Health, Culture and Religion in South Asia

Critical Perspectives

Assa Doron, Alex Broom

• Publisher: Routledge
• Year: 2013
• Print ISBN: 9780415848817
• eBook ISBN: 9781317988373
• Topic: Theology & Religion
• Subtopic: Religion & Science

Health, Culture and Religion in South Asia brings together top international scholars from a range of social science disciplines to critically explore the interplay of local cultural and religious practices in the delivery and experiences of health in South Asia. This groundbreaking text provides much needed insight into the relationships between health, culture, community, livelihood, and the nation-state, and in particular, the recent struggles of disadvantaged groups to gain access to health care in South Asia.

The book brings together anthropologists, sociologists, economists, health researchers and development specialists to provide the reader with an interdisciplinary approach to the study of South Asian health and a comprehensive understanding of cutting edge research in this area. Addressing key issues affecting a range of geographical areas including India, Nepal and Pakistan, this text will be essential reading for students and researchers interested in Asian Studies and for those interested in gaining a better understanding of health in developing countries.

This book was published as a special issue of South Asian History and Culture.

Class and the clinic: the subject of medical pluralism and the transmission of inequality

Kalpana Ram

Department of Anthropology, Macquarie University, Sydney, Australia

This article, based on ethnographic work in rural Tamil Nadu, explores the relative invisibility of class and its characteristic modes of operation in the literature on medical pluralism in India. Using, as key concepts, habit, comfort, pre-familiarity and familiarization, the article suggests that we can shift the way we think of ‘pragmatism’, the term that is routinely used to describe subjects who follow pluralist strategies. In reconceptualizing pragmatism, we can allow ourselves to glimpse anew the workings of class within pluralist strategies. The article takes inspiration from Gramsci’s critique of the self-evidence of ‘common sense’, as well as from the phenomenological aspects of Bourdieu’s understanding of class and habitus. It explores the very different levels of comfort and authorization that different classes display in relation to biomedical spaces and practices, as well as towards non-biomedical discursive practices.¹

Since the 1970s, medical anthropology has foregrounded the perspective of the ‘layman’ and (belatedly) the ‘laywoman’, at the expense of the previously reigning perspective of intellectuals. A durable paradigm emerged from this realignment by anthropologists which has cohered around the figure of pluralism, taken to be the characteristic and defining feature of the health strategies of the layperson. The phenomenon of pluralism is real enough. Consider the following description taken from my field notes. Here, Melanie, a coastal woman from the Mukkuvar fishing community of Kanyakumari, described to me the long-awaited birth of her first child:

For five years I had no children, and I prayed at the koil [church, same word as for temple] at Ovari. I did not consult doctors, nor did I use naaTu maruntu [local remedies]. When I became pregnant and felt ill for four months I went to Kannikke Mata hospital [Catholic clinic]. I also had water retention. I had taTuppu uuci [preventive vaccinations for tetanus, vigorously pushed by local non-governmental organizations and primary health centres]. The birth was at Kannikka Matha hospital. It started at home, we waited for three hours before going to hospital. There I laboured for another nine hours. I had a cinna operation [little operation – an episiotomy], and there was much pain after that. For four days after that I did no work and my mother looked after me. I had Horlicks and some pills, but then started having naaTu marundu [indigenous medicines]. This consisted of ginger, pepper, dill, mint and garlic all ground with palm sugar and boiled up. This I had once a day on alternative days, and it makes the internal lesions and tears heal. On every other day, we have the same things, only without palm sugar. We have this for twelve days. This increases the milk and gives bodily strength. Some people add these ingredients to the curry, but in my family we do not.²

Medical pluralism is an empirical reality, as is the fact that it exists across classes. But in a class-based society, no phenomenon is accorded even value, nor do its meanings remain uniform. Class, and its characteristic modes of operation, its intrusions into seemingly neutral understandings and spaces, provides the connective tissue of this article. Class is explored, in particular, through the modality of the implicit, the taken-for-granted and the ready-to-hand. Such a modality exists in a form that eludes either a purely mentalistic understanding of consciousness or a biomedical definition of the body. I therefore utilize two interrelated concepts, that of habit and of the habitus. Both can be said to entail dimensions of bodily disposition and orientation.³ Habit foregrounds the constellation of bodily attachments assembled in an individual’s lifetime, whereas habitus deals with the transmission of dispositions over generations. The habitus also illuminates the spatial elements of class as a dwelling place. How do the operation of habit, comfort, pre-familiarity and the habitus alter the workings of a seemingly pluralist set of strategies? How do both habits and the habitus inform the biomedical clinical encounter, particularly when patients are from the labouring classes?

