Medical Marginality in South Asia

Situating Subaltern Therapeutics

David Hardiman, Projit Mukharji, David Hardiman, Projit Bihari Mukharji, Projit Mukharji, David Hardiman, Projit Bihari Mukharji

• Publisher: Routledge
• Year: 2013
• Print ISBN: 9780415502412
• eBook ISBN: 9781136284021
• Edition: 1
• Topic: Politics & International Relations
• Subtopic: Politics
• Index: Politics & International Relations

Examining the world of popular healing in South Asia, this book looks at the way that it is marginalised by the state and medical establishment while at the same time being very important in the everyday lives of the poor. It describes and analyses a world of 'subaltern therapeutics' that both interacts with and resists state-sanctioned and elite forms of medical practice. The relationship is seen as both a historical as well as ongoing one.

Focusing on those who exist and practice in the shadow of statist medicine, the book discusses the many ways in which they try to heal a range of maladies, and how they experience their marginality. The contributors also provide a history of such therapeutics, in the process challenging the widespread belief that such 'traditional' therapeutics are relatively static and unchanging. In focusing on these problems of transition, they open up one of the central concerns of subaltern historiography. This is an important contribution to the history of medicine and society, and subaltern and South Asian studies.

1
AGENDAS

Guy Attewell, David Hardiman, Helen Lambert and Projit Bihari Mukharji

The present project began in 2008, when the four of us began meeting together to discuss ways in which we could understand and frame our respective research and writing on non-elite forms of medical and therapeutic practice in South Asia. This led to two workshops, the first in the Centre for the History of Medicine at Warwick University in June 2009, and the second at the Centre for the Study of Developing Societies in Delhi in February 2010. We found that most existing studies in the field of South Asian medical history and the sociology of medicine focused either on biomedicine or the systems that now go under the acronym AYUSH (Ayurveda, Yoga and Naturopathy, Unani, Siddha, Homoeopathy). Beyond this, there were many studies by ethnologists and medical anthropologists of popular therapeutics. Few attempts had been made, we felt, to integrate the latter within the wider field of study, or to grapple with the issue of how such therapeutics had evolved and changed over time.

Ayurveda, Unani Tibb and Siddha are often described as the ‘classical’ systems that were practised in India before the period of British rule. As it was, their gentlemanly practitioners – the vaids and hakims – served only a relatively small elite at that time. The British brought to India the self-styled ‘scientific’ form of medical practice that is known there, variously, as allopathy, ‘Western’ or ‘English’ medicine, or biomedicine. This imported medical system likewise provided health care for only a small minority. Even after the demise of colonial rule and up to today, it is still largely inaccessible for large numbers of people, either on grounds of cost, or lack of facilities, or because of deliberate exclusion. Similarly, Ayurveda, Unani Tibb and Siddha – in their more erudite, textually grounded forms – have been, and still are, largely inaccessible for the mass of the people. This situation has allowed for a range of healing practices to flourish alongside each other. There are unqualified or socalled ‘quack’ healers who mix biomedical and popular remedies together eclectically, local bonesetters and masseurs, village midwives, itinerant peddlers of cures, travelling mendicants, priests at healing shrines, faith healers, diviners, exorcists and herbalists. Many cures are carried out within the home, using charms, rituals and plant-based remedies.

Various formulations have been used to try to distinguish elite medical practice from popular practice, none of which we find satisfactory, for the reasons stated. These are:

