Medical Pluralism in Contemporary India

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About the Book

Medical pluralism in contemporary India interrogates the received view of indigenous systems of medicine as ethno medicine or as cultural vestiges of a traditional past. Their practitioners vastly outnumber those of biomedicine and their services to be sought by people across the country. This volume explores the reasons behind the enduring presence and therapeutic significance of systems of medicine such as ayurveda, siddha, unani and other health care traditions in contemporary India. It has been more than a century since these systems of medicine entered the formal collegiate education and state health services. The authors engage with the implications of the coexistence of plural medical systems for the future of medical knowledge notions of therapeutic efficacy, public health administration and the commercialization and globalization of traditional medicines. The essays based ongoing research at the interface of multiple forms of medicine and the state, market and society, set out the prospects as well as the problems of indigenous systems of medicine. Written by researches from various social science disciplines, they offer a refreshingly new perspective on medical pluralism that moves beyond old and simple binaries like traditional modern and science culture. The contributors draw attention to the possibilities of bridging the epistemological divide between knowledge systems and prepare the ground for a socially and prepare the ground for a socially and culturally inclusive approach to healing and health care in contemporary times. The reader will also find in this collection a comprehensive discussion of previous research on the carried complex and fascinating aspects of medical pluralism in India. This book will be useful to students and scholars of medical sociology history of medicine as also to policy makers health activists public health professionals medical practitioners and those interested in south Asian studies.

About the Author

V.Sujatha is associate professor at the centre for the study of social systems Jawaharlal Nehru University New Delhi Leena Abraham is associate professor at the centre for studies in the sociology of education, Tata institute of social sciences Mumbai.

Preface

Our fieldwork in the last three decades and those of our contributors in this volume has clearly shown that indigenous systems of medicine are found not only in isolated rural locations but are widespread throughout the country. While the fact that this dynamic aspect of Indian reality has escaped the attention of social science researchers surprises us, we feel the reasons, may lie in the overwhelming influence of modernisation theories in social research that does not permit an imagination beyond the epistemology of scientific development. As a result, the past or 'tradition' is viewedskeptically and as a deterrent to development and progress. In associating the oppressive systems and ideologies of caste, patriarchy and superstition with tradition, the traditional epistemologies of medicine have been also wished away. The idea of biomedicine as medicine in the singular sense seems to permeate studies on health in India. Attempts to make systems of medicine the object of study, to seriously engage with the epistemological diversity, production and reproduction of their knowledge, their cultural and structural linkages with local and larger societal systems and what their practitioners actually do in the field of health care are hard to come by in our context.

After decades of discourses of development and progress, postcolonial nationstates have had to come to terms with the situation of the consistent and pervasive presence of what was considered obsolete. Even as state policy and market are trying to grapple with the dynamics of popular health behaviour, there is a lot for the social sciences to find out in terms of how ancient traditions of medicine are growing and gaining global significance. Like other forms of pluralismsuch as religious, ethnic and cultural pluralism medical pluralism offers challenging research questions that entail enquiry into a whole range of institutional domains in science, state, market, household, clinic, village and city. It also provides a vantage point to examine caste, class, gender and their politics. Despite the asymmetries associated with the biomedicalisation of indigenous medicines, we think that the continuity of indigenous systems of medicine and the emergence of complementary and alternative medicines worldwide is a serious statement that calls for debates in the philosophy and sociology of science on more than one episteme of the body.

This volume has emerged out of the need we felt as researchers to engage with some of the myriad formations in which plural, indigenous medicines appear in contemporary settings and the promise such studies hold in advancing our understanding of Indian society. As teachers, we have also felt the dearth of detailed studies on plural medical knowledge and practices necessary for a wider discussion on systems of medicine and their significance in modern societies. The volume is a culmination of discussions on our field notes, on the rich material produced by medical anthropology in general on Asian systems, and our strong impulse to go beyond the anthropological approach to Asian medicines as well as the linear model of social change suggested by the dominant theories.

We had three guiding principles in putting together a collection of this kind. Firstly, to draw on a broad base of scholarship from various social sciences so that our approach did not amount to cultural essentialism. Secondly, we wanted to collate and furnish in our introduction a comprehensive review of the literature available in India on the subject; here we wanted to present the debates on indigenous medicine along with the paradigms they represent. Thirdly, we wanted to delineate areas for further enquiry in a manner that would motivate researchers to explore this exciting trajectory of ancient medicine in the twenty first century.

