Shifting Medical Bottles: In Between Medical and Indigenous Worlds
Johanna Gonçalves Martín
Keywords: preserving, separating, holding, measuring, dosing, transporting, healing, encapsulating, covering, protecting, encompassing, wrapping, packaging, separating, containing, enveloping
A seemingly simple exchange habitually takes place in the health posts in the Upper Orinoco, Venezuela, where many Yanomami live. Yanomami people come to a health post when ill and receive from doctors a variety of medicines in different presentations. Some of these are directly applied at the health post, being injected, nebulised for inhalation, or given as a single dose of medicine to be ingested right away. But very often, Yanomami patients receive a small bottle with liquid medicine, or a box containing blisters with many pills, and they are instructed to take them at home at specific times and in specific doses. An extensive amount of anthropological work has paid attention to the exchange of these medicines. Adapting the concept of ‘social lives’ (Appadurai 1988) to medicines, researchers have examined how medicines shift along ‘regimes of value’ as they go from being part of scientific research, to market commodities or healing technologies distributed to health centres and pharmacies, until they are finally prescribed to patients who will ingest them in order to experience some bodily effect usually associated with healing (van der Geest et al. 2003). These are important points in thinking about medicine as a thing, and in uncovering its multiplicity across societies. However, another constitutive element of medicines has remained relatively unaddressed, namely, its artefacts of containment. What happens when pots, boxes, and blisters travel across societies?
Pharmaceuticals never come on their own but need something to contain them. They come in bottles or jars made of plastic or glass, in metal or plastic blisters, glass ampules and vials, plastic infusion bags, or other more complex forms such as the pumps for inhaled medicines. But these containers have remained invisible due to a prevailing Western notion that they are inert – and they are actually supposed to be inert in order to ‘just contain’. But if medicines shift, become other substances throughout their ‘careers’ in between worlds, and have other effects, can we imagine that the containment accomplished by boxes, jars, pots, and vials may also shift and involve other kinds of operations? I will focus on the medicinal bottle for a simple reason. While blisters and pumps are discarded after use, medicine jars usually have a second life in the Upper Orinoco. They may be re-used for containing all sorts of things, both by the doctors and by the Yanomami. And in their use by the Yanomami, they reveal a different concept of what exactly is contained, what the container is, and what kind of operation containment is.
The lifetime of these medicines and their containers does not seem immediately cyclical: they begin in research and are then industrially produced and packed for distribution to pharmacies and health posts, where health professionals hand them out in specific dosages to people with different afflictions. Then they are consumed, but their containers are never returned for recycling, for example. In the Amazon, empty containers end up in improvised landfills where doctors bury their rubbish (where they begin a long and unlikely process of decomposition that may last many centuries). Alternatively, they take a spiral leap and are used as another kind of container to hold something else. For doctors, crucial elements of their initial properties are lost in this kind of social recycling – they are no longer clean, no longer sealed. But it may be that for the Yanomami, properties of containment continue undisturbed.
I will begin by describing medicine bottles’ lives among the worlds of doctors and pharmacists, when they contain medicines and protect them from the elements. Though there is a rich history of different kinds of medicinal bottles (Griffenhagen and Bogard 1999), a single dominant cosmology predominates: that of an increasingly technological Western medicine, in which better containers also follow. But in the daily practice of medicine, even the history of these objects recedes into the background. While an older doctor or nurse may reminisce about a time before plastic and sterile packaging – for example, about using reusable glass syringes, now unthinkable in the era of HIV – young doctors rarely waste time reflecting on the transformations of these containing techniques; most just assume that such techniques get better with technical and material improvements.
