Engrained with modernity: commodification, medicalisation, and cross-border medical travel for health care in Nepal

Biomedicine was introduced in Nepal by Christian Missionaries en route to Tibet and China. When Nepal entered the democratic era in the early 60s, a considerable influx of biomedicine was brought into Nepal by the modernizing state as part of the promise of national development. After the 60s, biomedicine expanded in Nepal mainly through private sector involvement. This had consequences in the health-care domain in Nepal including the commodification of health-care services and increasing medicalization. The practice and expansion of biomedicine is also closely associated with its social and cultural mediation. This article focuses to examine how the macro process of health development shaped the medical practices, especially the healing trajectories and cross-border medical travel of Maithili Brahmin women from Nepal’s Tarai. This article shows that the three prominent avenues of health-care services, namely, medicalization, commodification, and cross-border medical travel predominant in the study area, are thriving and intertwined in such a way that they are reciprocally strengthening each other. This article is based on primary ethnographic data generated from field research conducted in a social cluster among the women from Nepal’s Tarai.


Introduction
A nthropologists are interested in studying health-care systems cross culturally. The focus of anthropologists has been varied as per their interests; spanning from symbolic and linguistic analysis (Frake, 1961;Turner, 1967;Rosaldo, 1972), health care and public health aspects of modernization (Leslie, 1974) to comparative studies of medicine in large-scale non-Western societies (Kleinman, 1980). Examining the embeddedness of health and illness in the local cultural milieu, some early prominent anthropologists (Rivers, 1927;Evans-Pritchard, 1976) studied the ethnomedical ideas and practices of the communities in which they followed. On the other hand, the spread of modern health facilities, and the increasing expansion of biomedicine as a mainstream healing method had also attracted the attention of anthropologists (Brown, 2012;Van der Geest and Finkler, 2004). Recently, employing a political economy of health approach, Shah (2020) examined the Bangladeshi health-care system and he found that almost all governmental policy-making and activities aimed to promote biomedicine justify it on the grounds of becoming modern, specifically for the need to develop a modern healthcare system. Biomedicine, a term medical anthropologists use for the medical practices that some people refer to as "Western" or "modern medicine", was introduced in Nepal by the Capuchin missionaries in the middle of the eighteenth century. The widespread use of biomedicine increased rapidly during the first half of the nineteenth century (Dixit, 2000). As Nepal opened up to the discourse of development and democracy in the 1950s, the state leadership imagined a modernist future (Shah, 2018, p. 103). Such opening up of the country brought in fundamental changes in Nepali social, political and administrative arenas, paving the way for the expansion of biomedicine. Lock and Nguyen (2018, p. 80) pointed out that biomedicine was thriving in many places in the 1960s as an emblem of nation building and modernization. State support for public health and clinical care were widely recognized as integral to the modernization process in the West, which by the end of the nineteenth century began to expand across the globe. This period witnessed a considerable incursion of biomedicine in Nepal as part of the promise of national development. Streefland (1985) stated that one of the thrusts of this era was the expansion of health services through the establishment of health centers in the countryside. Through her ethnographic study Pigg (1995) had rightly articulated how local people link healing practices with the powerful mantra of bikas, development, in Nepal.
The health facility in my study area in Nepal's Tarai can be regarded as a project of modernity, a part of a larger project of "rationalization of culture and society" through intervention in the health-care domain. The process of biomedicine arriving into the area came at the cost of other alternative healing practices. This aligns with what Harper (2014) has characterized as a general picture of public health in Nepal, a "capsular" promise narrowing health into a curative medical domain. The involvement of multilateral development agencies in developing healthcare services and in micromanaging and measuring their performance through metrics has subsumed the quality within metrics . As part of the promise of modernity in the health sector, The National Health Policy (MOHP, 1991) and subsequent periodic plan, particularly the ninth 5-year plan, paved the way for private sector involvement to promote healthcare services. In this article, I examine the cultural ideas and practices related with the health and illness of Maithil Brahmin women from Nepal's Tarai. In doing so, it aims to show how the course of such social and cultural mediation is entangled with the process of commodification and medicalization of health-care services. Gaines and Davis-Floyd (2004) claimed that the modernizing process actually promoted only three points: "…in economics, capitalism; in production, industrialization; in health care, Biomedicine" (p. 104). Biomedicine presents itself as being an exclusive and objective healing system based on science and downplays other healing practices as being traditional, superstitious and unscientific (Winkelman, 2009). Bureaucratic rationalization (Weber, 1978) had also been embedded in modern health-care services. Bureaucratization in health-care services, as Gupta (2012) argues, has become a form of structural violence depriving these Maithil Brahmin women from taking health-care services in government health facilities.
