Cultural Notions Versus Social Actions: The Case of the Socio-cultural History of Leprosy in Thailand

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Cultural Notions Versus Social Actions: The Case of the Socio-cultural History of Leprosy inThailandAuthor(s): Liora NavonSource: Social Analysis: The International Journal of Social and Cultural Practice, No. 40(September 1996), pp. 95-119Published by: Berghahn BooksStable URL: http://www.jstor.org/stable/23171699 .

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SOCIAL ANALYSIS No. 40, September 1996

Cultural Notions Versus Social Actions: The Case of theSocio-cultural

History of Leprosy in Thailand

L. Navon

The nature of the relationship between cultural notions and social actions has long

been recognized as one of anthropology's central concerns (Murphy 1990). However,

as years go by and the theories in this field develop, controversies over the subject

seem only to proliferate. On the basis of a study of leprosy's medical, social and

cultural history in Thailand, the present paper deals with three focal issues in these

controversies: the degree of congruence between social reactions to a phenomenon

and its cultural image, the way in which changes in each of these two variables affect

the other and the nature of their transformation following scientific and

socioeconomic developments.

Following Weber (1946) and Durkheim (1961), such past anthropological

theories as British and American functionalism used to distinguish between social

actions and cultural meanings, identifying the former with concrete behaviour and the

latter with thoughts, beliefs and ideas. They generally assumed, however, that the

social reactions to a phenomenon maintain full congruence with its cultural image

and hence conclusions about either variable can directly be drawn from a study

focusing solely on the other (Marcus and Fischer 1986; Schneider 1976; Spates

1983). Accusing these theories of reductionism, post-structuralists like Mary

Douglas, Michel Foucault and Jurgen Habermas set out to investigate culture in

interaction with social actions, assuming that the study of observable social behaviour

can illuminate the rules that underlie cultural patterns. Nevertheless, their analyses

have been criticized for providing formalistic depictions of cultural phenomena rather

than an insight into people's own interpretations of their worlds (Wuthnow 1987;

Wuthnow, Hunter, Bergesen andKurzweil 1984).

Rejecting both the view of full congruence between social actions and cultural

meanings and their perception as necessarily interacting with each other, structuralists and symbolic anthropologists called for an analytical distinction

between them and for the study of symbolic systems as a separate autonomous realm

which includes phenomena that are exclusively cultural (Geertz 1957; L6vi-Strauss

1963; Schneider 1976). A similar approach was adopted by researchers who sought

to understand the relationship between cultural notions and social actions by means

of linguistic investigations, focusing on metaphors and key verbal concepts (e.g. Parkin 1978; Quinn and Holland 1987). Such analyses of cultural phenomena as

autonomous have recently gained much currency in both sociology and anthropology



(Alexander 1990). However, they have been accused of neglecting the social

behavioural dimension (Murphy 1990) and of being unreliable and methodologically

naive (Keesing 1974; Marcus and Fischer 1986).

The inability of all of these perspectives to escape criticism clearly indicates that

the extent of congruence between social behaviour and cultural notions remains

controversial. It comes as no surprise, then, that disputes over more specific issues

concerning the relationship between these two variables, such as the way one affects

the other, have not yet been settled. In the past, British structuralists and American

sociologists interpreted cultural concepts as deriving from social phenomena, whereas

Malinowski and many American anthropologists perceived social phenomena as a

product of cultural patterns (Geertz 1957). An example of the persistence of this

controversy can be found in the recent criticism of constructionist sociology's

assumption that cultural beliefs influence social actions, which according to the

critics contradicts this perspective's own Wittgensteinian and Garfinkelian roots

(Button and Sharrock 1993). An alternative approach to this subject was developed

by proponents of practice theory, neo-Marxism or critical theory, who maintain that

cultural ideas are produced by upper classes, intellectuals or other dominant social

groups. Their studies revealed that since this production process is publicly

unnoticed or even intentionally obscured, cultural practices reproduce the structure

that produces them. Accordingly, these analysts suggest that a constant dialectic

exists between social behaviour and cultural patterns (Adorno 1976; Bourdieu 1977,

1984; Gartman 1991; Sahlins 1985). Schneider (1976), on the other hand, believes the controversy over this issue to be pointless, as there is no way to test and determine

the relative effect of one variable on the other.

In light of this debate it is no wonder that the differential change of social actions

and cultural notions under external influences, such as scientific and socio-economic

developments, is subject to another controversy that has yet to be resolved. For

example, Schneider (1976) argues that cultural symbols are characteristically more

stable than the norms dictating social actions, whereas Rabinow (1975) contends that

in many situations external developments effect changes on the social level more

rapidly than on corresponding cultural levels. Holy and Stuchlik (1983), dissatisfied

with all these disputes, suggest focusing the investigation of notions and actions on

their concurrent examination and on the analysis of the relationship between them.

Kuklick (1983), Ortner (1984) and Alexander (1990) pin their hopes for a

breakthrough in the understanding of the relationship between the two variables on

studies that combine anthropological and historical research methods, yet the

majority of the researchers have no practical solutions to offer beyond calling for

further empirical research in this field (e.g. Griswold 1987; Swidler 1986; Wuthnow et al. 1984; Yengoyan 1986).

The present article aims to contribute to resolving the controversies over the

congruence between cultural notions and social actions, their mutual influence and

their differential transformation due to external influences. These issues are

examined through an analysis of the changes in the treatment of leprosy, in the

cultural image of the disease and in the social reactions towards the patients over the

past one hundred years in Thailand. These changes were investigated separately

96



within a framework of anthropological field-work combined with historical

investigation. The data collection thus accords with the suggestions put forth by Holy

and Stuchlik (1983), Kuklick (1983), Ormer (1984) and Alexander (1990).

Methodology

The findings in this paper are based on field-work conducted in Thailand over a

period of two years and eight months, which were spent in four hospitals for the

treatment of leprosy, seven rehabilitation villages and government colonies set up for

patients receiving welfare, nine out-patient clinics, five sites inhabited by patients

discharged from treatment, two prisons for beggars with leprosy and in three normal

residential areas covered by leprosy control teams. These sites, spread throughout

Thailand, were chosen so as to represent the country's four geographical regions, all

types of facilities in which people with leprosy are treated and live, and all types of

organizations in charge of such facilities: the Thai government, Protestant and

Catholic missions and local volunteer associations.

