Dengue and Dualism: Medical Pluralism in a North-Central Urban Marginal Zone of Bangladesh

Dengue and Dualism: Medical Pluralism in a North-Central Urban Marginal Zone of Bangladesh | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Dengue and Dualism: Medical Pluralism in a North-Central Urban Marginal Zone of Bangladesh Sheikh Mehzabin Chitra, Chayan Chakma, Sheikh Mehbuba Moitree This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7161124/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract In the late 1970s, Aurther Kleinman’s concept of medical pluralism was developed and become the central to understanding how cultural values and economic constraints can shape and influence individuals’ health seeking behaviors and take decisions of which healthcare system option they will choose. This ethnographic study in Ershadnagar Resettlement Camp is situated in Gazipur, Bangladesh, it is a peripheral urban marginalized group. This paper explores how the residents of Ershadnagar manage dengue fever by drawing on multiple healthcare systems. Through 27 in-depth and key informant interviews with traditional healers, biomedical practitioners, and community members, This study examines the explanatory models examined that illness shapes by structural constraints and cultural beliefs through the health seeking behaviors. Findings reveal that medical pluralism in Ershadnagar is not merely a cultural remnant but a pragmatic adaptation to conditions of economic precarity, spatial marginalization, and the embedded presence of trusted traditional healers. This research finds that medical pluralism in Ershadnagar is a pragmatic response to social embessedness of traditional healers, limited access and economic precarity but not simply the matter of continuity of culture. Traditional healthcare system remains deeply trusted and widely used in Ershadnagar, while biomedical healthcare system dominates in state health discourse, traditional healing remains widely used and deeply trusted by the community. This pluralistic reality produces both tensions and collaborations between traditional healers and biomedical practitioners. The findings of this study has contributed to make connection with medical anthropology by positioning pluralism within lived experiences of marginalized urban community facing growing health crises like dengue fever. And also this pluralistic setting produces the conflict and cooperation between healers and biomedical practitioners. By situating medical pluralism within the lived experiences of a marginalized urban population, this study contributes to medical anthropology’s broader engagement with informal healthcare systems, trust, and the everyday negotiation of health crises such as dengue fever. Medical pluralism Dengue fever Urban marginality Traditional healing Health-seeking behavior Bangladesh Introduction Medical anthropology is a subfield of anthropology which explores relationships and interplay among cultural, historical and social factors in shaping illness, healing practices and health across many different societies. This sub-discipline has contributed to understanding how diverse the medical system can be through the range from biomedical to traditional or Indigenous healing practices that coexist, respond and interact with the population's needs. In 1960, medical anthropology was established as a formal sub-field that critically examines these systems' function. Medical treatment is not only some methods of treating physical ailments but also cultural practices and it reflects spiritual beliefs, historical experiences and social hierarchies (Foster, 1962; Kleinman, 1980). Dengue fever is the most widespread prevalence now because it is one of the most pressing health concerns in Bangladesh today. For public health systems in the country, especially in urban and peripheral urban areas, this disease has been a persistent challenge with annual outbreaks among millions of people. Diagnostic testing and antiviral treatments are examples of modern biomedical practices that have made an important impact. But also traditional and Indigenous healing practices are continuing play vital roles in addressing the health needs of the population, particularly for the marginalized and constrained communities. The relationship among biomedicine, traditional and indigenous healing practices from the core of the concept of medical pluralism that defines the characteristics of using multiple medical systems in a single society (Kleinman, 1978). In Bangladesh, for the treatment of Dengue, medical pluralism can be seen where both biomedical and traditional healing practices are employed alongside with one another that also reflects the how broad the culture dynamics of health and healing in the country (Ahmed et al., 2015). The Dengue fever has its own significance in Bangladesh that cannot be overstated. According to the WHO (World Health Organization), in the list of the promptly spreading vector-borne diseases, Dengue is the one of them. And it has increased in recent years dramatically. Because of the major issues like inadequate vector control measures, rapid urbanization and poor waste management, Dengue fever has increased, creating a favorable environment to the explosion Aedes mosquitos that spread the virus. The biomedical treatment response to Dengue fever includes important early diagnoses such as symptom management, blood tests, and supportive care. But in many peripheral urban areas and rural areas formal healthcare facilities are limited, so people in these areas are connected with traditional healing practices and deeply entrenched and most of the time the first point of contact for individuals seeking medical attention (Good, 1993; Waterston, 2015). In many parts of the world, including Bangladesh, healing practices such as the use of folk knowledge, herbal remedies and spiritual healing are passed down through generations. Slums and resettlement areas in peripheral urban areas and in rural settings Hakim (herbal practitioners) and Kabiraj (traditional healers) often provide the health service. These healing practitioners sometimes offer spiritual healing processes through prayers and some rituals and they also utilize locally available natural remedies, herbs and plants. In modern times, while biomedicine dominates in centers of urban areas, meanwhile these traditional healing practices remain deeply integral to healthcare for the people of the areas which are in more remote and economically disadvantaged. The determination of traditional practices despite the presence of biomedicine demonstrates the dynamic relationship between biomedical and traditional healthcare system in Bangladesh, especially in the context of Dengue fever (Manderson, 2020). Medical anthropology, the subfield of anthropology evolved as a formal subject and discipline in the 1960s. George Foster, one of the pioneers of this field, established an introductory concept that significantly highlighted the societal structures and cultural norms are intertwined with medical systems. Foster emphasized his work on humoral medicine and showed that health systems are not only biomedical but are also shaped by cultural and social beliefs about healing, balance and illness. Foster’s framework is particularly relevant when aiming to study Dengue, this disease is most of the time understood not only as a biomedical treatment but also through the culturally lenses, for example, local understand the disease when they know the notions of blood imbalance or cold and hot and they response to the treatment (Foster, 1962). In the 1970s, the work of Arthur Kleinman (1978) first popularized the concept of "explanatory models" within medical anthropology, which attempted to explain how people from differing cultural backgrounds interpret illness and hence choose treatment. Kleinman's framework helps explain why some communities would rely on traditional healers as opposed to biomedical practitioners, when those are available. Explanatory models of Dengue in Bangladesh might also range from the biomedical understanding of a viral infection to traditional beliefs of imbalance or spiritual afflictions. Medical pluralism by Kleinman provides an important concept in explaining the way residents of poor and peripheral urban areas navigate the coexistence of these dual health systems. As medical anthropology developed, numerous researchers throughout the 1980s into the 1990s explored how structural inequalities and cultural practices shaped healthcare access. Researchers such as Nancy Scheper-Hughes (1984) and Paul Farmer (1988) resisted the biomedical hegemony, suggesting that health outcomes are linked to socioeconomic and political contexts. It holds more value in Bangladesh in cases of urban slums or resettlement areas where deficiencies in infrastructure coupled with poverty become a limiting factor in health care availed. Persistence of Dengue in such areas reflects the requirement of comprehensive health care solutions integrating not only the biomedical treatments but also culturally appropriate, accessible alternatives such as the traditional remedies (Scheper-Hughes, 1984; Farmer, 1988). The specific focus of this research was the Ershadnagar Resettlement Camp in Gazipur, an urban peripheral to Dhaka in Bangladesh. The particular location epitomizes a peripheral site where the use of traditional medicine and its intersection with biomedicine is especially high. Ershadnagar resettlement camp is a place for people who are originally migrated from rural areas of the countries since they have low income and have poor access to get any services in their livelihood. And Ershadnagar is an appropriate study site to explore how traditional medicine plays the role where people have limited facilities aside of poor infrastructures and the economic constraints to get access formal healthcare system in the management of Dengue fever. In many rural and marginalized communities’ people use traditional medicine but not the biomedicine or modern medicine properly and it does not mean to state that it is their choice of matter but economic condition and inaccessibility play the role here to avoid modern medical treatment (Vindrola-Padros, 2013). So, at this stage, understanding the people’ health seeking behaviors in this issue quite useful to make public healthcare strategies in Dengue fever to reduce the infectious diseases and burden of Dengue. This study investigated the healthcare-seeking behavior of residents in the Ershadnagar Resettlement Camp regarding the use of biomedicine and traditional healing systems in the management of Dengue fever. It looked into how cultural beliefs, socioeconomic status, and access to healthcare services influence their decision-making. This study worked through the anthropological perspective, contribute to the general debate on medical pluralism and the way in which both biomedicine and traditional healing could be usefully accommodated within more effective public health arrangements in urban areas. This study had yield valid data that could be used in order to develop more inclusive, culturally sensitive policies relating to healthcare for the large peripheral urban areas, similar to the Ershadnagar area. Methods Study Design: This study explored the ethnographic fieldwork in Ershadnagar Resettlement Camp, Gazipur, Bangladesh, between January to June 2025. This urban peripheral setting was selected for its diverse characteristics which marked by limited biomedical healthcare infrastructure, persistent reliance on traditional healers and high rates of infectious disease outbreaks. This study focused on how cultural values and economic constraints can shape and influence individuals’ health seeking behaviors and take decisions of which healthcare system option they will choose between traditional medicine and biomedicine. Study Settings: The fieldwork for this research was conducted in the Ershadnagar Resettlement Camp, located in Ward 49 of Gazipur city, a peripheral urban settlement near Dhaka. Established in 1984 during the regime of former President Hussain Muhammad Ershad, the area was originally developed to accommodate internally displaced individuals and rural migrants seeking better livelihoods. Over time, Ershadnagar has transformed into a densely populated, low-income settlement, home to thousands of residents with diverse socio-cultural and occupational backgrounds. The majority of the population works in informal labor sectors such as garments, construction, small-scale trade, and domestic work. Public health infrastructure remains limited, and access to formal healthcare is often constrained due to economic hardship, overcrowding, and lack of awareness. Sampling Strategy: Participants were selected using purposive and snowball sampling, beginning with contacts provided by local health workers and community leaders. Data Collection Method: employed qualitative, ethnographic methods. A total of 27 interviews were conducted: 22 in-depth interviews (IDIs) with residents who had recent experience with dengue, and 5 key informant interviews (KIIs) with traditional healers, biomedical health professionals, and local pharmacy operators. In addition to observation was conducted in both formal and informal care spaces government clinics, herbal dispensaries, and healing sessions along with informal conversations and household visits. These observations contextualized the narratives and allowed for insight into daily interactions between different healthcare systems. Data Collection Procedure: All interviews were conducted in Bangla, audio-recorded with consent, transcribed verbatim, and translated where necessary. Data Analysis Method: Thematic analysis was used to identify key patterns across interviews, focusing on explanatory models of illness (Kleinman 1980), structural barriers to care (Farmer 2003), and health-seeking behavior. Data collection was concluded upon reaching thematic saturation , when no new patterns or insights were emerging from additional interviews. Ethical Considerations : Participants were informed about the purpose of the research and gave verbal consent before interviews or observations. To protect the privacy and confidentiality of all participants, their names and identifying details have been omitted entirely from the transcripts and analysis. The research prioritized sensitivity to local norms, voluntary participation, and the respectful handling of all data collected. Ethics and Consent to Participate: This research was approved by the Department of Anthropology at Shahjalal University of Science & Technology, Bangladesh. All participants provided verbal consent after being informed about the nature and purpose of the study. Due to the ethnographic nature of the research and local literacy limitations, written consent was not obtained, in line with ethical norms for verbal consent in anthropological fieldwork. Funding: This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Results (Table 1 presents the categories and demographic characteristics of the 27 respondents, including their gender, age range, occupations, and roles within the study). Table 1: Categories and Characteristics of the Respondents (n = 27) Category Gender (M/F) Age Range Occupation/Role Examples Interview Type n Traditional Healer 1M / 1F 50–56 Herbalist, Spiritual Healer KII 2 Biomedical Practitioner 4M / 5F 32–50 Doctors, Nurses, Medical Consultants KII / IDI 9 Community Resident 7M / 9F 26–50 Housemaids, Laborers, Garment Workers, Vendors IDI 16 Total 12M / 15F 26–56 — — 27 Factors Shaping Residents’ Treatment-Seeking Behavior for Dengue Recognition and Understanding of Dengue Symptoms The majority of participants identified fever, body pain, weakness, and vomiting as primary signs of Dengue. People did not usually differentiate between viral fevers unless the symptoms became severe or unusual. Recognition often came through community knowledge, neighbors’ suggestions, or past experience rather than formal medical diagnosis. This participant identifies Dengue through the duration and intensity of symptoms, especially when the fever lingers and affects the entire body. The sign of the body getting cold or repeated vomiting is seen as an indicator of the illness turning serious, prompting greater concern. Her understanding seems shaped by accumulated community observations and personal vigilance during illness. One IDI participant stated: “When someone has high fever for days, feels weak, and their whole body aches, we think it’s Dengue... if someone keeps vomiting or their body gets cold, it’s dangerous” (Female community resident, age 32, IDI). This respondent connects his understanding of Dengue with a painful personal experience. His recognition of symptoms like persistent fever and weakness comes from a past episode involving his son, which has left a lasting impression. His statement reflects learning through crisis and emotional memory. A father expressed: “High fever that doesn’t go away, body pain, weakness… I learned the hard way when my son got sick” (Male, community resident, age 38, IDI). Some participants relied on visual signs to confirm their suspicions: As a healer, this participant relies on visible physical cues—the body’s appearance—to detect illness. She uses practical diagnostic methods available to her, such as checking the tongue, eyes, and skin. Her confidence in identifying Dengue comes from close, everyday bodily observation rather than formal medical tools. The female healer noted: “If someone has high fever, joint pain, and can’t eat, I check their tongue and eyes. If there are red spots on the skin, I know it is Dengue.” (Female, Traditional Healer, age 39, KII). Initial Responses and Home Remedies A common first response to suspected Dengue was traditional or home-based remedies. Due to financial hardship and cultural familiarity, people began with herbal preparations before considering hospitals. One of the respondents stated: “At first, we try home remedies. We give coconut water, raw papaya leaf juice, or boil neem leaves.” (Male, community resident, age 30, IDI). (Table 5 details the specific traditional remedies and healing practices used for managing dengue symptoms, reflecting local cultural logic and health beliefs). This participant follows a common practice of starting with familiar, low-cost remedies. These items are seen as safe, accessible, and culturally trusted. His approach reflects a belief that the illness might resolve on its own with natural support, and medical care is only needed if things worsen. A wife mentioned: “Before, I used to give herbal water, papaya leaf juice, and prayers. But after what happened to my husband, now I go to the hospital if the fever doesn’t go down.” (Female, community resident, age 32, IDI). This respondent shows a shift in behavior shaped by a past trauma. Her earlier reliance on herbs and spiritual acts has changed after her husband’s illness, suggesting that her trust in home remedies was shaken. She still values them, but now uses them cautiously and watches for signs that medical attention is needed. (Table 2 summarizes illustrative quotations from participants that reflect core themes related to medical pluralism, barriers to care, and beliefs about dengue)> Treatment Preferences and Medical Pluralism Treatment preferences varied depending on severity, belief, and affordability. Many respondents acknowledged using both systems at different stages of illness—an expression of medical pluralism. One resident stated: “We prefer traditional treatment