For Marx (1906, p. 41), expediency of a thing is a basic property of a commodity on which it acquires exchange value. In contrast, Kopytoff (1988, p. 64) argues that the same thing may be treated as a commodity at one time and not at another. Goods can become a commodity only when it contains a market element. Strasser (2003, pp. 7-8) emphasizes that the expansion of the commodification process embraces ever growing areas of social life and goods through the spread of consumer culture. Therefore, market relationships have expanded into different spheres of social life and market-based consumption has become so pervasive that virtually everything has been embraced within it.
To lure the consumers, as Appadurai (1988) stated, certain images of goods and services are projected, which in return act as vectors of globalization. As commodities, they are embodied with certain ideologies. Increasing consumerism had been directly linked with the ever expanding capitalist ideologies and processes. Appadurai (1988, p. 15) rightly posited the wide embracing nature of the commodification process: In modern capitalist societies, it can safely be said that more things are likely to experience a commodity phase in their own careers, more contexts to become legitimate commodity contexts, and the standards of commodity candidacy to embrace a large part of the world of things than in noncapitalist societies.
As professionals involved in particular areas of expertize, health professionals charge for their services and medicinal products. The commodification of medicine and health-care services has a long history. The inception of each domain of healing somehow entails transactional elements to compensate the professionals contributing in healing and producing objects and services having healing power. In this regard, analyzing plural healing context of Nepal, Subedi (2003) is also with the idea that cost is a significant determining factor in shaping people's choice of a particular medical practice. Henderson and Petersen (2002) regard commodification of health care as a recent phenomenon. According to them, this is embedded in different policy shifts in the health-care domain, such as the deregulation and privatization of services and an emphasis on cost-effectiveness, "user-pays", "self-care", and "community-based care". Increasingly, this process led to health becoming a "commodity" and the individual subject of health care defined as "client" or health-care "consumers" (p. 1). On the other hand, the term consumer also connotes empowerment of the actor and his/her access to freedom of choice of health-care services. The consumption of particular health-related goods and services is shaped not simply by perceived health advantages, rather, by their association with particular images, lifestyles, and tastes (p. 3). Mazanderani et al. (2013) expanded analytical coverage of health commodification to include how illness narratives are commoditized through the ways they are produced, circulated, used and exchanged to generate distinctive forms of value. I do not adopt their notion of commodification; instead, I take a political economic approach to look at how economic value is associated with medicine and its implication for the availability of health-care services.
In resource poor gendered social settings, often having inadequate infrastructure, with a lack of human resources and insufficient means to carry out diagnoses, increasing availability of medical services can lead to the emergence of medicalization by reframing social problems in medical terms. This gradually leads to the situation of medical social control (Conrad and Schneider, 1993) through medical technology, medical collaboration, medical ideology, and also due to the influence of big pharma as a new engine of medicalization (Conrad, 2005). In explaining social phenomena in terms of hegemonic biomedical narration portrayed in the text of medical journals "medicalization implies the desocialization and reification of disease and illness and the explanation of the social problems in the biomedical terms" (Filc, 2004(Filc, , p. 1277. Over the period of its wider usage, scholars had pointed out the limitation of medicalization to explain the emerging situations such as the exponential growth of medical technology. They argue for the application of a concept like biomedicalization to analyze the complex dynamics and effects of technoscientific innovation (Bell and Figert, 2015;Clarke and Shim, 2011). Considering the forces shaping the desocialization of dis-easeness and the level of advancement of medical technology in the study area, I think the term medicalization better fits in analyzing data from a study area with less sophisticated medical technology. In Van der Geest and Whyte's opinion (1989), poor countries have a dense conducive situation for both the excessive attraction to medicines and thus it can be argued that it may aggravate the medicalization of social problems.
My departure from some of these earlier anthropologists is that I am examining the embeddedness of health seeking practices focusing on biomedicine and not on traditional medicine. Therefore, though one can find the coexistence of traditional healing and biomedicine (Zank and Hanazaki, 2017) in the study area, I focus on the hegemonic position of the latter. My firm position is that understanding of health and illness experience is rooted in a cultural context not only in the case of traditional and alternative medicine but also in the context of biomedicine.
This article is based on information acquired from ethnographic research designed to comprehend health seeking practices of Maithili Brahmin women from Nepal's Tarai. Maithili Brahmins consider marriage as an essential part of personal and social life and arranged marriages by senior male family members are the dominant form of marital practice among them along with Dahej (the dowry) as an inherent cultural practice. Once married, normally, women were not expected to move out from their patrilocal family, unless accompanied by senior female in-laws, including for their visit into the local health facility. A married woman, especially the young ones have to wear Ghunghat (veil) to cover their face. Women use the end of the Sari to cover their face. Newly married women cover their face in such a way that they only keep some space to see. Whereas, elder women cover the top of their head, not necessarily the whole face. Wearing Ghunghat had more emblematic import than the coverage per se with the physical object. Family and marriage shape the typical kind of self and situation of these women (Dahal, 2018, p. 170) and becoming a woman itself is embedded within the gendered and hierarchical social structure.
