Well Around The World

inspiring healthcare innovation through medical anthropology and ethnographic research

Cambodia - The pharmacist shaman

At a bookstore in Phnom Penh, we find out some interesting Cambodian cultural titbits: avoid closing business deals on Wednesdays as it brings bad luck; when a cat gives birth people dry and keep the cat placenta in their house for good luck; and it's common for Cambodians to seek the help of a shaman when they are unwell. The latter of course interests me the most. These shamans are called kru in Khmer, derived from the Sanskrit word for teacher 'guru'. The guide book continues “... don't be disturbed if the kru spits on and rubs saliva over your face.” Sounds like an intriguing story for WellAroundTheWorld, so we set out on our mission to find a kru.

 

In Siem Reap we hire a tuk-tuk driver for multiple days to visit Angkor Wat, Banteay Srei and the other breathtaking sites of the ancient Khmer empire. As we get to know our driver Mr L, we stir the conversation towards health and eventually ask him whether he knows a kru. He is surprised about this request but agrees to take us to one.

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A little bit of background: Mr L is 32 years old and a farmer. He is married and has four daughters. His wife takes care of the farm and he contributes to the family income operating a tuk-tuk mostly for tourists. He's been a tuk-tuk driver for seven years and local English classes have helped him to become fluent for his day-to-day business. His fashionable glasses and fluent English let him appear more educated and worldly than he actually is. Mr L took his first pill at age 18. He's only had one experience with needles, that was one year ago when he was given infusions for malaria.

 

Mr L tells us about the options for treating a health problem for local Cambodians: “When you have money, you go to the hospital. When you don't have money, you go and see a kru. Children are different, we can take them to the local Children's hospital. That is free of charge, but a farmer like me can only afford the kru.”

As we are sitting in the tuk-tuk full of anticipation, James and I envision dark alley ways, a place tucked away from the hustle and bustle of the touristy streets of Siem Reap, pots full of herbal medicine boiling over wood fires, strange smells, and a chanting kru performing the spitting ritual.

When Mr L pulls off to the curbside, we stand in front of what looks like a normal pharmacy. Maybe it's got a second room inside where the 'magic' takes place?

Nothing.

It's a normal pharmacy selling Western medicine. The most exotic thing we find is chicken essence soup cubes. What's has happened? Did he misunderstand our request?

Mr L tells us: “This kru is really good. I explain to him what I have and he gives me medicine. Last time I came here I had an upset stomach. I got a tablet and felt better within a couple of days. He is number one kru. I used to go to a different one, but he wasn't any good. This kru is the best.

To Mr L, there is no difference between a pharmacist trained in western medicine and a kru who administers herbal medicines and other rituals. To him, a kru is simply someone who gives you advice and helps you get better. Kind of makes sense, but we can't help being disappointed that we missed out on the kru experience that we had imagined.

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Austria – Save 'fragile illnesses' from medication 'bombs'!

One day in April during our world trip, we had brunch at my friend and former colleague's house in Vienna. Since James and I aren't coffee drinkers, Ina asked us the typical tea drinker question: “What kind of tea would you like?”

Her selection was broad and included quite a few herbal teas, with labels such as Erkältungstee (tea mixture against colds) and Bronchialtee (tea mixture against bronchitis). The latter caught my attention as it was a mixture that was especially prepared for Ina with a handwritten label of all the different kinds of herbs.

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Ina Biechl* relies on herbal teas for non-serious ailments. This tea has been especially prepared for her according to directions from her family doctor. He ordered the pharmacist to mix this blend when Ina had a nasty cough that wouldn't go away. According to her, it helped much better than some of the stronger treatments she'd used in the past. In her words, “why go against fragile illnesses with forceful bombs?” (“Warum mit starken Bomben auf zarte Krankheiten losgehen?”).

European pharmacies and drug stores offer a wide selection of herbal teas. While browsing through pharmacies in Munich, Frankfurt, Vienna, Budapest, Belgrade and Sofia, herbal teas occupy quite a large section of the retail space.

Pharmacy in Vienna, Austria:

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Drugstore in Budapest, Hungary:

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The teas fall under four categories:

1 – What the tea is made of: for example, camomile tea consists of dried camomile flowers.
The cross-section of herbs is coming close to an undergraduate course in botany.

2 – What the tea aims to cure: such as Acid Reflux tea, Rheumatoid Arthritis tea, flue tea.

3 – Which organ, bodily function or body part the tea supports: such as nerve tea, kidney tea, stomach and intestine tea.
NB: most continental European consumers are ok with bodily functions being called out by their names.

4 – the desired outcome of the tea: sleep tea, relaxation tea, invigorating tea .


Ina's mental model of 'fragile' illnesses caught my attention and made me think about mental models for the non-serious ailments in different cultures. It struck me how people in continental Europe view these teas as natural support for the non-serious, the usual and the seasonal ailments that occur regularly. Having grown up in Germany, I view colds as important to my wellbeing. It's natural to get colds and have the body fight through it. It's like an 'update' for my immune system, kind of like running antivirus software on a computer. It takes time and that's ok.

