Five cases of women from Tubulamo are presented in this subsection, providing insight into the treatment options and preferences of the women who participated in the research. These cases show the types of health facilities the women visited and the different services they used to become well and remain healthy.
The case of Boga illustrated the common preferences followed by many women in Tubulamo when they are ill. The formal public health system was the only option for many women and like Boga, they had positive experiences of public facilities. She said:
My feet started getting cold with itchiness in my throat (neck) and watery eyes. This led to swelling of my throat and my younger sister advised me to get herbs and avoid
taking sweets, because the swelling always increased as I ate more sweets. I could not talk because of itchy throat and watery eyes. I did an X-ray, scan and other tests before I got admitted to the hospital and went through surgery for eight hours. I got 13 stitches and was hospitalised. I now do not have major illnesses except colds and flu.
However, some women, such as Gunua, preferred to use the formal private health providers:
I used to have pains when having my menstruation but did not take any action about it. One day in late 2014 (November) when I was doing laundry, I had very severe pains. So, in December, I went to see my doctor at the private hospital for medical check. The tests showed that I had fibroid in my uterus and required surgery. During my second visit to the doctor, I was advised of the costs (PGK8, 560) of surgery at the private hospital. So I made arrangements with Micro Bank (financial institution) for a loan. Upon successfully securing the loan, I called the doctor and confirmed. In February 2015, I went through surgery and spent three nights in the ward. When I got discharged, I did not come home to the village due to difficulties in moving round to use toilet facilities but spent four nights in a lodge.
Gunua’s case was not the norm, because many women are unable to afford the fees at the private health facilities. Gunua could afford the medical fees, including after-surgery care in a lodge, because she owned a small business in the village. Her case clearly demonstrated that there were options available for women with access to financial resources. Other women use both public and private health care providers. For instance, Gemo visited the private health facility when the services provided at the formal public health facilities did not help her condition to improve. She said:
I had gastroenteritis during one night in March 2015 and was in so much pain. The first choice was to come to Kwikila Health Centre because that is the nearest health facility to me. I was carried into the health centre because I could not walk. But I was told by health workers to go home and talk about my problem because they assumed it was related to a family dispute or sorcery-related, and gave me chloramphenicol and Panadol and return every six hours for injection. However, there was no change. The next day, I asked for referral letter to PMGH and after two days, I went to St Mary’s Clinic in Port Moresby. Because I had only PGK200, I could not afford the scan but the doctor explained the cause of my illness and gave me medicine. I later went to PMGH for scan, X-ray and blood tests, which showed I was anaemic, hence my illness.
These cases illustrate the treatment options taken by many women who use only formal biomedicine. In addition, they illustrate that biomedicine was able to diagnose and treat their illnesses. However, some village women rely on relatives to take them to private health facilities, as seen in Nita’s case. She said:
I fell very ill around early February 2015. My throat was blocked and swollen and I could not eat for two weeks but only drink water. I went to a private doctor and was given medication after tests. But this did not help because tablets were blocked in my throat so I went for X-ray three times but nothing was detected. So I returned home and resorted to prayer. I went again to another private doctor and was put on IV fluid. In just an hour, the drip was finished. The doctor called my brother in and we prayed. Immediately, the blockage was removed and something green came out of my throat. I felt better and returned to the village. However, when I came to the village and went to lie down again in my house, one side of my body started becoming numb from head to feet. My husband called my brother in Port Moresby to come and take me to see a doctor. When I went to my brother’s house, the numbness and sick feeling disappeared. So I came back to the village again. But when I came into the house, I felt numb again. This time I was taken to Kwikila Health Centre and got medication. After this, we had family discussions and prayed. I was healed at the end of February.
Thus, Nita’s illness was treated by using formal private and public health providers and informal healing options, such as family discussions and prayer which is considered to play a role in healing. Biomedical and traditional treatment options are generally combined if an illness is not cured by the first care provider, with the next option pursued being dependent on the individual’s resources. In Nita’s case, her brother was able to transport her quickly to Port Moresby, so she could seek the services of a private health provider and visit the nearest district health facility when she was back in the village and needed help. However, many women do not have family members or relatives who are formally employed and living in Port Moresby, so this option for support is not available and their lives are more at risk. In some parts of PNG, including the Tubulamo area, when an illness is unable to be treated by biomedicine and is understood to be caused by disharmony in social relations, a common option is for family members to sit together and discuss possible causes. In such circumstances, there will be discussion of any grievances with other people and the option of resolving the dispute will be considered (Strathern 1968a; Strathern 1968b).