In all the research sites, participant observation was conducted, focusing on the

social attitude towards leprosy, the patients' ways of coping with potential stigma,

public education campaigns initiated by the care institutions and the extent of the

treatment facilities' assimilation in their environment. In addition, on the basis of a

random sampling in all sites, interviews were conducted with 450 patients on past

and present social reactions to their disease and on their own attitude towards it. An

additional 119 patients and 307 informants, including medical staff, Buddhist monks,

Christian missionaries, relatives of patients and people from society in general were

interviewed on specific issues relating to the history of leprosy and the attitude

towards it in Thailand since the end of the nineteenth century. Information on these

subjects, as well as on the history of Thailand and leprosy in general over the past one

hundred years, were the focus of a literary and archival survey carried out as part of

the research.

The data were divided into three categories: medical views, social reactions and

cultural images. 'Medical views' comprised attitudes toward leprosy underlying

treatment policies, public education campaigns and legislative measures. "Social

reactions" included the various responses actually manifested toward leprosy

sufferers in daily spheres of interaction, whereas 'cultural images' encompassed

values, beliefs and mental attitudes, that is, the most accepted dimensions in the

sociological study of culture (see Wuthnow and Witten 1988). The data comprising

each of these categories were processed chronologically by means of content analysis.

The validity of the analysis was ensured by a comparison between interviewees'

accounts, bibliographical sources and personal observations (seeDenzin 1989).

Since the findings indicated that the social reactions and the cultural images

underwent changes that corresponded to four different phases in the history of the

treatment of leprosy, the data presented in this paper are divided into four historical

periods, each focusing on a separate stage in the development of the medical, cultural

and social attitudes to the disease. In this regard, however, three points warrant

97



clarification. First, this chronological treatment does not imply that at each stage an

entirely new set of images and social reactions replaced the former one. Indeed, older

conceptual and behavioural patterns still persisted in subsequent periods;

nevertheless, turning points in their ongoing decline and the emergence of new

patterns allowed identification of distinct phases in the process of their

transformation. Second, such a division of these transformations may seem to ignore differences in their manifestation and timing among the various socio-economic

groups composing Thai society. However, this generalization is based upon a

synchronic analysis of the findings which preceded the diachronic one and revealed

that such differences were quite insignificant. The relatively homogeneous reactions

at each stage stem from their dependence —

enlarged upon below — on medical

developments to which all strata of society in all regions of Thailand were similarly and simultaneously exposed. The same applies to the transformation of images that

is described below as being contingent mainly on changes in interactions with and

perceptions of beggars with leprosy. Third, since the present paper covers a period of

one hundred years, it relies heavily on the interviews and the archival survey.

Moreover, space limitations did not allow the inclusion of detailed illustrations of

current reactions towards patients that were personally observed in the course of the

study. However, all the references to such reactions appearing in this article, with the

exception of some citations from the literature, are derived not only from the

interviews but from first-hand information gained through systematic observations.

Stage 1: Leprosy in Thailand from the Late 19th Century to the 1950s

The Medical View: Leprosy as an Incurable Plague

Leprosy is caused by Mycobacterium leprae and transmitted mainly through the

respiratory tract. Most people are naturally immune to the disease and only those

who are not can contract it. Untreated, leprosy may cause some of its sufferers severe

neural and muscular injuries, which may lead to loss of sensation, macules and

nodules on the skin, sores, blindness, collapse of the nose, claw hands and drop feet,

as well as bending and shortening of the fingers and toes (Jopling 1984). In the late

nineteenth and early twentieth century, many countries throughout the world forced

people with leprosy into isolation, but in Thailand, no formal action was taken with

regard to these sufferers. Modern medicine in the country was not developed at the

time and leprosy — like other diseases — was ineffectively treated by local healers

who specialized in Siamese traditional medicine or in the use of such magical means as amulets, incantation and exorcism (McKean 1913).

At the turn of this century, Protestant missionaries in northern Thailand initiated

organized aid to beggars with leprosy who knocked at their doors in quest of alms. In

1907 they founded the Chiengmai Leper Asylum, the first shelter for leprosy

sufferers, known today as the McKean Rehabilitation Institute. Inspired by their

work, the Thai government established a similar shelter — the Red Cross Leper Asylum

— in 1923. By the mid-twentieth century, owing to additional government

and missionary initiatives, Thailand had three hospitals for the treatment of leprosy,

98



out-patient clinics, rehabilitation villages and government colonies established for

welfare-dependent patients and their families (McKean 1928; Thailand Leprosy

Control Divisionn.d.).

In addition to economic and nursing assistance, the patients at these sites received

medical treatment in the form of chaulmoogra oil injections. Beginning in 1913,

these painful injections were considered world-wide to be a remedy for leprosy, until

in the late 1930s it was established undisputedly that they were wholly ineffective

(Karat and Ramanujam 1973). In the 1940s, the first laws dealing with leprosy were

enacted in Thailand. The Leprosy Act (Thailand 1943) restricted the rights of people

suffering from the disease to travel by public transportation, work in government jobs

and serve in the army. The Act for the Control of Beggary (Thailand 1941)

prohibited them from seeking charity in the streets, but its actual enforcement

nationwide began only in the 1950s (Thailand 1953). In 1919, a medical survey

conducted in Thailand estimated erroneously that the number of leprosy sufferers in

the country was only 17,000 (Thompson 1967). Although leprosy was still considered an incurable plague, this survey raised hopes that the official measures

that had been implemented until the mid-1950s would rapidly lead to the eradication

of the disease.

The Cultural Image of Leprosy: A Negative Physical Condition

Prior to the 1950s, most of the Thai population was still unaware of these medical

developments. Treatment facilities for leprosy patients were built in remote areas and

the laws concerning the disease were not publicized. Thai people's beliefs about the

medical aspects of leprosy were thus influenced mainly by Siamese traditional

medicine, which regarded the disease as hereditary, rather than infectious, and attributed its cause to an imbalance of the body's components. Since all diseases

prevalent in Thailand were similarly explained at the time, these explanations cannot

be seen as a source of stigmatizing attitudes towards leprosy.