My ethnographic examples are diverse in location, taken as they are from different periods of fieldwork in rural Tamil Nadu since the 1980s. My longest and most sustained interaction in rural areas has been with the Mukkuvar fisher-people of Kanyakumari district, where I have retained connections since my doctoral fieldwork in the 1980s. This community, more than any other, informs my sense of the ‘flow’ between medical encounters and everyday practices. However, I have also included references to experiences from a later period of fieldwork in Chengalpattu district. By this time I had become expressly interested in the work done by non-governmental organizations (NGOs) and developmental agencies to reform and reconstitute rural subjectivity in specific areas such as maternity and infant health. In addition to interviewing NGO health workers and agricultural labouring women from Dalit communities, I also conducted interviews and observed the public hospital. For comparative purposes, I have included an observation of a doctor fitting intrauterine devices (IUDs) at the Voluntary Health Association in Chennai.

Class and the differential adjudication of pluralism

In 1977, Leslie argued that there is no hard-and-fast division between traditional and modern medicine. Instead, there is only a continuum of practitioners who have been substantially integrated through the practices of ‘laymen’. There was a good reason for Leslie’s insistence on the perspective of the lay practitioner. He hoped to soften, if not abolish, the invidious distinctions between the polarized and hierarchical categories of ‘indigenous’ and ‘cosmopolitan’:

The integration of indigenous and cosmopolitan medicine is even more obvious when one adopts the perspective of laymen, for throughout Indian society they utilize whatever forms of medical knowledge and practice are available to them. They are less concerned with whether therapy is indigenous or foreign, traditional or modern, than with how much it will cost, whether or not it will work, how long it will take, and whether the physician will treat them in a sympathetic manner. In these respects, laymen everywhere are pretty much alike.⁴

This view from ‘the ground’ was offered in implicit contrast with the prevailing ‘view from above’, the world view of intellectuals who take biomedical categories and state organized services as their starting point. Both elites and non-elite practices, Leslie insisted, share the practice of pluralism.

There is much of value in this paradigm. To show that Indian elites and subalterns share a pluralist orientation to medical practices is to undermine, in part, some of the effects of binary oppositions between the indigenous and the cosmopolitan, inherited by a postcolonial modernity.

But distinctions between cosmopolitanism and the indigenous do not lose their intellectual force through critique, for they were not created purely by intellectual means in the first place. The distinctions between tradition and modernity, and between the indigenous and the cosmopolitan, have been created by histories of colonialism, nationalism, gender and class. They are not so easily abolished, but re-emerge in the midst of pluralist practices and in reflections on these practices. Pluralism falls under relatively little challenge in the practices of elites, in part because elite orientations to ‘tradition’, and indeed to the past itself, do not give rise to immediate suspicions of ‘backwardness’. Quite the opposite. In diverse areas, ranging from ‘classical’ music and dance to favoured medical traditions such as Ayurveda, the ability to invoke ancient wisdom has been a constitutive feature in the very making of the middle class. Berger’s study of the formation of a specifically Hindu urban middle-class identity in Uttar Pradesh demonstrates the privileging of Ayurveda in the emergent public domain, in the first half of the twentieth century.⁵ Similarly, in a study of doctors and patients at various in vitro fertilization (IVF) clinics, Bharadwaj describes the unselfconscious way in which elites enjoy a ‘continuous relationship with the past’, a relationship which feeds into ‘daily conversations, acts and attitudes towards the rapidly changing surroundings’.⁶ In dealing with the incapacity of IVF technology to deliver certainty, doctors and patients from the educated middle classes in India invoke a wide range of religious understandings.