In this ethnographic study, my focus was on exploring the meaning behind the ideas and practices enacted in seeking health care. I employed ethnographic design to understand people's ideas and actions through gaining access to the perspectives of those being studied (Denzin and Lincoln, 1998). In other words, I have explored "a set of rules which describe how people act in their culture" (Berreman, 2004, p. 159). I conducted the fieldwork during 2012 and 2015 in the central Tarai area in the social cluster among Maithili Brahmin women, to which I have given the pseudonym of Lakhanpur.
The study was conducted both in the community and also at the Primary Health Care Center (PHCC) located in Lakhanpur. In addition to women in the community, conversations were held with significant others including their family members, people involved in providing health-care services to them, and the pharmacists who made medicines available to them in their vicinity, staff of the health facility, traditional healers, private pharmacists, and also with health seekers. Observations were made in the community and mainly in the health facilities, both in Nepal and in India.
Here, I have departed from adopting the conventional ethnography of limiting the study entirely in the community in two respects. I collated information from the health facilities as part of doing "hospital ethnography" (Van der Geest and Finkler, 2004) to generate information from the site where these women visit to seek their health-care services. Likewise, I also adopted the multisited ethnography (Marcus, 1998, p. 7) following the women in their health seeking journey and their interactions with the health-care service providers at the local health facility and also at the neighboring Indian cities.
I was not a native of the study area where this research was carried out. Bajjika, Hindi and Nepali were the main conversational language in Nepal side of the field, whereas, English was employed while carrying out fieldwork in neighboring India. In addition to time and place specificity of the study, my position of being a man had placed me in a restricted situation. I am sure, had I been a woman and/or local, my positionality and thus information generated would have been different. I constantly made reflexive analyses of culled facts and my relationship with my research participants and how that shaped my positionality in the field (Hill et al., 2010) and reshaped the knowledge arising from the research.
Engaging with the key literature that informed my thinking, this introductory segment traces this article's links with some key social science research dealing with the embeddedness of health and illness within the social and cultural realm. It also documents the prevalence of medicalization and commodification of healthcare services in the locality and that arose through the process of modernity, which forms the theoretical basis of this article. I have presented the findings in three empirical sections. Initially, I illustrate that traditional and popular healing practices are marginalized. Secondly, I discuss the expansion of private pharmacies in the locality and its impact on the availability of health-care services and the people who access them. Thirdly, I show that in prevailing health-care services available in the locality, local people chose to adopt cross-border medical travel to neighboring towns and cities in India. In conclusion, I argue that all these three dimensions of health-care practices are intertwined with the process of commodification and medicalization of health-care services.
Marginalized traditional and popular healing. There is a Durga temple in the middle of the settlement in Lakhanpur. This huge temple was constructed recently. However, Maithil Brahmins had a symbolic and cultural legacy with this temple, which they think is 250 years old. Before the massive flood of 1969 A.D., which displaced them into this area, this temple was on the other side of the river. Though they were not able to bring anything from the old Durga Temple, they still consider the new temple to be a continuation of the previous one, which was completely swept away. This temple became a symbol of their collective solidarity and caste status in the locality. These Brahmins have faith that the Goddess Durga can influence many things. They related their overall well-being with the blessings of the Goddess. Nevertheless, I found that people did not go to this temple for their everyday health problems. These Brahmins clearly opined that it is aastha (faith and reverence) that makes them pay homage to the Goddess.
Bhakta, sometimes referred to as Janne Manchhe (a type of knowledgeable person in the locality) healed various illnesses through the recitation of hymns and herbal medicines and can also cure infertile women, especially if they are incapacitated by magical attack, Dayan (witchcraft) or a ghost. These supernatural forces can do kokh line (take the womb). Bhakta were consulted initially for many diseases. People consulted Bhakta for the diseases, which they think are caused by ghosts or a witch, whereas, in the case of other diseases not caused by such spirits, they would initially go to the doctor. If a doctor could not cure them, then they suspected attack from supernatural forces and then they consulted Bhakta. Help seeking from Bhakta can also be taken simultaneously with the Angreji Dabai ("English medicine"), which denotes biomedicine. Often biomedicine is interpreted in Lakhanpur area juxtaposing it with the healing of Bhakta.
At the time of my fieldworks, many people turned to dominant alternatives available in the domain of state supported biomedicine as healing pathways. This was reflected not only in government budget allocation for it but its aura and ramification can be seen in other domains of public life, which has contributed to a flourishing biomedical hegemony (Baer et al., 2003). For instance, an in-charge of the PHCC by virtue of his position enjoyed some of the status associated with membership in the Village Development Committee (VDC) Council, and the VDC Wash Committee, whereas an in-charge of Ayurveda Health Center is deprived of that. As Lock and Nguyen (2018, p. 82) have argued in their review article, biomedicine has proliferated at the cost of other healing trajectories; this is also true in case of Lakhanpur.