The same can be said for the Thais' religious beliefs about leprosy held in the first

half of the century. Buddhism officially debars male leprosy sufferers from fulfiling

their traditional duty of joining the monastic order for a period of at least three

months in their lives (Vajirananavarorasa [1917-18] 1973). Originally decreed to

ensure the monk's ability to practise his duties, this prohibition was not, however,

viewed by the Thais as implying any moral blame, and furthermore in many cases it

was not actually enforced. In fact, since Buddhist doctrine holds that leprosy, like

any other event in a person's life, is a result of karma, it does not assign this disease

any unique status. Popular belief even ascribed this specific disease exclusively to

karma from former life cycles, which precluded any blame of the sufferer.

Nevertheless, leprosy was perceived as an exceptionally abhorrent physical

condition, to the extent that the popular view was that it took a great number of life

cycles to accumulate such negative karma that would have such dire consequences.

This view stemmed from Thai people's selective exposure to beggars who suffered from this disease. While other people with leprosy were either misdiagnosed or kept

away from the public eye, those suffering from severe disfigurement and lacking

99



familial support were forced to make a living from begging for alms. In their effort to

arouse pity, they would display their deformities by removing their shoes and

stretching out their disfigured hands. Numerous writings from the period under

discussion provide evidence of their wanderings through Thailand, the intense

impression they left and their erroneous perception as representative of all people with leprosy (e.g. Brown c.1925; Cantlie 1897; Gillies 1923). The daily encounters

with these beggars generated the cultural image of leprosy as the most rejected of all

diseases — an ugly, deforming and incurable disease which degrades its victims to

'living death'. This image, however, was interlinked with Buddhism's emphasis on

succouring the ill and needy (see Butr-Indr 1973; Khantipalo 1973). The physical repulsion aroused by the beggars, on the one hand, and the perception of their

condition as blameless, on the other, combined to generate the cultural perception of

the person with leprosy as pitiful.

Social Reactions to People with Leprosy: Internal Exclusion

The actual reactions of Thai people to the beggars suffering from leprosy accorded

with their ambivalent image. On the one hand, they aroused deep fear, causing

people to avoid physical contact with them. On the other hand, they were allowed to

roam public places and even to beg for rice from door to door. Since all people with

leprosy were perceived in terms of the beggar's ambivalent image, anyone diagnosed

as suffering from this disease evoked similar reactions of dread and pity. In some cases, the newly-diagnosed people continued to live with their families, but were

physically isolated behind a partition. Others were taken care of by monks in

Buddhist temples. In more extreme examples of separation, leprosy sufferers were

kept in solitary huts on the outskirts of their village. When several people were thus

separated, a hamlet developed alongside the original place of residence. At times,

these people aroused a fear so great that it extended to everyone and everything that

had contact with them. They were prevented access to wells, rivers and food sold in

the markets, and even those who stayed with their families had separate dishes,

bedding and laundry. Healthy offspring born in the hamlets of leprosy sufferers were

forbidden to attend regular schools and had difficulty finding spouses. Patients

already living in treatment facilities aroused particularly intense fears among those

who knew of their existence. Anyone who did dare to work in these places took

stringent precautions. Even general hospitals refused to admit leprosy patients

requiring treatment for other illnesses.

Only m rare cases, however, were people with leprosy the victims of extreme

manifestations of stigma, such as stoning or banishment from their villages. Even

those who were separated from their homes were still regarded as members of their

community and their relatives continued to associate with them and provide for their

needs. Likewise, when leprosy sufferers were forced to beg it was not owing to

ostracism, but rather to the death of relatives who had previously supported them, or

due to their voluntarily leaving their villages out of shame or to avoid becoming a burden to their families. Both the reactions towards the beggars and the various

patterns of separating other people with leprosy shared the common feature of

100



segregation withm the bounds of the community, segregation which may be termed

'internal exclusion'. These patterns of exclusion combined with inclusion made it

possible to bridge the gap between the repugnance and fear evoked by the leprosy sufferers and the pity felt towards them. Up till the 1950s, then, there was full

congruence between the social reactions towards people with leprosy and their

ambivalent image as loathsome yet worthy of assistance.

Stage 2: Leprosy in Thailand in the 1950s and 1960s

The Medical View: Leprosy as a Curable Disease

In the late 1940s a cure for leprosy was found, and additional effective drugs were

discovered in the 1960s. The treatment of the disease also profited from the

introduction of reconstructive surgery and modern physiotherapeutic methods.

Throughout the world long-term hospitalization was replaced by ambulatory

treatment and by case-finding surveys aimed at early diagnosis of leprosy cases

(International Leprosy Congress 1959). In Thailand too, these breakthroughs marked

a sweeping change in the treatment of the disease. A sample survey conducted in

1953 estimated the number of people with leprosy in the country at 150,000

(Ramasoota c.1985). Since this figure denoted a prevalence rate of 5 per thousand,

leprosy was recognized as one of Thailand's major health problems. In 1956, the

government introduced a nationwide leprosy control programme under the guidance

of the World Health Organization. As part of the programme, medical teams

conducted mass examinations on large population samples and provided ambulatory

treatment to newly-diagnosed cases. By 1970, the programme included 40 of the 72

provinces in Thailand and in 1971 the number of people treated had already reached

88,417 (Thailand Ministry of Public Health 1972). These developments involved an essential change in the medical conception of the disease: once an incurable plague

identified with severe deformity and long-term medical care, leprosy could now be

detected before the appearance of visible symptoms, treated without hospitalization

and cured.

While these developments were taking place, the Thai government launched

public education campaigns that focused on the early symptoms of leprosy and made

a nationwide effort to enforce the regulations prohibiting leprosy sufferers from

begging. However, in stark contrast with the trend to replace hospitalization with

ambulatory treatment, new villages were being established for people with leprosy by

missionaries who came to Thailand after being forced to leave China, by local volunteer organizations and by the McKean Rehabilitation Institute, which was being urged by its funders to reduce the number of its inmates (Fisher 1967; Fraser 1952).

