THE HEALTH CARE SYSTEM
The health care system of the Yi community is what Charles Good called an ethnomedical system that includes the total medical resources available to and utilized by this community (1987, 22). It is concerned not only with how to manage bodily suffering but also with the economic lives, ideologies, and sociopolitical relationships among the Yi people and their interactions with the outside world. The Yi, like any other people, have, over time, developed their own ways to cure and prevent illnesses by integrating other people's ideas and techniques into their healing practices. Yi healing practices are thus a mixture of indigenous beliefs and outside influences.
Theory of Illness
Yi consider etiology in terms of both natural and supernatural aspects. According to Azi Ayue, a Yi physician trained in traditional Chinese medicine, the Yi consider “wind” to be the most important cause of illness. Normally, wind is the dynamic of life and production, but it also causes sicknesses under certain circumstances. Poisons and worms also lead to illnesses (1993, 98—99).
Supernatural causes are many. For example, an illness may result from the fact that an ancestor blames the living descendants for not providing sacrifices on time. Or perhaps one's ancestors are too weak to protect their descendants because they have not received enough offerings. Or an illness may be a message that an ancestor injured by wild spirits sends to living descendants in order to ask for their assistance. Spirits avenge themselves on people who offended them, and this may take the form of an illness. People lose their souls by being frightened or seduced. People see strange phenomena, such as snakes copulating or a cow's tail tangled with a tree, phenomena
Although many Yi do not reject biomedical causes of sicknesses, most interpretations of illnesses are still based on the traditional theory of supernatural causes. These beliefs are constructed by the Yipeople from their cosmology and other aspects of ideology,and constitute one of the major factors that determine patterns of illness behavior and health-care decision-making. Some of these beliefs are less important, so people are not very serious about them. Others, such as evil caused by various spirits, and ancestors' roles in health problems, have been deeply rooted in most people's minds at both conscious and unconscious levels over time. Therefore, it is very difficult to change or eliminate them.
Spirits as the Cause of Illness
Yi divide spirits into good and evil. Some spirits attack people aggressively, some punish people who offended them, while still others help ritual practitioners heal patients. Spirits are usually named after the illness they cause, such as the spirit of leprosy, of headache, of red eyes, of the drowned, of the people who jumped off cliffs, and so on. Regarding the latter two, a person seduced by one of these evil spirits would lose control of his or her mind and jump into deep water or off a cliff; thus these are considered the result of illness. The Yi call on ritual healers to invoke a certain kind of spirit to release the relevant sickness from the patient when possible. There are so many spirits in the world of the Yi that the interactions between human beings and spirits take place at least as frequently as those among people themselves. Spirits resemble human beings in that both need food and both have feelings, so, like people, spirits can be pleased or offended. Although people carefully maintain good relations with their ancestors and good spirits, and endeavor to stay away from bad spirits, they cannot avoid offending or running into the latter because the spirits are invisible. Dissatisfaction, anger, punishment, and invasion by the spirits are common causes of sickness (Lin 1961; Qin et al. 1988; Ma Xueliang 1943). Punishment can be the result of the spirits' dissatisfaction and anger, but invasion can be initiated by ancestors and other spirits for other reasons, such as by request of the victim's human rivals. Of all supernatural beings, ancestors are particularly significant to the Yi.
The Role of Ancestors in Health Care
In contrast to Han Chinese, who see ancestors primarily as benign beings, the immediate concern of the Yi with their ancestors tends to be etiologic,
Cosmology
Yi have a strong interest in, and keep searching for, the origin of the universe and of human beings. This is manifested in Yi traditional culture in the form of myth, both in oral epics and classic literature written in the old Yiscripts. Expressions of the cosmology of Yi people vary from one subgroup to another. Some describe water as the origin of the universe. They say that “the first thing evolved from Chaos was water,” then all things on the earth were developed from it (SFAS 1960). Some suggest that the air or fog formed the sky, the earth, and all kinds of beings and items in the world (Luo and Chen 1984; GINS 1982; Guo and Tao 1981). In an Axi epic the original form of the universe and everything in the world was a cloud (HIFY 1978). A wellknown Yimyth in Yaoan entitled Meiguo describes how a tiger's body became the universe and all planets and things on the earth were gradually generated from it (CIFY 1959).