There was one Ayurveda Health Center in Lakhanpur, at the corner of the bazaar. While looking at the location of this health facility, it could be regarded as enjoying a better position in comparison to a biomedical health institution. When I visited there one winter day in 2014, I found two persons, one of them was an in-charge of the Center. He at once told me that Ayurveda is in the shadow of biomedicine not only in this locality but also everywhere in Nepal. Even the government policy is discriminatory against Ayurveda, which merely recognizes it and other nonbiomedical healing practices as "alternative healing" (Johnston, 2004). The disparity between these two sectors can be easily seen when one compares the total number of 4100 allopathic 1 health facilities in different levels, which has expanded up to VDC level in comparison to 277 Ayurvedic health facilities (MOHP, 2014). Similarly, in the fiscal year 2019/20, Homeopathy/Unani and Ayurveda sector was allocated 1.80% of the health budget (MOHP, 2019) and the rest (98.20%) of the budget went to the biomedical sector. Cameron (2009) relates the feminization of Ayurveda in Nepal with its marginalization, which happens amidst the proliferation of allopathic medicine and the government support for biomedical education.
The in-charge of this Ayurveda Health Center further elaborated the significance of Ayurveda in regard to its capacity to heal: Ayurveda is effective in healing the ailment rather than curing them temporally. Due to the aggressive marketing of modern medicine and indifference of the government towards Ayurveda, it is not popular among the people. These days people rarely visit us for medicines.
During my 5 h of stay in this health facility, I observed that only one woman visited there, for the cleaning of her ear. The incharge had also realized that people rarely visit this Ayurvedic center for medical treatment. While saying this, the in-charge pointed to a table full of dust in the dispensary room. However, some people recently began to visit there to clean their ears. He was still not aware of why people came for this. Later on, in my conversation with one of the influential health personnel from the PHCC, I got to know about such an unprecedented flow. He clearly told me that it was he who created the rumor among the patients that Ayurveda has a good cure for ear problems. He satirically opined that it's a kind of support for them to find some visitors.
Nevertheless, one can see the prevalence of hybridization (Marsland, 2007, p. 751) of healing practices comprising of little components from other healing methods added to the main healing practice. The medical hybridization in Lakhanpur was led by the patients themselves and thus it was different from the Tanzanian case as stated by Marsland, where it was actively developed by the traditional healers to show the progressive nature of their practices.
Likewise, Baidh are the healers who are knowledgeable in Ayurvedic medicines. They acquire Ayurvedic knowledge via their family members or from a knowledgeable person in the locality. There were 3-4 Baidh in the study area. They traveled by bicycle and pass through the village settlements. People could call them if they needed their service. Conventionally, they dealt only with Ayurvedic healing. They diagnosed the patient through observation and touch, along with listening to their illness narration. They often prescribed medicines that they either prepared themselves or they brought from Ayurvedic stores in neighboring Indian towns. Following the expansion of biomedicine, they also began to sell these medicines. Some of them even learned to provide saline water and give injections, which they carry in their bag. As Marsland (2007, p. 751) has rightly pointed out in the case of Tanzania, these Baidhs have added biomedical components in their healing methods to demonstrate the progressive nature of their practices.
Leaving behind Ayurvedic medicines and other home-based treatments, people had been inclined towards biomedicine. Certain perceived qualities of biomedicine had lured the increasing number of people in the private pharmacy where they get medicines instantly. As modernity is associated with swiftness, people's choice of biomedicine reflects people's disposition towards modernity. In the words of Rupmati Jha, a woman in her late forties: These people are in hurry, they seek fast results. Angreji Dabai treats people swiftly and this is why more and more women are lured by this…In our community, women are not expected to step out of their homes, even to go for medication. Rich people call on "doctors" at their homes. But not all people can afford this. We prefer to go to the clinic/pharmacy, where we do not have to wait for a long time. There, we can quickly get medicine.
The growing attraction of local people towards modern medicine can be seen in the career trajectory of Mr. Sohan Jha. Three years ago he studied Ayurveda to become a Health Assistant (HA) in Ayurveda in the District headquarters. He could not get the government job of Kabiraj (equivalent to a Health Assistant who is trained in biomedicine). He found that there were rarely any positions open for Ayurveda trained manpower. Therefore, he began to run a medical shop 5 years ago. He came to realize that people preferred allopathic medicines, which had become a symbol of modernity in the area. Therefore, he gradually turned his Ayurveda medical shop into an allopathic drug store. When I visited him in 2015, there were very few Ayurveda medicines in his store. He estimated that there could be only 35 to 40% of Ayurvedic medicine in his store, which was still named "Ayurvedic Store".
