The Ambiguous Authority and Cultural Economy of Vernacular Biomedicine at Retail Pharmacies in Bangladesh

Abstract

Drawing on fourteen months of ethnography in urban and rural locations in Bangladesh, in this thesis, I reveal how biomedical authority has been vernacularised and reinvented by a different group of practitioners of biomedical practices beyond state health and biomedical legitimacy. Apart from qualified registered physicians in Bangladesh, various unauthorised biomedical practitioners like medical assistants and non-medical workers (dispensers/pharmacists) are active in retail pharmacies. In addition to formal physicians, people also rely on pharmacy owners/operators, called daktars (doctors), who practice and prescribe as practitioners of biomedicine in retail pharmacies. Despite their government-unauthorised status, pharmacy daktars remain a popular choice because they offer competitively cost-effective primary healthcare such as free or low-cost consultations, treatments, health check-ups (including pregnancy care), urgent first aid services, home visits, referrals and flexible payment options. I show how the perceived biomedical and actual cultural 'authority' of practitioners, in reality, is neither homogeneous nor universal, irrespective of state legal authorisation. Unauthorised pharmacy practitioners operate under varying legal-rational statuses and biomedical frameworks, where a cultural-moral economy of healthcare constitutes their performative and charismatic role as the transformed and readopted authority in vernacularised biomedicine. Their unauthorised identity and existence are influenced by political, cultural and economic factors such as health and drug policy loopholes, corruption of health governance, and aggressive pharmaceutical marketing. The broader level of corrupt practices in the formal sector (e.g. Gift-Bribe-Corruption triangle) also influences the informal sphere and unauthorised biomedical practices. Such inducements drive 'mental corruption' (Chouhan and Sarma, 2020, p. 214), leading some pharmacy daktars to perform unskilled prescribing, treatments and uncontrolled drug dispensing for profit, raising public health concerns. Simultaneously, the political economy of healthcare forces them toward unethical strategies to negotiate their illegal status, such as bribing or using proxy pharmacists. However, pharmacy daktars persist and thrive largely because they provide needed and wanted services to the people, suggesting that it is crucial to recognise their contribution to primary healthcare. I conclude with recommendations that pharmacy daktars can contribute better and strengthen the mainstream healthcare delivery structure as a supporting workforce if their status is legalised, and they are trained and supervised effectively.