In Bali, there are two ways of responding to health problems: traditional Balinese medicine or allopathic "Western" medicine. Both systems co-exist in Bali, and local people will commonly go back and forth between doctors and healers - called Balian or Dukun - in their search for a cure.
Traditional medicine refers to a wide range of techniques and modalities which are described in palm leaf manuscripts called lontar. There is a remarkable array of lontar on a variety of subjects. Some are quite specific and demonstrate a strong understanding of human anatomy - describing, for example, the weight and length of a human intestine. But central to the traditional approach to health is the Balinese belief in a spiritual reason for health disorders. One never simply "gets sick", there is always a niskala, or "unseen" reason behind an illness or accident. Often the "prescription" is mantras and offerings. Even when medicinal herbs are prescribed, the herbs themselves are not considered the cure, but merely a means through which counter-active white magic can enter the body.
Since the arrival of Dutch colonialists, there has been allopathic medicine in Bali. It was not until the early 1900's that Indonesians medical doctors were minted, but the number of Indonesian doctors remains to this day woefully low - only 1 per 120,000. This makes allopathic medicine something of a luxury in Indonesia, and out of reach for many rural and urban Indonesians. The empirical or mechanistic foundations of allopathic medicine run counter to the Balinese propensity to see the body as a spiritual vessel held in balance by complementary forces. What kind of problems arise when a Balinese patient's belief system contrasts so markedly with the scientific approach of allopathic medicine? And what happens when western people, grounded in western empirical thinking, look for a cure from healers whose conception of disease is spiritual in nature?
The Body in Bali.
In the Balinese world view, the human is surrounded on all sides, as well as above and below, by forces held in balance by the cosmic order. To the north, kaja, is Gunung Agung, the sacred mountain. This region is considered positive. The east, kangin is also considered favorably. The South, kelod, and the west, kauh are generally regarded in a negative light. The Gods reside in heaven and the buta kala, "demons", reside under the earth. This basic order repeats itself over and over in Balinese culture - the head is good, the feet are dirty, the right hand is clean, the left is not. A Balinese home is likened to a human body as well, with the head as the family temple, the stomach as the kitchen, the anus as the toilet, and so on. The body is balanced in the center of all these forces, and should one side get too strong, health can break down.
Consistent with this geomancy is the placement of four guardian spirits which guard over your health if you are Balinese. These spirits are called the kanda empat ("Four Brothers" or "Four Sisters"), and they watch over you from the spirit world from the moment of your birth. These spirits have a physical manifestation as well. At birth, they are associated with the placenta, amniotic fluid, blood, and vernix caseosa that are expelled during labor. The placenta, or ari-ari has an important function in helping a Balinese maintain their own health. The ari-ari is buried in the family compound and offerings are made to it. A lamp is burned on that spot for the next 40 days to guard it. A new mother might sprinkle breast milk on the soil near her child's ari-ari to feed the Kanda empat - and the Balinese say it has an added effect of stopping the baby from crying. Throughout life, whenever there is a health issue, offerings will be made to the kanda empat, whose names change over the passage of time. When a Balinese travels abroad he or she may take some soil from the area of the ari-ari with him to maintain that spiritual connection.
The Kanda Empat are associated with parts of the body on a physical level and the greater universe on a macro level. At birth, the Kanda Empat have the names Babu Sugian, Babu Lembaba, Babu Abra and Babu Kekere. They are associated with the amniotic fluid, the blood, the placenta, the umbilical cord, and the directions of north, south, west and east . Later in life the names of the Kanda Empat change, and they are associated with different parts of the body, the heart, the liver, the gall bladder and the kidneys, respectively. When a sick Balinese visits a Balian, the healer will call upon the Kanda Empat, invoking these spirits to aid the patient.
Balian
There are many types of healers in Bali. Balian Usada are learned healers who treat patients using mantras written in the lontar. Balian Pijat or "tukan pijat" are "massage workers" who manipulate muscles and energy with their hands. Balian Taksu go in to trance and, with little prompting, tell a patient what their problem is and how it can be cured.
What happens when a westerner visits a Balian? There are no Kanda Empat, and so there are no spirits to invoke. Bruce Carpenter notes that a comedy of errors may be the result: "If a westerner goes for a healing, and if he doesn't have ancestors in Bali, then any rituals that are performed are basically meaningless as far as the Balinese are concerned. But they are very polite people so when a Westerner comes and smiles and participates they are happy to sprinkle him with holy water. They don't really mind. But they probably think that you are a nut. They don’t really know what he is doing there."