There was one Homeopathic drug "store" a few meters away from the bazaar area. Rita Mishra's family was running it from their own residence. I had been to that house many times as one of the daughters of the owner had worked as a research assistant for my previous study. I had asked the family several times about the availability of alternative healing practices in Lakhanpur area. They never mentioned the homeopathic medicines they sell.
Only after 2 years of my research in 2013, when I entered Rita's house simply to say hello, I noticed that her husband had just arrived back from the District headquarters. He was taking many medicines out of his bag. When I noticed this I inquired about whether everyone was fine in the family or not and why all these medicines were there. Then, they told me about the homeopathic medicines, which they had been selling over the last decade. They had homeopathy medicines for general health problems such as fever, headache and stomach-ache. People only came to their place but these people often did not go for Ayurveda medicines and Angreji Dabai.
That unfolding of the selling of Homeopathic medicines, despite several attempts to inquire about the availability of alternative healing practices, made me look at my fieldwork reflexively. One aspect of obvious doubt was the level of rapport I have had with her and the family. While looking back at her efforts to introduce me to her neighbors and relatives and sometimes explaining to them about the kind of research I was doing, I could not consider that it was because of a poor rapport. I had never presented myself as judgmental and thus she would not have been worried about how I would think about this dimension of the therapeutic trajectory.
Later on, Rita told me that many people laughed at homeopathy and this is why she hid this from me. Even though they had been selling homeopathic remedies over the last 10 years, she managed not to disclose it to me for such a long time. I found this quite interesting aspect of ethnographic studies which as Geertz (1973) stated, a new facet of the reality may keep on unfolding in different levels over the long period of fieldwork. Local people's perception was so much influenced by the high value attributed to biomedicine that people "naturally" became hesitant to talk about alternative medicines like homeopathy. It was an appropriate illustration of how hegemony suppresses (Gramsci, 1971) the articulation of wrong and right. It also reveals the fact that despite prevailing dominant hegemonic ideas and ideals, alternative views and practices may prevail, hidden somewhere in the undercurrent of everyday life of common people in the locality. The very existence of such practices in hidden form can be taken as a form of resistance and prevalence of alternatives to the hegemonic biomedical ideas and practices.
Choice of a healing method has become a kind of symbolic marker of social and cultural identity (Millard, 2013;Crandon-Malamud, 1991) in the locality. People choose a particular healing method for the treatment of ailments simultaneously and this choice is related to who they are. Crandon-Malamud has referred to the social function of medicine relates to the identity and status of a patient and their family members, which goes beyond healing ailments. Echoing many other local people, a woman in her late fifties, told me during the course of our conversation about the choice of healing method that clearly shows the link with the status and identity of the patients or the family: Some 20 years ago, initially we used to go to Bhakta, the local traditional healer. But nowadays we have become aware that we have to go to the health facility first. We are no longer that much backward. In our locality, many women consult "doctors" these days for their health problems.
This section has delineated the situation of Ayurveda, homeopathy and other local healing methods in the study area and how people's healing choices are embedded with their identity and status. The narratives of choice of healing trajectories can broadly be seen in the context of state supported biomedicine, its hegemonic expansion and growing appeal marked by the increasing number of private pharmacies in the locality. Nonetheless, traditional medicine has managed to co-exist (Zank and Hanazaki, 2017), albeit in a marginalized form, amidst the reality of biomedical hegemony. The coming section highlights the increasing number of private pharmacies in the study area and the process in which patients were becoming consumers.

Flourishing private pharmacies: making patients consumers.
Anthropologists have analyzed the implications of the commercialization of indigenous healing practices, and also the role of state power or government policy (Cremers, 2019;Adams, 2002) on them, and this article is keeping with this approach. Streefland (1985) has pointed to the tendency of biomedicine in developing countries to act as a vehicle for capitalism and commercialization, and this has clearly been the case in Nepal. Many curative institutions, medical practitioners and drug sellers in Nepal are private entrepreneurs and for them, profit making is an important consideration in the delivery of health-care services. This brings in the situation of "entrenched modernity" (Alam, 1999, p. 39), having a close link between modernity and capitalism, which is clearly visible in the study area. This leads to the situation in which doctors and pharmacies are concentrated in urban areas (Streefland, 1985) and unqualified practitioners and drug sellers are found in the villages. Therefore, access to quality care becomes far away from the people living in the rural areas.
There were 12 private drug stores in Lakhanpur, a number, which had escalated from six during my 3 years of fieldwork. Four of them were established over a 6 months period in the year 2014. All those established in the year 2014 are owned by returnee migrants from the Gulf region. Most of the pharmacists are themselves owners of the pharmacy, a few of them have hired another person to run their pharmacy. One of the prominent features of these pharmacies was that the dispenser at the pharmacy remains there for longer hours, until the evening, which is longer than the government health facilities. This made it easier for health seekers to approach them at their convenience. It also increased the chances of health seekers returning to the pharmacy, which heightens the possibility for patients and pharmacists to be in "regular" contact over the years making it easier for the pharmacists to know more about the health and family situation of the patients.
