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Четвъртък, 14 Март 2013 00:00

Providers–Users of Medical Knowledge on the Bulgarian Net

Galina Goncharova

From Personal Responsibility for One’s Health to “Salvation” in Holistic Therapies

 

Abstract: The article analyzes the increasing use of the Internet for medical and health purposes in Bulgaria, which activates and “reinvents” certain Western models of medicalization, related to the popularization and legitimatization of unconventional medicine in the last three decades. The notions of e-health revolution, cyberchondria and healthism, developed in the field of contemporary criticism of the dissemination of medical knowledge, are implied in the local context in order to reveal the interrelation between the growing interest in holistic therapies and the disappointment in the national “democratic” healthcare system. As a result of the analysis of the presentation of local medical agency on the net, the article arrives at the conclusion that the Bulgarian e-health revolution contributes to the construction of a new, postmodern publicity of alternative medicine, but at the same time it is falling out of the evolution of the healthcare services in the digital era.

When sick on the net

What do you do when you have a sore throat, run a fever, or when you catch a bad cold? You go online and discover that you have fallen victim to a flu epidemic, caused by a virus of the A, B or C type. You browse, as if by obligation, through the well familiar “grandma’s cure”: herbal tea with honey and home-made ointments. While searching for something new, you open the website flu.com, only to find out with slight disappointment that it happens to be an advertisement for ImmunoVital. Eventually, you check out the “Flu – treatment” section  of the “Dar” Health Center in an unsuccessful attempt to imagine the “urine enemas” for constipation, recommended along with a three-day starvation diet.

What do you do when you or a relative of yours are diagnosed with Hashimoto’s Thyroiditis? You log onto the web and read diligently through the articles on Wikipedia, Doctor.bg and Pharmacy.bg, written in highbrow scientific style, packed with heavy terminology, which corroborate your background knowledge on contemporary autoimmune diseases. Disheartened by the gloomy prognosis for a life-long treatment, you have the ambition to dig out “everything” written on the subject and find yourself showered with ads for “unconventional therapies” – starting from homeopathy, and magnet therapy, up to the “Emotional Freedom Technique” in Energy Psychology.

What do you do when you want to slim down after the holidays? Unlike your friends (mostly girl friends), the net offers you an unlimited choice of diets together with recommendations for an appropriate fitness regime, dietary supplements and relaxation techniques, which enhance or guarantee the effect of the control over appetite. Having spent hours in choosing the right diet, you realize that you have gone too far when after tens of links you have checked out, you come across the Program “I Love My Body” with item number five in it reading: “Unblocking two of the energy meridians in the body, which according to the traditional Chinese medicine facilitate the accumulation of extra weight”.

The e-healthcare system

The examples above are only a small portion of the cases in which the Internet is used, to put it succinctly, for personal health purposes, not only in Bulgaria but also around the world. The net assists in choosing a hospital and a doctor – with lists of medical experts or with forum posts about one or another (un)successful visit at the doctor’s; it helps with the purchase of medicaments – with websites of pharmacies and pharmaceutical companies offering detailed factsheets with information on the ingredients and prices of the products on offer. It initiates into and enlightens on unique and alternative methods of treatment, endorsing or denouncing certain traditional, scientific or pseudo-scientific views on disease(s). It is precisely on the basis of such examples that journalists and researchers of the contemporary channels of production and distribution of medical knowledge have coined the terms e-health revolution, healthism and cyberchondria. Whereas the first one refers to the political, economical and ethical aspects of the digitization of medical information in view of the optimization of the national healthcare systems, the second and the third articulate the postmodern intuitions about the transgressive practices of the contemporary consumer of medical drugs and therapies, obsessed with the ideal of the healthy, ecological, balanced, optimal way of living. The notion of the high democratic values of the digital format has thus made its way in the framework of social medicine. Thanks to it, people from different regions and of different social status get broad access to expert care and opinion (through references in medical encyclopedias, online consultations with specialists); those battling grave illnesses find solid emotional support (by sharing their concerns in the forums of various groups and organizations); the administering of medical information is made easier and more accurate (by introducing electronic forms and patients’ files). At the same time, e-healthcare is criticized both from the “left” and from the “right” on account of the depersonalization and dehumanization of the doctor–patient relations, or on account of the fact that they exclude specific groups of the population (for example, the extremely poor, living in remote rural regions, who are not educated enough, nor have enough money to take advantage of the high technologies). The problem of the regulation of health agents’ advertising is considered to be just as important, as it brings together the conflicting interests of the state, the corporations and the non-governmental organizations (West and Miller 2009).

