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Paper short abstract

Patients with prolonged (muco)cutaneous leishmaniasis in the Ecuadorian Amazon pragmatically navigate diverse therapies in response to multiple forms of suffering, including biomedical after-effects. Medical pluralism reflects the coexistence of multiple ontologies shaping healing efficacy.

Paper long abstract

Leishmaniasis is a vector-borne neglected tropical disease that remains underdiagnosed and undertreated worldwide. In the Ecuadorian Amazon, Indigenous populations face structural barriers to biomedical care, often resulting in health-seeking delays of more than one month after symptom onset. This paper examines the healing pathways of patients living with prolonged (muco)cutaneous leishmaniasis, focusing on the reasoning that underpins therapeutic choices within contexts of medical pluralism.

This qualitative research with 43 patients from seven ethnic groups analyses therapeutic navigation, including biomedicine, local remedies, diets, prayers, behavioural moderation, and shamanic experiences. These practices form cumulative, personalised and non-linear assemblages of care rather than sequential or competing therapeutic regimes. Patients’ decisions are shaped by embodied experiences of treatment efficacy, moral evaluations of care, and (non-)human relational obligations. Coexisting therapies are not experienced as contradictory or hierarchical, but as a coherent response to illness understood through relational logics.

Using assemblage theory, healing pathways are conceptualised as forms of ontological navigation reflected in the movement across different logics of illness and care. Patients may engage biomedical treatment through a naturalistic ontology, while interpreting after effects or persistent discomfort as signs of social, spiritual or ecological imbalance, prompting complementary forms of care grounded in relational ontologies. Patients move pragmatically between ontologies, assembling responses that address multiple dimensions of suffering. As a result, the legitimacy and efficacy of therapies are evaluated contextually through lived experience rather than fixed institutional hierarchies of knowledge. Ontological plurality foregrounds medical pluralism as a non-exclusive, pragmatic process shaping therapeutic choice in forested settings.