People in Lakhanpur referred to private medical stores as "pharmacies", "drug stores", or "clinics" interchangeably. All the private pharmacies were run by male pharmacists or an attendant. They were located at the main road in Lakhanpur or around the place where the Haat (a local temporary market), was held twice a week on Monday and Thursday. Of the twelve pharmacies, only one specialized in Ayurvedic medicines, although the others also sold some Ayurvedic medicines. These pharmacies also provided diagnosis and counseling services to people. One of the big pharmacies, run by a staff of the PHCC, also provided pathological services to the people, 24 h a day. Two of these pharmacies also had a visiting consultant doctor on Mondays and Thursdays, when there was the Haat and thus the dense flow of the people. In fact, the visiting doctor, the same person in both the pharmacies, was an Ayurvedic doctor but the advertisement on the sign board of the pharmacy did not disclose this. I got to know about this while chatting with the pharmacists about the visiting doctor. Considering the popularity of biomedicine in the locality, it is curious that the pharmacies did not disclose this fact to lure patients. Leslie (1980, p. 193) portrayed prevalence of such practice of biomedicine in India as a form of quackery, by the people trained in other areas of healing.
The more the experience of the pharmacists and the persons working there, the more people went there for consultation. If the pharmacy was new or the person working there was new, then people went there mainly to buy drugs. I never encountered situations in which pharmacists had advised patients to go to the PHCC/doctor prior to their consultation. While talking to a pharmacist about whether he could diagnose all the patients who approached him or not, he told me: Even if I refer them to go to the doctor, which is in district hospital or beyond, they will end up at another pharmacy in the locality. That means a loss of a business for me. That loss will be forever. So, I better opt to prescribe medicines to them on my own.
Binod, a pharmacist from the locality, told me that drug stores have to be registered with the government office and medical council. Previously, one had to be a pharmacy graduate or have a diploma to be eligible to apply for a license. As he did not have either of these degrees, he showed the certificate of another person, to whom he paid some money every year for using his certificate. As he had shown the certificate of his Aafno Manchhe (one's own people) (Bista, 1991), he did not have to pay much, but he did not disclose to me how much he paid. After 6 months of registration of the pharmacy in this way, one can transfer the ownership into one's own name.
One of the most prominent medical doctors from the district headquarters had also opened a clinic in the local bazaar area of Lakhanpur. He came to this clinic every Monday and Friday, during the days of Haat. One can register to see him in the remaining days in a week and depending on the number of patients, he would decide to come or not on that particular day. There was another Ayurvedic doctor who also attended two different pharmacies around the Haat, Monday in one and Friday at another. Private pharmacies use this strategy to expand their business. Both of these pharmacies were opened only in 2015.
I had known Sohan Jha for some years when I entered Lakahnpur for my research. He had become a good friend. When I went into the field, sometimes we took breaks together and sometime I even stayed at his shop without talking about my research. However, eventually, the conversation somehow came around to the subject under study. One day, during our conversation Sohan Jha stated that Lakhanpur was becoming an allopathic medical hub in the locality: Private medical stores have doubled in number to twelve. There are two MBBS doctors in the local PHCC and two other physicians regularly come to Lakhanpur, though in different clinics. These days, people from neighboring VDCs also travel to Lakhanpur for their medical check-ups. Having a PHCC in Lakhanpur as a referral center in the locality as per the Government of Nepal's health system, has also contributed to the development of Lakhanpur as a medical center in the vicinity.
The "technical rationality" (Kleinman, 1995, p. 37) in the form of standardized practices, and the bureaucratization of biomedicine of government owned local health facilities in its different dimensions has contributed to the flourishing of private medical stores. It compels people, regardless of their situation, to go to private medical stores. Private pharmacies have been providing supplementary, complementary and sometimes even alternative health-care services to the bureaucratic rigidity of government health facilities, such as limited opening hours and who can and cannot visit a health facility.
While talking to a drug store owner, nearby the PHCC building, Mr. Durgesh Mandal tried to summarize to me why private pharmacies are flourishing in the Lakhanpur area. Biomedicine, thus, has been perceived in the locality as a symbol of modernity in contrast to traditionality (Connor and Samuel, 2001). He stated that: If people open a school etc. they will eventually fail. Health is the only business where one never goes in loss. One gets disease whether he is rich or poor. These days most of the people go for allopathic medicine. Who else, these days, will go to Baidh and other traditional healers?