because it’s cheap... but in the hospital, they ask for tests, and that costs a lot.” (Male, community resident, age 44, IDI). This respondent frames his treatment choice in terms of economic survival. He doesn’t necessarily reject hospital care but sees it as financially burdensome. Traditional treatment is chosen not out of ignorance but because it fits better within his limited resources. A father expressed with concern: “I used to trust the traditional healers, but now I don’t take risks... My son didn’t make it because we waited too long.” (Male, community resident, age 38, IDI). This quote expresses regret and a personal turning point. The loss of his son is directly tied in his mind to the delay caused by relying on traditional healing first. His words reflect a painful reassessment of his past trust, and a conscious decision to change future behavior to avoid similar outcomes. Another individual stated: “I still make my son drink neem water, but I also take him to the hospital.” (Female, community resident, age 32, IDI). This participant combines both systems, showing a blended strategy. She hasn’t abandoned traditional remedies but now uses them alongside biomedical care. Her thinking reflects a desire to leave no option unexplored — mixing comfort, habit, and practicality with precaution. Factors Influencing Treatment Choice Participants commonly pointed to financial limitations, geographical distance, and communication difficulties as reasons for avoiding biomedical care. Cultural trust and familiarity with healers also played a key role. A local health seeker mentioned: “Money is the biggest problem... The Hakim is nearby, and he understands our problems.” (Male, community resident, age 50, IDI). This respondent made it clear that financial hardship drives his preference. The closeness of the Hakim and his perceived empathy make him a practical and emotionally supportive option. The healer was not just affordable, but approachable, which contrasts with the distant image of formal healthcare. Another participant stated: “Doctors don’t have time for poor people. Healers listen to us.” (Male, community resident, age 36, IDI). Here, the choice wasn’t just about treatment—it’s about dignity. The speaker felt ignored and dismissed by doctors, while healers provide a space where he feels seen and heard. Listening becomes as valuable as medicine itself in his care experience. Perceptions of Effectiveness: Traditional vs. Biomedical There was a shared perception that traditional treatment is helpful for mild cases, but severe cases need hospital care. However, the boundaries between “mild” and “severe” were often blurry in the minds of respondents, contributing to delayed decisions. A community resident expressed: “Traditional medicine works for mild cases... but if someone starts bleeding or gets too weak, only the hospital can save them.” (Male, community resident, age 42, IDI). This participant saw a practical boundary between what traditional medicine can handle and when biomedical care becomes essential. His statement suggests a balancing act—using tradition first, but recognizing the limits once symptoms cross a certain line. A local woman pointed: “For Dengue, they don’t [work]... The hospital saved my husband and my son.” (Female, community resident, age 32, IDI). Her trust in biomedicine stems from firsthand experience with survival. The success of hospital care has reshaped her belief, positioning traditional remedies as ineffective in serious Dengue cases. Her conclusion is personal and emotionally grounded. Decision-Making under Pressure: Fear, Hope, and Desperation For many families in Ershadnagar, health decisions are made under intense emotional and economic pressure. People are often forced to choose between spending money they don’t have, relying on traditional methods, or risking death. A father cried out for his late son: “I had no savings, but I begged my boss for a loan. I couldn’t afford another grave.” (Male, community resident, age 38, IDI). He revealed the emotional weight of poverty in life-or-death situations. His desperation reflects the trauma of past loss, and his actions show how the fear of repeating that grief compels people to make sacrifices beyond their means. Another participant stated: “We gave her neem water. But we also tied a red thread on her wrist... we did everything we could think of.” (Female, community resident, age 32, IDI). This participant expressed a sense of doing all that’s possible, mixing physical and spiritual remedies. The act of tying a red thread shows belief in symbolic protection, but also reflects an emotional need to stay active and hopeful during uncertainty. Survival beyond Cure: The Emotional Aftermath Those who survived Dengue or lost loved ones carried deep emotional scars, and these experiences often redefined how they approached future illnesses. In these stories, grief became a teacher, pushing families to abandon old practices or adapt them cautiously. An participant mentioned with concern: “I will take loans, borrow, do anything... I’m never trusting herbs alone again.” (Male, community resident, age 38, IDI). His words came from deep loss and changed perspective. The failure of herbs in the past has led him to abandon exclusive reliance on tradition. Now, even debt seems more acceptable than risking another tragedy. A female respondent who used both medical system: “Now I go to the hospital. But I still pray. I don’t know what works, so I do both.” (Female, community resident, age 32, IDI). Her dual approach reflected uncertainty and emotional insurance. She didn’t want to abandon prayer, but also didn’t want to depend on it alone. For her, blending both paths was a way of not closing any door to healing. Waiting as a Survival Strategy, Not Inaction Delays in seeking biomedical care were not necessarily caused by ignorance or negligence, but often by strategic waiting—a survival method where people wait and see if traditional treatment works, saving the hospital as a last resort when symptoms become life-threatening. A mother expressed based on her perceptive: “If the fever stays more than three days, then we think about the hospital.” (Female, community resident, age 35, IDI). She described a practical timeline based on observed patterns. Her response wasn’t passive—it was a calculated wait, aimed at minimizing cost and effort unless the illness clearly demands more. A female respondent who used herbs first: “We try herbs first, because what if it gets better? Why spend money we don’t have?” (Female, community resident, age 33, IDI). She thought terms of risk management. Trying herbs first was a way to avoid unnecessary expenses. The logic was grounded in experience—some fevers get better, and with limited funds, she ouldn't afford to assume the worst right away. Dynamics, Conflicts, and Collaboration Between Biomedical and Traditional Healers Role of Traditional Healers in the Community Traditional healers held significant symbolic authority in Ershadnagar. Their services were not only affordable and accessible, but also emotionally supportive, often combining herbs with prayer or symbolic rituals. A male health seeker noted: “The Hakim is like a doctor for us. He gives herbal medicine, tells us what to eat, and prays for us.” (Female, community resident, age 35, IDI) This participant viewed the Hakim as a full-spectrum caregiver, someone who not only treated the body but also provided guidance and spiritual support. Her statement reflected how trust in healers extended beyond medicine to encompass emotional and social care. The male healer pointed out: “Dengue is a fever of the blood. I give herbal extracts to cool the body... and special diets to balance the body's heat.” (Male, Traditional Healer, age 56, KII) he healer described Dengue using his own diagnostic language. He believed that balancing bodily heat through herbs and diet could restore health. His method was rooted in a system that prioritized internal harmony over pathology. The healer stated again: “I believe in balance—herbs for the body, faith for the mind.” (Male, Traditional Healer, age 56, KII) This statement revealed the healer’s dual focus on physical and emotional well-being. He did not separate the medical from the spiritual, showing how he valued treating both the body and the inner self. Another KII female traditional healer stated: “I don’t give strong herbs to children or pregnant women. And if someone is getting worse, I send them to the hospital.” (Female, Traditional Healer, age 50, KII) This healer showed caution and ethical restraint in her practice. She recognized her limits and made decisions based on the vulnerability of her patients. Her willingness to refer critical cases reflected a sense of responsibility, not competition. Biomedical Perspectives on Traditional Treatment Doctors and nurses offered a contrasting view, expressing frustration at the delays caused by reliance on traditional methods. However, some professionals acknowledged that better integration and education could reduce these risks. One biomedical practitioner stated: “Almost every second Dengue patient I see has wasted days drinking boiled leaves... Some come when it’s already too late.” (Male biomedical practitioner, age 45, KII) This doctor expressed clear frustration, believing that time lost on traditional remedies often worsened patients’ conditions. To him, the delay represented a dangerous misstep in care. Another biomedical practitioner stated: “Traditional healers don’t understand real medicine... If anything, they should be banned from treating Dengue cases.” (Male biomedical practitioner, age 45, KII) His statement reflected a firm stance against traditional healing in the context of Dengue. He saw it not just as ineffective, but potentially harmful, and supported strict boundaries around who should treat what. (Table 4 outlines the primary reasons residents preferred traditional healing over biomedical care, highlighting cost, proximity, trust, and emotional comfort as key drivers). A doctor stated: “If traditional healers were trained to recognize danger signs and refer patients earlier, it could help.” (Male biomedical practitioner, age 38, IDI) This practitioner acknowledged a middle ground. Instead of total rejection, he saw potential in improving the referral process through education. His view suggested that cooperation could reduce harm. A nurse stated: “I’ve seen too many children die because their parents waited too long.” (Female biomedical practitioner, age 36, IDI) Her response carried emotional weight and grief. She blamed delays in switching to biomedical care for avoidable deaths and highlighted the human cost behind these choices. Tension between Healing Systems The relationship between traditional and biomedical systems was marked by tension, mistrust, and missed opportunities. Traditional healers expressed frustration at being dismissed, while biomedical professionals criticized their lack of medical training. Male healer stated: “Doctors don’t respect us… but we help people when hospitals are too expensive.” (Male, traditional healer, age 56, KII) The healer described feeling disrespected by formal medical professionals, despite serving a real need. His words suggested that traditional healers filled a gap that the state or hospitals couldn’t meet—especially for the poor. A male doctor expressed his thought: “Traditional medicine does nothing to stop Dengue. People think drinking neem water will cure them, but they’re only getting sicker.” (Male, biomedical practitioner, age 45, KII) This doctor viewed traditional remedies as deceptive and ineffective. He saw public trust in them as harmful, especially when symptoms worsened under delayed care. Yet, some nurses and doctors recognized the potential value of cooperation, if paired with proper training and regulation. A nurse pointed out: “If traditional healers were trained to recognize danger signs and refer patients sooner, it could help.” (Female, biomedical practitioner, age 42, KII) Her position echoed that of others who supported collaboration under certain conditions. She didn’t dismiss traditional healers entirely but emphasized the need for structured referral systems. Self-Regulation and Ethical Practices among Traditional Healers Interestingly, most traditional healers interviewed showed a degree of ethical awareness and boundaries in their practice. Many emphasized that they refer severe cases to hospitals, and they refrain from treating vulnerable patients (children, pregnant women) with strong herbs. Male healer mentioned: “We are healers, not magicians. If the patient is vomiting blood, I tell them to go to the hospital.” (Male, traditional healer, age 56, KII) This healer showed self-awareness and practical judgment. He acknowledged the limits of his capabilities and did not hesitate to refer patients when symptoms exceeded his expertise. Female healer expressed: “I never use anything harmful. If I see someone is too weak, I tell them to go to the hospital.” (Female, traditional healer, age 50, KII) She emphasized a cautious, harm-reducing approach. Her words suggested that traditional healers often took patient safety seriously, especially with vulnerable individuals. Healers as Mediators of Belief and Biology Unlike doctors who work within biomedical logic alone, traditional healers serve as bridges between spiritual belief, herbal knowledge, and social reassurance. Traditional healer stated: “Illness can be in the body or in the spirit. Sometimes you need medicine. Sometimes, you need to be protected.” (Male, traditional healer, age 56, KII) This healer described a holistic view of sickness. He believed that healing involved more than just physical treatment, it required spiritual defense and symbolic acts of protection as well. Cultural Beliefs and Economic Realities in Healthcare Decisions Spiritual and Symbolic Interpretations of Illness While some respondents understood Dengue as a mosquito-borne illness, others saw it as a spiritual affliction, especially when symptoms were unusual or persistent. This led many to seek protection through symbolic acts, prayers, or amulets alongside herbal medicine. A mother who believed in spirituals: “This isn’t just Dengue… He speaks to someone in his sleep.” (Female, community resident, age 35, IDI) This participant believed that the illness her loved one was facing went beyond physical symptoms. For her, talking in one’s sleep was not simply a sign of fever but a spiritual signal—possibly of possession or disturbance. She interpreted Dengue not just as a virus, but as something that could involve supernatural forces. Her words showed how spiritual readings of illness shaped treatment choices, especially when symptoms were perceived as unusual or frightening. Traditional healer mentioned about spirit “Illness is not just in the body. It can be in the spirit too.” (Male traditional healer, age 56, KII) This healer explained illness as something layered—partly physical, but also deeply connected to the spirit. He likely treated patients not only with herbs but also with rituals and prayer, because he believed spiritual well-being was just as important for recovery. His understanding came from years of community trust and cultural knowledge, which made him see healing as both emotional and sacred. Misconceptions and Misinformation Misunderstandings about the cause and treatment of Dengue were widespread across the community. These misconceptions were reinforced by both traditional healers and community gossip. A medical consultant mentioned that: “Some think Dengue is caused by eating certain foods… Others think it’s a punishment from God.” (Female biomedical practitioner, age 32, IDI) This respondent highlighted how misinformation circulated within the community. From her perspective, the people’s understanding of Dengue was shaped more by fear, rumor, and spiritual belief than scientific explanation. These beliefs led people to avoid hospitals or rely on home cures, making timely treatment difficult. She seemed frustrated, but also aware of how deeply such ideas were embedded. A health seeker who trusted the healer: “The Kabiraj said I should avoid cold water, or that my blood was bad.” (Male, community resident, age 30, IDI) This participant recounted advice he had received, which reflected traditional explanations of disease. Instead of talking about viruses, the healer spoke of bad blood and coldness, suggesting that internal imbalance caused illness. The respondent accepted this advice, showing how healer instructions shaped daily behavior and diet during illness—even when those ideas contradicted biomedical thinking. Doctors also stressed how these beliefs delayed diagnosis and, in some cases, contributed to preventable deaths. A nurse mentioned with concerned voice: “Too many believe in ‘hot and cold’ imbalances or spirits. They wait too long and come when it's too late.” (Female biomedical practitioner, age 36, IDI) She reflected on how local cultural interpretations, such as heat imbalance or spiritual causes often delayed life-saving care. From her viewpoint, these beliefs were not only wrong but dangerous, especially when people clung to them despite worsening symptoms. Her tone suggested concern mixed with helplessness in changing these deep-rooted ideas. Invisible Costs: Debt, Work Loss, and Long Recovery Several families mentioned the economic consequences of Dengue treatment missed workdays, taking loans, or selling belongings. Even when patients survived, their families suffered long-term financial setbacks. A father expressed: “I am buried in debt now. But I didn’t care. My daughter is alive.” (Male, community resident, age 38, IDI) This father made it clear that saving his child outweighed every financial cost. Though the hospital bills left him in severe debt, he spoke without regret. His quote showed how families often made desperate choices borrowing money, selling belongings, or begging—just to secure treatment. Dengue not only affected bodies but destabilized entire livelihoods. A mother stated about her poverty: “We had to stop sending our son to school that month. All our money went to tests and medicine.” (Female, community resident, age 45, IDI) This mother’s quote illustrated the ripple effect of illness in poor households. Medical costs didn’t just drain their savings, they disrupted her son’s education. Her decision showed the harsh trade-offs families had to make, where treating one illness meant pausing or sacrificing other essential parts of life, like school or food. Erosion of Institutional Trust The biomedical system, although medically superior, was often experienced as hostile, disempowering, and unresponsive leading to deep-rooted skepticism, especially among women and older patients. One participant stated: “They [doctors] talk like we are stupid. They don’t explain anything. Just write and go.” (Female, community resident age 48, IDI) This participant expressed resentment toward doctors who treated her with dismissal or condescension. For her, the hospital experience was cold and impersonal—one where her voice didn’t matter. The lack of explanation made her feel disrespected and inferior, reinforcing her distrust of the system. Another pointed out: “Even if the doctor knows more, it doesn’t help if we’re too afraid to ask questions.” (Female, community resident age 26, IDI) Here, fear played a major role. Despite knowing doctors were trained experts, this participant avoided asking questions out of intimidation. Her hesitancy revealed