Homeopathy for Breast Cancer Treatment Towards Hindu Women

This study was intended to reveal the facts regarding homeopathy in the breast cancer treatment for Hindu women in Buleleng regency. Through qualitative research methods, phenomenology theory, power and knowledge relation, health-seeking behavior, and the theory of health believe and explanatory model can reveal the reasons underlying the homeopathy occurrence in the breast cancer treatment, i.e., low medical awareness, accumulated awareness of praxis, and chemotherapy, confidence and treatment behaviors. Homeopathic practices in the breast cancer treatment included Balian/shaman (Balinese spiritual) as a traditional Balinese homeopath, breast cancer etiology, disease diagnosis, preliminary therapy, core therapy, and advanced therapy, and cure categories. Homeopathy in the breast cancer treatment has implications for the sustainability of the traditional Balinese treatment culture; implicates the patient in three ways, e.g., the delay and increased stage of cancer, giving psychic comfort to the patient without positive effects for healing, and providing psychic comfort as well as positive effects for healing; has medical implications as the antithesis of medical systems, media of reflection and instruction for the medical, and the desire emergence for some medical circles to combine medical and nonmedical.


Introduction
The breast cancer is the most common type of cancer for the women worldwide. The incidence of breast cancer in the United States is 27/100,000 and is estimated to occur over 200,000 new cases per year (Honig, in Manuaba (ed.), 2010: 3). In Indonesia, the incidence of breast cancer according to pathology-based registration has a relative incidence of 11.5% (11 to 12 new cases per 100,000 at-risk population) (Manuaba (ed.), 2010: 1). In Bali, there are about 1233 new cases of the breast cancer in 2012 (Basic Research Health Balitbang Kemenkes RI 2013). Meanwhile, the data from Buleleng regency Health Office in 2015 was noted that the number of breast cancer patients in Buleleng Regency was 101 people and 47 of them died. The delay in early detection of breast cancer is still a constraint that often occurs, therefore, many patients come to the doctor, clinic, or hospital is in an advanced stage.
Although the death risk of breast cancer patients is quite high, the detection speed and accuracy in treatment, these risks can be minimized (Purwanto, et al. (Peny.), 2015: 19). In the medical world, it is known axiom that stated "The diagnosis of breast cancer at an advanced stage is not difficult, but the results of treatment are less than the maximum. Conversely, early diagnosis is not easy, but the treatment will be more leverage ". The data in RSUP Sanglah showed that breast cancer patients who came to the hospital in the last 3-4 years was more than 70% in stage III and IV and found the peak frequency at 35-40 years old. This delay is due to several factors, (1) in Bali, there is no screening program for breast cancer; (2) the delay of the community to go to a doctor or hospital; and (3) other factors, unlike the alternative medicine widely advertised by the mass media (Sudarsa, 2000: 1;Manuaba, 2008: 3).
Complementary alternative treatment for breast cancer is quite rampant lately. One of them is homeopathy, a treatment system using natural medicines sourced from minerals, herbs, and animals (Campbell, 2008: 2). The homeopathy development in Western countries is more advanced than Indonesia. In the UK, there is a homeopathic hospital named "The Royal London Homeopathic Hospital" and the Faculty of Homeopathy founded in 1944 by The British Homeopathic Society -a homeopathic organization that was established in 1843. In the United States, homeopathic remedies have been patented under the guidelines of The Homeopathic Pharmacopeia of the United States (HPUS) which was subsequently included in FDA (Federal Food, Drug, and Cosmetic) regulations in 1938 (Cassam, 2006: 3-5). Conversely, in Indonesia, homeopathic remedies are still often debated, especially in the medical community. Manuaba (2008: 3) explicitly stated that alternative medicine whose success stories are widely broadcasted by the mass media is totally unfounded and unaccountable and unmeasurable.
Regardless the controversy, the phenomenon of rampant homeopathic treatment in the breast cancer treatment also occurs in Buleleng regency. The pilot studies show that nearly 80% of patients with advanced breast cancer who come to doctors, clinics, or hospitals claimed to have followed previous homeopathic remedies. In the perspective of the health anthropology, this phenomenon is interesting to be studied in depth due to the treatment belief and its implementation is a major element of public health culture (Foster & Anderson, 1986: 61). That is, the homeopathic phenomenon in the breast cancer treatment for Hindu women in Buleleng regency is seen closely related to the community culture, related to traditional Balinese culture and patriarchal culture which tend to position for Hindu women as a subordinate group. Based on this background, this study focuses on three issues: (1) Why is homeopathic practice in the breast cancer treatment for Hindu women in Buleleng regency?, (2) How is homeopathic practice in the breast cancer treatment for Hindu women in Buleleng regency?, and (3) What are the homeopathy implications in the breast cancer treatment for Hindu women in Buleleng regency on medical, patient, and medical cultures? This study aims to reveal the facts about homeopathy in the breast cancer treatment for Hindu women in Buleleng regency according to the three problems formulation. Furthermore, the results of this study are expected to be useful theoretically as the scientific anthropology development of Hindu health and practically as a scientific reference for the parties concerned in preparing the policy plan in the breast cancer prevention in Bali particularly and in Indonesia generally.