No matter how diverse the ideas about the origin of the universe are, all emphasize movement and change. The word universe is written in old Yi as two symbols, OO
e . Although Yi characters are primarily phonetic, some of them, such as these two, are hieroglyphic. O indicates the space in which all things exist; O
e is an egg, which implies life and relentless movement (Bai 1995, 67, 93; Zhu Juyuan, personal communication, 1995). As far as the origin of human beings is concerned, myths and legends express awareness
Male and Female In the Yi myth of creation, uplands, trees, grass, stones, and people are all divided into male and female. Things exist and develop only as pairs, such as the sun paired with the moon, the sky paired with the earth, big stars paired with small stars, and black clouds paired with white clouds (CIFY 1959; HIFY 1978). One can still see the trace of dual cosmology in Yi daily life. For example, the Lipo subgroup of the Yi in Tanhuanshan, Yunnan, divides natural objects and household utensils into female and male according to their size: the larger objects are female and the smaller ones, male. The Yi in Ninglang had used a solar calendar composed of ten months in a year and thirty-six days in a month. The Yi named the months after five pairs of elements—wood, fire, earth, copper, and water—so they had five female months and five male months each year (Liu Yaohan 1985, 59). Yi astrology, according to the associations of sun-female bright and moon-male-dark, divides a day and night into female day and male night (ibid., 96). Some Lolopo families in Yunnan enshrine their ancestors in calabashes. Each calabash contains a couple's spirits: parents, grandparents, and great-grandparents. The calabash inhabited by the souls of male and female ancestors is called nielomo. Portraits of ancestors (male and female together) are worshiped in some Yi households. The descendants call this portrait nielomo as well. Nie means ancestral spirit, lo means tiger, and mo means female. That is, they use the female ancestor to represent the ancestors of both sexes. Interestingly, the way the Yi categorize the features of male and female is very similar to that of the Moso and the Lahu, among whom women are highly respected (Du Shanshan 1992; Yan and Song 1983).
Seven and Nine The Yi use the number seven to signify female and nine to indicate male. In a Nuosu cremation, for example, they make a coarse wooden chair with two long boards on either side and a wooden plank across
Left and Right According to Liu Yaohan, the Yi, unlike many groups in the world, see the left as positive, the right as negative, and they associate female with the left and male with the right (1985). Meiguo, a Yi myth about the universe being developed from the body of a tiger, says the tiger's “left eye became the sun and right eye the moon” (CIFY 1959). The Yi highly value the left. When a bimo holds a ceremony, he calls the souls of the ancestors with his left hand while he drives away evil spirits with his right hand. Some Yi literature recorded the ancient custom of handing things to ancestors, respected ones, seniors, and parents with the left hand, and to wild ghosts and belittled ones with the right hand. The Lolopo in Yunnan make ancestral tablets with the female on the left and the male on the right. All these data indicate that the left is considered better, stronger, and more positive than the right in Yi cosmology, and that the Yi relate the female to the left, the sun, and ancestors (Liu Yaohan 1985, 48—49).
The above discussion of cosmology may seem a digression from the subject of the Yi health care system, but it signifies the ideological and historical aspects of Yi culture. It is on this cultural ground that Yi developed their health beliefs, forged their interpretations of illnesses, and evaluated health care providers in each sector. These peoples' understanding and evaluation of different health care sectors affects what kind of health care they choose—how they make their decisions and act on them. Having examined these basic cosmological beliefs, we can now consider where the Yiseek medical help.
Sectors of the Health Care System
As far as health care is concerned, both Arthur Kleinman (1980) and Charles Good (1987) suggest that people choose methods from three different sectors. The popular sector, Kleinman states, can be seen as a matrix containing several levels: individual, family, social network, and community beliefs and activities. The traditional (folk) sector refers to medicine and is frequently classified into sacred and secular parts, but the division is often blurred in
The Popular Sector Among most peoples in the world, the family is the first place to seek healing for illness and injury, an estimate of the seriousness of one's health problems, and help in making decisions for further treatment. Many people in Yi communities know at least some methods of curing an ailment or minor injury and are able to hold simple rituals for the purpose of healing illness. Commonly, the Yi people ask for medical help from neighbors or kin. Most ailments are actually handled within households. For example, to stop bleeding Yi apply a kind of efflorescent stone powder, a glue made from spider webs, or chicken feathers to the wound. To treat different kinds of pains, they use massage, steam, and/or single or combined herbal remedies. The Nuosu patrilineage plays an important role in preventing and curing illness in Liangshan. Some healing rituals involve a whole lineage: when a ritual is held to imprecate evil spirits or divine the agent who cast a spell on the patient, each family has a representative attending the ritual to join the chanting or shouting, because a collectivity will make this kind of ritual powerful. Hu Qing jun (1985) describes a sort of children's gathering called axyi momge in the Liangshan area. To halt a disease that was quickly spreading from village to village, all children of the village attended the meeting under the guardianship of their parents. This meeting, held by one of the headmen of the lineage, was actually an exorcism of the evil spirit that causes this disease. In this way, the lineage serves to manage children's health problems, both by decision making and ritual performance.
The Traditional Sector The traditional sector of a health care system is classified by Kleinman (1980) as having both secular and sacred components. In Yi areas, the secular part includes herbalists, massagers, bonesetters, and midwives. Most of these healers inherit prescriptions from their older generations, as well as collect valid therapies through their own experiences. Some of them were recruited by the local government into the state-run township clinics after 1956.
