as tissue analysis, ultrasound imaging and major operations, patients are referred to Yangon, which is highly costly and therefore unaffordable for many. Health centres are also understaffed and under-equipped. Health centres are run by a health assistant and a midwife while sub centres are run only by one midwife. Both are equipped to treat only minor ailments such as coughs, fevers and diarrhoea. People also complain that the staff is often absent and even when present they are negligent and sometimes rude, especially to people of low socioeconomic status.
Despite the weak quality of the biomedical services, their cost remains quite high and as mentioned, people have to pay almost all of their medical fees out of pocket. A fisherman from Lintha explains ‘the government supplies hospitals and health centres with medicines and materials intended to be given for free to patients, but these being very limited the staff is compelled to also buy products from outside and charge them to patients.’
Compared to public services, private ones are generally considered a better option because, despite the fact that they are equipped only for treating minor cases, they have a good supply of medicines and doctors are more considerate of patients even though, as everybody states, ‘they don't do it out of loving-kindness but because the money goes directly in their pocket’. The problem here is that these services, especially those run by specialists, are more expensive and thus unaffordable for many people.
While people base their choice on the suitability of the services to deal with their specific problem as well as on economic criteria, they also consider the distance from their homes, as well as the nature and character of the health care practitioners and the degree of familiarity they have with them. Aye Tan Shin went to the hospital first because the pain was really severe and she happened to be in Thandwe.
For those who opt for indigenous medicine the choice is between the more traditional practitioners that operate outside the system recognised by the state and those belonging to this system. Most people in Thandwe prefer those outside the government system. They respect and trust them and sincerely appreciate their practical expertise and skills. The state-recognised practitioners of indigenous medicine represent something people are not very familiar with and, like the biomedical services, these services are seen as lacking in organisation, instruments, and material. Despite this preference for the traditional practitioners, turning to them is becoming problematic. These masters are becoming rare because the new generation is not interested in continuing this tradition and also because their presence is being made obsolete by the growing popularity of Western medicine.
Dealing with illness as a form of misfortune
If, after a certain period of following a medical treatment a patient's symptoms do not disappear, as in the case of Aye Tan Shin, or if, in addition to the disease, the person encounters other difficulties in his/her life, they will start considering the possibility that some karmic, planetary, or supernatural factors are involved and are preventing the medical treatments from being effective. In this case, the person turns to practices and healers dealing with misfortune. In general, most people would first resort to a diviner or an astrologer to know the state of their karma and, if needed, to be prescribed some yadaya or delivered some protective amulets. Some diviners, like Ma Shan Aye, are able to identify whether or not the disease results from supernatural aggression and chase away a minor aggressor. Yet if the aggressor is powerful, like a witch or a sorcerer, the patient will need to consult an exorcist (payagwga hsaya) in order to perform an exorcism, as was the case for Aye Tan Shin. In both cases, economic factors do not seem to be an issue; these specialists seldom openly request payment and people donate what they can afford.
‘Maximising the chances of healing’
Depending on the nature and the gravity, real or presumed, of the disease, and of the availability and accessibility, in geographic, economic and sociocultural terms, of the resources, one's health-seeking process can be more or less complex. Resources can be used in a way which is seldom unidirectional. The more resources are used and the closer the resources are to each other, the more the process translates a need to gain cognitive and pragmatic control on the illness and the uncertainty related to it. This process is also a reflection of a certain anxiety originating from the idea that misfortune is cumulative and contagious in that, if ‘untreated’, it can spread and affect other aspects of a person's life and also those of his/her relatives.
Several authors who have attested a similar phenomenon in other regions explain it by saying that people just try whatever is available to them, without worrying if these choices are incoherent or contradictory.Footnote 56 I depart from these opinions and agree with Pottier who stated regarding Laos, that such a diversity of choices stems from the ‘wish to maximize the chances of healing’ or ‘to solve all the possible causes of the disease’.Footnote 57 By acting on different causal factors they all contribute, at least potentially, to healing as noted by Golomb in Thailand.Footnote 58 Hence, I propose to speak of compound healing, where different layers of therapeutic practices eventually lead — or at least aim to lead — to the final recovery. There is a logic guiding people's choices which is the awareness that there are different possible causes to one's illness and that these might be interlinked in complex ways, and that different kinds of healing or treatment differ in the factors they address and that even when they address the same factors they do it in different ways, which are unequally effective and satisfactory. It must also be noted that some practices, such as divination, for instance, are particularly appreciated — even at a subconscious level — not so much for their efficacy in attenuating the symptoms but because they provide people with an acceptable explanation, or with a certain mastery, agency or, more simply, with hope.