The new models of medicalization

Subject to this critique are also the ironic analyses of the addiction to websites and forums on health topics which bring up the issue of the (human and civil) responsibility not of the providers but of the users of medical knowledge on the Internet. The descriptions of cyberchondria fully reproduce literary characters and overdone comedy plots. Similarly to the main character in Jerome Jerome’s Three Men in a Boat, who, having read through the medical encyclopedia in the British Museum, establishes that the only thing he is not sick with is a chronic inflammation of the knee-cap, cyberchondriacs are defined as healthy people who imagine to be ill after browsing the Internet, or people “who are ill but after trawling the net with their symptoms decide they’ve got something far more serious than they have, so a stress headache becomes a secondary symptom of a pork tapeworm.”[1] The term won high media popularity with the study by Ryen White and Eric Horvitz at Microsoft’s research department, who analyzed a representative sample of web searches of disease symptoms on the Internet.[2] Unlike cyberchondria, healthism has a longer history and is not directly linked to the specifics of the process of adapting to the “digital era”. It was introduced by the political economist Robert Crawford in 1980 to denote the model of medicalization imposed in America in the 1970s, which “situates the problem of health and disease at the level of the individual”, in other words, which inculcates personal moral responsibility for one’s medical treatment and keeping up a sound (psycho)physical condition (Crawford 1980). Both Crawford and other researchers associate healthism with the holistic and integrative concepts of the harmonious unity between body and soul, narrowing down the reasons for the illnesses to leading an inappropriate way of life (Bendelow 2009), ranging from low self-esteem, suppressing emotions, etc. to lack of physical activity, and wearing clothes in gloomy colors. In as much as the net offers an unlimited, global choice of lifestyles, it also caters to healthism as one of the leading consumerist ideologies of the present times.

E-health revolution in the Bulgarian way

Is Bulgarian society going through an e-health revolution, and does it have its local specificities, which align it with or set it apart from what is happening on a world scale? The obvious fact of the more and more common use of Google both in the world and in our country as a medical encyclopedia or as a substitute of the general practitioner is not sufficient enough to draw compelling parallels. To say the least, the quality of the digitalized medical information is completely different. Whereas a European or an American has access to the outstandingly rich libraries of prominent universities and centers, under the section “online medical library” the Bulgarian user will find a topic on kaldata.com, where links to the very same libraries are provided, quite naturally ignoring the collections of the local universities whose websites only refer to paper-based publications. Whereas in America and England the system of electronic medical archives has been in place since the 1960s, showing a tendency for a growing control of the patient over the presentation of his health status (Frazer 2002: 103), in Bulgaria the promised in 2009 health portal with 40 thousand filled-in “electronic personal ambulatory cards” of civil servants has not been launched yet, or at least is not yet visible on the net.[3] Parallels should rather be sought along the lines of the associated phenomena – cyberchondria and the propensity for holistic health systems. The existing Bulgarian websites on medical topics only give some basic “rating” information on hospitals and experts in the country, to a large extent resorting to popular science materials. Puls.bg – “the biggest Bulgarian health portal” – offers an up-to-date directory of the medical establishments, pharmacies and legislative initiatives in addition to an abundance of advice and commentaries pertaining to a wide range of symptoms of bodily (dis)comfort, arranged in the following sections: “diseases and medical conditions”, “drugs and homeopathy”, “nutrition and fitness”, “beauty / cosmetics”, “sex and health”, “emotional health”, “pregnancy / children”, “green living”. In general, even when surfing at random on websites with medical content, you would notice the snowballing supply of “ecological”, “(un)conventional”, “non-toxic” methods for curing all sorts of ailments and discomforts – from ads for magnetic bracelets for insomnia up to recommendations for prophylaxis of women’s diseases by avoiding “anything that causes blood and stagnation in the abdomen and in the liver, and constipation”[4]. The descriptions of these methods not only “enrich” the common views, concepts and notions of health and illness of the non-medics, they literally colonize and assimilate the virtual terminological corpus and professional realities of the scientific or the conventional medicine. The Bulgarian web has been taken over by commentaries on vitamin-rich diets, programs for “boosting the immune system” and prescriptions on how to regulate the “body balance”.