Many leprosy sufferers, in view of welfare allowances offered in the institutions and

the newly-established villages, preferred them to rehabilitation within the community,

and the number of in-patients at the different treatment facilities grew by

unprecedented proportions. Thus, despite the breakthrough in the treatment of

leprosy, it still remained markedly distinct from all other diseases.

101



The Cultural Image of Leprosy: A Negative Social Phenomenon

During the 1950s and 1960s, Thai people were not acquainted with the optimistic

implications of these developments but were witness only to the establishment of new

villages for leprosy sufferers, the massive case-finding surveys and the arrest of

beggars with leprosy in the streets. Furthermore, these arrests did not reduce public

exposure to the beggars, as many of the patients now living in the rehabilitation

villages turned to begging to make easy money. In addition, the medical information

imparted to the public through the education campaigns was met with disbelief, since

concepts such as bacteria, infection and early diagnosis conflicted entirely with the

perception of leprosy in terms of karma, heredity and visible symptoms. Moreover,

in order to encourage leprosy sufferers to seek treatment, these education programmes focused on a frightening portrayal of the disease rather than on attempts to improve

its image. Consequently, the scientific breakthrough did not affect Thai people's

views on the medical aspects of leprosy, beyond a growing awareness of its

treatability. The rest of the new developments only served to confirm leprosy's

cultural image as a disparate disease, and its perception thus continued to be moulded

by the daily encounters with beggars in the streets.

However, since many people with leprosy who now begged for the sake of easy

money did not have severe deformities, they were often mistaken for regular beggars.

Similarly, the latter were sometimes taken to be suffering from leprosy. This

confusion indicates that leprosy was gradually becoming identified with beggary in

general rather than with the unique physical characteristics of beggars with the

disease. Its cultural image could thus be imbued with new meanings, derived from

Thai society's general views of people living off charity. Following economic reforms introduced by the military regime in 1958 and

strengthening of ties with the United States during the Vietnam War, Thailand

underwent accelerated industrialization and urban expansion (Silcock 1967).

Westernization and modernization became admired ideals, and order, hygiene and

health were given special attention. Since the persistence of beggary clashed with

these new ideals, Thai people began to identify this phenomenon with backwardness,

disorder and a disgrace to the country. Beggars were now perceived as social

parasites who should be eliminated from the streets (Maraengsid 1976; Thanarat

1960). Although these developments adversely affected the image of beggars with

leprosy too, in the 1950s and 1960s the negative attitudes were not yet overtly

expressed in their presence. While other beggars now experienced negative reactions,

those suffering from leprosy were still regarded as pitiful; hence even people who

harshly criticized them continued to provide them with donations. This contrast

between their perception and the actual responses towards them indicates that their

negative image began to undergo a process of separation from the sphere of concrete

events. Since the beggars were still being mistakenly perceived to represent all

people with leprosy, these developments intensified the negative cultural image of the

disease as a whole.

102



Social Reactions to People with Leprosy: Symbolic Separation

The negative meanings imbued in the image of leprosy in the 1950s and 1960s

contradicted the growing awareness that it was a treatable disease, which in itself

caused confusion as to the appropriate reactions towards its sufferers. It comes as no

surprise, then, that people with leprosy began to encounter a variety of responses,

ranging from the traditional 'internal exclusion' to full social acceptance.

Manifestations of the improved social reactions in the various treatment facilities

included increasing willingness of people to work there, relaxation of precautionary

measures, establishment of settlements in their vicinity and commercial ties that

began to develop between the patients and their neighbours. In addition, people with

leprosy who needed care in general hospitals met with less antagonism, and their

children were allowed to attend regular schools. Moreover, the majority of those

newly diagnosed were no longer segregated, and some even managed to keep their

diagnosis a secret.

Nevertheless, in most cases leprosy sufferers did not yet encounter full social

acceptance. In very similar circumstances, the same people sometimes took

precautions in their presence and sometimes did not. For instance, many people

avoided eating and touching objects in the homes of leprosy sufferers but welcomed

them in their own homes and allowed them to touch their own belongings. Other

people were scared of any affectionate gestures on the part of leprosy sufferers but did

not mind touching them as long as the interaction was not intimate. Some people

with leprosy encountered frightened reactions when being met alone, but were not

feared when the interaction took place in public. Others were specifically forbidden

to touch babies or to use their family members' personal belongings, but otherwise

had normal relations with their relatives.

It appears, then, that the fear formerly evoked by any contact with leprosy sufferers was now being replaced by reactions contingent on contextual factors, such

as the location of the interaction, the number of its participants, the degree of

intimacy and the ownership of objects involved. Instead of the strict separation

patterns people with leprosy had been subjected to in the past, precautionary

measures now taken in their presence were confined to specific deeds, objects and

circumstances and these restrictions were also open to flexible changes. These

precautionary steps no longer reflected severe repugnance, nor could they offer

protection against infection. They may thus be interpreted as patterns of symbolic

separation that focus on the meaning rather than on the true nature of contact with

leprosy sufferers, and respond to psychological rather than practical needs. This

change in attitudes towards people with leprosy accords with the separation of the

beggars' image — and thus of the image of leprosy as a whole — from actual

relations with them. However, since the relations with leprosy sufferers improved

within the framework of these developments while their general perception was

imbued with negative meanings, this stage marks the beginning of a divorce between

the actual reactions encountered by them and their cultural image.

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Stage 3: Leprosy in Thailand in the 1970s and 1980s

The Medical View: Leprosy as a Normal Phenomenon

In the 1970s and 1980s, further research on leprosy established the view that the

disease is transmitted through the respiratory tract. Increasing awareness of the social

problems stemming from leprosy stigma impelled many countries to repeal laws

discriminating against people with the disease. In addition, the World Health

Organization began encouraging governments to transfer the treatment of leprosy from special agencies to the general health services, so that it would be treated as a

normal disease (WHO Expert Committee on Leprosy 1970). In light of these

developments, leprosy care in Thailand underwent several changes. By 1976,

implementation of the government control programme was complete in all parts of

the country and treatment of the disease was incorporated into the general health

services. By the end of 1983, 147,033 leprosy sufferers were detected through this

programme. Surveys conducted in 1982 showed that, compared to 1956, the

prevalence rate had declined from 5 to 0.9 per thousand (Ochasanond 1984). According to criteria set by the World Health Organization, leprosy ceased to be

defined as a public health problem in Thailand.