• The medicine of recognised physicians as against ‘folk medicine’. This approach is found in much of the ethnographic reporting of popular practice in the late nineteenth and early twentieth centuries. It is assumed that such practice is merely a quaint survival from the past, and that it will wither away as biomedicine advances. This has not, however, proved to be the case at all. Such therapeutics have continued to enjoy a dynamic and ever-evolving presence in South Asia, and we need to grapple with the reasons for this.
• Practice that is rooted in texts, as against non-literate practice. The problem here is that popular practice is often informed by textual knowledge of one sort or another.
• ‘Modern’, as against ‘traditional’ medicine. The assumption here is that the ‘traditional’ gradually gives way in time to the ‘modern’ – as has to a large extent been the case in Western societies. The ‘modern’ is equated with science and rationality, as against the ‘superstition’ of the traditional. This rests on an evolutionary model of medical development, e.g. the idea that medical practice develops over time from the ‘primitive’ to the ‘modern’. It is a view propagated by liberal modernisers, rationalists, orthodox Marxists and many others. Such people typically engage in crusades to eradicate what are seen as popular superstitions and irrationalities. The problem here is that only biomedicine is considered truly ‘modern’ and ‘scientific’, even though, as medical history has revealed very clearly, there is much in it that is rooted in religious and other such cultural understandings of disease and its cure, while practices that may seem to be ‘traditional’ may in fact be quite effective. In the late twentieth century there was a ‘revival’ in several supposedly ‘traditional’ medicines. In South Asia, these are found largely in the AYUSH category. As it is, these ‘traditional’ systems tend to be very ‘modern’ in many aspects of their practice, so that the lines between what is ‘modern’ and what is ‘traditional’ become blurred. Similarly, subaltern therapeutics have for the most part also evolved to suit contemporary conditions, so that it is very different from what it might have been in the past. In this respect, the distinction between ‘tradition’ and ‘modernity’ does not prove to be a useful one.
• Hegemonic systems of medicine as against non-hegemonic forms of healing. In modern times, only biomedicine is really hegemonic in such a way – that is, it projects itself as being scientific, progressive and modern, and it enjoys strong state backing almost everywhere. In this sense, all other systems are non-hegemonic. The problem here is that beyond the West, there are alternative systems that claim a civilisational hegemony.
• The ‘great’ and ‘little’ traditions. This allows us to differentiate between systems of healing that project themselves as global or civilisational – whether these are the biomedicine of Western civilisation, or the ‘classical’ systems of healing found in the old civilisations, such as Ayurveda, Unani Tibb and Chinese traditional medicine – and popular forms of local eclectic practice. A difference is thus posed between the systems that span large territories, and the practice that is rooted in particular localities that lack any claim to have a wider applicability. This approach fails, however, to bring out the way that non-Western practices exist in a state of inferiority to Western ‘scientific’ medicine. We need better tools for understanding the way that such hierarchies operate. Another objection is that popular forms of healing often share features that are global. For example, healing through exorcism or divination may in some senses be local and particular, but practices such as these are found in many societies all over the world.

The system as a whole has also been characterised as one of ‘medical pluralism’. While social scientists and historians often use this term to include all forms of practice and therapy found in a given setting, policymakers in India have generally deployed it more narrowly to refer to the presence of certain categories of non-allopathic medicine (‘AYUSH’) within the formal health care sector. These types of medicine have been legitimated and incorporated through conformity to certain regulations and accreditation requirements imposed by the state at central and provincial levels. However used, the term, in our view, has only limited value, since it effaces stratifications across and within therapeutic domains, asymmetries in the kinds of treatments and resources available in different localities, as well as different modes of governance in the name of health. It also, in the governmental use of the term, tends to exclude the non-regulated sector.

Here, we are proposing a different approach to the issue that focuses far more centrally on the relationships of power that run though the whole field of medicine and therapeutics and its governance. We distinguish between practice that is sanctioned and regulated by the state – whether it is biomedicine or the AYUSH cluster – and that which is not. The latter we define as the realm of subaltern therapeutics. In addition to this realm, we also consider the subaltern encounter with and experience of statist medicine (whether biomedicine or AYUSH) as integral to the examination of medical subalternity and some of our case studies are concerned with this dimension. The two domains are, of course, intimately interconnected since experiences of economic or social exclusion from state-sanctioned medical institutions and discrimination at the hands of elite practitioners are frequently associated with continuing preferment of unregulated or non-legitimated forms of therapy.

