The basic premiss of this book, introduced in Chapter 1, is the triumph of practicality. That is, it is assumed that despite the official and formal distinctions in legitimacy and effectiveness between traditional and modern medical systems made by governments and the modern medical profession, people make use of both systems according to their own perception of what is good for them. Furthermore, this trend is deemed to be immune to modernization. The dual use of traditional and modern medicine — well documented in the 1960s and 1970s — is expected to continue despite the process of modernization experienced in Third World countries throughout the 1980s.

Correspondingly, three answers were suggested in the first chapter to Fabrega's (1982: 248) important question on why people use both traditional and modern medicine. These tentative answers were: the presence of pragmatic acculturation, the level of accessibility to both modern and traditional medical services, and the consumers’ subjective perception of the benefits of using those services.

Based on the data from the five nations covered in this study, this concluding chapter summarizes the evidence collected on the above assumptions. The summary is presented in terms of the two mam questions or themes guiding the study, namely, the mam patterns of dual utilization of traditional and modern medical systems and the current role of governments concerning the integration of the two systems.

Main Patterns of Dual Utilization

If one were to encapsulate some of the findings of this study in one sentence, it would be: yes, dual utilization persists and gives no signs of disappearing with modernization. But, of course, such a concise report does not explain why people continue to combine modern and traditional methods of healing. The three answers suggested at the outset, namely, pragmatic acculturation, level of accessibility, and subjective perception of benefits, are supported by the evidence reported in the preceding chapters. Let us review each of these answers briefly.

The idea for this volume began taking shape during the preparation for the session on traditional and modern medicine, which was one of the sessions organized by the Research Committee on Medical Sociology (now Sociology of Health) of the International Sociological Association (ISA) as part of the Xlth World Congress of Sociology held in New Delhi in August 1984. I was invited by the Chairman of the Committee, Ray Elling, to organize that session. Three of the papers presented in the session, namely, the paper on Hong Kong, Sonoda's paper on Japan, and the paper on China, were selected for inclusion in this volume. They appear here, revised and enlarged, as Chapters 5, 3, and 2, respectively. Their contributors, Ranee Lee, Yuet-wah Cheung, Kyoichi Sonoda, and Li Jing-wei, had worked extensively on the study of medical systems from different perspectives and were specially invited to participate in the ISA Congress. For the other chapters, I approached Tsunetsugu Munakata from Japan and Santhat Sermsri of Thailand, prompted by their valuable contributions to the study of medical systems in their respective countries. Sonoda's chapter provides an overview of the link between traditional and modern medicine in Japan while Munakata centres on the more specific area of mental health, which is a very relevant aspect in the high-technology and rapid pace of life in Japan in the 1980s. One of the main contributions of this book is that it offers the views of social scientists from the countries studied. Of course, we paid the price in terms of time. Indeed, as is common in collaborative efforts, the bulk of the revision work was done by correspondence. However, in the spring of 1988, I had the opportunity to go to Beijing to finalize the chapter on China.

The main aim of this study is to present current documentation on the resilience of the traditional medicine system in Asian nations undergoing rapid modernization and to explore the reasons for people's persistent combination of modern and traditional medical resources in their everyday life.

The analysis of the current dual health care system in Singapore reveals that people enjoy a wide variety of choices, from both modern and traditional options, while most consumers tend to be educated enough to make sound decisions based on their specific needs without feeling unduly restricted by the cost of health care. These are, briefly, the basic lines in the sketch of dual utilization of health services.

The details of the situation will be presented following the guidelines introduced in Chapter 1, that is, the discussion on Singapore will be divided into four sections. The first section will focus on the providers of health services and will discuss the available modern and traditional medical services. The second section will deal with the patterns of utilization of both types of medical services. The third section will look into the pattern of dual utilization of traditional and modern medical services. The concluding section summarizes the main findings.

Singapore, as most other Third World nations, is a land of contrasts. But what makes Singapore unique is the nature and intensity of the contrasts between East and West, tradition and modernity. The political, economic, social, and religious events of the country evolve and blend in the lives of a multiethnic population of 2.7 million people sharing as their home, an island of merely 570.4 sq. km. (or 620.2 sq. km. if one counts the main island and the offshore islets). Within the confines of this small island republic, among the Chinese majority (76 per cent of the total population), Malays (15 per cent), Indians (8 per cent), and other smaller minorities, four official languages (Mandarin, Malay, Tamil, and English) and numerous dialects are spoken; and at least three world religions are represented (Islam, Christianity, and Buddhism) in addition to Taoism, Hinduism, and Sikhism, among others.

Singaporeans enjoy the second highest gross national product (GNP) per capita in Asia after Japan, that is, S$l3,088 or about US$6,087 in 1986 (Department of Statistics, 1987: 2).

Until not too long ago, ethnographic descriptions of traditional healing practices were welcomed by experts as ancient jewels of human behaviour that had to be preserved in records before they became extinct. It was taken for granted that such traditional ways of preventing or handling illness would eventually disappear as people became enlightened by the concepts and effectiveness of modern medicine.