As a result of this progress, special out-patient clinics and villages providing shelter for people with leprosy were closed down. Hospitals for the treatment of this

disease adopted occupational training programmes encouraging patients to conduct

an independent life within the general community. Patients who had lived in these

hospitals for years were discharged. Permanent residence in the treatment facilities,

to which all people with leprosy had formerly been entitled, was limited only to those

whose physical and financial condition warranted it (Thailand Department of

Communicable Disease Control 1985). Another manifestation of the normalization

of the disease was the repeal of the Leprosy Act. Furthermore, the educational

programmes dealing with the disease were expanded and updated to convey the

message that leprosy was no different from other diseases and thus did not deserve

the stigma attached to it.

The Cultural Image of Leprosy: A Negative Moral Trail

Much hope was pinned on the prospect that the educational campaign would change

the image of leprosy, but KAP (knowledge, attitudes, practice) questionnaires

administered in the 1970s and 1980s by the Thai government to large population

samples showed that no significant improvement had been achieved (Ramasoota

c.1979, 1981). It appears that the image of the 'normal leprosy patient' imparted to

the public through this campaign was no match for the strong impression left by the

beggars suffering from the disease. Furthermore, in the 1970s and 1980s, the number of these beggars declined substantially since most people with leprosy were no longer

motivated to live off charity. Nevertheless, Thai people continued to be exposed to

the association of the disease with begging, owing to fund-raising campaigns aimed

at financing the government control programme and the welfare aid given to needy

patients. In order to arouse public compassion, these campaigns presented leprosy as

104



a disfiguring and socially rejected disease, and thus revived its original image derived

from face-to-face encounters with beggars. This image was further reinforced by a

wave of patient demonstrations against attempts to evict them from the various

treatment facilities. By harnessing the media for their struggle and conveying to the

public a similar message to that of the fund-raising campaigns, the patients themselves perpetuated their identification with the image of the beggar.

During this period, the image of beggars in Thailand underwent further

deterioration. Traditional familial aid to the needy was replaced by the country's

expanding welfare services, and additional economic advances improved social

attitudes towards productive work. These developments strengthened the view of

beggars as parasites, and the Thai press launched a campaign against them, ascribing to them immoral traits and habits, such as criminality, trickery, child exploitation,

drug abuse, laziness and cruelty (e.g. Sedtakid 1979). While in the 1950s and 1960s begging was considered a national ignominy, its condemnation now focused on the

beggar as an individual. At the same time, secularization processes led to a gradual abandonment of the perception of leprosy as a result of karma from former life cycles and the corresponding view of its sufferers as blameless victims. This paved the way for the attribution of the immoral traits that were ascribed to beggars in general to

those suffering from leprosy as well. Furthermore, Thai people were beginning to

adopt ideas from popular psychology, which explained undesirable behaviour as

being the product of mental disorders. In light of these explanations, begging by

people with leprosy was interpreted as evidence of psychological problems caused by their physical condition (Somkhanay, Ramasoota and Thardtong 1983). Since the

image of the beggar continued to shape that of all leprosy sufferers, in the 1970s and

1980s the latter's traditional view as blameless victims evolved into a negative and

irrefutable stereotype, binding their disease to immorality while at the same time

releasing them from responsibility on the grounds of their alleged mental defects.

The invisible personality traits, anchored in a supposedly scientific psychological theory now being ascribed to invisible beggars, constituted a further stage in the

disentanglement of the beggars' image from concrete reality and hence in the

symbolization of the overall conception of the disease.

Social Reactions to People with Leprosy: Social Acceptance

In former times the social reactions towards leprosy sufferers reflected a

reconciliation between contradictory views of these people: their perception as both

frightening and fearful led to their internal exclusion, and their conception as both

disgraceful and treatable resulted in their symbolic reparation. In the 1970s and 1980s, the extremely negative cultural image of leprosy could no longer be reconciled

with its presentation as a normal disease and with the normal looks and behaviour of

the newly-diagnosed patients. Since their appearance markedly contradicted that of

beggars, their diagnosis was often met with incredulity. Consequently, these patients

did not experience any change in their social relations. Other people with leprosy preferred to keep their diagnosis a secret, hence they too were spared any fearful

reactions. Tremendous improvements were also indicated during this period in the

105



attitude towards patients still living at the various treatment facilities. As towns and

villages expanded, these sites were assimilated into the surrounding settlements.

Extensive commercial, social and marital ties developed between patients and their

neighbours. Regular families settled in these residential facilities and children from

surrounding communities began attending schools located within the treatment sites.

People suffering from other diseases sought treatment in institutions initially established exclusively for leprosy patients. Strict precautionary measures taken to

protect staff members against infection were now removed. Vacant posts offered in

these sites began to attract numerous candidates. In general, during the 1970s and

1980s, the majority of people with leprosy in Thailand began to lead entirely normal lives and enjoy full social acceptance.

An especially interesting development in the reactions towards people with

leprosy is that since the 1970s, provincial delegates to the National Assembly have

considered the residents of leprosy institutions as an electoral force. In exchange for

recruiting votes, these politicians help patients and their families to put pressure on

senior government officials to meet their demands for improved living conditions and

to abrogate plans for eviction. Owing to their ties with the politicians and also to

their widely publicized demonstrations, these patients have gained so much power that they have managed to arrange meetings with senior government officials, bring about the dismissal of institution directors, cancel rehabilitation programmes and

obtain financial benefits. From a completely powerless social category, the in

patients of leprosy institutions have become pressure groups wielding the power to

dictate policies regarding their treatment. All these developments imply that the

cultural image of people with leprosy as miserable and contemptible beggars has

been completely divorced from the real lives of most of those suffering from the

disease.