In the event the illness turns out to be incurable or a person dies, karmic actions are considered to be the cause. Karma represents the origin but also the limits of the space of freedom,Footnote 59 the extent to which one can manipulate one's fate, a clear expression of the dominant position Buddhism occupies in the medico-religious field and in the social world in general.
Medicines, especially biomedicine, tend to play a central role in health-seeking processes, rather than in prevention. Because of its availability and the trust people have in its technological and scientific power, villagers are turning more towards biomedicine as a first resort. Yet due to the inadequacy of biomedical services and the several obstacles hindering access to them, people often forgo appealing to them or, rather, fail to find in them the solution to their problems. While this certainly contributes to people continuing to resort to more traditional practices, it is not the only reason why people do so. Indigenous medicine has its own value and seems to address some problems more effectively than biomedicine. Moreover, biomedicine, like indigenous medicine in its modernised version, cannot apprehend either conceptually nor practically the non-biological factors of an illness. Nor are its practitioners able to help people cope with the uncertainties they face. Here, the role played by divination is noteworthy as it enables patients to attribute a meaning to the illness which is pertinent to the person's biography, it provides strategies for them to cope with their illness and predicts their degree of efficacy.
If Buddhist practices, at least the practices performed by a sick person, play a minor role here compared to their role in prevention, they are central to the practices of healers, especially diviners and exorcists.Footnote 60 Only their engagement in Buddhist practices and their contact with Buddhist superior beings allows them to acquire prophetic powers and only the use of the authority conveyed by the weikza, Buddhist symbols, and mantras enables them to win over evil, proving the role of Buddhism as guarantor of the cosmic order. Buddhist practices also contribute to enhancing the power of other practices when they do not determine it in the first place and they provide the healers respectability and legitimation. This being said, Buddhist practices as enacted by the patient, in both present and past lives, remain important as well given that it is the karma produced by their actions which determines the final outcome of every cure.
Conclusion
In their daily lives, Rakhine villagers constantly engage in a plurality of practices and rituals which contribute in one way or another to maintaining health, preventing illness, and to improving their general health in both their current and future lives. This is accomplished by appealing to a plurality of practices that aim to keep the balance within the body and with the social, spiritual, and physical environment. Whenever the balance is upset and symptoms appear, these practices are intensified and others are appealed to, according to processes largely shaped by the social, geographical and economic accessibility of these practices. Even if fewer resources are used in the curative process, the entire panoply remains in the background as potential options. The whole system is also appealed to as soon as the recovery process is over. Indeed, as Thomas Csordas and Kleinman argue, the therapeutic process neither starts nor stops with a specific healing event.Footnote 61 This clearly reflects and indicates that prevention and cure do not differ greatly. In both cases it is a matter of aiming for the restoration of a certain order, the only difference is in the gap between the current condition and the ideal order.
Although from an external perspective many of these practices are clearly of a hybrid nature, raising the question of the limits between categories, notably those between Buddhist and non-Buddhist,Footnote 62 villagers understand and present them as belonging to different categories: Buddhism, medicine, astrology, etc., each with specific, complementary yet hierarchical functions and legitimacy. The very existence of categories is necessary to their understanding of different traditions as connected by complementary relationships and hierarchy and thus to the maintenance of the coherence — and, to a certain extent, the efficacy — of the whole.
Within this plurality Buddhism and medicines, notably Western medicine, have somehow a superior position. For Buddhism this position derives from its being the main religion, supported and promoted by the state, providing the main features of the local cosmology and philosophy which frames the world in which people live operating as a map of, and for, the world.Footnote 63 Buddhism, in this sense, represents and guarantees the order of the universe. It also provides the system of value which gives meaning, orients people's actions, and represents an important source of efficacy and respectability. Further, it sets the limits within which individuals shape their lives.Footnote 64 Buddhist practices are also considered more powerful than others and even condition the efficacy of these other methods. As for biomedicine, its dominant position stems from being officially recognised and supported as the proper method to deal with illness and from its association with modernity and science, which are highly valued. Nevertheless, despite their superior positions, both Buddhism and medicine have their limits, in terms of concepts, efficacy, and/or accessibility, which render them incapable of providing answers and solutions to all health-related problems. It is only by combining them with other components of the system that people can ideally achieve a better and more satisfying mastery of their health and of the uncertainty related to it. Only the plurality discussed above can grant healing, ‘making whole’, to cure, and to save.
The dominant position of Buddhism and medicine, and especially the power attributed to both, explain in some ways the informants’ answers that I started this essay with and which actually seem to express an ideal situation, where one is able to prevent illness by following the Buddha's teaching and cure it with medicine. Those answers do not reveal that in reality the complex interplay between cosmological-aetiological conceptions on the one side, and social, economic and political forces on the other, makes a multiplicity of resources a necessity.