Research Method
This research was designed qualitatively with phenomenology approach in interpretative paradigm. The phenomenological approach on two methodologies, i.e., epoche and eidetic reduction by providing 'breaking out' of any prejudices or presuppositions that precede the true experience. Regarding this method, the phenomenon is seen as an objective experience that also engages subjective elements unlike perception and reflection (Conolly, 2002: 111). In order to understand this phenomenon, it requires interpretation, awareness, and intersubjectivity between researchers and individuals who are the subject of the research.
The research location is in Buleleng Regency. The data were collected by observation techniques, interviews, and document studies. The informants were determined purposively, i.e., subjects or individuals directly related to homeopathic practices in the breast cancer treatment, included patients, healers, and some traditional homeopathy experts in Bali. After all, data has been collected, the data are analyzed in three stages: data reduction, data presentation, and conclusion (Miles and Haberman, 1994: 10). Furthermore, the data analysis results are presented according to the research themes that have been set before in the problem formulation.

Concepts and Theories
The basic principle of homeopathy as a treatment is inspired by Hippocrates (300 BC) in his writings, 'through the same substances the disease can be inflicted and through the same substance the disease can be cured.' Furthermore, the principle of homeopathy was developed by Samuel Hahnemann (1753 -1843) as described by Ramakrishnan and Coulter (2001: 1) below: The science of homeopathy, founded by Samuel Hahnemman around the beginning of the nineteenth century, is based on the Law of Similars. This means that a medicinal substance capable of producing a set of morbid symptoms in the healthy individual will remove similar symptoms occurring in an individual suffering from illness.
In short, homeopathy is a treatment art based on similibus curentur law that disease can be cured by the reflection effect of the substances that produce symptoms of disease in healthy people. Basically, homeopathy emphasizes workings of drugs with some of the following characteristics, (a) derived from natural substances found in plants, minerals, or animals; (b) is generally safe to eat, has no side effects, not to contain toxic or hazardous chemicals; (c) homeopathic remedies are often in the form of liquids, granules, and tablets; (d) the substance of the drug is obtained by the process of continuous dilution; and (e) efficacious for stimulating the immune system, accelerating healing, preventing complications without side effects, as well as overall, physical, emotional, and mental treatments (Campbell, 2008: 79-80).
Meanwhile, the cancer is a disease that arises from the abnormal growth of body tissue cells that turn into cancer cells (Infodatin Kemenkes RI, 2015: 1). The breast cancer is cancer that attacks a person's breast which in medical science is called carcinoma mammae or breast cancer (Manuaba, 2010). According to WHO (1984), the histology classification of breast cancer can be divided into two, i.e., Non-Invasive Carcinoma and Invasive Carcinoma (Manuaba (ed.), 2010: 19). Non-invasive breast cancer is a benign breast cancer found in the breast ducts and has not spread. Meanwhile, invasive breast cancer is a breast cancer that develops in the cells forming the breast channel and can spread beyond the breast (Infokes, 2013: 4-5).