Holistic Doctors and Unique Therapies

Healthism as a mode of alternative knowledge on strengthening and improving the psychic-and-physical condition of the individual pre-determines the way specialized information is handled and structured, oftentimes lending it an anecdotal form or marginalizing it under sections for unconventional therapies. Thus, on Лекар БГ on the webpage with the logo “Tell me, Doc!”, evoking associations with online consultations, one finds small-print announcements for articles on anesthesia during child labor, allergies to metals, alopecia, etc. Next to them, in large print, one finds reviews of homeopathic drugs and opinions of “holistic doctors” about “green energy, colastra, and EFAs”[5]; and in the upper banner there appear photos of people telling stories about their miraculous healing with the help of the “unique herbal combination” Demir Bozan.

The electronic “business cards” of that particular combination, striking with respect in terms of their sheer number and variety, are representative of both the mechanisms of successful marketing of a Bulgarian trademark of health products, and of the complex trajectories of the medicalized imagination of the local user. The ads for Demir Bozan appear on almost all health websites, YouTube and “yellow” electronic publications. In these ads doctors and patients of all ages and lines of work share their enthusiasm for the “secret herb of the hodjas” (offered in packs of 90 filter bags for the price of 43 Bulgarian levs) which helped them to lose weight, lower their cholesterol levels, or recover after a stroke. In addition to a website and a Facebook page, the “miraculous drug” has opened up an individual topic in the BG-Mamma forum (read 34 137 times), where the ingredients of the tea are debated over with Latin names, geographical references and scientific sources, and the options alternate between sumac, devil’s eyelashes (Tribulus terrestris) and meadow rue (Thalictrum minus).

facebook.com_screen_capture_demir

 

The diseases of the transition

Leaving aside the vast subject of the unregulated advertising of health products on the Bulgarian web, it needs to be clarified that in its Bulgarian version healthism is not the only form of medicalization which complements and expands the national healthcare system or provides yet another field for giving expression to consumerist passions. Rather, it appears to be resistance “from below” against the system, against the (un)regulated by the law health services, the uneven liberalization of the medical market, the National Healthcare Fund… against “the diseases of the transition” towards “a European, legal and social state”. The local context of heightened public attention and critical attitude towards the establishment of democratic institutionality, respectively – towards the reorganization and optimization of the hospital network, the consulting rooms, the pharmaceutical industry, dictates the striving towards the emancipation or appropriation of medical authorities, along with the growing interest in holistic concepts. Healthcare in our country is more than an individual responsibility. It is under this imperative that alternative elites of the “true” knowledge about the dysfunctions of the individual and collective body come into being. It has to do with New Age gurus and communities with exotic Internet profiles, providing “cure” for the psychoses of civilization, as well as with advertisers tempted by the topic, bloggers, members of informal groups, groups of friends and forums of popular newspapers, who share their disappointment with the “local medical reality”. The Natural Energy website offers algae products by AquaSource for coping with the stress of the economic crisis. Again, the economic crisis and the critical attitude towards the health reform carried out in the country are the major motives for the creation and online presentation of Dom-Zdrave Ltd. “volunteer health network”. The representatives of BG-Mamma not only demonstrate their competence in herbs, but they also compile “black lists” of doctors, educate in professional jargon, try out and debate over the merits of silver water, the Buddhist Diet, the Iridodiagnostics, acupuncture, etc. In the local, unofficial e-network of medical (mutual) aid, even cyberchondria loses its negative connotations. Thus, on the website of the Psychical Center one can read a translated article on the potential of web search engines to “escalate medical concerns”, surprisingly ending with the statement that “you shouldn’t rely on Internet only, however, it wouldn’t hurt checking out on the Internet too”. A major argument in favor of such an interpretative turn is the case with person X who has been taking antibiotics for angina prescribed by his GP for years, only to find out after a consultation with “Doctor Google” that the swelling of his tonsils is due to a seasonal allergy and to have it confirmed after a difficult-to-arrange appointment with an allergist.

