Rabeya, a village woman in her mid-40s, had been suffering from severe itching all over her body for a long period of time. Looking at the symptoms of rash, itchy hands and eyes, and swelling, she initially thought it was an allergic reaction. By the time I reached Vanggonpur for my field study, Rabeya already had consulted two doctors at a medical college hospital in the nearby city. One winter morning after I had begun fieldwork at the hospital, Rabeya arrived to consult a doctor for the third time. I joined her at the main entrance of the hospital. She arrived at the clinic at 9 a.m. but the doctor had not yet appeared. In the hospital premise more than 15 other patients like Rabeya were waiting for the doctor. The doctor arrived at around 10:15 a.m. On his arrival, a gatekeeper directed all the patients to line up in a queue. The gatekeeper seemed to be very strict in maintaining discipline. As soon as the doctor went inside his clinic, two pharmaceutical representatives entered his room and stayed there for ten minutes. Three more sales representatives then followed the first two into the doctor’s room and spent almost half an hour with the doctor. As Rabeya was standing first in the queue, she expected to get a call from the doctor soon. Meanwhile, the gatekeeper informed the patients waiting in the queue that, the doctor was busy with paperwork so all the patients would have to wait. In the meantime, one patient queue-jumped and went straight in. Another patient complained about this but the gatekeeper answered: “What’s up? He is a member of the hospital staff so he will be given the first priority”.

Finally, Rabeya was called inside. “What’s the problem?” the doctor asked Rabeya and she replied: “Itching, itching in the skin. I have been suffering from itching all over the body for many days and these are my previous prescriptions”. The doctor listened to Rabeya and had a quick look at the prescription. Afterwards, he advised her to continue the medicines prescribed in the existing prescription by just saying: “There is no need to alter the medicines”. While Rabeya was still in the doctor’s room, he called a male patient in. The patient took off his shirt and said: “There is a bit of improvement”. The doctor looked at the man’s body for a few seconds. On observing this, Rabeya partially removed her dress to reveal her lower back and then requested the doctor to have a look at her rash as he had done for the male patient. She said: “I cannot tolerate it anymore. I want to get relief from this unbearable suffering. Please take a proper look”. The doctor was annoyed but looked at the rash for a moment and advised her not to eat prawns, beef and Ilish fish. In the meantime, another patient entered the room. I said to the doctor: “Rabeya is very poor. Her condition causes her a lot of sufferings”. The doctor responded: “Ok, I am changing the medicines, which will cost less”. But Rabeya wanted certainty: “How long do I have to take these medicines to be cured?” “It may be 10 or 15 years, or as long as you are alive”, the doctor replied.

After leaving the hospital, Rabeya looked for a pharmacy where she could buy ashol (genuine) medicines. She was concerned about the vezal (adulterated) medicines available at the market. She asked me if I knew any of the good pharmacies in that location. She had no idea about the price she would be charged for the medicines: she said, “I need to buy medicines from a good pharmacy, a pharmacy that actually sells ashol medicine without alteration. But if I purchase from a local pharmacy, there is a possibility that they will alter the medicines and substitute it with koma [substandard] medicines and that won’t work properly”. Later with the help of a health provider I knew, Rabeya could buy the correct medication from a pharmacy. Following this, she continued to take the medication for two weeks although there was no improvement in her health condition. Moreover, the medicines were very expensive for her that caused much stress on her. Having no alternative, Rabeya decided to go back to one of the village doctors who had treated her before she visited the doctor at the hospital. On hearing of the current health problem, the village doctor remarked: “My medicine will give you temporary relief, but this is not a permanent solution. It is better that you go to a specialist. If you wish, I can fix an appointment with a valo [reputed] doctor”.

Rabeya agreed, despite being concerned about the doctor’s fees and other costs. She had been widowed and was working as a day labourer to survive. Sometimes she had to depend on her young son for support. She borrowed some money from her neighbours and decided to visit the specialist with the village doctor. As requested, they informed me about the appointment so that I could join them. The specialist doctor worked in a private clinic that was located very close to the hospital. With patience he listened to Rabeya and the village doctor, checked the previous prescriptions and said: “You are a victim of maltreatment. You are actually suffering from malnutrition but you have been given the wrong treatment and that made the disease more complex. You will be cured but it will take a longer time”. However, the doctor did not examine her body at that time and advised her to undergo four diagnostic tests. On hearing this, Rabeya became worried, not because of the disease, but rather about the cost of the tests. Later, following the advice of the doctor, Rabeya purchased the new medicines prescribed by the doctor and continued for a month but her health condition deteriorated. Thus, there were no bounds to Rabeya’s sorrow. She did not know where to go, or how to get proper treatment for her health problem. Even if she did find somewhere to treat her, she might not be able to afford it anymore.