how the power dynamics inside hospitals silenced patients, especially younger women, and made biomedical care emotionally inaccessible. Silence, Shame, and the Language Barrier Many respondents avoided hospitals not just because of cost, but because they feared the language of medicine itself—a barrier of jargon, forms, and cold instructions that left them feeling stupid, lost, or invisible. Another participant stated his negative impression on formal medical care: “The doctor used English words I don’t understand. I just nodded and left.” (Male, community resident, age 50, IDI) This man felt excluded by the language doctors used. Instead of asking for clarification, he pretended to understand out of embarrassment or fear. His experience showed how technical jargon and English terms common in hospital settings alienated patients and made them feel disconnected from their own treatment process. Community as the First Line of Healthcare Most participants did not begin their treatment journey in clinics or hospitals, but within their own neighborhoods—through neighbors’ advice, nearby healers, and collective experience. A respondent who listened her neighborhoods: “We hear from the neighborhood... who tried what, what worked, where to go.” (Female, , community resident age 28, IDI) This participant relied on neighborhood talk as her first source of medical advice. She didn’t start with professionals but with people around her family, neighbors, friends who shared what had worked for them. Her words revealed how healthcare decisions were often shaped communally, not individually. A mother who has trust on healers: “If someone in the area says ‘Hakim's medicine helped my son,’ we follow that. We trust our own people more than outsiders.” (female, community resident, age 42, IDI) This person emphasized community-based trust over institutional faith. The experiences of others carried more weight than official advice. In his world, healing was local and relational outsiders, even if doctors, were treated with suspicion unless endorsed by community stories. Trust in Healers: More than Just Medicine The community’s deep trust in traditional healers stems from more than herbs—it is built on relationships, emotional support, and cultural continuity. Another participant stated: “He talks to us. He doesn’t rush. He prays for us too.” (Female, community resident, age 39, IDI) For this woman, the healer’s role went far beyond giving medicine. He took time, listened carefully, and offered spiritual comfort qualities she didn’t find in hospitals. Her trust came from feeling cared for as a whole person, not just a body with symptoms. A respondent expressed that: “They speak in a way we understand. Doctors give us papers. The Hakim gives us comfort.” (Female, community resident, age 40, IDI) This participant contrasted two styles of care: one technical and distant, the other warm and human. She valued the Hakim not just for treatment but for reassurance and clarity. The healer's accessibility gave her a sense of belonging and emotional ease. Transmission of Healing Knowledge and Generational Practices Among both traditional healers and community members, there was a strong emphasis on the intergenerational transfer of healing knowledge—not just as skill, but as identity and responsibility. Male traditional healer stated: “My father was a healer, and his father before him. I learned from them and from books on Unani medicine.” (Male, traditional healer, age 56, KII) This healer’s identity was rooted in family lineage and tradition. Healing was not just a job, it was a legacy passed through generations. His mention of reading Unani texts also showed how traditional knowledge could mix oral transmission with formal learning. Female traditional healer stated: “I became a healer because someone saved my daughter with herbs. I learned from her and started helping others.” (Female traditional healer, age 50, KII) Her journey into healing was deeply personal and emotional. Gratitude inspired her transformation. Her experience showed how healing knowledge wasn’t always inherited, it could also emerge from lived experiences, empathy, and a desire to give back. The Social Labor of Care Caring for a Dengue patient in Ershadnagar is not an individual burden but a collective endeavor, often shared by mothers, neighbors, and sometimes even local healers. One participant stated: “When my son got sick, the neighbor gave me neem leaves. Another woman helped me boil them. We are poor, but we help each other.” (Male, community resident, age 42, IDI) This participant described a web of mutual aid in his community. Even without money, neighbors stepped in with herbs, time, and care. His story showed how collective caregiving compensated for the absence of formal healthcare support. Traditional healer mentioned that: “Sometimes people bring patients to me because they can’t carry them to the hospital.” (Female traditional healer, age 50, KII) She recounted how her role as a healer often extended beyond medicine. In emergencies, she even helped with physical transport. Her words reflected the healer’s role as a community anchor—someone people turned to when hospitals were out of reach. Healing as Reciprocity, Not Transaction While hospitals operate on a transactional model (test–treat–discharge), traditional healing was often reciprocal and relational. Payments weren’t always monetary—sometimes they were rice, blessings, or simple gratitude. Traditional healer pointed out the trust and faith: “One man brought me rice after his wife got better. He couldn’t pay, but he said thank you like I saved his world.” (Female traditional healer, age 50, KII) This healer described an emotional form of payment. Her work was not measured in cash but in gratitude, food, or gestures. Her story showed how traditional healing was built on relational exchange, not economic terms making it more accessible and human-centered. Healers as Gendered Safe Spaces While biomedical care was technically available, it was emotionally and socially inaccessible—especially for women. Many women, particularly younger or married, preferred female healers or elderly Kabirajs not only for medical help, but because they offered dignity, privacy, and emotional safety. A female who prefer to go to female healers: “Doctors are men. We can’t say everything to them. But Apa (referring a female healer), she listens to everything.” (Female, community resident, age 26, IDI) This young woman revealed how gender shaped access to care. She felt unable to express herself openly to male doctors, but found emotional safety and openness with a female healer. Her experience showed how traditional spaces, especially when led by women, provided comfort that hospitals often lacked. The Quiet Power of Ritual Rituals—like tying threads, whispering prayers, or preparing herbs in specific ways—weren’t seen as magical. Instead, they gave people a sense of control in a chaotic situation. It’s not just about healing; it’s about doing something, anything, to push back against helplessness. One participant stated: “This thread, it may not cure, but it protects. It means we did our part.” (Female, community resident, age 39, IDI) This woman found meaning and relief in ritual, even if she didn’t see it as a direct cure. For her, tying a thread was an act of responsibility and hope. It gave her emotional control in a situation where she felt helpless. Rituals, in her view, were ways of staying engaged in the healing process. Table 2: Relevant Quotations from Study Participants Relating to Medical Pluralism and Dengue Treatment Practices Themes Sub-Themes Comments from Study Respondents Recognition and Understanding of Dengue Symptom Identification When someone has high fever for days, feels weak, and their whole body aches, we think it’s Dengue... if someone keeps vomiting or their body gets cold, it’s dangerous. Learning Through Experience High fever that doesn’t go away, body pain, weakness… I learned the hard way when my son got sick. Physical Observation by Healers If someone has high fever, joint pain, and can’t eat, I check their tongue and eyes. If there are red spots on the skin, I know it is Dengue. Initial Treatment Practices Herbal and Home Remedies We use coconut water, neem leaf juice, and rest. We believe it cleans the blood. Prayer and Symbolic Acts We gave her neem water. But we also tied a red thread on her wrist... we did everything we could think of. First Response Logic We try herbs first, because what if it gets better? Why spend money we don’t have? Medical Pluralism in Practice Dual System Use Now I go to the hospital. But I still pray. I don’t know what works, so I do both. Strategic Switching If the fever stays more than three days, then we think about the hospital. Blended Belief I still make my son drink neem water, but I also take him to the hospital. Barriers to Biomedical Treatment Cost and Accessibility We prefer traditional treatment because it’s cheap... but in the hospital, they ask for tests, and that costs a lot. Physical Distance The clinic is far. The Hakim is just a few houses away. Language and Shame The doctor used English words I don’t understand. I just nodded and left. Trust and Relationship with Healers Cultural Familiarity The Hakim is like a doctor for us. He gives herbal medicine, tells us what to eat, and prays for us. Emotional Connection He talks to us. He doesn’t rush. He prays for us too. Ethical Practice I don’t give strong herbs to children or pregnant women. And if someone is getting worse, I send them to the hospital. Perceived Effectiveness and Risk Traditional vs Biomedical Traditional medicine works for mild cases... but if someone starts bleeding or gets too weak, only the hospital can save them. Disillusionment After Loss I used to trust the traditional healers, but now I don’t take risks... My son didn’t make it because we waited too long. Experience-Driven Confidence The hospital saved my husband and my son. Role of Traditional Healers Knowledge Transmission My father was a healer, and his father before him. I learned from them and from books on Unani medicine. Balance and Holism I believe in balance—herbs for the body, faith for the mind. Medical Ethics We are healers, not magicians. If the patient is vomiting blood, I tell them to go to the hospital. Tensions with Biomedical Practitioners Criticism of Delays Almost every second Dengue patient I see has wasted days drinking boiled leaves... Some come when it’s already too late. Dismissal of Healers Traditional healers don’t understand real medicine... If anything, they should be banned from treating Dengue cases. Call for Integration If traditional healers were trained to recognize danger signs and refer patients earlier, it could help. Cultural Interpretations and Belief Systems Spiritual Causes This isn’t just Dengue… He speaks to someone in his sleep. Heat-Cold Misconceptions The Kabiraj said I should avoid cold water, or that my blood was bad. Symbolic Healing Illness can be in the body or in the spirit. Sometimes you need medicine. Sometimes, you need to be protected. Socioeconomic Consequences of Dengue Debt and Work Loss I am buried in debt now. But I didn’t care. My daughter is alive. Long-Term Setbacks We had to stop sending our son to school that month. All our money went to tests and medicine. Erosion of Institutional Trust Powerlessness in Clinics They [doctors] talk like we are stupid. They don’t explain anything. Just write and go. Fear of Asking Questions Even if the doctor knows more, it doesn’t help if we’re too afraid to ask questions. Community-Based Health Systems Collective Decision-Making We hear from the neighborhood... who tried what, what worked, where to go. Relational Trust If someone in the area says ‘Hakim’s medicine helped my son,’ we follow that. We trust our own people more than outsiders. Table 3: Sequence of Treatment Actions Taken by Residents (n = 27) Treatment Stage Action Taken Frequency (n) % of Respondents Stage 1: Symptom onset Used home remedies (e.g., neem, papaya, rest) 22 81.5% Stage 2: Symptoms persist (>3 days) Visited traditional healer 17 63% Stage 3: Severe symptoms (e.g., bleeding) Sought hospital/clinic care 13 48% No Biomedical Contact Only used traditional/home methods 7 26% Combined (traditional + biomedical) Used both methods during illness course 15 55.5% Table 4: Reasons for Preferring Traditional Healing Over Biomedical Care Stated Reason Number of Respondents (n) Representative Quote Cost and affordability 19 “We prefer traditional treatment because it’s cheap…” Trust and emotional support 16 “He talks to us. He doesn’t rush. He prays for us too.” Proximity and availability 14 “The Hakim is nearby… He understands our problems.” Cultural familiarity and comfort 13 “We trust our own people more than outsiders.” Language and communication barriers 11 “The doctor used English words I don’t understand…” Fear of hospitals/medical spaces 8 “Doctors don’t have time for poor people. Healers listen to us.” Table 5: Traditional Remedies and Practices Used for Dengue Symptom Management Remedy or Practice Reported Use (n) Common Belief / Purpose Neem leaf juice 17 Purifies blood, reduces heat Papaya leaf juice 14 Increases platelet count Coconut water 12 Keeps the body hydrated, cools the system Tulsi (holy basil) tea 9 Used to lower fever and promote balance Red thread/amulet tying 8 Symbolic protection from evil/spiritual forces Fasting/light diets 6 To avoid ‘heat-producing’ foods Herbal decoctions 10 Strengthens the immune system Discussion The concept of medical pluralism is central to understanding healthcare behavior in marginalized and transitional urban communities. As Kleinman (1980) originally proposed, medical pluralism refers to the simultaneous use of multiple medical systems—such as biomedicine, traditional healing, and complementary therapies within a single cultural setting. In Bangladesh, this phenomenon has become increasingly visible in peripheral urban settlements, where socioeconomic barriers often shape people’s therapeutic choices (Rahman et al., 2012; Ahmed et al., 2015). Traditional medicine in Bangladesh includes systems such as Unani, Ayurvedic, and folk practices. Practitioners like Kabiraj and Hakim provide herbal, dietary, and spiritual remedies that are culturally embedded and community-based (Waterston, 2015; Subedi, 2019). These systems offer not only treatment but also cultural legitimacy, emotional support, and spiritual reassurance—especially important in low-income communities where biomedicine may be physically or socially inaccessible (Scheper-Hughes, 1984; Patil et al., 2024). Modern and biomedicine holds the power an hegemonic authority to marginalize the traditional knowledge though the licensing, state policy and institutional dominance and that imbalance creates the limits collaboration and systematic inequality between multiple healthcare system (Cant, 2017; Foran, 2007). Researchers identified that traditional healing can worsen health outcomes because of delaying in biomedical care, but they also notify and inform against terminating traditional systems, where biomedical care is not strong enough (Kleinman, 1978; Moshabela et al., 2017). This parallels cultural beliefs in Bangladesh, where dengue fever may be seen not just as a viral infection but as a consequence of blood “imbalance,” heat, or even the "evil eye." These beliefs often prompt people to consult herbalists or spiritual healers first, rather than seeking formal medical care (Kleinman, 1980; Rahman et al., 2012; Moshabela et al., 2017; Singh, 2023).during the early stages of illness, these beliefs influence individuals from cultural and social perspectives and these shapes individuals’ minds too. And health seeking behavior is not only influenced by cultural and social values, but also cultural narratives, systemic exclusion, economic constraint and patient agency in Ershadnagar. The field research in Ershadnagar explored the medical pluralism which deeply connected with the cultural belief and everyday practice of individuals. Residents of Ershadnagar start dengue treatment with their home remedies and traditional medicine at first, such as coconut water, neem water, papaya juice and tulsi leaves and other dietary recommendations which are driven by practical need and cultural beliefs too. Most of the families “waited to see” with home and traditional remedies before going to medical or spending money on necessary test or diagnostics (The typical treatment pathways followed by residents from home remedies to hospital visits are outlined in Table 3). Residents of Ershadnagar do not prefer to visit medical at the very first point and it reflects the structural constraints such as high cost, overcrowded, long line, missed work opportunities, doctors do not seem to understand them or ignore their words while they want to say something about their illness, inaccessible, unaffordable. In this research gender emerged as a critical and crucial factor, women made therapeutic decisions aside of taking the primary caregiving role. Most of the residents expressed discomfort with unfamiliar clinical spaces and male doctors. Women preferred their familiar and good relational atmosphere of traditional healers. For men and women, both view the healing and traditional healthcare system as social and emotional not just physical. And the traditional healers in Ershadnagar expressed their thoughts about biomedical limitations. Some avoided treating the patients who are in complex situation in dengue cases and referred the patients and their families to visit medical as soon as possible. Other emphasized emotional healing and proper dietary alongside with traditional herbal remedies and it reflects a holistic health model. Their society’s elders, counselors added to their legitimacy. Meanwhile, the professional biomedical practitioners often mistrust the traditional healers, they think that Kabirajs and Hakims should take the blame of why patients come in the medical in delay when the situations get worsen. They claimed that traditional healing practices are unsafe. On the other side, traditional healers feel excluded from the formal medical system. Although some of the both sides stated that cooperative collaboration can erase the mistrust, systematic barriers, and unequal power relations. Kleinman’s (1978) concept of explanatory model is connected with the findings of Ershadnagar. The explanatory model shows that the way residents of Ershadnagar interpret dengue in terms of divine displeasure and heat imbalance, not only the virological symptoms(Moshabela et al., 2017; Subedi, 2019). The structural violence also defines that the residents avoid to go to the medical or avoid formal healthcare systems because of the marginalization, economic costs and infrastructure within rural areas and urban resettlement spaces push patients to relay on traditional healthcare system. Traditional healers acts as medical providers and cultural actors at the same time, they try to fill the gap left by a powerful formal healthcare system, it reflects the same type of documented in other parts of Global South (Farmer, 1996; Patil et al., 2024; Singh, 2023). Janzen’s (1978) concept of “therapy management groups” is proven true. The residents of Ershadnagar often make decisions based on the advice their neighborhoods, family and healers give to them. These advices shape the decisions. This collective logic adds an aspect to the explanatory model, often overlooked in biomedical discourse. Many literatures emphasize the