This kind of spiritual tourism presents the danger of turning deeply held religious beliefs into tourist commodities, but few of the healers I spoke to considered it to be a serious problem. As a group they believed that Western people can benefit from traditional healing, even if they were not born into the Balinese cultural context and don't fully understand the esoteric mechanisms behind a healer's practice. They also believe that traditional medicine may be the only answer when a westerner falls victim to black magic, which they insist is not uncommon. Ketut Arsana, a healer in Ubud, recalls a time when tourist was brought to him in the middle of the night, rigid and trembling and covered with a red rash. Arsana recognized immediately that he had been victim of the occult equivalent of a hit and run accident. A spell has been sent by a leyak to hurt someone else and the tourist had been at the wrong place at the wrong time. The desti, or spell, had entered him. Recognizing the symptoms, it was relatively easy for Arsana to release the spell through massage, and the tourist recovered in a matter of hours.
The Medium is the Massage
Most westerners get their first experience of traditional medicine in the form of a Balinese massage. I am not referring to the massages offered on Kuta beach, which have nothing to do with traditional medicine, and rarely deserve to be called massage - but the types of massages offered by healers versed in what is originally an Indian import - the aurivedic tradition. This tradition describes energy channels called nadis. When you are healthy, your nadis are open and prana, or life-force, is allowed to flow. Problems arise when the nadis become blocked. due to imbalance in panca maka buta, the five elements earth, wind, fire, ether, and water, that according to Balinese philosophy, is the stuff from which all things are made. The deep tissue massage that is traditionally performed in Bali is used to break open the blocks one develop in the nadis.
Ketut Arsana opened Bali's first spa, The Bodywork Center, 25 years ago, starting a trend that now seems completely out of control. He is one of the few healers who can articulate his methodology - which he does with great reluctance, because many of his western patients are already too "pandai", or clever, for their own good already. "They are so clever, they are stupid." he laughs. Westerners spend far too much time engaged in intellectual and critical activities that they lose touch with the physical and spiritual aspects of their lives - and the physical health always seems related to spiritual well-being in the Balinese worldview.
According to Ketut Arsana, Westerners experiencing traditional medicine are either very open and accepting - thus easy to treat, or extremely "kaku" - "stiff" both intellectually and physically. I got the sense that he did not want to open the subject of the spiritual dimension of illness to western clients because the amount of explication involved was endless and incomprehensible to someone not born into the Balinese worldview. A common problem with westerners is slipped discs. Arsana says this is a fairly easy condition to treat. Does the patient really need to know that the cure involves releasing blockage in a small nadi connecting the stomach to the lower back, or is it better just to solve the problem? In Arsana's experience it is better to heal the patient: explanations can get in the way.
Some aspects of the healers art are closely held secrets that might cause problems if they were widely known. Many lontar contain the warning "Do Not Disseminate" written on them, making it clear that information in the wrong hands can be dangerous, particularly when it pertains to the world of black magic. A healer is supposed to study diligently under proper supervision so that the syllables of healing mantras eventually enter his body and actually inscribe to regions of the healer's anatomy. These sacred syllables, called Modre, can be invoked and made to vibrate or speak to the equivalent area of a patient's stricken body, which has the effect of releasing the illness. This type of knowledge is a very closely guarded secret among literate usada healers.
Ketut Arsana believes that a healer should immediately know the problem without the patient saying a word. And the patient should not question the reasoning behind a particular treatment because it is disrespectful and counterproductive to the healer and the process. In traditional medicine, a policy of "Don't ask, don't tell" is the norm - quite the opposite of the western ideal of "informed consent".
This cultural norm of "don't ask, don't tell" can confound the application of allopathic medicine in Bali. Many Balinese visit doctors with the same ingrained expectations they used to bring on visits to Balian. A Balinese will never explain to a Balian Taksu why they have come. The Balian is supposed to know the reason intuitively without a word spoken. The unfortunate reality is that some bad Indonesian doctors - doctors who don't question their patients, doctors who make a cursory examination, a quick diagnosis and prescribe a shot of B-12 - may impress a Balinese due to cultural conditioning rather than a good doctor who exhaustively questions a patient. The latter might be regarded at lacking "sakti" for not knowing, intuitively the nature of the illness. A doctor who prides himself on his willingness to spend time with patients, ask them thorough questions on their symptoms, and empower them with vital information, might go unappreciated here.
Dr. Denny Thong is a doctor who is fascinated by the ability of certain balian to diagnose illnesses, particularly mental illnesses such as depression. Thong is intimately involved in the two worlds of health care in Bali. Trained as a psychiatrist, he ran the mental hospital in Bangli for many years. With co-author Bruce Carpenter, Dr. Thong wrote about his experiences in the highly readable book "A Psychiatrist in Paradise". Upon arrival in his new job, he soon learned that standard therapies used in western mental hospitals were wholly inappropriate in the Bali. The simple act of separating a patient from his family and confining him in a cell would have a devastating effect on both the patient and the family. Relatively few patients who were admitted into the hospital ever left - not only because of the stigma attached to mental disease but because of the high cost of the ceremonies that would have to be performed before the patient could be re-admitted into the family compound.