The sacred components of the traditional sector of the Yi include mainly two kinds of healers: bimo and sunyi. Bimo are also called baima, beima, abeima, bumo, xipo, xibo, duoxi, and so on, depending on the dialect and translation. Bimo work as diviners, ritual practitioners, and healers who communicate with both natural and supernatural worlds. In the Yi language, bimo means “teacher” and “the one who knows.” It is an office achieved rather than inherited, though it is important for a person to have bimo family or lineage
Of all kinds of knowledge preserved by bimo, medical theory and techniques have been sought most frequently. During a healing ritual, a bimo reads or recites ritual scriptures for hours, sometimes for a few days. He also makes sacrifices or sticks twigs into the ground symbolizing the way for the return of the patient's soul. As healers, some bimo also use herbal medicine or other healing techniques, such as massage. A bimo named Nurtiha was so good at massage that people called on him mainly for this, rather than for prayer, though he was also a very good ritual practitioner (Li Shikang 1995, 108).
Another kind of sacred healer is the sunyi. Unlike bimo, sunyi can be either male or female and need not be literate in Yi writing. Sunyi do not inherit the position and skills from their family or lineage members, nor is their education systematic like that of the bimo. However, they too must learn from experienced sunyi (Azi 1993, 11). Usually, those who become sunyi are people who have had the experience of suffering from mental illness. After recovering, they have a bimo divine for them and hand them a drum made of sheepskin, which is their major ritual implement. Sunyi drive evil spirits away from patients by beating the drum and by whirling and dancing with the whole body shivering while muttering chants of exorcism (Lin 1961, 127; Hu 1985). Although bimo and sunyi are different in many ways, their distinctions are blurred in practice. Usually bimo rituals are language-oriented, while sunyi rituals are performance-oriented; most practitioners conduct their kind only. However, some practitioners can perform both kinds of rituals. Bimo and sunyi, together with herbalists, have traditionally taken responsibility for protecting the health of Yi people.
The Professional Sector Western missionaries introduced biomedicine to the Yi. The earliest hospitals in both Liangshan and Chuxiong were built by missionaries, who brought biomedical techniques into the areas where they were preaching, in the early twentieth century. Later, the Guomindang government established some biomedical facilities in cities and towns. By 1949, in the fourteen counties of Chuxiong prefecture there were 10 clinics, with a total of 20 beds and 47 medical personnel. Some people in the cities could reach the facilities if they wished, but before the establishment of the People's Republic of China in 1949 the Yi living in the uplands had much less access to the clinics (WLYG 1985; WCYG 1986), so biomedicine was of little importance to them as a means of resolving health problems.
It was the Chinese Communist Party state that made it possible for peasants in remote rural areas to use biomedical health care. After the Communist revolution, the state set up a medical network in the early 1950s reaching from the capital city to the villages. The People's Hospital of Chuxiong was established in 1951, and dispensaries in surrounding counties were gradually
The morbidity and mortality rates for infectious diseases diminished notably. For example, the morbidity rate of leprosy was .2 percent in 1962, but it was reduced to .046 percent by 1984, and the relevant medical institutions expect to reach the goal of eradicating leprosy by the end of this century. In the 1950s some vaccines began to be used, including smallpox vaccine, T.A.B. vaccine,
[1] The vaccine for typhoid and paratyphoid A and B.
cholera vaccine, and bacillus Calmette-Guerin for tuberculosis. Since the 1960s, vaccines for polio, measles, and epidemic encephalitis have been used. The morbidity rate and breadth of epidemics of these diseases have been greatly reduced; special attention has also been paid to malaria, dysentery, and hepatitis. Health care for women and children has improved since 1953. The prefecture started to train midwives in new methods of delivery,and had retrained more than a hundred traditional midwives by 1954. By 1984, in Chuxiong Prefecture there were 749 rural midwives in addition to village health workers (WCYG 1986).The biomedical sector is now organized in the following way: At the lowest level, the village, there is usually one health worker (known during the 1970s and 1980s as a barefoot doctor) who serves more than a thousand people. The most important responsibilities of this position are family planning, immunization, and sanitation. The village health workers treat ailments, perform first aid, and refer patients to higher-level medical facilities as well. At a higher level, there is the township clinic with several physicians, who are usually trained in a middle-level medical school. The physicians supervise the work of village health workers, perform family planning surgery,and treat patients with both biomedicine and Chinese medicine. Physicians at this level usually do not go to the villages; rather, patients come to see them. These physicians avoid, at least publicly, communicating with religious healers because clinics are seen as official, scientific institutions, while healers are private and seen by the state as “superstitious.” Township physicians treat most diseases, but if the patient's situation is severe or requires surgery or mental health care, they refer the patient to a higher-level (county or prefecture) hospital, which has better equipment and doctors with medical degrees. In fact, very few patients are sent to provincial hospitals, because hospitals at the prefecture level are able to heal most diseases, and patients from rural areas usually cannot afford to pay for care far from home, even if it is necessary.