Classification of breast cancer stage according to Union International Contra le Cancer (UICC) and
American Joint Committee on Cancer Staging and End Repulsions Reporting (AJCCSERR) can be distinguished on the diagnosis basis of several elements, included tumor size (Tumor/T), lymph node condition (Nodes/N), lymphatic pathology (Nodes Pathology/Np) and metastasis (Metastasis/M). Accumulation of the elements diagnosis can determine the breast cancer stage into five, i.e., Stage 0, Stage I, Stage II (IIA and IIB), Stage III (IIIA, IIIB, and IIIC), and Stage IV (Manuaba, (ed.), 2010: [21][22][23][24][25]. Based on the cancer stage, the breast cancer therapy can be performed by surgery (mastectomy), chemotherapy, radiotherapy, target drug therapy (molecular targeting therapy), hormonal therapy, and biological therapy. Non-invasive breast cancer therapy is performed through a simple mastectomy, breast-conserving therapy/surgery, and adjuvant therapy. The invasive breast cancer therapy is performed on the patient stage. At an early stage through a modified radical mastectomy and neoadjuvant therapy, while it advanced stage with chemotherapy and radiotherapy (Manuaba (ed.), 2010: 40).
Unlike the medical procedures in the breast cancer treatment that has been established systematically, precisely the procedure of homeopathy is not known for sure. Although the homeopathy phenomenon in the breast cancer treatment takes place in the community, the truth of the treatment still needs for the further search. Therefore, this study uses several theories to analyze homeopathy in the breast cancer treatment in Buleleng regency, e.g., phenomenology theory, power relations theory and knowledge, health seeking behavior, and theory of health believe and explanatory model. These theories are used eclectically according to multivariate data in the field.
The phenomenology theory stated that individual action is always built by consciousness as an accumulation of perception of phenomena, typification, reflexivity, and motives. The individual is related to an objective world that provides the experiences variety. The individual interprets and understands the experience through the stock identification or stock entry its possesses. Then, the individual reflects its interpretation and understanding of experience in subjective consciousness. Furthermore, the individuals take action based on "in order to motive" and "motive for" (because of motive). The awareness built through the process is communicated to other subjects within the framework of intersubjectivity (Campbell, 1997, Adian, 2002. The relevance of the homeopathy theory in the breast cancer treatment occurs due to the individual's awareness involved in it mainly the healer and the patient. Homeopathy as a treatment phenomenon is captured, interpreted, understood, reflected in the subjective consciousness, and ultimately motivates the act of treatment performed. The power relationship and knowledge theory emphasize a reciprocal relationship between knowledge and power (Foucault in (Carette (ed.), 1999, Barker, 2005). The truth regarding homeopathy in the breast cancer treatment is a knowledge discourse that takes place in a series of power practices. Inherent in the discourse practice, and hence language become the dominant tool for articulating power. In this case, the homeopath has its own genealogical knowledge of the breast cancer treatment channeled to the patient through discourse. Through this discourse, the power of healers affects the patient acceptance, the patient also builds their own knowledge and power in determining the treatment that is right for their illness. Therefore, this theory can reveal the operation of knowledge and power of homeopathy in the breast cancer treatment for Hindu women in Buleleng regency as an intensive treatment.
The theory of health seeking behavior is the complex and holistic interaction result between individuals and the environment and existing health services. The pattern of health seeking behavior in the society can be divided into five forms of trust to the healer chosen by a person, i.e., (1) professional health expert; (2) non-professional health professionals; (3) treatment with a spiritual approach; (4) traditional medicine with herbal medicine and massage; or (5) alternative treatment (Notoatmojo, 1993: 23). One's belief in determining healers is determined by several factors that WHO defines as follows: B= f (TF, PR, R. C). Behavior (B) health seeks is influenced by factors (factors/f), included knowledge, belief, attitude (thought and feeling/TF); others references (personal reference/R); individual resources (resources/R); culture and lifestyle of the society (culture/C). These factors will be further explored in this study.
The theory of health belief and explanatory model is a combination of health belief model theory and explanatory model. The health belief model theory suggested that health behavior is determined by personal beliefs or perceptions of disease and strategies available to reduce the disease occurrence (Hochbaum, 1978). According to Becker (1980), there are five thoughts that underlie one's belief in health efforts, i.e., Perceived barrier to action; and, (e) Cues to action. The theory is combined with an explanatory model, Kleinman (1980) argued that public health measures against disease are determined by three overlapping sections e.g., the popular sector, the professional sector, and the folk sector. The popular sector is a sector that includes the layman, non-professional or non-specialist, i.e., someone trying to treat their own illness. The professional sector consists of a healer or healer who has knowledge of the disease and how to treat it, such as a doctor. Meanwhile, the folk sector is a non-professional, non-bureaucratic sector, and includes specialists covering sacred and secular activities in healing, e.g., shaman, traditional psychotherapy, and folk healers (Kleinmen 1980: 51-52 ).