The widespread dominance of Christianity in PNG means that prayer is a treatment option or combined with taking medicine or using home remedies and other natural therapies, as was demonstrated by the case of Kala. She said:
I had a boil on my left arm, which started from a small spot-like a pimple in 2014. The boil grew big each week with discharge until it grew worse. I got medicine from the village aid post but stopped after two months because there was no change in the sore. The CHW was unable to apply any medicine on the sore because it was difficult. My husband and I resorted to prayer and applied herbal mixture from pawpaw leaves and coconut oil to heal the boil. This took many months and the boil finished in January 2015, leaving me with a scar (see Figure 4.3).
Figure 4.3: Kala’s Scar
Thus, when the formal public health provider was unable to treat her condition, Kala preferred to use informal healing and treatment options, including natural therapies and prayer. Kala lived in a remote village and access to services, including health care, was difficult. She also had three small children, no income and was dependent on subsistence gardening, so it was difficult for her to leave the village and seek treatment in Kwikila or Port Moresby. Kala’s case illustrated some of the treatment options pursued by women in remote Tubulamo villages when they are ill or when their illnesses cannot be treated by biomedicine.
One of the findings of the Tubulamo case study was the coexistence of biomedicine and informal treatment practices. There were two options for treatment under the biomedical
health care system: public and private health providers. The case studies showed that the choice of the health provider was determined by the financial resources individuals had at their disposal. Public health provider was the preferred option rather than the private health provider. Several informal traditional treatment practices were utilised, including natural therapies and home remedies (involving herbs, barks, leaves and other natural objects) and Christian prayer. A second finding was that use of the different treatment practices was dependent on the women’s choices, which were determined by factors such as income, education, age, culture and religion, as well as the perceived benefits of the treatment option pursued. Tubulamo women classified illnesses in terms of their seriousness. They said liklik sik (minor illness) to describe illnesses considered less severe and bikpela sik (major illness) to describe illnesses considered serious, complex and potentially life threatening, such as diabetes, TB and gynaecological-related illnesses. For minor illnesses, such as colds, flu, fever and body aches, they generally used natural therapies, reserving formal biomedicine for illnesses they deemed serious. While the majority of women had several treatment options, there were some women with more limited treatment options available to them. Third, the treatment option used was not linked directly to the women’s health knowledge. For instance, the majority of women trusted biomedicine for treatment but they used informal treatment practices for various reasons. In the case of Nita, there was family discussion and prayer when biomedicine did not cure her illness. Kala could not go beyond the village aid post and seek help from a larger health facility, because of distance and inability to afford the costs of transport and treatment. A few women visited traditional healers for illnesses that biomedicine could not cure and that they considered natural, but this was done secretly because the doctrine of the church in the village prohibited the use of traditional healing. Some Christian churches disapprove of traditional healing particularly those using magic and often label these satanic practices.
Biomedicine and natural therapies were the two major treatment options preferred by the women in this area. However, they did not follow a straight path in any sequential order. As noted earlier, whether a person used biomedicine or other treatment options depended on their assessment of whether the illness was liklik sik or bikpela sik. For major illnesses, the women used formal public or private health providers depending on the factors highlighted earlier, such as access to money and transport. However, natural therapies were utilised before, after and at the same time as biomedicine and the women moved between biomedicine and informal treatments if their illnesses were not cured or if they
were not satisfied with the treatment they had received. Many women made more than one visit to the same formal public health provider or to others. A small number of women chose the services of the private health provider but the majority used natural therapies. Table 4.3 presents the different treatment options that were available and the number of women who used them.
Table 4.3: Tubulamo Women’s Use of Health Services by Type
Type Formal Health Care Informal Health Care Public Private Traditional
Healers Faith Healers Herbal Treatments Over-the-counter Treatments or Pharmacies 22 5 2 0 12 3
Note: Some participants used more than one type of health care provider for the treatment of illness Table 4.3 highlights several significant aspects. First, the greater number of women using formal public health services was consistent with the women’s socio-economic status and sources of income in Tubulamo, with fewer than 10 women having a regular source of income. Second, the two most common informal treatment options that the women used were natural therapies and Christian prayer, because traditional healing was unpopular in the area; half of the women used natural therapies and fewer than three visited a traditional healer as a last resort when the biomedical health provider was unable to treat the illness. Christian prayer was one of the most common options used by the majority of women. Such women did not necessarily visit a pastor or use other treatment options for their illnesses. The combination of biomedicine and informal treatment practices was very popular among the women, with many more women using natural therapies than self- treating by taking medicines bought from chemists.