This narrative gives a brief picture of public and private health care services, of the roles of informal village doctors and how they communicate with formal health providers, and articulates concerns about the quality of pharmaceuticals available to people like Rabeya. More crucially, the account describes the uncertainty and sufferings that Rabeya and people like her experience at several levels within the biomedical health centres in rural Bangladesh. Specifically, the narrative illustrates how rural people experience long periods of suffering, multiple providers’ uncoordinated actions, long waits for consultations, disrespect from the care providers, corporate dominance, gender disparity, seemingly random diagnosis and prescriptions, concern about the quality of medicines, the need to accumulate money by means of loans to obtain health care and the helplessness of patients who have nowhere to turn. Against the backdrop of this narrative, this research aims to provide a comprehensive picture of the way in which biomedicine has been localized and established in local medical systems and how this is influencing the health seeking behaviour of the rural people in Bangladesh. My work reveals how rural people struggle to have access to biomedical health care from both the public and private health care sectors. I have found the domination and privatization trends of biomedicine in rural Bangladesh, as well as its expansion in the lives of the local people and culture, as a part of the modernization of health care. I conclude that biomedicine has not only been localized in the local landscape of health care, but has also intensified the existing social inequality in rural Bangladesh. Thus I aim:

Biomedicine was introduced in the Indian subcontinent, including Bangladesh, during the nineteenth century. Local people tended to accept the new medicine as a useful addition to their current practices, rather than to connect it to the political and commercial intentions of colonialism and its legacy (Dirks, 2001). However, over time, the meaning of biomedicine began to change because of its multiple forms, increasing domination, and influencing the political economy of health care. Almost all of the health projects in the country are now based on biomedical knowledge, and considerably financed by donor agencies. Thus, in practice, almost all governmental policy-making and activities aim to promote biomedicine, by justifying this on the grounds of becoming modern and, specifically, for developing a modern healthcare system. Moreover, the guidelines and actions of donor organizations have been directed towards the advancement of private health care sector (Rahman, 2007). The World Bank (2003: 55) suggested that, “the Government should initiate an aggressive policy to encourage private investment in the curative health care sector”. With this end, the government is suggested to support and ensure a suitable atmosphere for domestic and outsider investors in private sector health care services, contributing to the already flourishing neoliberal economy. As a result, the health sector is becoming increasingly privatized and the business on health is growing rapidly. Thus, biomedicine and its practitioners are seemingly being given a relatively unchallenged space for domination in the healthcare system.

The country’s experience demonstrates that, its health policies and implementation depend on the national and international political context (Reich, 1994). This is favourable to pharmaceutical companies and to the intentions of both the global and domestic NGOs of biomedicine which predetermine health policies. It is thus important to understand the nature of biomedicine, and the way in which local people experience the biomedical care system in a particular cultural setting in the light of existing health policies. This research reveals how biomedicine influences the health seeking behaviour of rural people. By employing a political economy of health approach, this research gives an account of these issues in the sociocultural and economic contexts of rural Bangladesh.

My focus is on a rural community: 72% of the country’s population live in villages (MOHFW, 2012). I explore what kinds of biomedical health care are used by the villagers in order to assess the relative importance of biomedicine(s), as well as attempt to ascertain whether this global medicine is always accessible to the local people or not. I assess the nature and approaches, as well as local peoples’ experience of biomedical healing in relation to power relations and the capitalist world system through this case study of rural Bangladesh. I have been inspired to conduct this research, because very little ethnographic works have been previously undertaken on the nature of biomedicine in the context of rural life in Bangladesh. Thus, it is expected that in addition to being an academic contribution, the findings of this research could be used by the relevant policymakers in their assessment on trends and strengthening of policy implementation pathways in rural Bangladesh. Moreover, as a rich and detailed ethnography where very little enlightenment existed, it is expected that this research would contribute to further understanding of the idea that “modernities” are multiple (Eisenstadt, 2000), and add to the theory of ‘plurality of biomedicine’ (Hahn & Kleinman, 1983) which suggests that biomedicine becomes altered significantly in terms of clinical practices, medical theories and therapeutics when it is ‘re-adapted’ (Gaines & Davis-Floyd, 2004). Thus, this work contributes to an understanding of how biomedicine becomes culturally localized and what consequences this might have in a Third World country.