combination between multiple healthcare systems, the study in Ershadnagar reveals the gaps. Institutional exclusion, lack of mutual respect, power imbalance hinder collaboration but still both systems serve the same patients populations. The structural change can be achieved through healthcare policy, education and resource allocation. Ershadnagar case illustrated that medical pluralism is a lived necessity but not only the abstract theory. The policy should be formed and policies must try to add resource allocation, findings for traditional healthcare system by engaging it ethically, respectfully and inclusively (Janzen, 1978; Cant, 2017; Foran, 2007). Conclusion This study at Ershadnagar Resettlement Camp, Gazipur explored the lived experiences in the context of medical pluralism of how cultural belief system, healthcare infrastructure and economic constraints shape the residents’ health seeking behaviors in the treatment of dengue fever. The findings of this study revealed that the beliefs and simple preferences cannot only change or shape the individuals’ behaviors but there is a set of adaptive strategies which can influence individuals to make decision: cultural meanings, structural limitations and emotional needs. Residents do not rely on one system at a time, they sift and switch between traditional healers and biomedical practitioners in the treatment of Dengue fever. This sifting and switching processes do not reflect the confusion and ignorance but a complex intervention shaped by past experiences, poverty, institutional mistrust and social networks. In biomedical care, the healthcare systems are more effective but the residents of Ershadnagar feel linguistically exclusive, emotionally distant and emotionally distant, especially the elderly and women feel that. However, the traditional healers are deeply connected cultural, symbolic and social fabric of the society and community. They not only offer traditional medicines and herbal but also prayer for the patients and give emotional supports while listening about their sickness. Residents think that maybe traditional healers have limited knowledge about clinical and formal healthcare ideas but they are still helpful in many ways such as, the formal healthcare system is expensive, medicals or clinics are overcrowded places, inaccessible and unaffordable for the poor and low income individuals. This research on an urban marginalized population has contributed to understanding the anthropological perspective of medical pluralism. It explored the reason of why medical pluralism is not a static duality but also a dynamic process. It acmes the essential to move beyond the binary of “traditional medicine vs biomedicine.” Declarations Ethics Statement: The research paper titled “Dengue and Dualism: Medical Pluralism in a North-Central Urban Marginal Zone of Bangladesh” is based on fieldwork originally conducted for my undergraduate honours monograph in the Department of Anthropology at Shahjalal University of Science and Technology (SUST), Sylhet, Bangladesh. The research received ethics approval from the departmental ethics review committee of the Department of Anthropology, SUST. All participants were fully informed about the aims of the study and gave their voluntary and informed consent prior to participation. Anonymity and confidentiality were strictly maintained throughout the research. This paper was later developed collaboratively with two co-authors who contributed to the analysis and writing process based on the original data. No new fieldwork involving human subjects was conducted during this stage. Author Contribution S.M.C. conceived the study, conducted the fieldwork, and wrote the main manuscript text. C.C. contributed to theoretical framing and refined the conceptual framework. S.M.M. assisted with data collection and participant recruitment. All authors reviewed and approved the final manuscript. References Ahmed, A., Islam, M., & Hossain, M. (2015). The role of traditional medicine in healthcare in Bangladesh. Journal of Health and Social Behavior, 56(2), 241–254. Cant, S. (2017). Mainstream marginality: Professional projects and the appeal of complementary and alternative medicines in a context of medical pluralism (Ph.D. thesis). Canterbury Christ Church University. Farmer, P. (1988). Health, Inequality, and Human Rights: A Global Perspective. Oxford University Press. Farmer, P. (1996). On suffering and structural violence: A view from below. In P. Farmer (Ed.), Social inequalities and cancer (pp. 119–133). Plenum Press. Foran, B. J. (2007). Medical Pluralism and Global Health Policy: The Integration of Traditional Medicine in Health Care Systems. University of Western Sydney. Foster, G. (1962). The Study of Humoral Medicine. Cambridge University Press. Good, B. (1993). Medicine, Rationality, and Experience: An Anthropological Perspective. Cambridge University Press. Janzen, J. M. (1978). The Quest for Therapy in Lower Zaire. University of California Press. Kleinman, A. (1978). Concepts and a model for the comparison of medical systems as cultural systems. Social Science & Medicine, 12, 85–93. Kleinman, A. (1980). Patients and Healers in the Context of Culture. University of California Press. Manderson, L. (2020). Traditional healers and global health challenges: The case of dengue. Global Health Journal, 46(3), 12–20. Moshabela, M., Bukenya, D., Darong, G., et al. (2017). Traditional healers and bottlenecks in HIV/AIDS care. Sexually Transmitted Infections. https://doi.org/10.1136/sextrans-2016-052974 Patil, A. D., Singh, S., Verma, D., & Goupale, C. (2024). Exploring medical pluralism. Indian Journal of Integrative Medicine, 4(2), 49–59. Rahman, A., Ahmed, F., & Karim, S. (2012). Traditional healing in rural Bangladesh. Journal of Traditional Medicine, 45(2), 124–131. Scheper-Hughes, N. (1984). Death Without Weeping: The Violence of Everyday Life in Brazil. University of California Press. Singh, M. (2023). Indigenous healing and intersectionality. Journal of Applied Consciousness Studies, 11(2), 91–97. Subedi, B. (2019). Medical pluralism among the Tharus. Dhaulagiri Journal of Sociology and Anthropology, 13, 58–66. Vindrola-Padros, C. (2013). The role of traditional healers in urban healthcare. Journal of Urban Health, 90(6), 1064–1074. Waterston, A. (2015). Traditional healing in urban slums. University of California Press. World Health Organization. (2002). Traditional Medicine Strategy 2002–2005. World Health Organization. (2014). WHO Traditional Medicine Strategy 2014–2023. World Health Organization. (2019). Dengue: Epidemiological Update. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7161124","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":489069360,"identity":"0eb5253f-def2-44ff-83f3-191134b8ce7c","order_by":0,"name":"Sheikh Mehzabin Chitra","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABDUlEQVRIie3OMUvDQBjG8TcUMlVufYPUfoWDg6AgfpaUQKaggyAZpL0i3KZdDfZDtBTE8Y6DTIGuN3QpglOHiLt6jYtgTzs63H/LXX7cA+Dz/ccQQI05jsj2o/vtIuC/k+Mk4p2WYHsq/yDBmBcJlfuS/sONUuUTnrPlssJNsRoCqdlbA6e9mdxN6KpK1LzGy9ikYTStXxAwj1FCxpwEc6rWAoNH0wkPD4S2pBvbYXrgIv37i6Yli4m25N0SO6yR8OEkYHJQc4GDGaSWcEsgp3aYdBJqMqpKgQxNyk6mlY4EZldY05SVzmHp8+utGB6RiVqbzbUmhOhFUxRnvTvXsB+FX6/v+7vP5/P5dvUJ2bpk0/rhR8oAAAAASUVORK5CYII=","orcid":"","institution":"Shahjalal University of Science \u0026 Technology","correspondingAuthor":true,"prefix":"","firstName":"Sheikh","middleName":"Mehzabin","lastName":"Chitra","suffix":""},{"id":489069367,"identity":"4e2c7ea7-e213-4fbe-bf70-5377b9fb0ffd","order_by":1,"name":"Chayan Chakma","email":"","orcid":"","institution":"Shahjalal University of Science \u0026 Technology","correspondingAuthor":false,"prefix":"","firstName":"Chayan","middleName":"","lastName":"Chakma","suffix":""},{"id":489069368,"identity":"4d1f7253-1e17-42b0-9fe8-4e8b0c16e592","order_by":2,"name":"Sheikh Mehbuba Moitree","email":"","orcid":"","institution":"Bangladesh Maritime University","correspondingAuthor":false,"prefix":"","firstName":"Sheikh","middleName":"Mehbuba","lastName":"Moitree","suffix":""}],"badges":[],"createdAt":"2025-07-19 01:23:12","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7161124/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7161124/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":87499874,"identity":"97719180-eb53-429e-bdc3-7fcf740bf899","added_by":"auto","created_at":"2025-07-24 13:38:46","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1854695,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7161124/v1/e1846f58-daed-4109-9c46-c156cca54d57.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Dengue and Dualism: Medical Pluralism in a North-Central Urban Marginal Zone of Bangladesh","fulltext":[{"header":"Introduction","content":"\u003cp\u003eMedical anthropology is a subfield of anthropology which explores relationships and interplay among cultural, historical and social factors in shaping illness, healing practices and health across many different societies. This sub-discipline has contributed to understanding how diverse the medical system can be through the range from biomedical to traditional or Indigenous healing practices that coexist, respond and interact with the population\u0026apos;s needs. In 1960, medical anthropology was established as a formal sub-field that critically examines these systems\u0026apos; function. Medical treatment is not only some methods of treating physical ailments but also cultural practices and it reflects spiritual beliefs, historical experiences and social hierarchies (Foster, 1962; Kleinman, 1980).\u003c/p\u003e\n\u003cp\u003eDengue fever is the most widespread prevalence now because it is one of the most pressing health concerns in Bangladesh today. For public health systems in the country, especially in urban and peripheral urban areas, this disease has been a persistent challenge with annual outbreaks among millions of people. Diagnostic testing and antiviral treatments are examples of modern biomedical practices that have made an important impact. But also traditional and Indigenous healing practices are continuing play vital roles in addressing the health needs of the population, particularly for the marginalized and constrained communities. The relationship among biomedicine, traditional and indigenous healing practices from the core of the concept of medical pluralism that defines the characteristics of using multiple medical systems in a single society (Kleinman, 1978). In Bangladesh, for the treatment of Dengue, medical pluralism can be seen where both biomedical and traditional healing practices are employed alongside with one another that also reflects the how broad the culture dynamics of health and healing in the country (Ahmed et al., 2015).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe Dengue fever has its own significance in Bangladesh that cannot be overstated. According to the WHO (World Health Organization), in the list of the promptly spreading vector-borne diseases, Dengue is the one of them. And it has increased in recent years dramatically. Because of the major issues like inadequate vector control measures, rapid urbanization and poor waste management, Dengue fever has increased, creating a favorable environment to the explosion Aedes mosquitos that spread the virus. The biomedical treatment response to Dengue fever includes important early diagnoses such as symptom management, blood tests, and supportive care. But in many peripheral urban areas and rural areas formal healthcare facilities are limited, so people in these areas are connected with traditional healing practices and deeply entrenched and most of the time the first point of contact for individuals seeking medical attention (Good, 1993; Waterston, 2015).\u003c/p\u003e\n\u003cp\u003eIn many parts of the world, including Bangladesh, healing practices such as the use of folk knowledge, herbal remedies and spiritual healing are passed down through generations. Slums and resettlement areas in peripheral urban areas and in rural settings Hakim (herbal practitioners) and Kabiraj (traditional healers) often provide the health service. These healing practitioners sometimes offer spiritual healing processes through prayers and some rituals and they also utilize locally available natural remedies, herbs and plants. In modern times, while biomedicine dominates in centers of urban areas, meanwhile these traditional healing practices remain deeply integral to healthcare for the people of the areas which are in more remote and economically disadvantaged. The determination of traditional practices despite the presence of biomedicine demonstrates the dynamic relationship between biomedical and traditional healthcare system in Bangladesh, especially in the context of Dengue fever (Manderson, 2020).\u003c/p\u003e\n\u003cp\u003eMedical anthropology, the subfield of anthropology evolved as a formal subject and discipline in the 1960s. George Foster, one of the pioneers of this field, established an introductory concept that significantly highlighted the societal structures and cultural norms are intertwined with medical systems. Foster emphasized his work on humoral medicine and showed that health systems are not only biomedical but are also shaped by cultural and social beliefs about healing, balance and illness. Foster\u0026rsquo;s framework is particularly relevant when aiming to study Dengue, this disease is most of the time understood not only as a biomedical treatment but also through the culturally lenses, for example, local understand the disease when they know the notions of blood imbalance or cold and hot and they response to the treatment (Foster, 1962).\u003c/p\u003e\n\u003cp\u003eIn the 1970s, the work of Arthur Kleinman (1978) first popularized the concept of \u0026quot;explanatory models\u0026quot; within medical anthropology, which attempted to explain how people from differing cultural backgrounds interpret illness and hence choose treatment. Kleinman\u0026apos;s framework helps explain why some communities would rely on traditional healers as opposed to biomedical practitioners, when those are available. Explanatory models of Dengue in Bangladesh might also range from the biomedical understanding of a viral infection to traditional beliefs of imbalance or spiritual afflictions. Medical pluralism by Kleinman provides an important concept in explaining the way residents of poor and peripheral urban areas navigate the coexistence of these dual health systems.\u003c/p\u003e\n\u003cp\u003eAs medical anthropology developed, numerous researchers throughout the 1980s into the 1990s explored how structural inequalities and cultural practices shaped healthcare access. Researchers such as Nancy Scheper-Hughes (1984) and Paul Farmer (1988) resisted the biomedical hegemony, suggesting that health outcomes are linked to socioeconomic and political contexts. It holds more value in Bangladesh in cases of urban slums or resettlement areas where deficiencies in infrastructure coupled with poverty become a limiting factor in health care availed. Persistence of Dengue in such areas reflects the requirement of comprehensive health care solutions integrating not only the biomedical treatments but also culturally appropriate, accessible alternatives such as the traditional remedies (Scheper-Hughes, 1984; Farmer, 1988).\u003c/p\u003e\n\u003cp\u003eThe specific focus of this research was the Ershadnagar Resettlement Camp in Gazipur, an urban peripheral to Dhaka in Bangladesh. The particular location epitomizes a peripheral site where the use of traditional medicine and its intersection with biomedicine is especially high. Ershadnagar resettlement camp is a place for people who are originally migrated from rural areas of the countries since they have low income and have poor access to get any services in their livelihood. And Ershadnagar is an appropriate study site to explore how traditional medicine plays the role where people have limited facilities aside of poor infrastructures and the economic constraints to get access formal healthcare system in the management of Dengue fever. In many rural and marginalized communities\u0026rsquo; people use traditional medicine but not the biomedicine or modern medicine properly and it does not mean to state that it is their choice of matter but economic condition and inaccessibility play the role here to avoid modern medical treatment (Vindrola-Padros, 2013). So, at this stage, understanding the people\u0026rsquo; health seeking behaviors in this issue quite useful to make public healthcare strategies in Dengue fever to reduce the infectious diseases and burden of Dengue.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis study investigated the healthcare-seeking behavior of residents in the Ershadnagar Resettlement Camp regarding the use of biomedicine and traditional healing systems in the management of Dengue fever. It looked into how cultural beliefs, socioeconomic status, and access to healthcare services influence their decision-making. This study worked through the anthropological perspective, contribute to the general debate on medical pluralism and the way in which both biomedicine and traditional healing could be usefully accommodated within more effective public health arrangements in urban areas. This study had yield valid data that could be used in order to develop more inclusive, culturally sensitive policies relating to healthcare for the large peripheral urban areas, similar to the Ershadnagar area.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003eStudy Design:\u0026nbsp;\u003c/strong\u003eThis study explored the ethnographic fieldwork in Ershadnagar Resettlement Camp, Gazipur, Bangladesh, between January to June 2025. \u0026nbsp;This urban peripheral setting was selected for its diverse characteristics which marked by limited biomedical healthcare infrastructure, persistent reliance on traditional healers and high rates of infectious disease outbreaks. \u0026nbsp;This study focused on how cultural values and economic constraints can shape and influence individuals\u0026rsquo; health seeking behaviors and take decisions of which healthcare system option they will choose between traditional medicine and biomedicine.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy Settings:\u0026nbsp;\u003c/strong\u003eThe fieldwork for this research was conducted in the Ershadnagar Resettlement Camp, located in Ward 49 of Gazipur city, a peripheral urban settlement near Dhaka. Established in 1984 during the regime of former President Hussain Muhammad Ershad, the area was originally developed to accommodate internally displaced individuals and rural migrants seeking better livelihoods. Over time, Ershadnagar has transformed into a densely populated, low-income settlement, home to thousands of residents with diverse socio-cultural and occupational backgrounds. The majority of the population works in informal labor sectors such as garments, construction, small-scale trade, and domestic work. Public health infrastructure remains limited, and access to formal healthcare is often constrained due to economic hardship, overcrowding, and lack of awareness.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSampling Strategy:\u0026nbsp;\u003c/strong\u003eParticipants were selected using purposive and snowball sampling, beginning with contacts provided by local health workers and community leaders.