However, as the query on how different communities deal with disease continues and more evidence is collected, the premiss on the extinction of traditional health practices can no longer be accepted (Leslie, 1976; Klemman, 1984). Indeed, the study of traditional ways to treat and cure disease has evolved from being the curious subject of a few erudite scholars to the theme at the forefront of health care analysis by a wide range of disciplines. Cost-benefit analysis, geographical, sociological, and anthropological studies suggest that traditional healing practices have survived the competition of modern medicine.

Studies documenting the survival of traditional health practices substantiate the argument advanced by Gusfield (1973). He identified a set of six fallacies on the study of tradition and modernity, four of which are fully corrected by the evidence from the dual utilization of traditional and modern health services. These four fallacies are: “old traditions are displaced by new changes”; “traditional and modern forms are always in conflict”; “tradition and modernity are mutually exclusive systems”; and “modernization processes weaken traditions” (Gusfield, 1973: 335-39).

This book addresses the dual utilization of traditional and modern medical systems as it takes place in societies undergoing rapid modernization, and seeks to document the premiss that traditional practices are not merely “surviving” but, rather, they are “established” traditional ways of healing actively interacting with modern practices in health-related behaviour. By analysing the situation of five Asian nations at various stages of development and with diverse cultural settings, we will be able to compare the pervasiveness of the dual use of systems of health care, and the accommodations that have taken place in recent years on the part of traditional and modern medical systems to coexist and to meet the health needs of consumers in these countries.

The research design selected for this study was a survey with structured personal interviews. The main dependent and independent variables were ascertained by means of a combination of open-ended and closed-ended questions and a few Likert-type scales. The questionnaire may be found in Appendix B.

The most difficult aspect of this study was to obtain access to the type of population needed as defined by the nature of the problem under investigation. The target population was all married women who were 28 years old or older at the time of the data collection (that is, November 1981); who had been married for at least two years; and who had postponed the birth of their first child for reasons other than infertility of either spouse.

The search for such a population or group was conducted in several steps. First, it was estimated that in 1980, there was a population of 7,844 married women aged 28 to 44 with no children and no fertility problems. Such estimation was arrived at as follows: the official 1980 Population Census figures for ever-married women aged 25 to 44 with no children was 26,148 or 4.8 per cent of the total population of ever-married women (Khoo, 1981: 63). Considering the attitudes on the ideal age to have the first child, discussed earlier (SFPPB, 1979: 39), whereby most women believed that the ideal age to have the first child was 25, it was assumed that most of these childless women (about 70 per cent) would have tried to have a child unsuccessfully and, consequently, no more than 30 per cent of this population would be free from fertility problems. This 30 per cent is equivalent to 7,844 women and, if this estimation is right, they would constitute the target population for the study of voluntary postponement of first birth.

Most societies today are in a stage of transition, moving at different paces from one point to another along the continuum of modernity. In a situation of transition or cultural change, adults get married and become parents not only as a response to the social pressures to conform, but also according to their personal life goal s and priorities. The purpose of this paper is to focus on the married couple's decision concerning the timing of their first child, and to identify the relevant factors involved in such a decision.

The discussion is based on some of the findings from a larger study on delayed parenthood and is divided into four sections. The first section provides a brief background on the situation in Singapore, delineating relevant aspects of the social setting within which the study took place. The second section is a review of research findings from other studies concerning parenthood decisions, their causes and consequences. The third section presents and discusses the aspects of modernity and traditionalism that are found to be related to the choice of delayed motherhood. A concluding section summarizes the main findings and their implications. The description of the study design is provided in Appendix A; and the questionnaire used during the interviews appears in Appendix 8.

The main emphasis of this discussion is on the aspects of modernization and tradition as reflected in the wives' attitudes and behaviour concerning the meaning of marriage in their lives and motherhood postponement. Such aspects have been dealt with in the preceding pages. The original study included several other aspects assumed to be associated with the decision to delay parenthood, for example, the wife's perception of the decline in her own fertility and her perception of health risks for mother and child in late pregnancies. As these two are secondary aspects in the context of this presentation, it is sufficient to describe only the most salient findings.

As originally assumed, the perceptions of health risks and diminished fertility influenced, albeit weakly, the decision on postponement. Forty per cent of the women who did not see major health risks waited for three years or more to have their first child, compared to only 28 per cent of those who did believe that it was risky for their own or their babies' health to postpone the first child. It was also found that women who saw age and declining fertility as the main disadvantages of delayed motherhood, were more likely to believe that health risks were high, compared to wives for whom the major disadvantages of postponement were mounting family or in-laws pressure to have a child or marital problems (when the husband disagreed with the wife's desire to postpone having the first child).

Finally, some background characteristics of the wives had an impact upon the postponement decision. One such characteristic was the educational level of the wife and the couple's monthly income: the higher the level of formal education and income, the more inclined the wives were to use contraceptives. The influence of education upon parenthood decisions is well documented; the wife's education has been found to influence not only the timing of the first child but also the spacing of subsequent children.