Mr. Mandal's words reflect the emerging trend of the commodification process of the social sector including the health-care domain. As he narrated, one can invest in any sector such as health and education, and these are the main areas of investment in a semi-urban area like Lakhanpur. Considering the contemporary situation of health-care services in the locality, the viable alternative was the private sector mainly due to easiness to access it. With no great surprise, the motto of the pharmacy was profit. The efficacy and effectiveness of biomedicine with its character of scientism and also as a sector promoted by the government health policy and programs (Streefland, 1985), biomedicine is enjoying hegemonic power (Baer et al., 2003) over other alternative therapies in the study area.
One of the main results of the bureaucratization and institutionalization of health-care services was the strict opening/closing hours of the health facilities' out-patient department from 10:00 am till 2:00 pm. This state power had been exercised through professional health-care providers, which eventually led to the enforcement of the disciplinary power of biopolitics (Foucault, 1977) in the form of internalized "self-control", as an unintended consequence of bureaucratized health development, which made the patients reluctant to come back again. People knew that it was not always possible to get health care from the PHCC, therefore, they went to the private pharmacies and clinics in the vicinity and also across the border. The following section delineates how local women's healing choice has been affected by the proximity of the field area to neighboring Indian towns and cities with numerous private clinics and hospitals.
Medical treatment across the border. Local people from Lakhanpur often portrayed rail and medicines as part of the modernization process they have witnessed in India. Biomedicine was introduced in India through colonization and has a much longer presence than in Nepal (Arnold, 1993). Biomedicine had been regarded by Lakhanpur people as effective due to its capacity to make effective diagnosis and swift treatment.
Analyzing the frontiers of biomedicine in the Nepali context, Streefland (1985) argued that its expansion in developing countries is biased towards centralization. There is an urban bias not only in terms of the concentration of institutions of knowledge production, storage and training, but also in terms of treatment and care giving. Therefore, people living in rural areas have to travel to get such services to urban areas.
Located 15 Kilometers from the Indian border, following the expansion of biomedicine across the border towns in India, Lakhanpur people began to look for their medical care in India. They have a nuptial relationship across the border in India; some of their daughters-in-law come into their village from their natal home in India. They are already acquainted with the hospitals and medical care obtainable in the bordering Indian towns and cities. Similarly, their daughters are also married across the border in India and they also come to know from them and their relatives about the available medical treatments on the other side of the border.
Women need company to go to the health facility in their locality because of purdah, meaning "curtain", a cultural practice prevalent among Maithil Brahmins. It begins after the marriage of a woman with the aim of prohibiting their communications with people, mainly the males outside certain categories (Papanek, 1973). Male family members or elder women bring medicine to them. Only when their illness is severe they will visit the local health facility, usually in the company of the mother-in-law or a sister-in-law. A woman is rarely accompanied by her husband when visiting the local health facility. If they need to go outside of their locality, meet with the strangers, make financial arrangements and expenditures for the treatment, it becomes essential for her husband to accompany her. Only when he is unavailable, other family members will accompany her. For Maithil Brahmins there is a cultural notion that women are weak, and thus they need protection from the husband and other family members if they are to go on medical travel across the border.
People from various segments of society are not only knowledgeable about this cross-border medical travel practice but many have also performed it. Even the government officials who were supposed to deliver the health-care services in the entire district also took this as a common phenomenon in the locality. The District Health Officer (DHO) in a straightforward way told me about the imperativeness of medical travel to India: I know that people from different villages and even from the district headquarters go to India following the road in front of our district level hospital. We may not have been able to deliver adequate and proper services. It is not related with who the medical officers are here in the district hospitals. (I think) the problem lies in our health care system itself and the government has to make sure that ample services are available within the country.
As people are obliged to go for cross-border medical travel, I found that there was competition among the clinics and private hospitals in the destinations in India to attract the patients. To construct the ideal image for selling health-care services they present certificates showing that the doctors had acquired training and had links with America (USA). The USA was portrayed as the modern, western, scientific ideal and thus a model of high-quality healthcare. Certificates demonstrating training acquired with a US institution are presented. It is not necessary even to understand what is written on them. These certificates, posters and stickers serve in the process of "circulation of commodities in the social life" (Appadurai, 1988) and in return add to the commodification process of the health-care services. The US medical certificate serves here as a metaphor (Dahal, 2016), icon and imagery meaningful in the local cultural context, which lures people towards modern medicine and a western style of modernity.
In their publicity, some clinics also presented modern technology to impress the patients about the kinds of facilities available there. At Dr. Jaiswals' clinic in Sitamadhi, there was a flex board at the entrance of the clinic displaying information about a modern medical technology of B'ORZE digital video to get rid of unwanted operations. It was mentioned as bishwabikhyat (the world famous), modern technology. The board also contained information in ten bullet points about when a woman needed to go for this test. One can also observe unique combinations of modernity and traditionality in the hospital roads in Sitamadhi.