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Collection Method:\u003c/strong\u003e employed qualitative, ethnographic methods. A total of \u003cstrong\u003e27 interviews\u003c/strong\u003e were conducted: \u003cstrong\u003e22 in-depth interviews (IDIs)\u003c/strong\u003e with residents who had recent experience with dengue, and \u003cstrong\u003e5 key informant interviews (KIIs)\u003c/strong\u003e with traditional healers, biomedical health professionals, and local pharmacy operators. \u0026nbsp;In addition to \u003cstrong\u003eobservation\u003c/strong\u003e was conducted in both formal and informal care spaces government clinics, herbal dispensaries, and healing sessions along with informal conversations and household visits. These observations contextualized the narratives and allowed for insight into daily interactions between different healthcare systems.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Collection Procedure:\u0026nbsp;\u003c/strong\u003eAll interviews were conducted in Bangla, audio-recorded with consent, transcribed verbatim, and translated where necessary.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Analysis Method:\u003c/strong\u003e \u003cstrong\u003eThematic analysis\u003c/strong\u003e was used to identify key patterns across interviews, focusing on explanatory models of illness (Kleinman 1980), structural barriers to care (Farmer 2003), and health-seeking behavior. Data collection was concluded upon reaching \u003cstrong\u003ethematic saturation\u003c/strong\u003e, when no new patterns or insights were emerging from additional interviews.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical Considerations\u003c/strong\u003e: Participants were informed about the purpose of the research and gave verbal consent before interviews or observations. To protect the privacy and confidentiality of all participants, their names and identifying details have been omitted entirely from the transcripts and analysis. The research prioritized sensitivity to local norms, voluntary participation, and the respectful handling of all data collected.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics and Consent to Participate:\u003c/strong\u003e This research was approved by the Department of Anthropology at Shahjalal University of Science \u0026amp; Technology, Bangladesh. All participants provided verbal consent after being informed about the nature and purpose of the study. Due to the ethnographic nature of the research and local literacy limitations, written consent was not obtained, in line with ethical norms for verbal consent in anthropological fieldwork.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e(Table 1 presents the categories and demographic characteristics of the 27 respondents, including their gender, age range, occupations, and roles within the study).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1: Categories and Characteristics of the Respondents (n = 27)\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCategory\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender (M/F)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge Range\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eOccupation/Role Examples\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eInterview Type\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003en\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eTraditional Healer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1M / 1F\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e50\u0026ndash;56\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHerbalist, Spiritual Healer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eKII\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eBiomedical Practitioner\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4M / 5F\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e32\u0026ndash;50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eDoctors, Nurses, Medical Consultants\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eKII / IDI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCommunity Resident\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e7M / 9F\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e26\u0026ndash;50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHousemaids, Laborers, Garment Workers, Vendors\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eIDI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e12M / 15F\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e26\u0026ndash;56\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e27\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp id=\"_Toc197931313\"\u003e\u003cstrong\u003eFactors Shaping Residents\u0026rsquo; Treatment-Seeking Behavior for Dengue\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRecognition and Understanding of Dengue Symptoms\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eThe majority of participants identified fever, body pain, weakness, and vomiting as primary signs of Dengue. People did not usually differentiate between viral fevers unless the symptoms became severe or unusual. Recognition often came through community knowledge, neighbors\u0026rsquo; suggestions, or past experience rather than formal medical diagnosis.\u003c/p\u003e\n\u003cp\u003eThis participant identifies Dengue through the duration and intensity of symptoms, especially when the fever lingers and affects the entire body. The sign of the body getting cold or repeated vomiting is seen as an indicator of the illness turning serious, prompting greater concern. Her understanding seems shaped by accumulated community observations and personal vigilance during illness.\u003c/p\u003e\n\u003cp\u003eOne IDI participant stated:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;When someone has high fever for days, feels weak, and their whole body aches, we think it\u0026rsquo;s Dengue... if someone keeps vomiting or their body gets cold, it\u0026rsquo;s dangerous\u0026rdquo; (Female community resident, age 32, IDI).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis respondent connects his understanding of Dengue with a painful personal experience. His recognition of symptoms like persistent fever and weakness comes from a past episode involving his son, which has left a lasting impression. His statement reflects learning through crisis and emotional memory.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eA father expressed:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;High fever that doesn\u0026rsquo;t go away, body pain, weakness\u0026hellip; I learned the hard way when my son got sick\u0026rdquo; (Male, community resident, age 38, IDI).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eSome participants relied on visual signs to confirm their suspicions: As a healer, this participant relies on visible physical cues\u0026mdash;the body\u0026rsquo;s appearance\u0026mdash;to detect illness. She uses practical diagnostic methods available to her, such as checking the tongue, eyes, and skin. Her confidence in identifying Dengue comes from close, everyday bodily observation rather than formal medical tools.\u003c/p\u003e\n\u003cp\u003eThe female healer noted:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026nbsp;\u0026ldquo;If someone has high fever, joint pain, and can\u0026rsquo;t eat, I check their tongue and eyes. If there are red spots on the skin, I know it is Dengue.\u0026rdquo; (Female, Traditional Healer, age 39, KII).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInitial Responses and Home Remedies\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA common first response to suspected Dengue was traditional or home-based remedies. Due to financial hardship and cultural familiarity, people began with herbal preparations before considering hospitals.\u003c/p\u003e\n\u003cp\u003eOne of the respondents stated:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;At first, we try home remedies. We give coconut water, raw papaya leaf juice, or boil neem leaves.\u0026rdquo; (Male, community resident, age 30, IDI).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e(Table 5 details the specific traditional remedies and healing practices used for managing dengue symptoms, reflecting local cultural logic and health beliefs).\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis participant follows a common practice of starting with familiar, low-cost remedies. These items are seen as safe, accessible, and culturally trusted. His approach reflects a belief that the illness might resolve on its own with natural support, and medical care is only needed if things worsen.\u003c/p\u003e\n\u003cp\u003eA wife mentioned:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Before, I used to give herbal water, papaya leaf juice, and prayers. But after what happened to my husband, now I go to the hospital if the fever doesn\u0026rsquo;t go down.\u0026rdquo; (Female, community resident, age 32, IDI).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis respondent shows a shift in behavior shaped by a past trauma. Her earlier reliance on herbs and spiritual acts has changed after her husband\u0026rsquo;s illness, suggesting that her trust in home remedies was shaken. She still values them, but now uses them cautiously and watches for signs that medical attention is needed. (Table 2 summarizes illustrative quotations from participants that reflect core themes related to medical pluralism, barriers to care, and beliefs about dengue)\u0026gt;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTreatment Preferences and Medical Pluralism\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTreatment preferences varied depending on severity, belief, and affordability. Many respondents acknowledged using both systems at different stages of illness\u0026mdash;an expression of medical pluralism.\u003c/p\u003e\n\u003cp\u003eOne resident stated:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;We prefer traditional treatment because it\u0026rsquo;s cheap... but in the hospital, they ask for tests, and that costs a lot.\u0026rdquo; (Male, community resident, age 44, IDI).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis respondent frames his treatment choice in terms of economic survival. He doesn\u0026rsquo;t necessarily reject hospital care but sees it as financially burdensome. Traditional treatment is chosen not out of ignorance but because it fits better within his limited resources.\u003c/p\u003e\n\u003cp\u003eA father expressed with concern:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I used to trust the traditional healers, but now I don\u0026rsquo;t take risks... My son didn\u0026rsquo;t make it because we waited too long.\u0026rdquo; (Male, community resident, age 38, IDI).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis quote expresses regret and a personal turning point. The loss of his son is directly tied in his mind to the delay caused by relying on traditional healing first. His words reflect a painful reassessment of his past trust, and a conscious decision to change future behavior to avoid similar outcomes.\u003c/p\u003e\n\u003cp\u003eAnother individual stated:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I still make my son drink neem water, but I also take him to the hospital.\u0026rdquo; (Female, community resident, age 32, IDI).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis participant combines both systems, showing a blended strategy. She hasn\u0026rsquo;t abandoned traditional remedies but now uses them alongside biomedical care. Her thinking reflects a desire to leave no option unexplored \u0026mdash; mixing comfort, habit, and practicality with precaution.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFactors Influencing Treatment Choice\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants commonly pointed to financial limitations, geographical distance, and communication difficulties as reasons for avoiding biomedical care. Cultural trust and familiarity with healers also played a key role.\u003c/p\u003e\n\u003cp\u003eA local health seeker mentioned:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Money is the biggest problem... The Hakim is nearby, and he understands our problems.\u0026rdquo; (Male, community resident, age 50, IDI).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis respondent made it clear that financial hardship drives his preference. The closeness of the Hakim and his perceived empathy make him a practical and emotionally supportive option. The healer was not just affordable, but approachable, which contrasts with the distant image of formal healthcare.\u003c/p\u003e\n\u003cp\u003eAnother participant stated:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Doctors don\u0026rsquo;t have time for poor people. Healers listen to us.\u0026rdquo; (Male, community resident, age 36, IDI).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eHere, the choice wasn\u0026rsquo;t just about treatment\u0026mdash;it\u0026rsquo;s about dignity. The speaker felt ignored and dismissed by doctors, while healers provide a space where he feels seen and heard. Listening becomes as valuable as medicine itself in his care experience.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePerceptions of Effectiveness: Traditional vs. Biomedical\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThere was a shared perception that traditional treatment is helpful for mild cases, but severe cases need hospital care. However, the boundaries between \u0026ldquo;mild\u0026rdquo; and \u0026ldquo;severe\u0026rdquo; were often blurry in the minds of respondents, contributing to delayed decisions.\u003c/p\u003e\n\u003cp\u003eA community resident expressed:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Traditional medicine works for mild cases... but if someone starts bleeding or gets too weak, only the hospital can save them.\u0026rdquo; (Male, community resident, age 42, IDI).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis participant saw a practical boundary between what traditional medicine can handle and when biomedical care becomes essential. His statement suggests a balancing act\u0026mdash;using tradition first, but recognizing the limits once symptoms cross a certain line.\u003c/p\u003e\n\u003cp\u003eA local woman pointed:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;For Dengue, they don\u0026rsquo;t [work]... The hospital saved my husband and my son.\u0026rdquo; (Female, community resident, age 32, IDI).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eHer trust in biomedicine stems from firsthand experience with survival. The success of hospital care has reshaped her belief, positioning traditional remedies as ineffective in serious Dengue cases. Her conclusion is personal and emotionally grounded.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDecision-Making under Pressure: Fear, Hope, and Desperation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFor many families in Ershadnagar, health decisions are made under intense emotional and economic pressure. People are often forced to choose between spending money they don\u0026rsquo;t have, relying on traditional methods, or risking death.\u003c/p\u003e\n\u003cp\u003eA father cried out for his late son:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I had no savings, but I begged my boss for a loan. I couldn\u0026rsquo;t afford another grave.\u0026rdquo; (Male, community resident, age 38, IDI).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eHe revealed the emotional weight of poverty in life-or-death situations. His desperation reflects the trauma of past loss, and his actions show how the fear of repeating that grief compels people to make sacrifices beyond their means.\u003c/p\u003e\n\u003cp\u003eAnother participant stated:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;We gave her neem water. But we also tied a red thread on her wrist... we did everything we could think of.\u0026rdquo; (Female, community resident, age 32, IDI).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis participant expressed a sense of doing all that\u0026rsquo;s possible, mixing physical and spiritual remedies. The act of tying a red thread shows belief in symbolic protection, but also reflects an emotional need to stay active and hopeful during uncertainty.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSurvival beyond Cure: The Emotional Aftermath\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThose who survived Dengue or lost loved ones carried deep emotional scars, and these experiences often redefined how they approached future illnesses. In these stories, grief became a teacher, pushing families to abandon old practices or adapt them cautiously.\u003c/p\u003e\n\u003cp\u003eAn participant mentioned with concern:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I will take loans, borrow, do anything... I\u0026rsquo;m never trusting herbs alone again.\u0026rdquo; (Male, community resident, age 38, IDI).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eHis words came from deep loss and changed perspective. The failure of herbs in the past has led him to abandon exclusive reliance on tradition. Now, even debt seems more acceptable than risking another tragedy.\u003c/p\u003e\n\u003cp\u003eA female respondent who used both medical system:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Now I go to the hospital. But I still pray. I don\u0026rsquo;t know what works, so I do both.\u0026rdquo; (Female, community resident, age 32, IDI).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eHer dual approach reflected uncertainty and emotional insurance. She didn\u0026rsquo;t want to abandon prayer, but also didn\u0026rsquo;t want to depend on it alone. For her, blending both paths was a way of not closing any door to healing.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eWaiting as a Survival Strategy, Not Inaction\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003eDelays in seeking biomedical care were not necessarily caused by ignorance or negligence, but often by strategic waiting\u0026mdash;a survival method where people wait and see if traditional treatment works, saving the hospital as a last resort when symptoms become life-threatening.\u003c/p\u003e\n\u003cp\u003eA mother expressed based on her perceptive:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;If the fever stays more than three days, then we think about the hospital.\u0026rdquo; (Female, community resident, age 35, IDI).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eShe described a practical timeline based on observed patterns. Her response wasn\u0026rsquo;t passive\u0026mdash;it was a calculated wait, aimed at minimizing cost and effort unless the illness clearly demands more.\u003c/p\u003e\n\u003cp\u003eA female respondent who used herbs first:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;We try herbs first, because what if it gets better? Why spend money we don\u0026rsquo;t have?\u0026rdquo; (Female, community resident, age 33, IDI).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eShe thought terms of risk management. Trying herbs first was a way to avoid unnecessary expenses. The logic was grounded in experience\u0026mdash;some fevers get better, and with limited funds, she ouldn\u0026apos;t afford to assume the worst right away.\u003c/p\u003e\n\u003cp id=\"_Toc197931314\"\u003e\u003cstrong\u003eDynamics, Conflicts, and Collaboration Between Biomedical and Traditional Healers\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRole of Traditional Healers in the Community\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTraditional healers held significant symbolic authority in Ershadnagar. Their services were not only affordable and accessible, but also emotionally supportive, often combining herbs with prayer or symbolic rituals.