Here in the US on the other hand, where some people don't even have sick days it seems like that having a cold is having a weakness that needs to be fixed immediately. With this background, it makes more sense why there are maximum strength and extra strong doses of potent cold medicines readily available over the counter without having to talk with a pharmacist.

How many days per year do you allow yourself to be knocked out by a cold?
What's your mental model of why you get colds when you get them? 
Why does it seem to be important to some people to have help from natural remidies in their healing process?

 

**After I explained US patient privacy policies to Ina and how I wouldn't include her name or any information that would reveal her identity, she pushed back vehemently. She insisted to have her full name with any quotes I use from our interview. Thanks, Ina Biechl!

 

Vietnam - Southern Medicine: Vietnam's medical identity?

Vietnam seems to have one additional medical framework: Southern Medicine. Our Vietnamese friend Van explains, “while Western Medicine comes mostly in white tablets, Chinese Medicine consists mostly roots and animal parts, Southern Medicine, unique to Vietnam, is herbal leaves.”

It's fascinating to me, how Vietnam's three medical mindsets reflect the geopolitical forces the country has been exposed to throughout history: 1000 years under Chinese rule, French colonial rule and of course US military activity during the American War as the Vietnamese refer to the Vietnam war.  

A people that has been pushed and pulled in so many directions throughout history makes me wonder whether there is such a thing as a 'medicinal identity'. When is it of importance to have a set of remedies that is a true product of one's own culture and people, and not imported or introduced by outside rulers? Are there any studies that have shown a treatment to be more effective when cultural pride is involved, such as developed by culture X for culture X? I China, I've seen this design aspect being played out in consumer electronics and the claim that Chinese understand much better what Chinese need. How about in the health space?

In Sapa and Hanoi, we come across many shops selling Southern Medicine. It seems like they come in clusters occupying entire streets or certain areas of town. Van tells us that each herbal store in Hanoi is owned by a family and that the knowledge is passed down from father to son for multiple generations. We browse through them and they are a mixture of Chinese and Southern Medicine: dried roots, alcohol tinctures, various animal parts and dried leaves. We walk into a couple of them to try and find someone to talk with, but as it turns out the herbalists are busy during Tet (Vietnamese New Year), and the women and teenagers tending to the stores weren't able to answer any of my questions. They only pointed us to the self-explanatory drugs and supplements, such as weight-loss enhancers which are mostly imports from China. It seems that the younger generation isn't that interested in learning the family knowledge. But since the entire country isn't in its representative state, I don't want to draw any conclusions.

Have you had any experiences with Southern Medicine and would like to share your story? I would love to talk with you, please get in touch.

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China - Sheep placenta for grandma

In a pharmacy in Jingu, a city south of Kunming, James discovers an interesting item in the supplement aisle: sheep placenta extracts. The instructions read that this is particularly good for maintaining the health of senior patients.

This seams rather weird to us, and kind of gross.

In the US, walking down a supplement aisle at a Whole Foods store, there are the herbs against colds and other ailments (focus on what it is) and there are the supplements organized by their main ingredient, a vitamin or mineral (focus on what's in it). The only animal extracts, I seem to recall now, are cod-liver oil, but don't these go by the title of Omega-3 et al?

In the end, Chinese eat all parts of most animals and perceive Westerners as wasteful not making use of all organs and throwing away the intestines. So, in the end sheep placenta supplement only points out what Western supplements are missing out on. Or is it that we just don't know where our zinc and potassium is coming from?

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China - Chinese viagra

 

Browsing Chinese pharmacies, there is always a section of dried exotic animals such as sea horses, snakes, bats and penises of various animals such as seals, antelopes and tigers. The pharmacist explains that one places these animal parts together with other herbs and roots in alcohol and then drinks the infusion to improve and enhance one's health. But this is not for everybody, “just for men, to enhance their health” - meaning 'male potency' in Chinese.

I wonder whether this is more a thing of the older generation, as I haven't seen these infusions at any of my Chinese friends' homes. Or is this kept in the bedroom like I'd imagine Viagra would be in the West? Do men buy these for themselves or is this the perfect gift to be received from one's wife? Or even mistress as it is very common for Chinese men to have a mistress? Or, is this something that is only gifted between male friends?

Given the relatively high price for some of these aphrodisiacs and the elaborate packaging options available, my guess is that it's mainly for gifting.

The pharmacist does't quite understand what I am getting at. Will have to find out more about this.

 

 

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China - The bitter-er the better*

I remember on multiple occasions when I was unwell in China, that friends or colleagues would give me Chinese Medicine. Sometimes it came in tablets or capsules, sometimes as powder that just needs hot water to be added, and a couple of times, I have received what looked like pingpong balls covered in wax. When you break open the pingpong ball, a rather large brown something with a pungent smell stares at you, and you just wonder how you'd ever get this thing down your throat. Recently, the pingpong ball packaging has given way to blisterpacks, but the dosage form remains the same. From the pharmacist I learn, that elder folks prefer this dosage form to others. To them, it feels like this medication is really doing something. You have to stick it into your mouth, chew it, and swollow it. The act of taking the medication is definitely more noticeable than quickly swallowing a small tablet or capsule. Is this placebo at it's best? Adding extra effect to an otherwise potent but maybe not as quickly working medication as Western medicine would be? Recently, a study has shown that the act of taking a placebo can have a positive outcome even when patients are aware that they are taking a placebo.