Doctors in training learn that these containers help preserve the biochemical properties of the medicine, and thus achieve a certain concentration in the body when ingested. The hermetic seals on the jar make sure that no air or water comes in that could alter the chemical composition of the pharmaceutical product. The amber or brown colour of the jar prevents the degradation of medicines sensitive to UV light. The hermetic seal also guarantees that the product inside is sterile, preventing not only chemical transformations but also contamination by a range of bacteria or fungi. To further ensure this, the materials from which the container is made have to be chemically inert, so as to not react with either the environment or the substances contained. In sum, medicinal bottles make sure that what the patient consumes has the expected quality and amount of substance, and therefore, that assumptions about its bioavailability (how much medicine is actually absorbed through different routes) and pharmacological effect can be made. These preserving and protecting properties become especially crucial in the moist and hot conditions of the rainforest where the Yanomami live, and during expeditions in which doctors take medicines in their backpacks through muddy paths or along rivers. Inside the health post, pharmacies allow for medicines to be arranged and preserved (Figure 32.2). But when doctors take medicines on fieldtrips, further precautions – and layers of envelopment – are needed. Many containers are still sensitive to the elements, and in addition to the frequent rainfall, when visiting the villages one commonly encounters rivers that need to be crossed. Therefore, medicinal containers are often further contained in plastic boxes or waterproof bags, some of them specially designed for carrying medicines (Figures 32.3, 32.4).
Another fundamental aspect of medicine bottles is that each jar has a label with the name and concentration of its pharmaceutical components, and a specific date of expiration which tells until when it should be used. Labelling bottles is also an old tradition. In contrast to older labels, nowadays all references to the curative properties of the medicines contained are omitted by law. Labels are relatively more sophisticated, with catchy commercial names, and colourful strokes and font styles which respond to shifting marketing aesthetics. However, these newer labels are much more sensitive to the elements and are often damaged or washed away when they get wet. When a medical jar loses its label, doctors discard the whole bottle, being unable to know which medicine was held within, and its expiration date. So apart from preserving and protecting, labels may also have properties of attracting and marketing. Most importantly, labels give medicinal bottles other important functions of naming and classifying the substances contained inside them and indicating their lifetime.
In some cases, the bottle itself may serve as a dosing or dispensing device. However, it should be clarified that there is no practice in Venezuela of dispensing prescription bottles – that is, bottles with a personalised amount of a medicine meant to last for a specific amount of time. Standard concentrations and amounts of medicines are packed in each bottle, blister, or vial, and the task of calculating how much will be needed falls to doctors. Doctors may instruct people to administer or take the contents of a bottle in a prescribed way (for example, one spoonful three times a day), and to come for a second one when the bottle is empty – the need for a second bottle sometimes drives follow-up consultations, just as in other systems prescriptions must be filled each month or so by doctors, to be collected at pharmacies by the patients. Knowing, as they do, how much of a bottle a child will need for a full course of antibiotics, means that doctors may use the bottle as an indicator of how well the treatment has been administered: during a follow up visit at the patient’s house, the doctor may check how much medicine is left in the bottle, and calculate if it has been given too fast, or not at all. In these situations, the container becomes an object of evidence and of accountability from patients to doctors about whether they have ‘complied’ with – that is, ingested – the treatment.
On an administrative level, all forms of medicine containers, including medicine bottles, are part of an auditing system in which the health administration tracks how many containers are required and sent for each period of time, and uses this data to estimate how many medicines are actually distributed to a given number of people. Therefore, the total number of containers serves also as a proxy for measuring the health of a population, and doctors’ prescribing practices.
In a rainforest region like the Upper Orinoco, where spoons – commonly used elsewhere to measure liquid medicines – are not widely available, different parts of the bottle, or the bottle itself, may additionally serve as dosing devices. The screw-on cap holds more or less the same volume as the bowl of a teaspoon and serves as a good substitute. Some bottles come with their own plastic measuring cup, with which more accurate measurements can be made. But because most Yanomami are not skilled in Western numeracy, doctors add marks to the cup for people to remember how much medicine should be given. It should be added that the notion of dosing is not foreign to the Yanomami; it is part of their own use of plants for healing or for magical purposes, and they are usually very aware of the effects of over- or under-dosing.
Finally, some medicines come in a small bottle that holds a single dose to be administered entirely at once, so that the bottle itself becomes the measuring device. The whole bottle can also serve as an artefact for measuring in a different sense than dosing, as when powdered medicines come with a notch or indication of the level of water that needs to be added, in order to be reconstituted at the right concentration of its active principle.