\u003c/p\u003e\n\u003cp\u003eA male health seeker noted:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;The Hakim is like a doctor for us. He gives herbal medicine, tells us what to eat, and prays for us.\u0026rdquo; (Female, community resident, age 35, IDI)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis participant viewed the Hakim as a full-spectrum caregiver, someone who not only treated the body but also provided guidance and spiritual support. Her statement reflected how trust in healers extended beyond medicine to encompass emotional and social care.\u003c/p\u003e\n\u003cp\u003eThe male healer pointed out:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Dengue is a fever of the blood. I give herbal extracts to cool the body... and special diets to balance the body\u0026apos;s heat.\u0026rdquo; (Male, Traditional Healer, age 56, KII)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003ehe healer described Dengue using his own diagnostic language. He believed that balancing bodily heat through herbs and diet could restore health. His method was rooted in a system that prioritized internal harmony over pathology.\u003c/p\u003e\n\u003cp\u003eThe healer stated again:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I believe in balance\u0026mdash;herbs for the body, faith for the mind.\u0026rdquo; (Male, Traditional Healer, age 56, KII)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis statement revealed the healer\u0026rsquo;s dual focus on physical and emotional well-being. He did not separate the medical from the spiritual, showing how he valued treating both the body and the inner self.\u003c/p\u003e\n\u003cp\u003eAnother KII female traditional healer stated:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I don\u0026rsquo;t give strong herbs to children or pregnant women. And if someone is getting worse, I send them to the hospital.\u0026rdquo; (Female, Traditional Healer, age 50, KII)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis healer showed caution and ethical restraint in her practice. She recognized her limits and made decisions based on the vulnerability of her patients. Her willingness to refer critical cases reflected a sense of responsibility, not competition.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eBiomedical Perspectives on Traditional Treatment\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDoctors and nurses offered a contrasting view, expressing frustration at the delays caused by reliance on traditional methods. However, some professionals acknowledged that better integration and education could reduce these risks.\u003c/p\u003e\n\u003cp\u003eOne biomedical practitioner stated:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Almost every second Dengue patient I see has wasted days drinking boiled leaves... Some come when it\u0026rsquo;s already too late.\u0026rdquo; (Male biomedical practitioner, age 45, KII)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis doctor expressed clear frustration, believing that time lost on traditional remedies often worsened patients\u0026rsquo; conditions. To him, the delay represented a dangerous misstep in care.\u003c/p\u003e\n\u003cp\u003eAnother biomedical practitioner stated:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Traditional healers don\u0026rsquo;t understand real medicine... If anything, they should be banned from treating Dengue cases.\u0026rdquo; (Male biomedical practitioner, age 45, KII)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eHis statement reflected a firm stance against traditional healing in the context of Dengue. He saw it not just as ineffective, but potentially harmful, and supported strict boundaries around who should treat what. \u003cstrong\u003e(Table 4 outlines the primary reasons residents preferred traditional healing over biomedical care, highlighting cost, proximity, trust, and emotional comfort as key drivers).\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA doctor stated:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026nbsp;\u0026ldquo;If traditional healers were trained to recognize danger signs and refer patients earlier, it could help.\u0026rdquo; (Male biomedical practitioner, age 38, IDI)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis practitioner acknowledged a middle ground. Instead of total rejection, he saw potential in improving the referral process through education. His view suggested that cooperation could reduce harm.\u003c/p\u003e\n\u003cp\u003eA nurse \u0026nbsp;stated:\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I\u0026rsquo;ve seen too many children die because their parents waited too long.\u0026rdquo; (Female biomedical practitioner, age 36, IDI)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eHer response carried emotional weight and grief. She blamed delays in switching to biomedical care for avoidable deaths and highlighted the human cost behind these choices.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTension between Healing Systems\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe relationship between traditional and biomedical systems was marked by tension, mistrust, and missed opportunities. Traditional healers expressed frustration at being dismissed, while biomedical professionals criticized their lack of medical training.\u003c/p\u003e\n\u003cp\u003eMale healer stated:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Doctors don\u0026rsquo;t respect us\u0026hellip; but we help people when hospitals are too expensive.\u0026rdquo; (Male, traditional healer, age 56, KII)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe healer described feeling disrespected by formal medical professionals, despite serving a real need. His words suggested that traditional healers filled a gap that the state or hospitals couldn\u0026rsquo;t meet\u0026mdash;especially for the poor.\u003c/p\u003e\n\u003cp\u003eA male doctor expressed his thought:\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Traditional medicine does nothing to stop Dengue. People think drinking neem water will cure them, but they\u0026rsquo;re only getting sicker.\u0026rdquo; (Male, biomedical practitioner, age 45, KII)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis doctor viewed traditional remedies as deceptive and ineffective. He saw public trust in them as harmful, especially when symptoms worsened under delayed care.\u003c/p\u003e\n\u003cp\u003eYet, some nurses and doctors recognized the potential value of cooperation, if paired with proper training and regulation.\u003c/p\u003e\n\u003cp\u003eA nurse pointed out:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;If traditional healers were trained to recognize danger signs and refer patients sooner, it could help.\u0026rdquo; (Female, biomedical practitioner, age 42, KII)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eHer position echoed that of others who supported collaboration under certain conditions. She didn\u0026rsquo;t dismiss traditional healers entirely but emphasized the need for structured referral systems.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSelf-Regulation and Ethical Practices among Traditional Healers\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInterestingly, most traditional healers interviewed showed a degree of ethical awareness and boundaries in their practice. Many emphasized that they refer severe cases to hospitals, and they refrain from treating vulnerable patients (children, pregnant women) with strong herbs.\u003c/p\u003e\n\u003cp\u003eMale healer mentioned:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;We are healers, not magicians. If the patient is vomiting blood, I tell them to go to the hospital.\u0026rdquo; (Male, traditional healer, age 56, KII)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis healer showed self-awareness and practical judgment. He acknowledged the limits of his capabilities and did not hesitate to refer patients when symptoms exceeded his expertise.\u003c/p\u003e\n\u003cp\u003eFemale healer expressed:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I never use anything harmful. If I see someone is too weak, I tell them to go to the hospital.\u0026rdquo; (Female, traditional healer, age 50, KII)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eShe emphasized a cautious, harm-reducing approach. Her words suggested that traditional healers often took patient safety seriously, especially with vulnerable individuals.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHealers as Mediators of Belief and Biology\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003eUnlike doctors who work within biomedical logic alone, traditional healers serve as bridges between spiritual belief, herbal knowledge, and social reassurance.\u003c/p\u003e\n\u003cp\u003eTraditional healer stated:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Illness can be in the body or in the spirit. Sometimes you need medicine. Sometimes, you need to be protected.\u0026rdquo; (Male, traditional healer, age 56, KII)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis healer described a holistic view of sickness. He believed that healing involved more than just physical treatment, it required spiritual defense and symbolic acts of protection as well.\u003c/p\u003e\n\u003cp id=\"_Toc197931315\"\u003e\u003cstrong\u003eCultural Beliefs and Economic Realities in Healthcare Decisions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSpiritual and Symbolic Interpretations of Illness\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWhile some respondents understood Dengue as a mosquito-borne illness, others saw it as a spiritual affliction, especially when symptoms were unusual or persistent. This led many to seek protection through symbolic acts, prayers, or amulets alongside herbal medicine.\u003c/p\u003e\n\u003cp\u003eA mother who believed in spirituals:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;This isn\u0026rsquo;t just Dengue\u0026hellip; He speaks to someone in his sleep.\u0026rdquo; (Female, community resident, age 35, IDI)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis participant believed that the illness her loved one was facing went beyond physical symptoms. For her, talking in one\u0026rsquo;s sleep was not simply a sign of fever but a spiritual signal\u0026mdash;possibly of possession or disturbance. She interpreted Dengue not just as a virus, but as something that could involve supernatural forces. Her words showed how spiritual readings of illness shaped treatment choices, especially when symptoms were perceived as unusual or frightening.\u003c/p\u003e\n\u003cp\u003eTraditional healer mentioned about spirit\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Illness is not just in the body. It can be in the spirit too.\u0026rdquo; (Male traditional healer, age 56, KII)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis healer explained illness as something layered\u0026mdash;partly physical, but also deeply connected to the spirit. He likely treated patients not only with herbs but also with rituals and prayer, because he believed spiritual well-being was just as important for recovery. His understanding came from years of community trust and cultural knowledge, which made him see healing as both emotional and sacred.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMisconceptions and Misinformation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMisunderstandings about the cause and treatment of Dengue were widespread across the community. These misconceptions were reinforced by both traditional healers and community gossip.\u003c/p\u003e\n\u003cp\u003eA medical consultant mentioned that:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Some think Dengue is caused by eating certain foods\u0026hellip; Others think it\u0026rsquo;s a punishment from God.\u0026rdquo; (Female biomedical practitioner, age 32, IDI)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis respondent highlighted how misinformation circulated within the community. From her perspective, the people\u0026rsquo;s understanding of Dengue was shaped more by fear, rumor, and spiritual belief than scientific explanation. These beliefs led people to avoid hospitals or rely on home cures, making timely treatment difficult. She seemed frustrated, but also aware of how deeply such ideas were embedded.\u003c/p\u003e\n\u003cp\u003eA health seeker who trusted the healer:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;The Kabiraj said I should avoid cold water, or that my blood was bad.\u0026rdquo; (Male, community resident, age 30, IDI)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis participant recounted advice he had received, which reflected traditional explanations of disease. Instead of talking about viruses, the healer spoke of bad blood and coldness, suggesting that internal imbalance caused illness. The respondent accepted this advice, showing how healer instructions shaped daily behavior and diet during illness\u0026mdash;even when those ideas contradicted biomedical thinking.\u003c/p\u003e\n\u003cp\u003eDoctors also stressed how these beliefs delayed diagnosis and, in some cases, contributed to preventable deaths.\u003c/p\u003e\n\u003cp\u003eA nurse mentioned with concerned voice:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Too many believe in \u0026lsquo;hot and cold\u0026rsquo; imbalances or spirits. They wait too long and come when it\u0026apos;s too late.\u0026rdquo; (Female biomedical practitioner, age 36, IDI)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eShe reflected on how local cultural interpretations, such as heat imbalance or spiritual causes often delayed life-saving care. From her viewpoint, these beliefs were not only wrong but dangerous, especially when people clung to them despite worsening symptoms. Her tone suggested concern mixed with helplessness in changing these deep-rooted ideas.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInvisible Costs: Debt, Work Loss, and Long Recovery\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSeveral families mentioned the economic consequences of Dengue treatment missed workdays, taking loans, or selling belongings. Even when patients survived, their families suffered long-term financial setbacks.\u003c/p\u003e\n\u003cp\u003eA father expressed:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I am buried in debt now. But I didn\u0026rsquo;t care. My daughter is alive.\u0026rdquo; (Male, community resident, age 38, IDI)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis father made it clear that saving his child outweighed every financial cost. Though the hospital bills left him in severe debt, he spoke without regret. His quote showed how families often made desperate choices borrowing money, selling belongings, or begging\u0026mdash;just to secure treatment. Dengue not only affected bodies but destabilized entire livelihoods.\u003c/p\u003e\n\u003cp\u003eA mother stated about her poverty:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;We had to stop sending our son to school that month. All our money went to tests and medicine.\u0026rdquo; (Female, community resident, age 45, IDI)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis mother\u0026rsquo;s quote illustrated the ripple effect of illness in poor households. Medical costs didn\u0026rsquo;t just drain their savings, they disrupted her son\u0026rsquo;s education. Her decision showed the harsh trade-offs families had to make, where treating one illness meant pausing or sacrificing other essential parts of life, like school or food.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eErosion of Institutional Trust\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe biomedical system, although medically superior, was often experienced as hostile, disempowering, and unresponsive leading to deep-rooted skepticism, especially among women and older patients.\u003c/p\u003e\n\u003cp\u003eOne participant stated:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;They [doctors] talk like we are stupid. They don\u0026rsquo;t explain anything. Just write and go.\u0026rdquo; (Female, community resident age 48, IDI)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis participant expressed resentment toward doctors who treated her with dismissal or condescension. For her, the hospital experience was cold and impersonal\u0026mdash;one where her voice didn\u0026rsquo;t matter. The lack of explanation made her feel disrespected and inferior, reinforcing her distrust of the system.\u003c/p\u003e\n\u003cp\u003eAnother pointed out:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Even if the doctor knows more, it doesn\u0026rsquo;t help if we\u0026rsquo;re too afraid to ask questions.\u0026rdquo; (Female, community resident age 26, IDI)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eHere, fear played a major role. Despite knowing doctors were trained experts, this participant avoided asking questions out of intimidation. Her hesitancy revealed how the power dynamics inside hospitals silenced patients, especially younger women, and made biomedical care emotionally inaccessible.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSilence, Shame, and the Language Barrier\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMany respondents avoided hospitals not just because of cost, but because they feared the language of medicine itself\u0026mdash;a barrier of jargon, forms, and cold instructions that left them feeling stupid, lost, or invisible.\u003c/p\u003e\n\u003cp\u003eAnother participant stated his negative impression on formal medical care:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;The doctor used English words I don\u0026rsquo;t understand. I just nodded and left.\u0026rdquo; (Male, community resident, age 50, IDI)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis man felt excluded by the language doctors used. Instead of asking for clarification, he pretended to understand out of embarrassment or fear. His experience showed how technical jargon and English terms common in hospital settings alienated patients and made them feel disconnected from their own treatment process.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCommunity as the First Line of Healthcare\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMost participants did not begin their treatment journey in clinics or hospitals, but within their own neighborhoods\u0026mdash;through neighbors\u0026rsquo; advice, nearby healers, and collective experience.\u003c/p\u003e\n\u003cp\u003eA respondent who listened her neighborhoods:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;We hear from the neighborhood... who tried what, what worked, where to go.\u0026rdquo; (Female, , community resident age 28, IDI)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis participant relied on neighborhood talk as her first source of medical advice. She didn\u0026rsquo;t start with professionals but with people around her family, neighbors, friends who shared what had worked for them. Her words revealed how healthcare decisions were often shaped communally, not individually.\u003c/p\u003e\n\u003cp\u003eA mother who has trust on healers:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;If someone in the area says \u0026lsquo;Hakim\u0026apos;s medicine helped my son,\u0026rsquo; we follow that. We trust our own people more than outsiders.