Stage 4: The Future of Leprosy in Thailand

The Medical View: Leprosy as an Eliminated Disease

In the 1980s, after several decades of far-reaching progress in the treatment of

leprosy, the optimistic prospects for complete elimination of the disease were

replaced by widespread pessimism. The appearance of drug-resistant bacteria gave rise to deep apprehensions that leprosy would again be transformed from a curable

disease into an incurable plague. However, between the early 1980s and the mid

1990s the estimated number of leprosy cases in the world has dropped from 11.5 to

2.7 million people (Sansarricq 1983; World Health Organization 1994). These

figures have dispelled the fears, and recent assessments even consider that by the year

2000 leprosy will be eliminated in most countries (World Health Organization 1993). This sharp transition from pessimism to optimism was also apparent in the estimates

regarding the elimination of leprosy in Thailand. Medical surveys conducted in the

early 1980s showed an increase in the prevalence rate of the disease after many years

of steady decline. However, after a short period of concern, in 1990 the prevalence

rate again dropped to 0.23 per thousand (Thailand Leprosy Division 1990). Smith

106



and Richardus (1993:9) note that "the leprosy epidemic in Thailand is coming to an

end and it is not unreasonable that the disease might well become a rarity by the year 2000".

The Cultural Image of Leprosy: A Negative Verbal Expression

The modern treatment of leprosy, its integration into the general health services, the

decline in the number of beggars in the streets and the secrecy kept by newly

diagnosed patients have all contributed to a notable decrease in the encounters of

Thai people with those who may be identified as suffering from the disease. A

fruitful way to predict the future cultural image of the disease in Thailand would thus

be to analyse the views of the younger generation, many of whom have never met a

leprosy sufferer. Most young people are completely ignorant of leprosy's symptoms and some are not even aware it exists in their country. Over the years more and more

youngsters have come to believe that the disease has long been cured and disappeared from the world.

Nevertheless, while leprosy sufferers have begun to sink into oblivion, the

younger generation — like the general public

— continues to be exposed daily to the

disease through its metaphorical use in the spoken language. In the past, many

designations, originating in the Siamese traditional medicine, foreign languages and

popular notions about the disease, were used to denote leprosy. Today, the meanings of most of these terms have been forgotten. The only terms to survive in the spoken

language are the stigmatizing labels for beggars with leprosy that originally generated

the cultural image of the disease: khirian, which denotes both a 'leprous person' and

a 'leprous dog'; khitud, with the same stigmatizing prefix khi, meaning 'dirt' or

'excrement'; and kuthang, with the prefix kut, meaning 'to be amputated' (Haas

1964). Currently, these terms serve as metaphors for social rejection and inferior

status. Thai people use them mainly to degrade another person or criticize someone of

inferior status pretending to be otherwise.

Through their persistence in the verbal sphere, designations of the beggar

suffering from leprosy continue to construct the cultural image of the disease as a

whole. In due course, when leprosy in Thailand is eliminated, its metaphorical use

will remain one of the only sources for moulding its image. Already many young

people with virtually no knowledge of the disease infer from its use in the context of

degradation that all leprosy sufferers are or were subject to extreme ostracism.

Similarly, since khirian denotes both a person and a dog, they conclude that people

with leprosy look or looked like oozy dogs: thin, covered with sores, dirty and

repulsive. This further stage in the symbolization of the disease thus imbues its

cultural image with additional negative meanings. Moreover, since this image is derived from figurative expressions meant to describe other phenomena, it is divorced

from the discourse on living leprosy patients, and hence is not likely to be affected by

disseminating information about the disease itself. Language, then, perpetuates the

association of leprosy with negative meanings, intensifies them and prevents their

refutation.

107



Social Reactions to People with Leprosy: Obliviousness and Assimilation

Just as the beliefs of Thailand's younger people may serve as a basis to predict the

future image of leprosy, their behaviour indicates the initial development of another

stage in the patterns of social reaction towards the disease. More than anybody else,

these young people are being exposed to educational programmes about leprosy in

their studies. However, in the course of the present research, observations of their

reactions towards 'theoretical leprosy patients' —

depicted in photographs, illustrations and statistical graphs and tables — indicate that the effort to impart

information about the disease and the need to consider it a normal phenomenon are

met with disinterest and boredom. For instance, during an audio-visual presentation of leprosy given at schools, pupils were observed playing and chatting among

themselves, and remembered nothing of a similar lecture they had sat through only a

week before. Attempts to induce pupils to take an interest in the disease by

combining educational activities with entertainment also encountered similar

difficulties: they attended the entertainment shows, but once the lectures on leprosy

began, most of them disappeared.

These reactions indicate that young people in Thailand no longer view leprosy as

a disease one might contract, and thus regard any information about it as irrelevant to

the reality of their daily lives. Considering their lack of interest in the subject, it is no

wonder that on encountering beggars with leprosy in the streets, they are unable to

recognize their symptoms. If even those beggars with severe deformities, who for

many generations shaped the cultural image of leprosy, are no longer identified as

suffering from this disease, this indicates full assimilation of people with leprosy

within the society at large. This development epitomizes the ultimate divorce

between the actual reactions towards leprosy sufferers and their extremely negative

cultural image perpetuated by the figurative uses of the disease.

Discussion

The medical history of leprosy in Thailand indicates that prior to the 1950s the

disease was considered an incurable plague, during the 1950s and 1960s it became a

curable disease, in the 1970s and 1980s it was treated as a normal phenomenon, and

nowadays it is on the brink of elimination. Along with these developments there has

been a gradual improvement in the social reactions to leprosy sufferers: initially

subjected to internal exclusion, then symbolic separation, most people with leprosy

were socially accepted in the 1970s and 1980s, and the current obliviousness of

today's younger generation as to their existence hints at a future situation in which

they will be fully assimilated into society. On the other hand, due to their

identification with beggars, the cultural image of people with leprosy gradually

deteriorated: prior to the 1950s this image focused on their negative physical condition, and then on their perception as a negative social phenomenon. Afterwards

it concentrated on associating their disease with negative moral traits, and the current

views of the younger generation suggest that in the future this image will be derived

108



solely from the use of the beggars designations as negative verba! expressions of

ostracism and degradation. The four stages in the last one hundred years of leprosy's

medical, social and cultural history in Thailand aresummarized in Table 1.

An analysis of the process illustrated in Table 1 may shed light on the questions

of congruence between cultural ideas and social behaviour, their mutual influence and

their differential transformation following scientific and socio-economic

developments. The contribution of this analysis to resolving the current controversies

over these issues is clarified and discussed below.