Now, what happens when a bottle of a certain medicine is given to the Yanomami? A few words about the Yanomami may help us understand the context of the exchange and subsequent transformations. The Yanomami are an indigenous people who live in a rainforest area between Venezuela and Brazil. In their perception, practice, and understanding of the world, humans, animals, plants, spirits, and even other elements such as rocks are animated. Diseases are never or only very rarely accidental: they result from the agency of other living beings who may use powerful transformative substances (called hëri) to affect a person, or from spirits who may attack the integrity of the body envelope that contains the vital inner principle or soul-like components of a person. They also result from failing to observe food prescriptions or activity prohibitions, which mostly aim to keep living beings – which in Amazonia are all endowed with agency – separate. Health and disease are manifestations of interactions within an ecology of life, in which shamans have a privileged role in managing the forms that relations between different beings take.
Doctors are perceived as having an analogous power to shamans, given that they can also see inside a body, and their medicines are very effective in healing. The Yanomami also call doctors’ medicines hëri, a semantic extension of the term which suggests that Yanomami people conceive medicines, too, as some kind of powerful transformative substance with bodily effects. As for the health system caring for the Yanomami in Venezuela, there are only seven health posts in an area as large as Ireland. For many Yanomami people, health posts are too far away to walk to them, especially when ill. But for the people who live in the vicinity of one of these health posts, they constitute important alternatives for treating disease. While shamans are still consulted first, health-post doctors are frequently part of a network of therapies the Yanomami may consult.
Adults come to the consultation on their own, or if they are too sick they are often accompanied by a relative. Mothers, or another female relative, are usually the ones to bring young children when ill. The most common diseases in children are infectious: diarrhoea, pneumonia, malaria, colds. Adults often complain of more chronic conditions such as abdominal pain and chronic coughs. These diseases very often call for antibiotics, fever reducers, or cough suppressants. While adults generally receive tablets, children often receive liquid medicines, so that medicinal bottles are more commonly given to mothers for their children. However, these are often subsequently shared between members of the household.
In the course of my anthropological work among them, the Yanomami often – and especially in the case of blisters – asked for an additional wrapping to contain the medicines: a piece of paper, or preferably some plastic, as this extra container would help keep the medicines dry until they arrived home. When none of these were available, it was common to see people take certain palm leaves – which they usually use for wrapping different kinds of things – in which to carry the blisters, syringes, or medicine jars given. They folded these medicines with remarkable meticulousness. When plastic bags were used, the Yanomami did not just drop the medicine inside the bag, as people in urban contexts in Venezuela might well do. They folded the medicines neatly inside the paper and then within the plastic bag, as they would also do with many other substances, such as food and hëri substances.
The care given to containing the medicines suggests that it is not a trivial task. One explanation may be that there is an intimate relation between a substance and its envelope. The envelope does more than just contain something: it also helps constitute that something. We find this relationship in other important forms of encompassing or enveloping care, and notably in practices of embodiment. For the Yanomami, as for all Amazonian people, the body is an important centre of perception and social action (Seeger et al. 1979). But this body is not conceived in a dualist way, divided between an inorganic or spiritual inner body and an outer organic skin. The skin is equally a ‘spiritual’ component that as an outer cloak shapes the perspective and the agency of the person (Viveiros de Castro 1998). Many practices that change the envelope have also the property of changing the person within it, such as ornamenting, clothing, and massaging. Similarly, the medicine container, more than just limiting a medicine within a volume, may also help to make up the medicine itself.
Given the importance of the envelope, it is not surprising that the Yanomami usually refer to the container as the sign of an effective medicine. Throughout several decades of medical care, the Yanomami have engaged in their own reverse anthropology and empirical evaluation of doctors, coming to identify what works. They often show up at the health post with preset ideas about which medicine they want, based on past efficacy. The way they indicate which medicines are good may be a matter of the colour and taste of the tablets or liquids contained in the bottles, but the outer container is also significant. Just as in the case of doctors, for trained Yanomami health workers the names and numbers on the labels become important indicators of what the medicine inside is used for. The health workers often share these names with patients, and therefore many people arrive at the health post asking for a specific name of antibiotic, even though they cannot read the labels.