\u0026rdquo; (female, community resident, age 42, IDI)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis person emphasized community-based trust over institutional faith. The experiences of others carried more weight than official advice. In his world, healing was local and relational outsiders, even if doctors, were treated with suspicion unless endorsed by community stories.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTrust in Healers: More than Just Medicine\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe community\u0026rsquo;s deep trust in traditional healers stems from more than herbs\u0026mdash;it is built on relationships, emotional support, and cultural continuity.\u003c/p\u003e\n\u003cp\u003eAnother participant stated:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;He talks to us. He doesn\u0026rsquo;t rush. He prays for us too.\u0026rdquo; (Female, community resident, age 39, IDI)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eFor this woman, the healer\u0026rsquo;s role went far beyond giving medicine. He took time, listened carefully, and offered spiritual comfort qualities she didn\u0026rsquo;t find in hospitals. Her trust came from feeling cared for as a whole person, not just a body with symptoms.\u003c/p\u003e\n\u003cp\u003eA respondent expressed that:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;They speak in a way we understand. Doctors give us papers. The Hakim gives us comfort.\u0026rdquo; (Female, community resident, age 40, IDI)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis participant contrasted two styles of care: one technical and distant, the other warm and human. She valued the Hakim not just for treatment but for reassurance and clarity. The healer\u0026apos;s accessibility gave her a sense of belonging and emotional ease.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTransmission of Healing Knowledge and Generational Practices\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAmong both traditional healers and community members, there was a strong emphasis on the intergenerational transfer of healing knowledge\u0026mdash;not just as skill, but as identity and responsibility.\u003c/p\u003e\n\u003cp\u003eMale traditional healer stated:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;My father was a healer, and his father before him. I learned from them and from books on Unani medicine.\u0026rdquo; (Male, traditional healer, age 56, KII)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis healer\u0026rsquo;s identity was rooted in family lineage and tradition. Healing was not just a job, it was a legacy passed through generations. His mention of reading Unani texts also showed how traditional knowledge could mix oral transmission with formal learning.\u003c/p\u003e\n\u003cp\u003eFemale traditional healer stated:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I became a healer because someone saved my daughter with herbs. I learned from her and started helping others.\u0026rdquo; (Female traditional healer, age 50, KII)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eHer journey into healing was deeply personal and emotional. Gratitude inspired her transformation. Her experience showed how healing knowledge wasn\u0026rsquo;t always inherited, it could also emerge from lived experiences, empathy, and a desire to give back.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eThe Social Labor of Care\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCaring for a Dengue patient in Ershadnagar is not an individual burden but a collective endeavor, often shared by mothers, neighbors, and sometimes even local healers.\u003c/p\u003e\n\u003cp\u003eOne participant stated:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;When my son got sick, the neighbor gave me neem leaves. Another woman helped me boil them. We are poor, but we help each other.\u0026rdquo; (Male, community resident, age 42, IDI)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis participant described a web of mutual aid in his community. Even without money, neighbors stepped in with herbs, time, and care. His story showed how collective caregiving compensated for the absence of formal healthcare support.\u003c/p\u003e\n\u003cp\u003eTraditional healer mentioned that:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Sometimes people bring patients to me because they can\u0026rsquo;t carry them to the hospital.\u0026rdquo; (Female traditional healer, age 50, KII)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eShe recounted how her role as a healer often extended beyond medicine. In emergencies, she even helped with physical transport. Her words reflected the healer\u0026rsquo;s role as a community anchor\u0026mdash;someone people turned to when hospitals were out of reach.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHealing as Reciprocity, Not Transaction\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWhile hospitals operate on a transactional model (test\u0026ndash;treat\u0026ndash;discharge), traditional healing was often reciprocal and relational. Payments weren\u0026rsquo;t always monetary\u0026mdash;sometimes they were rice, blessings, or simple gratitude.\u003c/p\u003e\n\u003cp\u003eTraditional healer pointed out the trust and faith:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;One man brought me rice after his wife got better. He couldn\u0026rsquo;t pay, but he said thank you like I saved his world.\u0026rdquo; (Female traditional healer, age 50, KII)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis healer described an emotional form of payment. Her work was not measured in cash but in gratitude, food, or gestures. Her story showed how traditional healing was built on relational exchange, not economic terms making it more accessible and human-centered.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHealers as Gendered Safe Spaces\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWhile biomedical care was technically available, it was emotionally and socially inaccessible\u0026mdash;especially for women. Many women, particularly younger or married, preferred female healers or elderly Kabirajs not only for medical help, but because they offered dignity, privacy, and emotional safety.\u003c/p\u003e\n\u003cp\u003eA female who prefer to go to female healers:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Doctors are men. We can\u0026rsquo;t say everything to them. But Apa (referring a female healer), she listens to everything.\u0026rdquo; (Female, community resident, age 26, IDI)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis young woman revealed how gender shaped access to care. She felt unable to express herself openly to male doctors, but found emotional safety and openness with a female healer. Her experience showed how traditional spaces, especially when led by women, provided comfort that hospitals often lacked.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eThe Quiet Power of Ritual\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003eRituals\u0026mdash;like tying threads, whispering prayers, or preparing herbs in specific ways\u0026mdash;weren\u0026rsquo;t seen as magical. Instead, they gave people a sense of control in a chaotic situation. It\u0026rsquo;s not just about healing; it\u0026rsquo;s about doing something, anything, to push back against helplessness.\u003c/p\u003e\n\u003cp\u003eOne participant stated:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;This thread, it may not cure, but it protects. It means we did our part.\u0026rdquo; (Female, community resident, age 39, IDI)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis woman found meaning and relief in ritual, even if she didn\u0026rsquo;t see it as a direct cure. For her, tying a thread was an act of responsibility and hope. It gave her emotional control in a situation where she felt helpless. Rituals, in her view, were ways of staying engaged in the healing process.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2: Relevant Quotations from Study Participants Relating to Medical Pluralism and Dengue Treatment Practices\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eThemes\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eSub-Themes\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eComments from Study Respondents\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eRecognition and Understanding of Dengue\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSymptom Identification\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eWhen someone has high fever for days, feels weak, and their whole body aches, we think it\u0026rsquo;s Dengue... if someone keeps vomiting or their body gets cold, it\u0026rsquo;s dangerous.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eLearning Through Experience\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHigh fever that doesn\u0026rsquo;t go away, body pain, weakness\u0026hellip; I learned the hard way when my son got sick.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePhysical Observation by Healers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eIf someone has high fever, joint pain, and can\u0026rsquo;t eat, I check their tongue and eyes. If there are red spots on the skin, I know it is Dengue.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eInitial Treatment Practices\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHerbal and Home Remedies\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eWe use coconut water, neem leaf juice, and rest. We believe it cleans the blood.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePrayer and Symbolic Acts\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eWe gave her neem water. But we also tied a red thread on her wrist... we did everything we could think of.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFirst Response Logic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eWe try herbs first, because what if it gets better? Why spend money we don\u0026rsquo;t have?\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eMedical Pluralism in Practice\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eDual System Use\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNow I go to the hospital. But I still pray. I don\u0026rsquo;t know what works, so I do both.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eStrategic Switching\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eIf the fever stays more than three days, then we think about the hospital.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eBlended Belief\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eI still make my son drink neem water, but I also take him to the hospital.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eBarriers to Biomedical Treatment\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCost and Accessibility\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eWe prefer traditional treatment because it\u0026rsquo;s cheap... but in the hospital, they ask for tests, and that costs a lot.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePhysical Distance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eThe clinic is far. The Hakim is just a few houses away.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eLanguage and Shame\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eThe doctor used English words I don\u0026rsquo;t understand. I just nodded and left.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eTrust and Relationship with Healers\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCultural Familiarity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eThe Hakim is like a doctor for us. He gives herbal medicine, tells us what to eat, and prays for us.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eEmotional Connection\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHe talks to us. He doesn\u0026rsquo;t rush. He prays for us too.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eEthical Practice\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eI don\u0026rsquo;t give strong herbs to children or pregnant women. And if someone is getting worse, I send them to the hospital.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ePerceived Effectiveness and Risk\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eTraditional vs Biomedical\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eTraditional medicine works for mild cases... but if someone starts bleeding or gets too weak, only the hospital can save them.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eDisillusionment After Loss\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eI used to trust the traditional healers, but now I don\u0026rsquo;t take risks... My son didn\u0026rsquo;t make it because we waited too long.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eExperience-Driven Confidence\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eThe hospital saved my husband and my son.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eRole of Traditional Healers\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eKnowledge Transmission\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMy father was a healer, and his father before him. I learned from them and from books on Unani medicine.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eBalance and Holism\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eI believe in balance\u0026mdash;herbs for the body, faith for the mind.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMedical Ethics\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eWe are healers, not magicians. If the patient is vomiting blood, I tell them to go to the hospital.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eTensions with Biomedical Practitioners\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCriticism of Delays\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAlmost every second Dengue patient I see has wasted days drinking boiled leaves... Some come when it\u0026rsquo;s already too late.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eDismissal of Healers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eTraditional healers don\u0026rsquo;t understand real medicine... If anything, they should be banned from treating Dengue cases.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCall for Integration\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eIf traditional healers were trained to recognize danger signs and refer patients earlier, it could help.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eCultural Interpretations and Belief Systems\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSpiritual Causes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eThis isn\u0026rsquo;t just Dengue\u0026hellip; He speaks to someone in his sleep.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHeat-Cold Misconceptions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eThe Kabiraj said I should avoid cold water, or that my blood was bad.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSymbolic Healing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eIllness can be in the body or in the spirit. Sometimes you need medicine. Sometimes, you need to be protected.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eSocioeconomic Consequences of Dengue\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eDebt and Work Loss\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eI am buried in debt now. But I didn\u0026rsquo;t care. My daughter is alive.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eLong-Term Setbacks\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eWe had to stop sending our son to school that month. All our money went to tests and medicine.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eErosion of Institutional Trust\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePowerlessness in Clinics\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eThey [doctors] talk like we are stupid. They don\u0026rsquo;t explain anything. Just write and go.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFear of Asking Questions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eEven if the doctor knows more, it doesn\u0026rsquo;t help if we\u0026rsquo;re too afraid to ask questions.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eCommunity-Based Health Systems\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCollective Decision-Making\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eWe hear from the neighborhood... who tried what, what worked, where to go.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eRelational Trust\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eIf someone in the area says \u0026lsquo;Hakim\u0026rsquo;s medicine helped my son,\u0026rsquo; we follow that. We trust our own people more than outsiders.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3: Sequence of Treatment Actions Taken by Residents (n = 27)\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eTreatment Stage\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eAction Taken\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eFrequency (n)\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e% of Respondents\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eStage 1: Symptom onset\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eUsed home remedies (e.g., neem, papaya, rest)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e81.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eStage 2: Symptoms persist (\u0026gt;3 days)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eVisited traditional healer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e63%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eStage 3: Severe symptoms (e.g., bleeding)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSought hospital/clinic care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e48%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eNo Biomedical Contact\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eOnly used traditional/home methods\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e26%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eCombined (traditional + biomedical)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eUsed both methods during illness course\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e55.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4: Reasons for Preferring Traditional Healing Over Biomedical Care\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eStated Reason\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eNumber of Respondents (n)\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eRepresentative Quote\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eCost and affordability\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026ldquo;We prefer traditional treatment because it\u0026rsquo;s cheap\u0026hellip;\u0026rdquo;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eTrust and emotional support\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026ldquo;He talks to us. He doesn\u0026rsquo;t rush. He prays for us too.\u0026rdquo;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eProximity and availability\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026ldquo;The Hakim is nearby\u0026hellip; He understands our problems.