The great healers on the net

The Bulgarian cyberchondriac is not a healthy person who falls ill on the Internet but a sick one who recovers, or at least, one who is filled with hope for recovery after a negative response from the Health Fund, from general practitioners and referrals to specialists, after inaccurate and obscure diagnoses and pricey drugs. These are replace by vivacious programs, smiling pictures of homeopathic doctors, chiropractors, or radiesthesists, promising ads for one-time full check-ups in clinics of integrative medicine, cheap and easy to follow “grandma’s recipes”, instant and fascinating diagnostics of the energy body over Skype. The salvation, or rather, the escape from the “local reality”, goes through the feeling of awe for nature, the emotive return to the “folk” traditions, and the pedantic interest taken in “the newest trends” and “unique methods” at the same time. Thus, in the e-category “great healers” one finds garlic, water, lucerne, honey, red wine, Peter Deunov’s disciple – Ivancho Kazhelov, Deunov himself, Peter Dimkov, the founder of Reiki Mikao Usui, the father of homeopathy, Dr. Samuel Hahnemann, the color essences of Dr. Edward Bach. Not less passionate than those on Demir Bozan are the comments on the net, incited by the InSighting Breath Intensive (IBI), introduced as a psycho-therapeutic practice in Bulgaria by Dr. Dimitar Tenchev. It fully meets the requirements of even the most demanding cyberchondriac. An admirer of his recounts how she couldn’t find the courage to set up an appointment with Dr. Tenchev and spent six months studying his website, so as eventually to “get” to her first seminar in breathing and to discover that “everything else is transitory and unreal, it disintegrates and dissolves when confronted with the power of the spirit that everyone carries within”.

The (non-)expert publicity of alternative medicine

If one can speak about an e-health revolution in Bulgaria at all, then it is inseparable from the popularizing and legitimizing strategies of the unconventional medicine. When discussing the 1980s and 1990s spiritual therapeutic movements in America, Marc Galanter focuses specifically on the main interpretive and organizational schemes which attract hordes of supporters. These are: the departure from the field of empirical medicine, the promises for alleviating the suffering, the call for self-realization, attributing efficiency to metaphysical and intangible forces, turning the sick into mediators and missioners of the unorthodox knowledge on health (Galanter 1999: 188-194). Those who opt for joining the sessions in intensive breathing, start their activities with Dr. Tenchev’s assurance that they would pull together “their shattered personality” and start “being themselves”, and end the session sharing “visions” from previous lives and enthusiasm about the feeling of complete re-birth and spiritual change, willing to recommend the therapy to all their friends and relatives.[6] Another important feature of the alternative therapies is the interplay between expert and non-expert discourses. According to Kathryn Hughes “defining ‘health’, ‘illness’ and ‘recovery’ is a process in which both patient/user/client and practitioner are involved in CAM[7] and where the patient/user/client has responsibilities in participating in the ongoing diagnostic process, developing criteria for success of treatment in synchrony with the CAM practitioner and negotiating around definitions of ‘health’, which do not necessarily relate to those used in other medical models” (Hughes 2003: 44).

The dynamic exchange of health attitudes and notions is explicitly articulated on websites such as that of Dr. Milen Hristov, where the interested reader can read through a number of clinical case studies and examine how, for example, in the course of a two-year trial of homeopathic treatment a patient suffering from multiple sclerosis improved his physical vitality and came to the conclusion that “his quality of life bettered”. In the electronic pharmacy Framar in addition to drug factsheets, the user has the opportunity to familiarize himself with the personal experience of experts and laymen, to vote on topical health issues, to read articles from a medical encyclopedia. This specific cultural situation of “negotiation” between those being treated, and those who provide treatment, between providers and users of medical knowledge on the local net in the recent years to some extent “calls to mind” the media attacks of the Bulgarian doctors’ guild against the traditional folk medicine at the turn of the 20th century – however, with several significant dissimilarities.

The public contract in the medical sector – before and now

What happened in those times? In the first years after the Liberation the reorganization of the institutional system inherited from the Ottoman Empire in line with the new civil governance spread over all spheres of public life, including the healthcare services and the regulation of the medical practice. The first acts and regulations explicitly outlawing the medical practice of individuals “who do not hold a diploma or a certificate from a medical faculty, or who have not presented such to the Medical Board” (Temporary regulations for the organization of the medical sector in Bulgaria, Chapter 4, Article 39) and opening a great number of public jobs for graduates of European universities made many Bulgarian medics come back from abroad and to seek realization in their native country. However, instead of heading forward to the projected bright future for the profession, they encountered the centuries-old authority of the local healing traditions and the unconditional trust of the population in the medical skills of medicine-women, witch-doctors, herbalists, and healers practicing blood-letting, chakrakchijstvo (a form of traditional manual therapy), etc. The situation was resolved by mobilizing new, modern, expert-based publicity which delegitimized the extremely positive and resistant image of the folk healers. Specialized newspapers and journals (the most popular one among them being Medical Talk) started to be published, in which the “deeds of the self-proclaimed medics and charlatans” were exposed and achievements of “science and civilization” such as the carbolic alcohol, the discovery of the tuberculosis bacillus, or the electrical installations “for healing various neurological, neurasthenic, etc. diseases” were presented in popular language. Thus the boundaries between the empirical and the vernacular medicine, between professionals and paramedics, between well-read educators in the science of health and disease and ignorant clients/patients/addressees of medical knowledge became clearly outlined.