Results and Analysis 3.1The reason underlying the occurrence of homeopathic practices in the breast cancer treatment for Hindu women in Buleleng regency
The reason for the occurrence of homeopathic practices in the breast cancer treatment for Hindu women in Buleleng regency due to low medical awareness, both in terms of prevention and treatment. The medical awareness reflects the operation of power and medical knowledge as the sole remedy for breast cancer. However, it is not fully established in the patient due to the lack of optimal health communication, the lack of health public awareness, as well as the objective and subjective conditions facing the medical in the breast cancer prevention. The low level of medical awareness opens up a growing space of nonmedical awareness. Therefore, homeopathy becomes a necessary choice for the patient in seeking a cure for their disease.
The further reason that the homeopathy practice in the breast cancer treatment for Hindu women in Buleleng regency occurred due to the praxis awareness accumulation. The awareness of patient praxis accumulated from panic after being convicted of breast cancer and quick recovery motivation. Therefore, the patients will take the treatment steps, both medical and nonmedical. Nonmedical treatment is conducted by the patient simultaneously with the medical, either complementary or the main choice. It can not be separated from the occurrence of medical treatment anomalies, unlike a relatively long process. The results are not quickly perceived patients, and costs tend to be expensive. This anomaly opens the way for homeopathy that offers advantages that patients do not get into medical treatment especially according to illness perception. That is, even though the patient is unable to provide a logical argument for their choosing a homeopathic practice in the breast cancer treatment, the patient does, therefore, their praxis consciousness.
Furthermore, the reason for the occurrence of homeopathy in the breast cancer treatment due to patients avoid surgery and chemotherapy. The reasons for the patient to avoid surgery include (a) mental condition, like surgerophobia or anxiety and fear of surgery; (b) uncertainty about the success of surgery, like healing opportunities and changes in breast shape and function; (c) costly operating costs; and (d) advanced therapy of adjuvant chemotherapy. Meanwhile, the patient's reasons for avoiding chemotherapy include (a) long (gradual) chemotherapy processes; (b) high cost; (c) side effects of chemotherapy; and (d) uncertainty of outcome in healing. These reasons encourage the patient to take homeopathy to avoid surgery and chemotherapy.
The beliefs and culture of treatment have an influence on the behavior of public health that opens the possibility of homeopathic practice in the breast cancer treatment. First, the belief that breast cancer is the result of karma, therefore, the treatment must be conducted on the supernatural power. This belief is reinforced by the resistance emergence to medical treatment measures, e.g., the physicians should not touch, not surgery, and should not be in contact with metal. Second, the belief is reinforced by a culture of social medicine that still believes in nonmedical treatment, regional factors, educational and economic levels, and patriarchal culture. Third, trust and culture also influence the society treatment behavior. Thus, opening the opportunity for the occurrence of homeopathic practice in the breast cancer treatment.

Homeopathic practice in the breast cancer treatment for Hindu women in Buleleng regency
Homeopathic practices in traditional Balinese treatment systems are carried out by shaman along to meet the following requirements. First, the treatment system is carried out using medicinal ingredients from plants, animals, minerals, and liquids (both aquatic and alcoholic). Secondly, the shaman may be referred as traditional Balinese homeopaths throughout their medicinal practices using medicinal ingredients in accordance with homeopathic rules. Third, the implementation of different homeopathic practices from each homeopath is a consequence of the different abilities and expertise of each shaman. It can still be categorized as homeopathic practice as long as its treatment practice still uses the medicinal ingredients of plants, animals, and minerals required in homeopathy.
Etiology or causes of breast cancer according to shaman can be distinguished on naturalistic (sakala), personalistic (niskala), and psychic causes. It is included in the naturalistic category, i.e., (a) general medical causes; (b) frozen breast milk; and (c) the entry of metal elements into the patient's body. Aetiology of breast cancer according to shaman that includes personalistic (noetic) causes, included: (a) salahang dewa (ancestral gods) and kapastu leluhur (ancestral cursed); and (b) ugig (evil), kena gelah anak, atau gegaen anak len/magic attack (active agent of person). The etiology of breast cancer is also thought to come from psychic causes, especially stress.
The diagnosis of breast cancer in homeopathy practices, included (a) through intermediate media; (b) the patient's marker or tether; (c) pulse examination checking (nadhi pariksa); (d) supernatural advice (sabda pramana); and (e) question and answer with the patient. There are several important things related to how the disease diagnosis, i.e., first, how the diagnosis depends on the ability of the treatment owned homeopath. Second, the diagnosis does not always rest on medical knowledge, but also nonmedical. Third, the use of supernatural powers is a necessity; fourth, the purpose of disease diagnosis is not only to know the type of illness suffered by the patient, but also to get a clue about the chances of cure and how to do the treatment.
Homeopathic therapy in the breast cancer treatment is carried out in three stages: (1) preliminary therapy, (2) core therapy, and (3) advanced therapy. First, preliminary therapy is performed after diagnosing the cause, the healing chance, and the treatment step that must be conducted. The forms of preliminary therapy performed by each homeopath (shaman) vary, as with supernatural or religious powers, and a combination of supernatural methods with the provision of natural medicines. This preliminary therapy is part of the complete healing stage of breast cancer. Secondly, the core therapy uses the effects of the drug like homeopathic principles. The ingredients used are not always the same for each patient, and the dosage used is only based on the instructions obtained. The medicinal ingredients used almost entirely contain compounds that are pharmacologically believed to have anticancer activity, e.g., antiproliferation (preventing the development of cancer cells), cytotoxic (toxic to cancer cells), proapoptotic (accelerate of killing of cancer cells), immunostimulants (keeping the immune from cancer cells that is malignant), antiseptic, and antioxidants, as the following table.