\u0026rdquo;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eCultural familiarity and comfort\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026ldquo;We trust our own people more than outsiders.\u0026rdquo;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eLanguage and communication barriers\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026ldquo;The doctor used English words I don\u0026rsquo;t understand\u0026hellip;\u0026rdquo;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eFear of hospitals/medical spaces\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026ldquo;Doctors don\u0026rsquo;t have time for poor people. Healers listen to us.\u0026rdquo;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 5: Traditional Remedies and Practices Used for Dengue Symptom Management\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eRemedy or Practice\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eReported Use (n)\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eCommon Belief / Purpose\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eNeem leaf juice\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePurifies blood, reduces heat\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003ePapaya leaf juice\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eIncreases platelet count\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eCoconut water\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eKeeps the body hydrated, cools the system\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eTulsi (holy basil) tea\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eUsed to lower fever and promote balance\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eRed thread/amulet tying\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSymbolic protection from evil/spiritual forces\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eFasting/light diets\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eTo avoid \u0026lsquo;heat-producing\u0026rsquo; foods\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eHerbal decoctions\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eStrengthens the immune system\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe concept of medical pluralism is central to understanding healthcare behavior in marginalized and transitional urban communities. As Kleinman (1980) originally proposed, medical pluralism refers to the simultaneous use of multiple medical systems\u0026mdash;such as biomedicine, traditional healing, and complementary therapies within a single cultural setting. In Bangladesh, this phenomenon has become increasingly visible in peripheral urban settlements, where socioeconomic barriers often shape people\u0026rsquo;s therapeutic choices (Rahman et al., 2012; Ahmed et al., 2015). Traditional medicine in Bangladesh includes systems such as Unani, Ayurvedic, and folk practices. Practitioners like \u003cem\u003eKabiraj\u003c/em\u003e and \u003cem\u003eHakim\u003c/em\u003e provide herbal, dietary, and spiritual remedies that are culturally embedded and community-based (Waterston, 2015; Subedi, 2019). These systems offer not only treatment but also cultural legitimacy, emotional support, and spiritual reassurance\u0026mdash;especially important in low-income communities where biomedicine may be physically or socially inaccessible (Scheper-Hughes, 1984; Patil et al., 2024). Modern and biomedicine holds the power an hegemonic authority to marginalize the traditional knowledge though the licensing, state policy and institutional dominance and that imbalance creates the limits collaboration and systematic inequality between multiple healthcare system (Cant, 2017; Foran, 2007). Researchers identified that traditional healing can worsen health outcomes because of delaying in biomedical care, but they also notify and inform against terminating traditional systems, where biomedical care is not strong enough (Kleinman, 1978; Moshabela et al., 2017). This parallels cultural beliefs in Bangladesh, where dengue fever may be seen not just as a viral infection but as a consequence of blood \u0026ldquo;imbalance,\u0026rdquo; heat, or even the \u0026quot;evil eye.\u0026quot; These beliefs often prompt people to consult herbalists or spiritual healers first, rather than seeking formal medical care (Kleinman, 1980; Rahman et al., 2012;\u0026nbsp;Moshabela et al., 2017; Singh, 2023).during the early stages of illness, these beliefs influence individuals from cultural and social perspectives and these shapes individuals\u0026rsquo; minds too. And health seeking behavior is not only influenced by cultural and social values, but also\u0026nbsp;cultural narratives, systemic exclusion, economic constraint and patient agency in Ershadnagar.\u003c/p\u003e\n\u003cp\u003eThe field research in Ershadnagar explored the medical pluralism which deeply connected with the cultural belief and everyday practice of individuals. Residents of Ershadnagar start dengue treatment with their home remedies and traditional medicine at first, such as coconut water, neem water, papaya juice and tulsi leaves and other dietary recommendations which are driven by practical need and cultural beliefs too. Most of the families \u0026ldquo;waited to see\u0026rdquo; with home and traditional remedies before going to medical or spending money on necessary test or diagnostics \u003cstrong\u003e(The typical treatment pathways followed by residents from home remedies to hospital visits are outlined in Table 3).\u0026nbsp;\u003c/strong\u003eResidents of Ershadnagar do not prefer to visit medical at the very first point and it reflects the structural constraints such as high cost, overcrowded, long line, missed work opportunities, doctors do not seem to understand them or ignore their words while they want to say something about their illness, inaccessible, unaffordable. In this research gender emerged as a critical and crucial factor, women made therapeutic decisions aside of taking the primary caregiving role. Most of the residents expressed discomfort with unfamiliar clinical spaces and male doctors. Women preferred their familiar and good relational atmosphere of traditional healers. For men and women, both view the healing and traditional healthcare system as social and emotional not just physical. And the traditional healers in Ershadnagar expressed their thoughts about biomedical limitations. Some avoided treating the patients who are in complex situation in dengue cases and referred the patients and their families to visit medical as soon as possible. Other emphasized emotional healing and proper dietary alongside with traditional herbal remedies and it reflects a holistic health model. Their society\u0026rsquo;s elders, counselors added to their legitimacy. Meanwhile, the professional biomedical practitioners often mistrust the traditional healers, they think that Kabirajs and Hakims should take the blame of why patients come in the medical in delay when the situations get worsen. They claimed that traditional healing practices are unsafe. On the other side, traditional healers feel excluded from the formal medical system. Although some of the both sides stated that cooperative collaboration can erase the mistrust, systematic barriers, and unequal power relations.\u003c/p\u003e\n\u003cp\u003eKleinman\u0026rsquo;s (1978) concept of explanatory model is connected with the findings of Ershadnagar. The explanatory model shows that the way residents of Ershadnagar interpret dengue in terms of divine displeasure and heat imbalance, not only the virological symptoms(Moshabela et al., 2017; Subedi, 2019). The structural violence also defines that the residents avoid to go to the medical or avoid formal healthcare systems because of the marginalization, economic costs and infrastructure within rural areas and urban resettlement spaces push patients to relay on traditional healthcare system. Traditional healers acts as medical providers and cultural actors at the same time, they try to fill the gap left by a powerful formal healthcare system, it reflects the same type of documented in other parts of Global South (Farmer, 1996; Patil et al., 2024; Singh, 2023). Janzen\u0026rsquo;s (1978) concept of \u0026ldquo;therapy management groups\u0026rdquo; is proven true. The residents of Ershadnagar often make decisions based on the advice their neighborhoods, family and healers give to them. These advices shape the decisions. This collective logic adds an aspect to the explanatory model, often overlooked in biomedical discourse. Many literatures emphasize the combination between multiple healthcare systems, the study in Ershadnagar reveals the gaps. Institutional exclusion, lack of mutual respect, power imbalance hinder collaboration but still both systems serve the same patients populations. \u0026nbsp;The structural change can be achieved through healthcare policy, education and resource allocation. Ershadnagar case illustrated that medical pluralism is a lived necessity but not only the abstract theory. The policy should be formed and policies must try to add resource allocation, findings for traditional healthcare system by engaging it ethically, respectfully and inclusively (Janzen, 1978; Cant, 2017; Foran, 2007).\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study at Ershadnagar Resettlement Camp, Gazipur explored the lived experiences in the context of medical pluralism of how cultural belief system, healthcare infrastructure and economic constraints shape the residents\u0026rsquo; health seeking behaviors in the treatment of dengue fever.\u003c/p\u003e\u003cp\u003eThe findings of this study revealed that the beliefs and simple preferences cannot only change or shape the individuals\u0026rsquo; behaviors but there is a set of adaptive strategies which can influence individuals to make decision: cultural meanings, structural limitations and emotional needs. Residents do not rely on one system at a time, they sift and switch between traditional healers and biomedical practitioners in the treatment of Dengue fever. This sifting and switching processes do not reflect the confusion and ignorance but a complex intervention shaped by past experiences, poverty, institutional mistrust and social networks.\u003c/p\u003e\u003cp\u003eIn biomedical care, the healthcare systems are more effective but the residents of Ershadnagar feel linguistically exclusive, emotionally distant and emotionally distant, especially the elderly and women feel that. However, the traditional healers are deeply connected cultural, symbolic and social fabric of the society and community. They not only offer traditional medicines and herbal but also prayer for the patients and give emotional supports while listening about their sickness. Residents think that maybe traditional healers have limited knowledge about clinical and formal healthcare ideas but they are still helpful in many ways such as, the formal healthcare system is expensive, medicals or clinics are overcrowded places, inaccessible and unaffordable for the poor and low income individuals.\u003c/p\u003e\u003cp\u003eThis research on an urban marginalized population has contributed to understanding the anthropological perspective of medical pluralism. It explored the reason of why medical pluralism is not a static duality but also a dynamic process. It acmes the essential to move beyond the binary of \u0026ldquo;traditional medicine vs biomedicine.\u0026rdquo;\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eEthics Statement:\u003c/h2\u003e\n\u003cp\u003eThe research paper titled \u0026ldquo;Dengue and Dualism: Medical Pluralism in a North-Central Urban Marginal Zone of Bangladesh\u0026rdquo; is based on fieldwork originally conducted for my undergraduate honours monograph in the Department of Anthropology at Shahjalal University of Science and Technology (SUST), Sylhet, Bangladesh. The research received ethics approval from the departmental ethics review committee of the Department of Anthropology, SUST. All participants were fully informed about the aims of the study and gave their voluntary and informed consent prior to participation. Anonymity and confidentiality were strictly maintained throughout the research.\u003c/p\u003e\n\u003cp\u003eThis paper was later developed collaboratively with two co-authors who contributed to the analysis and writing process based on the original data. No new fieldwork involving human subjects was conducted during this stage.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eS.M.C. conceived the study, conducted the fieldwork, and wrote the main manuscript text. C.C. contributed to theoretical framing and refined the conceptual framework. S.M.M. assisted with data collection and participant recruitment. All authors reviewed and approved the final manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eAhmed, A., Islam, M., \u0026amp; Hossain, M. (2015). The role of traditional medicine in healthcare in Bangladesh. Journal of Health and Social Behavior, 56(2), 241\u0026ndash;254.\u003c/li\u003e\n \u003cli\u003eCant, S. (2017). Mainstream marginality: Professional projects and the appeal of complementary and alternative medicines in a context of medical pluralism (Ph.D. thesis). Canterbury Christ Church University.\u003c/li\u003e\n \u003cli\u003eFarmer, P. (1988). Health, Inequality, and Human Rights: A Global Perspective. Oxford University Press.\u003c/li\u003e\n \u003cli\u003eFarmer, P. (1996). On suffering and structural violence: A view from below. In P. Farmer (Ed.), Social inequalities and cancer (pp. 119\u0026ndash;133). Plenum Press.\u003c/li\u003e\n \u003cli\u003eForan, B. J. (2007). Medical Pluralism and Global Health Policy: The Integration of Traditional Medicine in Health Care Systems. University of Western Sydney.\u003c/li\u003e\n \u003cli\u003eFoster, G. (1962). The Study of Humoral Medicine. Cambridge University Press.\u003c/li\u003e\n \u003cli\u003eGood, B. (1993). Medicine, Rationality, and Experience: An Anthropological Perspective. Cambridge University Press.\u003c/li\u003e\n \u003cli\u003eJanzen, J. M. (1978). The Quest for Therapy in Lower Zaire. University of California Press.\u003c/li\u003e\n \u003cli\u003eKleinman, A. (1978). Concepts and a model for the comparison of medical systems as cultural systems. Social Science \u0026amp; Medicine, 12, 85\u0026ndash;93.\u003c/li\u003e\n \u003cli\u003eKleinman, A. (1980). Patients and Healers in the Context of Culture. University of California Press.\u003c/li\u003e\n \u003cli\u003eManderson, L. (2020). Traditional healers and global health challenges: The case of dengue. Global Health Journal, 46(3), 12\u0026ndash;20.\u003c/li\u003e\n \u003cli\u003eMoshabela, M., Bukenya, D., Darong, G., et al. (2017). Traditional healers and bottlenecks in HIV/AIDS care. Sexually Transmitted Infections. https://doi.org/10.1136/sextrans-2016-052974\u003c/li\u003e\n \u003cli\u003ePatil, A. D., Singh, S., Verma, D., \u0026amp; Goupale, C. (2024). Exploring medical pluralism. Indian Journal of Integrative Medicine, 4(2), 49\u0026ndash;59.\u003c/li\u003e\n \u003cli\u003eRahman, A., Ahmed, F., \u0026amp; Karim, S. (2012). Traditional healing in rural Bangladesh. Journal of Traditional Medicine, 45(2), 124\u0026ndash;131.\u003c/li\u003e\n \u003cli\u003eScheper-Hughes, N. (1984). Death Without Weeping: The Violence of Everyday Life in Brazil. University of California Press.\u003c/li\u003e\n \u003cli\u003eSingh, M. (2023). Indigenous healing and intersectionality. Journal of Applied Consciousness Studies, 11(2), 91\u0026ndash;97.\u003c/li\u003e\n \u003cli\u003eSubedi, B. (2019). Medical pluralism among the Tharus. Dhaulagiri Journal of Sociology and Anthropology, 13, 58\u0026ndash;66.\u003c/li\u003e\n \u003cli\u003eVindrola-Padros, C. (2013). The role of traditional healers in urban healthcare. Journal of Urban Health, 90(6), 1064\u0026ndash;1074.\u003c/li\u003e\n \u003cli\u003eWaterston, A. (2015). Traditional healing in urban slums. University of California Press.\u003c/li\u003e\n \u003cli\u003eWorld Health Organization. (2002). Traditional Medicine Strategy 2002\u0026ndash;2005.\u003c/li\u003e\n \u003cli\u003eWorld Health Organization. (2014). WHO Traditional Medicine Strategy 2014\u0026ndash;2023.\u003c/li\u003e\n \u003cli\u003eWorld Health Organization. (2019). Dengue: Epidemiological Update.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Medical pluralism, Dengue fever, Urban marginality, Traditional healing, Health-seeking behavior, Bangladesh","lastPublishedDoi":"10.21203/rs.3.rs-7161124/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7161124/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eIn the late 1970s, Aurther Kleinman\u0026rsquo;s concept of medical pluralism was developed and become the central to understanding how cultural values and economic constraints can shape and influence individuals\u0026rsquo; health seeking behaviors and take decisions of which healthcare system option they will choose. This ethnographic study in Ershadnagar Resettlement Camp is situated in Gazipur, Bangladesh, it is a peripheral urban marginalized group. This paper explores how the residents of Ershadnagar manage dengue fever by drawing on multiple healthcare systems. Through 27 in-depth and key informant interviews with traditional healers, biomedical practitioners, and community members, This study examines the explanatory models examined that illness shapes by structural constraints and cultural beliefs through the health seeking behaviors. Findings reveal that medical pluralism in Ershadnagar is not merely a cultural remnant but a pragmatic adaptation to conditions of economic precarity, spatial marginalization, and the embedded presence of trusted traditional healers. This research finds that medical pluralism in Ershadnagar is a pragmatic response to social embessedness of traditional healers, limited access and economic precarity but not simply the matter of continuity of culture. Traditional healthcare system remains deeply trusted and widely used in Ershadnagar, while biomedical healthcare system dominates in state health discourse, traditional healing remains widely used and deeply trusted by the community. This pluralistic reality produces both tensions and collaborations between traditional healers and biomedical practitioners. The findings of this study has contributed to make connection with medical anthropology by positioning pluralism within lived experiences of marginalized urban community facing growing health crises like dengue fever. And also this pluralistic setting produces the conflict and cooperation between healers and biomedical practitioners. By situating medical pluralism within the lived experiences of a marginalized urban population, this study contributes to medical anthropology\u0026rsquo;s broader engagement with informal healthcare systems, trust, and the everyday negotiation of health crises such as dengue fever.\u003c/p\u003e","manuscriptTitle":"Dengue and Dualism: Medical Pluralism in a North-Central Urban Marginal Zone of Bangladesh","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-24 08:03:30","doi":"10.21203/rs.3.rs-7161124/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"fd0853d6-6b2c-4d21-ba37-e854c0de2ea2","owner":[],"postedDate":"July 24th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-07-24T13:38:34+00:00","versionOfRecord":[],"versionCreatedAt":"2025-07-24 08:03:30","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7161124","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7161124","identity":"rs-7161124","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}