Table 1

The Medical, Social and Cultural Attitudes to Leprosy in Thailand over

the past One Hundred Years

Stage Period Medical view Social reaction Cultural

image

1 prior to the 1950s incurable plague internal

exclusion

negative

physical

condition 2 1950s and 1960s curable disease symbolic

separation

negative

social

phenomenon

3 1970s and 1980s normal

phenomenon

social

acceptance

negative

moral trait

4 present and future eliminated disease obliviousness

and assimilat

ion

negative

verbal

expression

The Congruence Between Notions and Actions

As specified in the introduction to this paper, researchers are at odds on the issue of

overlap between cultural notions and social actions. Some maintain perfect

congruence between the two variables, some claim that an interaction exists between

the two, and others reject any possibility of complete overlap between them. The

findings of the present study show in this regard that in stage 1 there was full

congruence between the ambivalent cultural image of leprosy sufferers as both

loathsome and pitiful and the ambivalent reactions towards them evident in their

internal exclusion. In stage 2, their cultural image was imbued with a negative

connotation of disgrace to the nation, whereas the actual social reactions to them

improved insofar as they were only symbolically separated. This separation of notions from actions continued in stage 3, during which a further negative meaning of

moral blame was infused into the cultural image while most people with leprosy were

already socially accepted. Stage 4, in which these people are wholly assimilated into

society while language intensifies and perpetuates their association with irrefutable

109



negative meanings, represents the ultimate divorce between their cultural image and

the actual social reactions towards them.

These findings indicate that in a given culture, within a few decades, the

relationship between the cultural notion of and the social reactions to a phenomenon

may undergo radical transformation from full overlap to complete contradiction. This

conclusion both undermines and supports the conflicting claims put forward by the

various theoretical perspectives on this subject. Although none of these claims

explains the full scope of the process outlined above, each of them clarifies a different

stage in it. The controversy over the degree of congruence between social actions and

cultural ideas may thus be the mere result of the reliance of the various theoretical

approaches on studies conducted at different phases in the changing relationship

between the two variables.

This proposition merits special attention, since it challenges the current

commitment of theoretical perspectives in both sociology and anthropology to the

analysis of cultural phenomena as autonomous. Separate examination of the various

stages in the history of leprosy in Thailand may elucidate this point even further.

Besides undermining the current rejection of overlaps between notions and actions as

reductionist, the analysis of stage 1 indicated that the congruence between the two

variables was rooted in their common ambivalent nature. In view of the growing

interest in ambivalence, which until lately has been rather neglected in the

sociological and anthropological inquiry (Levine 1985; Soder 1990), it is reasonable

to expect that future studies of notions versus actions will lead to the detection of

further situations similar to stage 1 and hence to the recognition that these two

variables overlap more frequently than is presently believed.

Furthermore, even the most staunch advocates of the autonomy of cultural

phenomena, such as Schneider (1976), do not maintain that cultural notions are

actually utterly divorced from social actions. They rather claim that since the two

variables never fully overlap, on the analytical level cultural phenomena can be

examined separately. An analysis of stages 2 and 3 in the socio-cultural history of

leprosy leads to opposite conclusions: cultural views of a certain phenomenon may

actually be utterly divorced from the social reactions towards it, but in order to detect

and understand such processes researchers should follow Holy and Stuchlik's (1983)

suggestion to investigate and analyse cultural notions in conjunction with the

examination of the corresponding social actions. In fact, only in stage 4, when the

perception of leprosy sufferers is derived solely from verbal metaphors, has their

cultural image been divorced from the actual reactions towards them to such a degree

that its examination no longer calls for any attention to social actions. This stage

coincides with Baudrillard's (1983) description of hyper-reality, in which signifiers

begin to be associated with signifieds, regardless of the referents. Considerably more extreme in his view than researchers supporting the separate examination of cultural

phenomena, Baudrillard contends that there are cultural notions that actually rely on

simulations entirely divorced from the actual social behaviour. The present study

shows that only in the case of notions of this kind does their examination without

considering social actions allow for a full understanding of their sources, meanings

and characteristics.

110



The Mutual Influence of Notions and Actions

As clarified in the introduction to this paper, some researchers believe cultural

notions to be derived from social actions, others uphold the opposite view, still others

maintain a dialectic between the two variables, and there are also those who claim

that this issue cannot be investigated at all. Regarding the influence of actions on

notions, the findings of the present study indicate that over the past one hundred years

the majority of the Thai population was unfamiliar with leprosy sufferers who did not

engage in begging, since most of them were removed from the public eye prior to the

discovery of a cure for their disease, while subsequent to that development most of

the newly-diagnosed patients lacked visible symptoms and kept their illness a secret.

Consequently, the actual reactions towards these people did not have any impact on

the shaping of their cultural image. The only social reactions that did bear upon the

overall image of the disease were those manifested towards the particular category of

beggars with leprosy, the visible interactions with whom generated the view of

leprosy as the most rejected of all diseases.

Regarding the influence of notions on actions, the findings show that the beggar's

image played a significant role in shaping the actual reactions towards leprosy

sufferers in general. In stage 1, the internal exclusion of people with leprosy reflected

a compromise between the sense of fear stemming from their identification with

beggars and the religious precepts that stipulated their entitlement to assistance. In

stage 2, their symbolic separation mirrored a compromise between the tendency to

reject them due to their persisting identification with beggars and a growing

awareness of leprosy's treatability. Although in stage 3 the beggar's image continued

to affect the reactions towards leprosy sufferers, its influence was now reversed.

Since the normal appearance of these people and their ambulatory treatment were

incompatible with this frightening image, their diagnosis was met with incredulity, which led to their social acceptance. In stage 4, the cultural image of people with

leprosy still reflects their association with beggars. However it is now derived from

the metaphorical use of the latter's designations in the spoken language. The divorce

of the image's sources from concrete reality has resulted in complete annulment of its

influence on the social reactions towards people with leprosy and thus in their full

assimilation into society at large.