Accordingly, this volume has a diverse group of contributors: public health expert, scientist, economist, psychologist, sociologist, historical sociologist and anthropologist. The attempt is to arrive at a general sketch of medical pluralism agreed upon by all of us even if we differ on the details. A workshop in May 2008 at the Jawaharlal Nehru University (JNU), New Delhi, helped consolidate our views, as did several rounds of emails among the editors and authors on the various papers. The publication of a collection of five papers along with the introduction in a special issue of the Economic & Political Weekly (18 April 2009) was our first step in presenting the contemporary relevance of indigenous medicine to an Indian readership.

This volume carries seven new articles apart from those published in the EPW and indicates current discussions on the subject from our different vantage points and disciplinary moorings. The papers in this volume are based on ongoing work by researchers and activists and are substantiated by fresh and lessexplored data. Even while this is intended to augment the study of medical pluralism in India, the arguments in this volume contribute to international debates in the social sciences on medicine and dwell upon the concepts and praxis of medical pluralism in general. As editors of this collection, we realised that the process by which the volume has taken shape has been an enriching experience. The past three years did not seem to us to be so much collaboration for a specific objective as a process of mutual learning through discussion. We have talked on the phone for hours together about our field visits, meetings and the theoretical import of these developments. We shared the responsibilities of this volume and soon realised that we complemented each other in the nature of tasks we took up. It would not be possible to separate our contributions as editors of this volume because this has truly been a joint and equal effort in all respects. While the volume may not fulfill all the aims we set out with, we hope it will be a beginning.

We are thankful to the Centre for Advanced Study Programme (UGC) and the Global Studies Programme at the Centre for the Study of Social Systems (CSSS) in JNU for financial support to the workshop and for manuscript preparation. We are grateful to the chairs and discussants in our workshop for their valuable suggestions on various papers and to the editor of the EPW for bringing out the initial collection as a special section on indigenous medicine.

We thank EPW for granting permission to reproduce the articles by Mira Sadgopal, Bhargavi Davar and Madhura Lohokare, Leena Abraham, M. S. Harilal, and V. Sujatha in this collection. Inputs from and discussions with Professors P. S. Uberoi, Ashis Nandy and Andre Beteille have taken us a long way from our initial .ideas. We thank them for their constant encouragement and enquiries about the ongoing research. Professors Manorama Savur and Padma Velaskar have been sources of inspiration and support. K. Subramaniam made critical comments on the Introduction; Alito Sequeira encouraged us to pursue our passion. Our contributors have been exceedingly cooperative and it was a great pleasure to work with each one of them. We would like to thank the publisher's anonymous reviewer for the useful comments and suggestions, and Veenu Luthria and Majaz Panjatan of Orient BlackSwan for the copy editing and the publication of this collection. We have to mention Vilasini at New Delhi and Chaitanya at Mumbai for putting up with long hours of telephonic conversation between their mothers, and Venkatesh and Ravi at Delhi and Mumbai respectively for personal support. Finally, we would like to express our deep gratitude to the several practitioners in the field with whom we have interacted over the years, who have generously shared their time, knowledge and experiences with us and, more importantly, challenged us to think beyond the binaries and the linear histories to pay heed to the complexities of our social realities. They are too numerous to name and we dedicate this volume to them.

Introduction

Health care in India presents a complex scenario that is shaped significantly by colonial and postcolonial history and politics, and is enhanced by a vibrant and thriving medical pluralism. Multiple medical systems such as biomedicine,' ayurveda, unani, siddha, homoeopathy, naturopathy, yoga and a variety of folk traditions, all contribute to providing health care in the present time. Of these, unani medicine came from West Asia eight hundred years ago while hornoeopathy, naturopathy and biomedicine entered about two hundred years ago from Europe to become part of the medical traditions in this region. The emergence and arrival of different medical systems, their acculturation into various communities, as well as the way they syncretised and contested with the indigenous are quite unique to Indian medical and cultural history.

Though this region has been home to several systems of medicine, statesponsored health care since the twentieth century has been based on biomedicine. The Ministry of Health and Family Welfare in India is based on biomedical services and under it we have the Department of ayush (ayurveda, yoga, unani, siddha and homoeopathy) for all the rest.' The model is one in which 'other' systems of medicine, namely, the ayush systems that have popular support in terms of usage, cultural consonance and larger number of practitioners, have been cast against biomedicine which is the official system of state medicine. This is not only true of India but has been a trend in general, including in Europe and North America where biomedicine is the official system in the state health services and public demand for complementary and alternative medicine (CAM) has been at odds with state efforts to provide a standardised system of health care.

