Soc. Sci. Med. Vol. 29, No. 1, pp. 43-52, 1989 Printed in Great Britain. All rights reserved 0277-9536/89 $3.00 + 0.00 Copyright © 1989 Pergamon Press pic ACTIVE PATIENTS: THE INTEGRATION OF MODERN AND TRADITIONAL OBSTETRIC PRACTICES IN NEPAL NADJA REISSLAND' and RICHARD BuRGHART 2 * 'Department of Experimental Psychology, University of Oxford, South Parks Road, Oxford, England and 2 Seminar fur Ethnologic, Siidasien Institut, Universitat Heidelberg, Im Neuenheimer Feld 330, 6900 Heidelberg 1, F.R.G. Abstract—This paper describes the integration of modern and traditional obstetric practices in a provincial hospital in the Maithili-speaking area of southern Nepal. The doctors and nurses consciously distance themselves from the traditional practices of their obstetrical patients, whom they view as 'ignorant'; but because hospital resources are insufficient to impose the normative form of modern medical organization, patients and their relatives assert a more active role in providing hospital-based care. In consequence, mothers are delivered according to both modern, clinical as well as local cultural practices. Recent WHO policy has cast modern medicine as the agent in the integration of traditional healing within national health systems. This essay shows that in poor countries the powers of agency may not be exclusively in the hands of the medical profession. Patients, and others in their social networks, have become agents, constraining and negotiating the terms on which modern medicine is to be integrated within their traditional obstetric practices. Key words—traditional and modern healing in South Asia, child-birth, hospital organization, agency and passivity INTRODUCTION In 1978 the World Health Organization called upon member states to integrate traditional healing within their national health systems [1]. Two aspects of this policy are of particular interest. First, the promotion of traditional healers was seen to result from the consciously formulated decision of health planners as agents of modern medicine. Second, the agents of planned change rigidly circumscribed the terms of integration. Certain features of traditional healing, such as the use of native drugs, were thought to be of benefit but only after their efficacy had been proven by the methods of science. The integration of traditional healers and birth attendants into the lower echelons of the state medical system was advocated, but only after the healers had been properly trained in medically approved procedures. In the former case traditional medicine works, but only modern medicine knows why. In the latter case traditional healers are useful as medical auxiliaries, but only after modern medicine has rendered them in key respects scientific and in all other respects harmless. In brief, an ideological boundary, created and defended by modern medicine distinguishes it from traditional healing. Movement across that boundary was to be controlled by the agents of modern medicine. This paper looks at the ability of the medical profession in South Asia to maintain that ideological boundary in the organization of its clinical practice. Our locus of fieldwork is the provinces: the geographi- cal meeting point of modern and traditional medi- cine. Looking at the national health system from top down, provincial hospitals appear as regional centres of modern medicine, receiving referrals from village health outposts and implementing community health • To whom all correspondence should be addressed. programmes. Staffed with surgeons, physicians, nurses and pathologists, who have received training in medical schools on the subcontinent or abroad, the provincial hospital is the place where medicine in its modern institutional setting becomes accessible to local people. A rather different picture emerges, however, when one travels to rural districts and observes the organization of clinical practice. Provin- cial doctors are trained in curative medicine, but recognize that most of the illnesses they treat stem from poverty or 'ignorance'. Their skills are under- utilized; and for job satisfaction, if not professional advancement, they yearn for posting to a hospital in a major urban area. Meanwhile, the resources which come from the centre to finance the hospital and its dispensory are often insufficient. On the one hand, medical staff see themselves as a modern elite, restor- ing health to people who are 'backward', 'supersti- tious', 'ignorant' and 'destitute'. On the other hand, they perceive that their hospital, underfunded and understaffed, is constrained by the very same forces which impede the advancement of the people whom they are professionally committed to healing. Local, 'non-scientific' health care practices enter the provin- cial hospital not as part of a formal government plan to integrate traditional healing within the national health system, but as an admission of the hospital's inability to impose the normative form of their organization which obtains at the national capital. This, at least, is our analysis of the situation which prevails at Janakpur in the eastern Tarai of Nepal. Our research was carried out at the Janakpur Public Hospital, the hospital of referral for the Dhanusa district. The hospital grounds include the hospital with its three wings, a maternity ward, operating theatre and a small conference room and office. The administration is based in a separate building which it shares with the pathology laboratory and the offices 43