What is happening nowadays? The merging of “democratic changes” and “economic crisis” in the medical sector has created conditions for the appearance of healthist ideologies and for the emergence of new health agents who need to prove their merits to the established model of medical services. Informed patients and “great healers” on the Internet are faced with incompetent doctors, inaccurate and deficient diagnoses, “risk factors of the contemporary way of life”. In contrast to the indifferent and formal attitude of the medical staff in the public hospitals, they eagerly elucidate the benefits of the alternative methods of treatment – the “non-invasive regulation of the bodily functions” in the SCENAR therapy, the detoxifying qualities of magnesium, “the dissolution of negative energy” with the help of coded aroma sticks. They translate the scientific terms into plain language; they guarantee with personal experience the (un)successful outcome of a given treatment and bring to light the profound existential foundations of health self-education. A specific media space is thus formed, which combines the characteristics of the “cult environment” (“unorthodox science, alien and heretical religion, deviant medicine” (Campbell 2002: 14)) and the global public forums (of the contemporary social movements). The boundaries between alternative and traditional therapies, between doctors and patients, between users and providers of medical knowledge, are blurred in it. In this sense the e-health revolution in Bulgaria is to a larger extent linked to the construction of the new, postmodern publicity of alternative medicine, rather than to the evolution of healthcare services in the era of high technologies.

 

Bibliography

Bendelow, Gillian. 2009. Health, Emotion and the Body. Cambridge: Polity Press.

Campbell, Colin. 2002. The Cult, the Cultic Milieu and Secularization. – In: Kaplan, Jeffrey and Helene Loow (eds.), The Cultic milieu: Oppositional Subcultures in an Age of Globalization. Chicago & London: University of Chicago Press.

Crawford, Robert. 1980. Healthism and the Medicalization of Everyday Life. – In: International Journal of Health Services, 3, pp. 365-388.

Fraser, Hamish. 2002. Clinical information and decision support systems. – In: McKenzie, Bruce (ed.), Medicine and the Internet. Oxford: Oxford University Press.

Galanter, Marc. 1999. Cults: Faith, Healing and Coercion. New York: Oxford University Press.

Hughes, Kathryn. 2003. Health as Individual responsibility. Possibilities and Personal Change. – In: Tovey, Philip, Gary Easthope and Jon Adams (eds.), The Mainstreaming of Complementary and Alternative Medicine: Studies in Social Context. London & New York: Routledge.

West, Darrel and Edward Miller. 2009. Health in the Internet Era. Washington, DC: Brookings.

 
 
Galina Goncharova is Assistant Professor at the Department of History and Theory of Culture at St. Kliment Ohridski University of Sofia. She has a PhD in sociology, anthropology and cultural studies. Her academic interests include modern history of culture, social history of medicine, sociology of generations and sociology of youth culture. She has participated in projects on modern identities at the Centre for Advanced Study in Sofia, as well as in oral history projects (МICROCON, AHRC/ESRC Religion & Society – Third Phase, etc.).
 
 

[1]  See Are you a cyberchondriac? [15.01.2012].

[2]  See http://en.wikipedia.org/wiki/Cyberchondria [15.01.2012].

[3]  Atanasov, Nasko. 2009. Popalniha parvija lichen ambulatoren karton [The first personal ambulatory card was filled in]. [15.01.2012]

[4]  The recommendation comes from the website zdrave.org – it is a quotation from Peter Deunov’s Bulgarian Folk Medicine. See <http://www.dunov-knigi.com/balgarska-narodna-meditzina-p-432.html> [15.01.2012].

[5]  EFAs – essential fatty acids.

[6]  See Tsareva, Tsvetana. Dishaj! [Breathe!] <http://www.temanews.com/index.php?p=tema&iid=256&aid=6218> [15.01.2012].

[7]  CAM – Complementary and Alternative Medicine.

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