The social construction of competence: an ethnography of a clinical encounter in a Delhi slum
Nupur Barua (ICCIDD, All India Institute of Medical Sciences)
Paper short abstract:
The paper describes a clinical encounter in an untrained private practitioner’s clinic and explores issues of client satisfaction, perceived competence and ability to perform 'as a doctor' to understand why these practitioners are the primary resort for health services for the urban poor.
Paper long abstract:
This paper is part of a larger study on health systems reform in poor urban neighbourhoods in India, Indonesia and Thailand, with three components to it: a longitudinal household study of disease burden and resort to treatment; a household economic survey; and a desk study of the existing regulatory mechanisms of private practice. In most poor urban neighbourhoods the world over, health service is provided by 'nonqualified' medical practitioners. This is particularly so in the context of Delhi where these 'quacks' make regular headlines in the media in the aftermath of fatal accidents caused by misdiagnoses, and the Delhi government conducts raids in an attempt to shut their 'clinics'. But the fact remains that most of these 40,000 'quacks' continue to practice, albeit in many cases in clinics that bear no signboards or placards. They have their own associations and they constitute the backbone of the 'health service' for the urban poor. In the medical and social science literature these practitioners appear as 'quacks' and have over the years invited a growing body of criticism. While some of this literature suggests social and economic reasons for their existence and why patients resort to them rather than turn to qualified and often 'free' state-run institutions, little exists by way of an ethnography of the actual encounter between patient and practitioner in this context. The present study uses ethnography of such clinical encounters to understand why poor patients resort to such practices and what ensues in such settings. The paper discusses the social construction of competence in a context with obvious inconsistencies and clear indications of a lack of understanding of conditions (like polio, for instance) and the use of diagnostics. Whether the prescription is medically correct or appropriate is moot. While the accent is clearly on client satisfaction, and pragmatic concerns of ensuring a continuing (and sustained) patient base are apparent, there are also larger issues involved - of perceived competence, knowledge and ability to perform 'as a doctor' in a provider-patient setting - that drive the practitioner to perform. Use of detailed narrative analysis shows that the practitioner's main concern is to ensure that the key actors involved are satisfied with the treatment. An ethnographically grounded understanding of the motivations guiding this treatment seeking behaviour and the dynamics underlying the interactions in these clinics is crucial. This is particularly so if there is to be a regulatory framework that would work to protect patients in poor urban neighbourhoods against iatrogenic events when utilizing the private health delivery system.
Ethnographies of medical encounters between Europe and Asia