Some of the major forms of subaltern therapy that interest us are as follows (often one category may shade into another in practice, and the list is not exhaustive):

• Popular practice by vaids, hakims, kabirajs, Siddha-style healers, which incorporate an eclectic bricolage of methods, with a focus on ‘traditional’ medications and dietary and lifestyle advice, but which may include the use of charms and rituals. They may practice from homes, from shops, on street corners, at weekly markets, or on an itinerant basis, and often evade state rules and regulations. They are subversive in this respect, being seen by the state and mainstream practitioners as endangering the reputation of medicine and the medical profession in general.
• Popular allopathy or biomedicine, as practised frequently by unqualified or semi-qualified healers, who apply broadly ‘Western’ medical techniques such as the intravenous injection of analgesics and antibiotics or the provision of glucose drips. Such people may have some initial training or experience as a compounder or other form of assistant in a biomedical practice, and may have gained the government-recognised status of Registered Medical Practitioner. Although they might be considered respectable ‘doctors’ in the places where they practice, they are considered by MBBS doctors and government officials to be ‘quacks’. In this, they are implicitly subversive of the medical profession. Whether or not they provide a useful medical service is a matter for critical examination. Often, by their very presence, they expose the glaring failure of ‘legitimate’ biomedicine for the mass of people.
• Bonesetting and massage by specialists who practise from shops in the bazaar, providing treatment at a low cost as compared with biomedical orthopaedic specialists and physiotherapists. They are often known as haad-vaids, or ‘bone-doctors’. Often, wrestlers (pahalvans) are associated with such work.
• Healers of sexual weaknesses who often peddle their potions from street stalls using imaginative and dramatic selling techniques. In some cases, they publish cheap manuals that they sell with their remedies.
• Healing by itinerant sadhus and other religious mendicants. They provide mantras, or charms, as well as herbal remedies.
• Healing shrines, with priests (male or female) providing divination and exorcism. Found often at shrines of Sufi pirs. These are particularly popular in cases of what biomedicine would define as mental illness.
• Healing performances, that were performed both for the general well-being of the community as a whole, as well as for particular afflicted individuals. They are applied, for example, in epidemics – and there is a good ethnographic archive on such ‘driving away’ rituals from the late nineteenth century onwards.
• Healers who employ a diverse mix of divination, exorcism and herbal and animal-based remedies. They are known as buva, bhopa, bhagats, ojhas, etc., in different parts of India. Such healers learn their craft as a form of devotion to their deities, and they consider this a form of healing that stands apart from, and sometimes counter to, biomedicine. They may specialise in particular maladies, such as snake-bite, and have a reputation in this respect over an extended area.
• Faith healing by Christian denominations, such as the Pentecostalists. These have become increasingly popular in recent years, leading in some cases to a backlash by Hindu fanatics.
• Dais, or midwives – who provide treatment mainly for women, particularly pregnant women, and children. They are the ‘wise women’ who may at times be accused of exerting malign power, e.g. witchcraft.
• Itinerant practitioners, often of low caste or Muslim. There were the jaraha who practised surgery; dentists; inoculators providing variolation against smallpox, incorporating rituals that appease the goddess of smallpox, Sitala; branders, using cauterisation as a therapy; lithotomists who cut out stones; oculists who perform cataract operations; and veterinary practitioners. Such trades in many cases declined or vanished as categories during the twentieth century. Perhaps the only people of this sort found today are itinerant dentists, who can be seen practising on the street and in markets.

Our project, and its relationship to Subaltern Studies, will be explored further in the introductory chapter that follows. This will set out some of the findings that have come out of the endeavour so far. We would like to stress that this is – like Subaltern Studies itself – an open-ended project designed to open up discussion and debate, and that even within our editorial group we have not always reached a consensus on issues. In other words, we view this as an orientation for a working group, and the particular findings of each member should not be taken as necessarily representing the position of all in the group.

Our focus is on those who exist and practise in the shadow of statist medicine, examining how they operate and how they experience being in this position. Our aim is to provide a means to understand how subaltern practice has evolved and changed over time, and how it has related in ever-changing ways to other forms of medicine and healing. We find that there is considerable fluidity in this, so that a type of practice may be elite in one context, subaltern in another, and it is left up to each contributor to determine how this works out in practice.