Anyways, to show you more about this dosage form, James helped me document my attempt to take one of them. This one claims to just have general health benefits.
First of all, it's huge. Even bigger than I remembered. Let me break off a little piece. I am breaking rule number 1: stick the whole thing into your mouth. At first it doesn't taste too bad, but then, oh my, there's no way I can take this entire thing. Am breaking rule number 2 as I am gagging and forced to spit it out. I do remember one time though, when I was really unwell, that taking this kind of dosage form had helped me. Depending on how sick I am, am I more willing to endure the nasty experience? And was it the act of taking it and trusting the friend who'd given it to me that unleashed the full placebo effect together with the herbs?

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* Thanks Lucinda! This title is better-er than the original one, 'asking for their bitter medicine'!

China - The Forest Pharmacy

We spent a couple of days in a remote village, climbing a close-by mountain. Eating with the entire family, we also meet the 78 year old grandmother. While she sleeps in her own house, she comes over to her third son and his wife for the meals and is particularly interested in meeting us foreigners. Later we learn, that we've been the first foreigners ever to visit their village. Everyone has seen foreigners on TV and was kind of joking whether we had just walked out of one of their TV sets right into a living room. So many conversations we had focused on how we got to their village from San Francisco.

The grandmother was quite a character. With 78, she was very hunched over but moving around nimbly as a cat. Later we learned that currently she was part of the road construction team, collecting large rocks and filling up the other people's baskets who'd then use the rocks to pave the road. Who would have thought! Asking her about her general wellbeing and health, I learn that she is particularly proud of her teeth. She's still got all of them and this is how she does it: every evening she brews a strong green tea and lets it cool off over night. In the morning she brushes her teeth with this dark liquid. Grandmother's only complaint is her lower back. Not surprising to us, as everyone is bent over the entire day: working on the field, keeping the fire going, doing the laundry squatting down and cooking over the fire.

For her lower back, the village medicine man has told her to brew a tea out of some plants and roots that she collects herself in the woods. Imagine a 78 year old in the US being told by their doctor to go into the nearby national park and collect medicinal plants instead of filling a prescription at CVS.

I feel very fortunate to have met Grandmother and to get her permission to share her story and pictures with you.

 

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China - Technology in Pharmacies for Building Trust

 With pirated DVDs, fake luxury brand goods, and many fraudulent business practices, counterfeit drugs pose another daily challenge in people's lives. Sellers often talk openly about the level of sophistication of pirated goods. For example, a grade A fake Louis Vuitton bag used to cost half the price of a real one when I lived in Shanghai. Some piraters of luxury goods would even praise their skills by telling stories about placing a fake bag into a real store for a day to see whether the sales staff or customers would discover it. Fake medication is of a different matter. Here the sellers always claim that these are real – of course, which customer in her right mind would purchase bad meds for herself or someone she cares about? This leaves customers confused and with the only option: to stay away from small pharmacies as people don't know whether they will get the real drugs or something mixed up in someone's underground lab but professionally packaged. Common stories I’ve heard tell of people taking what they thought was an Aspirin but instead of helping with their headaches they got tunnel vision for half a day. So, large chains and established pharmacy brands such as Tong Ren Tang in Beijing become the trusted retailers.


The pharmacy chain Jian Zhi Jia, meaning Excellent Health in Chinese, has tried to create trust by installing high-tech touch screen-enabled information kiosks in their stores. In theory, you can scan the barcode of OTC medication packages and be reassured that the drug manufacturer is in the pharmacies database and so a trustworthy source. The terminal also offers information in terms of directions of usage, side effects and contraindications. Only some drugs have that barcode, yet, leaving me rather confused. I also wonder to what extent a system like this actually makes me feel less reassured, as the barcode could be slapped on any drugs, with some fake story of a reliable pharmaceutical company somewhere.


From the pharmacist I learn that this is already the third version installed, but people don't like using it. Not even for conditions that might have a stigma associated, e.g. mental and sexual health. (GI health is something people talk openly about in China). People rather talk with a pharmacist or doctor, the personal connection matters much more in terms of building trust, she tells me. Most Chinese pharmacies have a small clinic attached where a doctor for Chinese and Western medicine is available to do check-ups and write prescriptions – another great business strategy. Despite not being used, she claims that the information kiosk does play an important role in the building of trust: it shows to customers that the pharmacy is wealthy enough to afford this piece of technology giving the chain stores an air of trustworthiness. Is this really the case? Unfortunately, I didn’t get to sneak an interview in with a real customer. It was a cold day in Kunming where everyone rather stays at home.

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