Finally, having been dispensed by the doctors or health care workers, the medicines and their containers set off towards their final destinations among patients. After the doctor has given the patient or mother the medicine, these are carried to the village with varying instructions on how much to take and how often to administer them (Figure 32.5). The Yanomami often string the jars or boxes from the poles of the thatched roof, near the fire (Figure 32.6). Not only is this the driest and safest place in the house, protected from the dogs and children at ground level, but it is also the common repository of other important objects, such as calabashes containing the mortuary remains of relatives, or a variety of other hëri substances collected by people and used for different afflictions (or as love and hunting magic). Receiving the constant smoke of the fire – smoke that is also used to preserve meat – they acquire a blackish tint that further erases the details of the labels.
What happens when the contents are emptied and nothing remains inside the bottle? Sometimes, if doctors are the ones to empty a bottle at the health post, they may use it to store other substances, such as the colouring reagents used in microscopy, or rubbing alcohol. Doctors may also use bottles to transport liquid soap or shampoo, or even as a good way of keeping matches dry. These other uses continue to enact a naturalistic ontology in which certain substances need to be kept separate from the environment or from other elements in order to preserve their physical and chemical state.
When Yanomami people themselves are the ones who empty the bottles, they are rarely returned to the doctors, but put to a new use. While some of these transformed uses still suggest a simple need for keeping something within a physical limit, the bottles may acquire other forms of containing agency among the Yanomami. In a context of reduced exchange with outsiders, and a relative scarcity of industrialised merchandise, any kind of pot is greatly valued, even if already used. For example, plastic, two-litre fizzy drink containers are especially coveted for carrying and storing water, and may be kept by people for several years, until they break. Doctors are asked to bring them back from their trips to the city (either filled or empty). But while we can perceive a very pragmatic need for using these large bottles for carrying and storing water, the various uses of smaller and seemingly less useful medicinal pots suggest that for the Yanomami these containers are not just about storing, carrying, or keeping some substance or thing separate from other elements.
The second lives the medicinal bottles take among the Yanomami suggest instead that these are sometimes devices of spiritual or animistic containment. While the Yanomami may use the pots to protect medicines from the elements, this protection is not conceived in chemical or physical ways. It may still be important to keep them dry or to prevent contact with other substances, but in an animistic world in which different kinds of beings may be infused with vital principle (Descola 2005; Santos Granero 2012), a series of wrapping or enveloping practices have to do with a similarly animistic separation of different forms of life-principle or substance.
Let us examine some practices that delineate the relations between substance and container in Amazonia. It is by looking into these other practices of folding that certain aesthetic forms in Yanomami practices of containment or envelopment begin to emerge. We see that packaging, enveloping, and containing are very ubiquitous practices. They are used traditionally for bringing back hunted or collected food – which in Amazonia may also have some invisible or soul-like qualities – and for cooking it on the embers of the hearth. Men and women collect and keep their hëri inside different kinds of palm leaves, though nowadays they also use plastic bags, or very frequently, old medicine bottles. These hëri – which are used for attracting or repelling a love partner, for attracting prey in hunting expeditions, for chasing away snakes and supernatural spirits which may cause disease, and also for making other people ill – would result in uncontrolled and probably dangerous transformations if left unbounded.
However, I want to turn now to another set of analogies – based on the body – in order to understand better this need for enveloping and for maintaining boundaries between beings among the Yanomami and other Amazonian people. I remarked above that the external envelope or skin – for the Yanomami, the pei siki – is an essential spiritual or animistic component of the body, one which provides a form, the ‘cloak’ that both contributes to and results in a certain particular understanding of what constitutes personhood. Bearing this in mind, we can turn to examine practices of illness and bodily reconstitution to which this envelope is central. It is important to remember here that in Amazonia a disease is often conceived as a breakdown of the envelope of a person, by which vital substances may leak from or pathogenic substances enter a person. Alternatively, the orifices of a body may behave improperly by allowing too much – diarrhoea, frequent urination, vomiting – or too little flow – not speaking, not eating, not seeing/recognising, not urinating.