The unique portrayal of traditionality and modernity in the Hospital road to attract the patients signifies the ways biomedicine is constructed socially in the study area. Traditionality, at the face value, appeals to the patients by displaying the pictures of the gods and goddesses, attempting to link their healing practices with the supernatural power. Simultaneously, it also surrenders to the very supernatural forces that ultimately human attempts to heal the health situation of a patient is bounded with limits and it is the mercy of the God on which the outcome depends. In addition, these efforts of the clinics and private hospitals, where people go for medication are also influenced and supported by the recommendations from the knowledgeable or experienced person in one's network (Dahal, 2019).

Conclusions
The ubiquitous practice of biomedicine in a localized form in the study area shows that it is embedded in the local social and cultural realm in various ways; restricted mobility of women, and gendered hierarchy and dominating patriarchal norms are reflected in these women's journey to a healing trajectory and in their interactions with the service providers. No matter how strongly biomedicine claims to be scientific, in practice, it has not been capable to diagnose and treat the problematic health situation of health seekers being objective and value neutral only based on their pathological condition. Van der Geest and Finkler (2004) are right that hospitals reflect and reinforce the dominant social and cultural processes of society where they are located. The same can be said for health facilities in Nepal's Tarai.
Biomedicine has emerged as a hegemonic form of healing pathway in the study area "at the cost of other healing trajectories" (Lock and Nguyen, 2018, p. 82). Factors associated with the government's health policy of promoting biomedicine and the private sector, and marketing strategies of private hospitals, clinics and pharmacies presenting biomedicine as a commodity, are contributing to its expansion. Biomedical attraction relates to its promise of swift recovery and this has made people inclined to opt for it. The arrival, expansion and localization of biomedicine, entwined with the flourishing of private health-care services, has accelerated the process of its commodification.
While confronting other alternative medicines, biomedicine has taken help of nonmedical means in creating the appeal to adopt it. Use of particular kinds of imageries, projecting its strength with the help of gods and goddess, impression management through the projection of medical training acquired through the institutions, which are not only located in the USA and other western countries, the icons of modernity and efficacy, but also simply linking with their name can be seen widespread in the area. Neighboring Indian towns and cities are also attracting patients from Nepal through their fame for efficacy, cost-effectiveness, and imagery of modernity. While looking at the biomedical practice of borrowing social imagery to impress people and attract them, it can be argued that biomedicine is also not inherently modern enough to appeal and convince the patients, thus, the private hospitals and clinics have been taking help of various cultural emblems to construe modernity in it. The circulatory social life of non-biomedical commodities (Appadurai, 1988), such as certificates of training in the USA, contributes to cultivating modernity in biomedicine.
Seeking health-care services in the context of expansionary biomedicine has become a means to construe one's identity, as being modern. Mostly avoiding and neglecting conventional healing practices, these women have begun to take help from biomedicine. Therefore, the choice of healing is not merely an adoption of a particular therapy, rather, it is the process of construction and claim of one's identity in a particular way in a cultural context where one can acquire social value and status by adopting modernity. This kind of image of biomedicine has also contributed to promoting medical travel to seek better health-care services available across the border in India.
Sometimes, people use a combination of biomedicine and one or other form(s) of alternative healing practices, which Marsland (2007) considers as medical hybridization. While examining the wider influence of biomedicine, and, moreover, the ontological basis of good health and thus illness and healing, one can conclude that there is encroachment and domination of "remedial ontology" (Alter, 1999) of biomedicine, leading to what I would regard as biomedical hegemony. Nonetheless, one can see the coexistence of alternative healing practices amidst biomedical hegemony in the local health culture.
With the authority and professional power in modern society to label certain disorders as diseases, physicians have played a greater role in the medicalization process. Their hegemonic power is projected through the practices in the health-care domain itself. Medicalization eventually contributes to the emergence of the commodification of medicine, in terms of its availability in the market and its sale in generating economic value. The flourishing private pharmacies in the locality have proven that biomedicine has become a form of business.
This article has shown how the process of and thirst for modernization of health-care services on the one hand has expanded commodification and medicalization of health-care services while at the same time its unavailability at an affordable price in Nepal had made people go for cross-border medical travel to neighboring towns and cities across the border in India. Moreover, it has also shown that the three avenues of health-care services, namely, medicalization, commodification and crossborder medical travel prevalent in the study area, are flourishing and intertwined in such a way that they are mutually reinforcing each other.

Data availability
Qualitative data acquired from the ethnographic field research are still available with the author, in well-preserved condition, as field notes, field diaries and images. They cannot be deposited anywhere considering both the pragmatic (hundreds of field notes, diaries, and images) and the ethical (since they contain the real name of the place and people in actual time and dates) reasons.
Received: 7 April 2020; Accepted: 30 March 2022; Note 1 Sometimes people use this term to refer to biomedicine.