The term medical pluralism was introduced by the social sciences in the mid1970s to characterise the situation in the Third World in which people were resorting to multiple options for health care outside the government health care system based on biomedicine. By the nineties, however, medical pluralism became the buzzword in the West as well and came to denote the inclusion of CAM within the state health administration. The everincreasing demand for cure and care for a growing range of health conditions which elude any particular system of medicine has made pluralism in therapeutic options a way of (post)modern life. The emergence of 'New Age' movements for health and wellbeing has led to the rising popularity of complementary and alternative medicine in the USA, the UK, Germany, Australia and Canada. Statesponsored medical pluralism is now admitted as a reality of health care (Cant and Sharma 1999; Scam bier 2002; Turner 2004) in the West and is no longer a feature of societies that are deprived of biomedical care due to poverty and other economic constraints.

But even within the framework of statelegitimised medical pluralism, the relation between medicine, state and society varies considerably across nationstates. In the Britain of the nineteenth century, as in the rest of Europe and America a little later, the state played.sr key role in the ascendancy of the medical profession by banning all other medical practices. The indigenous systems of North America and Europe other than biomedicine, namely, homoeopathy, naturopathy, chiropractic and osteopathy had to go through a century of struggle with the mainstream that is biomedicine, in order to secure the position of CAM in public space. In India, on the other hand, neither the colonial state nor the independent Indian state could either ban or strictly regulate the indigenous systems of medicine, namely, ayurveda, siddha and unani (henceforth ISM) and the other new entrants like homoeopathy and naturopathy. The constraints in making western medicine available to the population, the efficacy of ISM practitioners and their medicines, the social and political power of ISM practitioners at the regional level, the growing market share of ISM medicines and services and the continued power of nationalistic and cultural ideologies, have all in varied measures contributed to the shaping of ISM and their character and content in independent India. We have a whole gamut of concerns thrown up by the spread and continuity of ISM today:

The attempts to incorporate these systems that hitherto operated through regional social institutions into a centralised and bureaucratic health infrastructure. Their appropriation by the pharmaceutical sector which has resulted in a vast expansion of the ISM component within the drug industry.

The negotiations among practitioners of various coexisting therapeutic systems and between patients and practitioners in terms of forms of legitimation. The position of psychosocial and spiritual dimensions of cure, care and wellbeing in the contemporary forms of indigenous systems of medicine.

The debate on notions of efficacy in a situation of multiple, coherent systems of medicine, each with welldefined standards of efficacy.

All these instances are worthy of serious study as they raise fundamental questions not just about ISM but about organising health care in India. Social sciences in India have perceived and theorised the relationship between medicine, state and society almost exclusively from the perspective of biomedicine. Modernisation. theories and political economy studies, the two most influential and contrasting strands of social science theorising in India, have both assumed definitions of health and medicine from biomedicine.

A framework for the analysis of ISM requires not only recognising the presence of diverse medical systems but engaging with them as live and efficacious traditions. The attempthere is neither to valorize these systems nor to expurgate them. But the presence of these systems over centuries and the fact that they serve a vast population with and without choices calls for serious, critical research. The essays in this collection will address a few, though not all, of the issues raised above. Before we proceed, some engagement with the term 'indigenous' as it is used in this collection is necessary. The more commonly used term; 'traditional medicine' conveys the sense of a foregone past and invokes the binary opposition between tradition and modernity which, as several articles in this volume show, is analytically not very insightful. 'Asian' medicine and 'Indian' medicine are other terms used in anthropological literature, but they do not provide scope for the simultaneous comparison of societies in the East and the West on the relation between nonbiomedical and biomedical systems. There is a divorce between medical anthropology studying 'Asian' medicines, on the one hand, and medical sociology looking at CAM in the West, on the other, and a virtual absence of crossreferencing between them in the international scholarship. In order to highlight the contemporaneity of the ancient systems of medicine and to show that there is a homology in the relation between nonbiomedical and biomedical systems of medicine in different societies, the term indigenous was preferred for the title; the papers here, however, may use the other terms interchangeably depending on the context.