Shamans, or other ordinary people with certain shamanic abilities, may subtract components of a person or insert pathogenic hëri to make a person ill. One example of the first case is when someone ‘takes the footprint’ a person has left in the forest (pei mãyo tëai). The stalking enemy collects the earth from a footprint with extreme care and wraps it inside palm leaves. Back home, he will either rub it with a pathogenic hëri or make a spirit-snake bite into it. At that same time, a snake in the forest will bite the person too. Unlike ordinary snakebites, this kind of bite progresses rapidly towards swelling, necrosis, and death. Important to note in this case is that the damage occurs by a series of transformations relating to the skin: a footprint that is left in the earth, a shamanic snake that bites onto this earth, and a real snake that simultaneously bites through the person’s skin, causing serious skin symptoms which end in death.
Rather than an accessory organ (as in a common biomedical understanding of dermatological problems), the skin in Amazonia is a fundamental site of articulation of histories and transformative interactions (Yvinec 2014). Many authors have registered the significance of skin transformations (including clothing) in an ongoing process of interethnic encounters (Bonilla 2009, Erikson 1996). Compared to other, more stable, components of the person or self in Amazonia, the skin is on a temporal scale of rapid changes that may seriously threaten existence. This explains why, in contrast to a relative negligence by Western health professionals of the skin, for Amazonian people diseases of the skin or body orifices are intensely feared. While in Western medicine greater importance is given to what is contained by the skin, for Amazonian people the container (skin) is what allows the body itself to emerge.
A further insight from Fausto (2011) concerning multiple encompassing layers of the body also helps us to perceive the complexity of container-contained relationships in Amazonia. Fausto argues that the duality between a powerful invisible or spiritual interior substance, and a visible, physical exterior fails to grasp the recursive constitution of a person. His ethnographical artefacts are masks with interior and exterior designs, which are used on top of already ornamented bodies and faces. A mask does not simply hold a unique inner subjectivity, temporally transforming a human into a spirit or animal. It also combines with and relates to underlying or superimposed designs. Masks are just another layer in a multiple and composite subjectivity.
A final example from my ethnography among the Yanomami further evidences a temporally and spatially disjointed process of Amazonian formation of the self that happens by a composite envelopment or encompassment of layers. This example concerned a young Yanomami man who spent several weeks in the intensive care unit of a city hospital (Gonçalves Martín 2015). He was suffering from intense swelling and haemorrhages that were suggestive of the much-feared snakebites. During the time he was hospitalised, his uncle tried several treatments in an attempt to reconstitute the external ‘skin’ (pei siki) envelope of his nephew, and also to control the adverse environmental conditions in the hospital, the entire hospital being perceived as a dangerous healing container. He massaged his nephew’s unresponsive limbs as a way of ‘awakening the body’. He used blankets to keep him warm. However, what really revealed the importance of re-containing or remaking the body envelope during healing was the following event: one day I saw the uncle tightly tying up a package made out of leaves. When I asked what was held inside, he explained he had taken part of his nephew’s vital principle (the pei puhi) and was sending it to the shamans back in his village for them to heal him. It was clear that the vital principle could be fragmented, split and sent elsewhere for shamans to work on the whole body. Why not just sent the vital principle on its own? Why use a package? It seems somehow that for certain things to exist or to have a form, an envelope is necessary.
I began with medical bottles that are used in recognisably medical ways in the Upper Orinoco by doctors, and then take on a second life as Yanomami people use them to store valuable or powerful substances such as hëri. I have suggested that in this second life, bottles may be much more than simple physical containers. The transformations implied by this change of use and understanding are often difficult to observe in practice. They involve operations that are sometimes outside of the range of possible observation, such as shifts between the potency of things enveloped in palm leaves or in plastic. However, the kinds of substances subsequently kept in these bottles, and the care with which they are prepared, do seem to support a theory in which the container exerts an important effect on the substance contained.