Thong also learned that patients were much happier with the treatment they got in the hands of Balian and there was evidence suggesting that had a far better record in "curing" mental illness that Psychiatrists. One healer in particular, Nyoman Jiwa, seemed to be adept in restoring patients to a more functional state. He did this by simply laying his hands on the patient. If the patient was a victim of black magic, they would feel a strong sensation not unlike an electric current. In acute cases, the pain was almost intolerable, and patient could only stand a few seconds of what appeared to be a gentle touch. After a series of treatments in this manner, the pain would disappear and mental health would be restored.
Intrigued by Jiwa's success, Thong asked him to help at the Bangli mental hospital. Thong created a "Family Clinic" on the hospital grounds. Patients and their families would visit the family clinic before being admitted to the mental hospital. If Jiwa diagnosed a case of black magic, the patient would not enter the hospital itself, and receive treatment in the family clinic in a series of out-patient treatments. By avoiding admitting patients except in extreme cases, the patient remained ritually clean and unstigmatized.
This new system seemed to work far better than the original system. Unfortunately, it attracted attention from the medical establishment in Jakarta. Dr. Thong was accused of promoting backward thinking and unscientific methods. For reasons which were never clear, Thong was transferred to Sulawesi to supervise a mental hospital there. The family clinic was demolished and the old, failed methods were reintroduced to the mental hospital in Bangli by the new director.
The moral of the Bangli experiment is that is that it is only western arrogance to imagine that allopathic medicine is universally appropriate regardless of cultural context. It underscores the necessity for the Balinese to judge for themselves which Western modalities it should import, adopt and embrace, be it Sigmund Freud, fast food, or MTV. The Bangli experiment does not create an optimistic picture. It demonstrates that a particular orthodoxy, when backed by Western power and dominance, can prevail despite evidence that it causes more harm than good. As far as psychiatry in Bali is concerned, Dr. Thong is skeptical but retains his sense of humor. The experience changed his perspective on his own discipline - "I no longer believe in Psychiatry!" he says with a laugh.
The future of traditional medicine
It seems unlikely that traditional medicine as currently practiced in Bali will survive many more generations. The effectiveness of allopathic medicine against what were once fearsome diseases has undermined - rightfully - the value of certain traditional treatments. Many lontar were written for diseases that are no longer a threat - The Usada Kacacar consists of mantras, local pharmacology, and diagnostic tips pertaining to the treatment of smallpox. Smallpox was wiped out by vaccines introduced in the 1920's. Similarly, it doesn't make much sense to consult the Usada Mala for treatment of goiter when modern medicine offers an effective treatment. Leprosy is a condition that, years ago, was the most fearsome disease ever to plague Bali. The Usada Ila (sometimes called Usada Cukil Daki) treats the disease as the worst form of black magic, and requires that those stricken move as far as possible from home. In these cases, the superiority of allopathic medicine over traditional medicine is obvious.
If traditional medicine is destined to die off, one can only hope that allopathic medicine will develop greater sensitivity to the cultural context of Bali and be open to incorporating new (old) ideas. There may be reason for hope in the regard, as recent Western research has actually proven via double blind studies that prayer - both by and for a particular patient - can significantly improve a patient's chances of recovery. In cases where a technique is effective without making empirical sense, the burden should be on modern medicine to study and incorporate it into acceptable practice.
Unfortunately, in politics as well as in the politics of medicine the economically dominant system will survive. Medicine is big business, and there is every indication that the huge gap in health care quality that separates the rich and poor in Indonesia will grow more acute. The problem is not in lack of resources - public health policy in a country like Cuba has been wildly successful, and Cubans now enjoy lower infant mortality rates and live longer than Americans - but it is unlikely that an equitable system of medicine will appear in Indonesia any time soon. The economics of an unequal system, that primarily serves to benefit Western-based pharmaceutical industry, seems to be firmly entrenched. Paradoxically, the high cost of allopathic medicine in Bali may help to keep Balian busy in the short term, since Bali's poor have no other recourse.
Western visitors to Bali, armed with up-to-date information, economic power, critical yet open minds on traditional medicine, and a grounding in empirical science are able to make informed decisions on their health-care options. The Balinese majority, however, are not so lucky. Accurate information is hard to come by, and 32 years of military rule did not generally support the development of critical thinking skills. Pharmaceutical companies take advantage of this and foist the equivalent of snake oil on the general population. The Balinese have little in the way of health care options, and indeed may get the worst of the two worlds.
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