This introduction and the essays to follow specifically focus on the Indian situation. While we use the generic term 'indigenous' for systems of medicine like ayurveda, siddha and unani, in order to distinguish them in terms of civilisational origin and temporal continuity in this region, we also note that temporal continuity is neither absolute nor invariant. We could talk of ayurveda, siddha and unani as indigenous systems of medicine in India in relation to biomedicine that was introduced by the colonial state two centuries ago. Interestingly, homoeopathy and naturopathyalso entrants during the colonial rulehave found considerable voluntary support among people and have been formally grouped together with the ISM in the current acronym of the government department (AYUSH). Homoeopathy in India today has the secondlargest number of practitioners after ayurveda, and naturopathy, which was consonant with Gandhi's philosophy of life, is aligned with yoga to offer a coherent model for a healthy lifestyle in contemporary India.

Yet we have to distinguish ayurveda, siddha and unani, which have been transmuted into a cosmology through longstanding historical processes generated and sustained through the lived experience of the people, from systems of cure like biomedicine and homoeopathy which are widespread more as therapeutic options, at least for now! The case of unani that underwent multiple processes of assimilation in different locations deserves special mention here. As the GraecoRoman system of medicine conserved and developed by the Arabs during the eighth to thirteenth centuries in the classical empires of Islam, it travelled to India in the twelfth century. It was subsequently indigenised in the Indian subcontinent through interchange with ayurveda and through the translation of Arabic medical texts into Persian and Urdu, acquiring the name Yunani tibb as the forthcoming sections will show; we do not intend to convey any sense of an unchanging indigenity, rather a dynamic one. In his outline of key debates in Indian philosophy, Matilal observes that certain themes and concepts consistently recur with reasonable precision in philosophical discussions over several centuries irrespective of major social and political changes (MatilaI1986). This is also true to a large extent of the basic principles of ayurveda and to a limited extent of its theory .The praxis however, may have varied considerably (Manohar 2005). The trend of focusing on differences, breaks and ruptures (Zimmermann 1978) notwithstanding, we refer to ayurveda or siddha as indigenous systems here. Our argument is that even the identification of a discontinuity presupposes continuity; the question is, therefore, not one of absolute discontinuity in which case no discussion about ayurveda or unani is possible. Further, the level or domain at which to look for continuitieswhether with regard to epistemology, theoretical framework, statements or practicesis a matter for consideration. Hence the language of difference and of continuity alternates in our accounts of ISM in this collection, depending on the level at which the observations are made and on the basis of the unit of analysis.

There are several difficulties in talking about the contemporary significance of ancient systems of medicine and the field is marked by several typifications like traditionmodernity and scienceculture whose temporal and spatial ramifications are unclear. The aim of this introduction is to give an overview of issues with regard to ISM in India across the disciplines of history, sociology and anthropology of medicine because there is very little crossreferencing between disciplines on the same subject and there is a need to draw them together to see what they are saying. Accordingly, two sections of this introduction are on disciplinary debates in history, on the one hand, and medical anthropology and sociology, on the other, followed by a last section on seminal concerns for the social sciences with regard to the situation of ISM today. The history of ISM from the medieval times onwards indicates that medical services were supported by the state as well as the wider society. The rulers seem to have extended patronage simultaneously to ayurveda and unani (Alavi 2007). There have been mutual translations from Arabic and Persian medical texts to Sanskrit and viceversa that led to a composite pool of medical texts in the subcontinent in the early sixteenth century (Kumar 1997). The crucial point, however, is that unlike the colonial state, the medieval state did not produce a discourse about its subjects/citizens (Cohn 1990). We have autobiographies, portraits and inscriptions, but no reports that classify and categorise subjects and their culture that could become the basis for history writing as in the colonial period.

Colonialism, apart from other changes that it produced, seems to have altered the relation between ISM and the state in two ways. It created a situation in which the state subscribed to one system of medicinethe official system. Secondly, parallel to policymaking and intervention, there was a discourse being advanced by the colonial state about its subjects who also were objects of investigation. In this process of building accounts of the colonial subject and their culture, the state discourse imposed its own present on that of the colony, evolving a monodimensional and linear narrative of knowledge in which the ISM's location in the temporal sequence of events was relegated to the realm of 'tradition' even while it was contemporary. As we know, it is this body of discourse enshrined in archives that has been the substance of the historiography of medicine in colonial India.' There is a large body of literature on several aspects of the colonial state and biomedicine and we are not going to engage with it here. Our point is that the historiography of medicine in India does bear the influence of it being created out of the state discourse on ISM rather than sources within ISM. A few observations on key concerns in the area will indicate the trend.

Contents