I have supported my ethnographically-based intuitions with further examples of healing containers among the Yanomami, and the way in which they function in an animistic mode of constitution through multiple and mutually encompassing layers. These layers include the skin in relation to the constitution of the body, but also other forms of envelopes such as hospitals, palm leaves, and baskets. I also touched on the importance of masks, but similar ideas are applicable to clothes or ornamentation. Examples abound, and I could have included other ubiquitous objects and practices among the Yanomami: calabashes for keeping the ashes of the dead; different kinds of tree bark that are either used as containers in ceremonial feasts, or are themselves burned or crushed to make powerful shamanic substances; baskets of different kinds which are selectively weaved either by women or by men, and in which the Yanomami transport their food and other belongings; pottery for cooking and storing certain foods – although these latter have virtually disappeared since the introduction of aluminium cooking points since the 1950s (Lizot 1984). Even the Yanomami’s round houses may be seen as another kind of sophisticated and multi-layered container. Each of these objects demands very careful preparation. The materials that compose these containers, and the ritual restrictions that are brought into effect during their making, are as important as the substances or materials they will come to hold.
This attention to containers is not a unique characteristic of Yanomami practices: other Amazonian people, and Amerindian people more widely, dedicate special attention to the materials and the process of making different kinds of containers. In his masterful analysis of Amerindian myths, The Jealous Potter (1985), Claude Lévi-Strauss emphasises the existence of a special philosophy of containment in Amazonia. In this book he compares myths about the origin of pottery, the regulation of flow of certain substances through the orifices of the body, and certain dispositions such as jealousy and stinginess. Although the aims of his comparison are broader, these myths show how the making of pottery brings into relation shapeless matter (clay, also disordered vines), which must then be turned into discontinuous pots through very precise (and gendered) practices. Containers are not only inert objects of separation but are themselves powerful shapeless matter that needs to be made into powerful but discontinuous forms. Here emerges another important topic in Amazonian cosmologies: the significance of a primordial ancestral state of infinite similarity, which gives rise to a (human) time of finite difference and discontinuity (Viveiros de Castro 2007). The containers – pots, bodies, masks, baskets – are above all creative devices of discontinuity.
Although the industrial production of medicinal bottles remains invisible to the Yanomami, their origin is still significant. The many objects brought by foreigners – their papers, their medicines, their machetes – are conceived by the Yanomami as loaded with real power coming from the outside. And the same understanding applies to containers. If such a significant ideology of containment is common among Amazonian people, these new, often plastic, containers must be seen as having a set of alternative properties. Their significance may lie precisely in their otherness: the medicines, the material, shapes and labels of these containers have been made by others, and therefore belong to a world of radical others, being thus able to enact other forms of healing or transformative power.
The medicinal bottle therefore resists taxonomical classification. In the dualism between the material and the spiritual which is common to Western naturalism, we may see the medicinal bottles and their labels as representing a medicine contained inside: a bottle and its label say something about the medicine’s potency or effects, and it may allow us, for example, to identify a group of sufferers who use the same bottle. By paying attention to the enactment of these bottles, a series of agencies is further revealed: protecting, measuring, dosing, accounting. But when we shift our attention to the use of medical bottles by Yanomami people, we find that these objects no longer fit into our naturalistic taxonomy. Within an Amazonian animistic ontology – in which there is a continuity of souls, and differences in identity are given by bodies – medicinal bottles are a device of form. But what is essential to keep in mind is that the relations between the envelope and the body in Amazonia are much more complex than an exterior-interior relationship. We may even say that the envelope is in fact the body itself.
We are left with a medicine bottle that when given to the Yanomami shifts before our eyes, so to speak, becoming a different object capable of different operations. Our habitual methods of making meaning, of designing taxonomies, or thinking through things as analytics, constitute an obstacle in conceiving this shift. The alternative approach described by Henare et al. (2007) is to think through things as heuristics – that is, to assemble a description of things as practised by other people, which leads to theories that refuse to follow our dichotomist predispositions. Rather than a taxonomy, we would need some sort of ontological grid that could show these transforming objects. An ethnography – or praxiology – serves this. However, we must be cautious in that any grid may still present us with too many divisions between containers and the contained.
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