2
INTRODUCTION

David Hardiman and Projit Bihari Mukharji

In 1812–13, Francis Buchanan carried out a survey of the two districts of Patna and Shahabad in Bihar. In his subsequent report, he described the many sorts of physicians, therapists and healers that practiced in this area:

Medicine (Baidya-sastra) is taught by several of the Pandits, some of whom also, although they are grammarians, practice the art. The books on medicine chiefly studied in these districts, are the Saranggadhar, Babhat and Chakradatta. Saranggadhar was the son of Damodar, a Brahman; but when or where he lived I cannot learn. Babhat and Chakradatta are also the names of the authors, but the people know nothing of their history. Among the Muhammedans, the practitioners of medicine, who study Arabic, are usually called Yurani, as the science of medicine was introduced among the Arabs by bad translations of the Greek authors, which are still much studied. A small part only of the practitioners understand Arabic, and the greater part of them content themselves with translations of Arabian authors into the Persian language, and many, I suspect, understand very little of even these. They are in general educated as private pupils, attaching themselves to some practitioner; but Moulavi Mosafer, who was formerly Mofti of the court of appeal, teaches medicine to several pupils, although he professes all other branches of Arabic science, and is not a practical physician …

Besides the professors of medicine, about 700 families of Brahmans, almost all of Sakadwip, practice that art, and are the only Hindu physicians who possess any thing like science… . [There are many] who practise medicine without some sort of learning, and without books. In the whole of the two districts there may be of such 30 or 40 families, mostly in the town of Patna, where they are called Atai-Baidyas, or pretended doctors. There are about 150 Jurrahs, or surgeon-barbers, who cup, bleed, and treat sores. The midwives are of the lowest tribes, and merely cut the umbilical chord. The low people, called Ajha, who cast out devils, cure the bites of serpents, and oppose witchcraft by incantation, are not so numerous in proportion to the population as towards the east; but still there are a vast number, and in general each confines himself to one branch of the profession. About 2,500 pretend to cure the bites of serpents, and 2,300 pretend to oppose the devil and witches. Some of these pretend that they themselves are occasionally possessed, having taken to themselves the devils that they have cast out from their patients. The Bhakats, being holy, are unfit habitations for the devils, who therefore soon afterwards go somewhere else in search of better accommodation. The Ajhas do not attempt to cure any disease except such as are attributed to devils and witches… .

Inoculation for the small-pox is here carried on by a class of people called Gotpachcha, or Pachaniya, who are not included among the Ojhas, although they in no respect differ in their practice from those of the districts hitherto surveyed. They are mostly of the Mali tribe, or of some other low caste, although to Europeans they often assume the title of Brahmans. I have heard that some Europeans have been silly enough to employ them to repeat their spells, even when an European surgeon had performed the operation. Not above 15 or 16 families reside in these districts, and those employed come chiefly from Tirahut.¹

While we may question the accuracy of Buchanan’s figures, his report revealed the great diversity of therapeutic practices that existed in Bihar at that time. It also brings out the way that he accorded a certain scientific legitimacy to the practice of some elite ‘Hindus’ and ‘Muhammedans’ whose learning was based on textual knowledge, while at the same time writing off the large residue of subaltern therapists as ‘pretended’ rather than authentic in their abilities. Implicit in this account is a tripartite schema: that of (1) Western biomedicine as the truly ‘scientific’ practice, (2) an intermediary category of indigenous medicine that had a certain textual base and theory – albeit outdated and outmoded – and (3) the remaining residue of folk therapy that was eclectic, unsystematised and rooted in false knowledge and superstition.

This tripartite division has informed much of both research and policy on South Asian medicine since that time. Contemporary South Asia is as a result unique in having a plural but hierarchic medical establishment. Predictably, at the top of this hierarchy is the globalised form of biomedicine. But next to it is a layer of legitimate and state-backed medical practice which is distinctive in modern South Asia. This layer is composed of what since 2003 has been known by the acronym AYUSH (Ayurveda, Yoga, Unani, Siddha, Homoeopathy, Naturopath...

Table of contents

• Cover
• Title
• Copyright
• CONTENTS
• List of illustrations
• Notes on contributors
• A note on dates
• 1 Agendas
• 2 Introduction
• 3 Community, state and the body: epidemics and popular culture in colonial India
• 4 ‘Pain in all the wrong places’: the experience of biomedicine among the Ongee of Little Andaman Island
• 5 Chandshir Chikitsha: a nomadology of subaltern medicine
• 6 Wrestling with tradition: towards a subaltern therapeutics of bonesetting and vessel treatment in north India
• 7 A subaltern Christianity: faith healing in southern Gujarat
• 8 The modernising bhagat
• 9 The politics of poison: healing, empowerment and subversion in nineteenth-century India
• Select bibliography
• Index