However, the ‘ability to have a continuous dialogue with its cultural past’ is not, as Bharadwaj would have it, a ‘unique’ attribute of ‘the contemporary Hindu worldview’.⁷ That ability is in a sense universally available – for all human existence enjoys an opening onto the past. But it is also more restricted than is imagined here. A rural woman such as Melanie also moves between biomedical facilities, home remedies and religious pilgrimages. On her visits to Ovari, to the shrine of the Virgin Mary, she may well have done more than just pray to the goddess. Catholic shrines also act as a meeting place for mediums who, possessed by the power of the saints and the Virgin, divine the cause of misfortune in their petitioners and offer divine help. The same pattern is to be found in Hindu and Muslim shrines. Yet in Melanie’s case, for a whole range of intellectuals – such as doctors, health workers, teachers, NGOs and social workers – there is no question of interpreting this as a ‘continuous dialogue’ between past and present. Instead, the mediums she consults are consigned to a past that stands over and dominates rural villagers, evidence of their intellectual incapacity to make sound distinctions between modern medicine and other superstitious treatments. Whether the authority is a parish priest, a bishop or ‘secular’ professionals, the consensus is the same: such mediums do not qualify as a repository of ancient wisdom, nor are they to be deemed authentic in their possession.

Judgements of this kind, once again, enjoy a force greater than intellectual judgements. They draw on the power to shape the public sphere and institutional authority. Since 2001, the congregation of mediums and the afflicted at popular shrines has come under a Supreme Court ruling. Following a fire and the deaths of several people at a Muslim dargah (shrine) in Tamil Nadu, the Supreme Court ordered all states to close shrines that were not covered by the Mental Health Act. State government vigilance officers were given legal authority to take custody of the mentally ill for medical treatment. According to a recent report, ‘a sizeable population needing psychiatric treatment was identified through diagnostic procedure and referred [to mental hospitals]. The Mental Health Act was enjoined to take suitable action against the dargah’.⁸

The pragmatic subject

The emphasis on pluralism in the literature is closely tied in with an emphasis on the practical nature of the subjectivity of the layperson. Given the pluralist nature of medical strategies, it is not surprising that we find the quality of pragmatism is frequently attributed to one agent or another in the literature on religion and on medicine. Mandelbaum, for instance, describes a ‘pragmatic’ complex in religion which is alive to practical efficacy:

A childless woman generally tries every conceivable supernatural resource in her anxious attempts to bear a child.⁹

By 1998, the figure of the pragmatic layman had given way to that of the ‘pragmatic woman’. But the two behaved very similarly, showing the same irreverence for formal boundaries in their pursuit of self-interested goals:

At the centre of many of the essays in this collection stands a pragmatic woman willing to use whatever biomedicine can provide in pursuit of her own goals or the protection of her independence.¹⁰

Pragmatism has allowed the agency of ordinary (‘lay’) subjects to emerge. Female agency, in particular, had been something of a casualty in an earlier feminist politics which conceived of women primarily as victims. For Lock and Kaufert, pragmatism allowed them to steer a course away from prevailing representations of women. No longer were women to be taken as inherently resistant to technological interventions or as passively shaped by cultural determination.¹¹

The problem with pragmatism lies, however, in the readiness with which it has come to be understood in terms of a very particular version of subjectivity. This is a subjectivity in which the lay subject has available, as if displayed in front of her, all the branches and varieties of medicine from which to choose. Informed by a strategic consciousness, and with perfect awareness, the lay subject proceeds to put together a package of curative possibilities. This version of pragmatism appeals to a certain common sense. The nononsense layperson ‘who is everywhere pretty much alike’¹² seems truly universal. What possible objection could one have?

We may turn to Gramsci for a diametrically opposed view. Gramsci, who devoted considerable energy to reflections on the ‘common sense’ that characterized the peasantry in his native rural southern Italy, concluded that ‘there is not just one common sense, for that too is a product of history and a part of the historical process’.¹³ Not only every epoch but every social stratum produces its own common sense.

Certain elements of ‘pragmatic man’ and ‘pragmatic woman’ seem self-evident precisely because they reflect the common sense of a dominant world order. Many of the characteristics of the pragmatic choosing and strategic subject of medical pluralism are in fact also the characteristics of the bourgeois subject of liberal pluralism and economic utilitarianism. The sufferer weighs up the options with impeccable utilitarian logic and, with goals clearly in sight, sets about pursuing them with a pragmatic zeal worthy of a neo-liberal subject. Villagers are turned into individual choosers, busy constructing ‘hierarchies of resort for curative practice...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Contents
• Abstracts
• Introduction: The social and cultural production of health in South Asia
• Section 1: Culture, power and lay medical interface
• Section 2: Public health and private illness
• Section 3: Traditional healing and local knowledge
• Index