Anticancer Agent
Third, the further therapy is performed according to the patient's health condition. Following therapy up is varied, e.g., through supernatural strength, massage, and continued medication consumption given in a core therapy. The progressive therapy is stopped if the patient is considered cured, or otherwise considered incurable. The cured categories from the perspective of the shaman are characterized based on (a) reduced pain in breast cancer; (b) loss of a lump or swelling in the patient's breast; (c) drying of the patient's breast; (d) the breast may function well; (e) the patient feels their health is better than before.

Homeopathic practices implications in the breast cancer treatment for Hindu women in
Buleleng regency towards treatment, patient, and medical cultures The cultural elements of the traditional treatment in homeopathic practices, e.g., shaman, treatment systems, medical facilities and infrastructure, and supporting information technology functionally each other. The use of homeopathic treatment practices is not due to the lack of supportive medical facilities or costly fees, but due to the cultural factors that are still very strong. This condition opens opportunities for the development of homeopathic practices by developing a traditional Balinese treatment system. In the case of high-risk breast cancer treatment, people still believe in traditional medicine, for other common diseases. That is homeopathy in the breast cancer treatment for Hindu women in Buleleng regency has implications for the sustainability of Balinese traditional medicine, both in the prevention of breast cancer and other diseases.
The homeopathic implications towards patients in the breast cancer treatment for Hindu women in Buleleng regency can be divided into three, i.e., (a) homeopathic practice before medical action has implications for increased breast cancer stage and delay in subsequent treatment; (b) homeopathic practice after medical action has implications for the creation of the better psychic condition of the patient, although not physically significant; and (c) homeopathic practice as a complement of medical acts has psychological implications, as well as an influence on the effectiveness of drug action due to the multiple incentives in the patient to breast cancer survivor. Based on the three implications, homeopathic practice as a complement to medical treatment has relatively more positive implications than other implications.
The homeopathic implications in the breast cancer treatment for Hindu women in Buleleng regency towards medical, included (a) the knowledge emergence regarding the breast cancer treatment as the antithesis of the medical treatment system; (b) reflection and introspection of medical services; and (c) the minds emergence of the medical circles to develop a holistic treatment that combines medical and nonmedical. The third implication is also not separated from the penetration of alternative medicine is very strong and massive.

Conclusion
The study was found that homeopathy in the breast cancer treatment for Hindu women in Buleleng regency was traditionally performed by a shaman. It was shown that USADA Bali (the coherence with the Balinese treatment system). The drugs used potentially to be developed in a more modern way. The traditional homeopathic practices do not fully comply with homeopathic rules, especially in dosage and drug mixtures, and have not been pharmacologically tested in accordance with the clinical procedures. Although, pharmacologically, almost all ingredients given by the shaman are believed to consist of the potential compounds as anticancer. The study was also found the fact that there has not been found homeopaths and medical experts who combine medical and homeopathic in the breast cancer treatment. That is the breast cancer prevention efforts in the future can consider the cooperation between two systems of this treatment, especially in the epidemiology of anthropology, medical cooperation and nonmedical undoubtedly conducted.

Conflict of interest statement and funding sources
The authors declared that they have no competing interest. The study was financed by private funding.