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Chapter 4 Caring and curing: the sectors of health care CASE STUDIES Case study: urban shamans in Ulan-Ude, Siberia, Russian Federation Humphrey22 studied the emergence of urban shamans in the city of Ulan-Ude, in the Buryat Republic of Siberia, since the fall of Communism. She describes the post-Soviet city, with its impersonal atmosphere, its shabby concrete buildings, and large anonymous apartment blocks, where most people find themselves living among strangers, instead of among kin. Most Buryats moved into the city from the countryside in the 1960s. This migration, plus the State’s promotion of atheism, and the suppression of Buddhism and traditional spirit beliefs, meant that many lost touch with their rural roots and traditional culture. Once in the city, most had little choice as to where they lived or worked, and this also helped fragment their sense of identity and community. The Buryat shamans that have emerged are mostly city born, and cater mostly for educated clients. They tend to explain illness and misfortune as being due to the client’s ancestral spirits, from the wilderness and steppes beyond the city. They often ask them about their genealogy, in order to identify the offending spirit so that it can then be exorcised or placated. To do this they often encourage them to find out more about their ancestors, and the areas from which they came. In some cases they encourage them to go back to these areas, to a particular mountain or tree where the spirit now resides, in order to perform a special ritual (alban) to placate it. Thus ‘by insisting on these country links, the shamans reconceptualize and segment the city, so that it is now composed of individuals belonging to familial or decent groups, whose origins lie far away.’ In this way, by ‘re-linking individual city people through half-forgotten familial ties with sacred–scary places in the countryside’, they are helping them adapt to their post-Soviet urban reality. At the same time, they help them adapt to the new, bigger context in which they find themselves. In their sessions the shamans evoke not only clients’ ancestral spirits, but also a less parochial and more eclectic range of ‘deities’ such as Archangel Gabriel, Japanese Samurai and even ‘Autopilots of the Cosmos’. Buryat urban shamans act therefore not only as lay psychotherapists and counsellors but by linking clients to their roots, and to a wider context, they also make them more comfortable in the new, anonymous urban spaces that they now inhabit. As Humphrey notes, the shamans’ ‘perception of evil and misfortune in the city implies an awareness of relational flows of spirit power from the outside.’ Case study: sources of lay health advice in Northampton, UK Elliott-Binns103 in 1970 studied 1000 patients attending a general practice in Northampton, UK. The patients were asked whether they had previously received any advice or treatment for their symptoms. The source, type and soundness of the advice were noted, as well as whether the patient had accepted it. It was found that 96 per cent of the patients had received some advice or treatment before consulting their GP. Each patient had had an average of 2.3 sources of advice, or 1.8 excluding selftreatment; that is, 2285 sources of which 1764 were outside sources and 521 self-advice. Thirty-five patients received advice from five or more sources; one boy with acne received it from 11 sources. The outside sources of advice for the sample were: friend, 499; spouse, 466; relative, 387; magazines or books, 162; pharmacists, 108; nurses giving informal advice, 102; and nurses giving professional advice, 52. Among relatives and friends, wives’ advice was evaluated as being among the best and that from mothers and mothers-in-law the worst. Male relatives usually said ‘go to the doctor’, without offering practical advice, and rarely gave advice to other men. Advice from impersonal sources, such as women’s magazines, home doctor books, newspapers and television was evaluated as the least sound. Pharmacists, consulted by 11 per cent of the sample, gave the soundest advice. Home remedies accounted for 15 per cent of all advice, especially from friends, relatives and parents. Overall, the best advice given was for respiratory complaints and the worst for psychiatric illness. One example of the patient sample was a village shopkeeper with a persistent cough. She received advice from her husband, an ex-hospital matron, a doctor’s receptionist and five customers, three of whom recommended a patent remedy ‘Golden Syrup’, one a boiled onion gruel and one the application of a hot brick to the chest. One middle-aged widower had come to see the doctor complaining of backache. He had consulted no one because he ‘had no friends and anyway if I got some ointment there’s no one to rub it in’. Elliott-Binns104 repeated this study 15 years later, on 500 patients in the same practice in Northampton. Surprisingly, the Cecil G Helman: Culture, Health and Illness © 2007 Cecil G Helman. Published by Hodder Arnold, an imprint of Hodder Education and a member of the Hodder Headline Group, 338 Euston Road, London NW1 3BH http://www.hoddereducation.com pattern of self-care and lay health advice had remained largely unchanged; 55.4 per cent of patients treated themselves before going to the doctor, compared with 52.0 per cent in 1970. The only significant changes were an increase in impersonal sources of advice on health, such as home doctor books and television, and a decline in the use of traditional home remedies (although they still accounted for 11.2 per cent of health advice). In addition, the use of advice from pharmacists increased from 10.8 per cent in 1970 to 16.4 per cent in 1985. Overall the study suggested that, in UK, self-care still remains the chief source of health care for the average patient.