It thus appears that, much like the controversy over the congruence between social

actions and cultural notions, the disputes over their mutual influence are

unwarranted. Cultural views can emerge from actual social reactions, and these

reactions can be moulded by cultural images. Although this conclusion is

incompatible with the claim that it is impossible to ascertain the mutual effect of

these two variables, neither does it support the existence of a simple dialectic between

them, for two reasons. In the first place, the findings indicate that an examination of

the influence of social reactions to a certain phenomenon on its cultural image must

take into account the extent of society's exposure to that phenomenon. In accordance

with Rothbart's (1981) claim, the present analysis shows that if the public is

acquainted with only select aspects of the phenomenon or with a non-representative

sample of people identified with it, the emerging cultural notions are likely to reflect

Ill



erroneous stereotypical perceptions of it. In the second place, the findings suggest that studies of the influence of notions on social actions must consider the interaction

between cultural images and such additional factors as religious beliefs, scientific

developments and their popular interpretations. In this regard, the present study

supports Keesing's (1987) and Quinn and Holland's (1987) position, according to

which cultural models and rules are not simplistically translated into actual

behaviour, since the influence of the former on the latter is determined by a wide

range of external factors. The findings also point to the possibility that the

involvement of such external factors may, over time, reverse the impact of notions on

actions and even annul its formerly extensive influence. As in the debate over the

congruence between the two variables, it is thus possible that part of the controversy over their mutual influence stems simply from the reliance of the theoretical

approaches to this issue on studies carried out when different patterns of influence

were taking place.

Changes in Notions and Actions Due to External Factors

Two conflicting approaches to the differential transformation of notions and actions

following scientific and socioeconomic developments were presented in the

introduction to this paper. The first predicts that such developments lead to a rapid

change in the social reactions towards certain phenomena whereas their cultural

images are more stable; the second supports the opposite view. In this regard, the

present study shows that, over the past one hundred years, entirely different external

factors have influenced the cultural image of leprosy sufferers in Thailand and the

actual reactions towards them. The cultural image was not affected by the medical

advances in the treatment of the disease but rather by general cultural and economic

changes. In stage 1, this image was influenced by religious beliefs. In stage 2, it was

affected by accelerated economic development and the establishment of government welfare services. Additional changes were noted in the image in stage 3 as a result of

secularization processes, the introduction of ideas from popular psychology and

further economic progress. In stage 4, however, when the cultural view of people with leprosy stems solely from verbal expressions, their image has become immune

to external influences.

The improvements in the actual reactions towards leprosy sufferers were, in

contrast, not affected by cultural and economic factors but rather by medical

developments. The discovery of effective drugs paved the way for the symbolic

separation of people with leprosy, and the treatment of leprosy as a normal disease

prepared the ground for their social acceptance. Likewise, their present assimilation

in society at large has not resulted from any socio-cultural development but solely

from the disease being at the brink of elimination in Thailand. However, it should be noted that all along the way the influence of the scientific advances on the social

reactions was mediated by popular interpretations of the results of the medical

treatment: when leprosy was already curable, Thai society regarded it at most as a

treatable disease; when medical authorities considered it a normal phenomenon,

reactions towards its sufferers improved owing to scepticism about their diagnosis;

112



and today, as efforts are still being made to eliminate it, the younger generation

believes that it has long ceased to exist.

This analysis suggests that at any specific point in time, the differential

transformation of social reactions towards and cultural notions of a certain

phenomenon may stem from the separate influences that entirely different external

factors have on each of the two variables. It thus appears that the controversy over

the relative stability and change of notions and actions under external influences may

have resulted from focusing on the impact of one set of cultural, economic or

scientific developments only, whereas the key to resolving this dispute is the

simultaneous investigation of a wide range of external factors that affect the two

variables separately.

Furthermore, from this analysis it is possible to learn whether two external factors

— the power of dominant groups such as social control agents and language's

capacity to construct meanings — merit the significance currently ascribed to them in

discussions about the relationship between social actions and cultural notions. Since

scientific views imparted to the public by medical authorities had no influence on the

image of leprosy sufferers, and even the actual reactions towards them were shaped

by people's own interpretations of the scientific developments, the present analysis

challenges both the attempts to assign to science exaggerated power to shape social

representations (see Billig 1988) and the general tendency to consider powerful social

agents as the producers of society's notions and actions. On the other hand, the

findings of this study corroborate the view that language should be regarded as a key

issue in analyses of the relationship between the two variables. In fact, the socio

cultural history of leprosy in Thailand illustrates Parkin's (1978) claim that key

verbal concepts outlive actual social behaviour ftom former days and in due course

they themselves begin to shape the cultural perceptions.

Conclusions

A divorce between cultural notions and social actions resembling the one described in

the present paper was also found in studies of leprosy conducted in the USA, Israel

and Kenya (Bijleveld 1978; Gussow and Tracy 1972; Meisels 1979; Risseeuw 1978).

Similar findings were presented in studies focusing on other phenomena as well. For

instance, students of culture discovered differences between the actual relationship

maintained by members of society and the cultural view of the nature of these

relations (e.g. Katriel 1991). Likewise, sociologists of deviance found discrepancies between the image of social deviants and the actual reactions encountered by them

(e.g. Goode 1975). However, in most cases this phenomenon was not investigated by

means of anthropological research methods combined with historical ones and its

analysis was not based upon simultaneous examination of notions, actions and

external factors affecting them. Consequently, such studies did not contribute to the

understanding of the relationship between actions and notions. On the contrary, to no

small extent they encouraged the tendency to analyse cultural phenomena as

113



autonomous and thus to ignore important processes preceding and significant factors

generating the divorce between the two variables.

It goes without saying that the present attempt to draw general conclusions from a

single case study dealing with the specific history of leprosy in Thailand does not

purport to claim that the process underlying and the factors leading to the divorce of

the disease's image from the actual reactions to it can be generalized to all instances

of discrepancies between notions and actions. Nevertheless, this single case study suffices to demonstrate that all possible degrees of congruence between the two

variables are likely to exist and that the patterns of both their mutual influence and

their differential transformation over time may take various forms. If future studies of

notions and actions corroborate these conclusions, many of the current controversies

over the relationship between notions and actions will be settled if not revealed as

pointless.

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Documents

Cultural Notions Versus Social Actions: The Case of the Socio-cultural History of Leprosy in Thailand