Socialist Health Review 1985 Vol. 2, No. 3, Dec.: System of Medicine
Item
- Title
- Socialist Health Review 1985 Vol. 2, No. 3, Dec.: System of Medicine
- Date
- December 1985
- Description
-
Dialectical approach to traditional medicine
Indigenous healers in independent India
Traditional and modern medical systems
Organising doctors - extracted text
-
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DIALECTICAL APPROACH TO TRADITIOflAL
(TiEDICIAE
-ia
IADIGEAOUS HEALERS If) IflDEPEADEAT
TRADITIOflAL
IflDIA
& fflODERfl MEDICAL SVSTEfDS
ORGAAISIAG
DOCTORS
Yol II
Number 3
SYSTEMS OF MEDICINE
1O1
Editorial Perspective
WHITHER OTHER SYSTEMS OF MEDICINE?
Srilatha Batliwala
105
A DIALECTICAL APPROACH TO TRADITIONAL
MEDICINE
Dhruv Mankad
Working Editors :
Amar Jesani, Manisha Gupte,
Padma Prakash, Ravi Duggal
Editorial Collective :
Ramana Dhara, Vimal Balasubrahmanyan (A P),
Imrana
Quadeer, Sathyamala C (Delhi),
Dhruv Mankad (Karnataka), Binayak Sen,
Mira
Sadgopal
(M P),
Anant
Phadke,
Anjum Rajabali, Bharat Patankar, Jean D'Cunha,
Srilatha Batliwala (Maharashtra) Amar Singh
Azad (Punjab), Smarajit Jana and Sujit Das
(West Bengal)
1 16
POLICIES TOWARDS INDIGENOUS
IN INDEPENDENT INDIA
Roger Jeffery
SYSTEMS OF MEDICINE
Sujit K. Das and Smarajit Jana
132
A SEARCH FOR ALTERNATIVE
Ravindra R.P.
135
Editorial Correspondence :
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Health Review,
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POLITICAL-ECONOMIC STRUCTURES :
APPROACHES TO TRADITIONAL AND
MODERN MEDICAL SYSTEMS
Catherine A. McDonald
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ORGANISING DOCTORS TOWARDS WHAT END
Anant Phadke
Dialogue : 1 51
The views expressed in the signed articles do
not necessarily reflect the views of the editors.
^^litorial' Perspective
WHITHER OTHER SYSTEMS OF MEDICINE ?
^^ndiaa,
like
other ancient
civilisations
of
the
worrld, had several highly evolved and sophis
ticated systems of medicine long before the
advernt of the so-called modern or allopathic system.
Histcorical forces, such as the Greek and Muslim
migration into the subcontinent, brought with them
yet other systems which flourished and grew, with a
mutually beneficial cross-fertilisation of ideas and
techniques. Alongside these 'formal' systems of
Avyurveda. Unani and Siddha (formal in that they
h;ad written treatises and established universities for
beaching and training), was the rich, varied and
Location-specific lore of folk medicine and folk
psychiatry, based on local plants, herbs and belief
systems. Tribal medicine, and the home remedies of
' Ajji cha batva' (grandmother's purse) fall into this
category. Another vital source of indigenous health
care were the traditional midwives or 'dais', who
not only performed the important function of
birthing, but also abortions, in addition to advice
and aids for contraception.
There is considerable controversy regarding
the role of these systems and their practitioners
in history, and indeed about the impact of the
arrival of western medicine on them. Some scho
lars argue that the latter was primarily responsible
for the atrophy and decline of traditional medical
systems, even stating that the British sought to
systematically destroy them on the grounds that
they lacked 'scientific' bases and were filled with
superstitioi'.s nonsense and positively harmful reme
dies. Others feel that this is too simplistic a view,
and that some of these systems were in decline
long before western medicine arrived on the scene.
This indicates the need for critical research
into the social history of the pre allopathic systems
of medicine. We need to understand their inter
action within the socio-political context of different
historical periods. What, for instance, was their
ideological framework, and how did this reflect
contemporary socio-economic and political struc
tures ? The question of 'scientificity' is also often
raised But it can be established that even preallopathic systems were scientific, if the term
means posing questions, seeking their answers
through methodical study (using the means available
at the time) and accepting a thing as true only
December 1985
if the same result is repeatedly derived. But this
spirit of enquiry and experimentation seems to
have gradually declined. Why this happened,
whether it was the lack of concurrent technological
development to facilitate it, or due to socio-cultural,
economic and political forces, is what must be
determined.
In this context, it is worth considering exactly
how one measures the role of a given medical
system, and how one assesses whether it has
declined, remained or grown. One must address
this question at two levels : first, at the level of
theory. What is the extent and nature of growth
of the theoretical base, both in depth and breadth,
over a period of time? Second, at the level of
practice, are the practitioners of a system growing
in number, and hence the number of recipients of
that type of care?
Evidence shows that upto Independence, the
availability of allopathictreatment was largely limited
to the cities and towns, and that too mainly to
the higher socio-economic groups. If this was the
case, then certainly the practice of other systems
was not seriously affected since the majority of
people, especially the poor, continued to rely upon
them. But at the level of theory, the 'formal'
systems at least seem to have suffered from stasis and
decline, and perhaps because of the following two
reasons : one, state patronage by Indian monarchs,
which had provided the chief source of support for
theoreticians and researchers, was not forthcoming
from the British.
Two, the growing intellectual
domination of western science and thought,
especially among the Indian elite, reduced the
legitimacy and credibility of nonallopathic systems.
This situation did not change drastically even
after Independence. The commitment of the post
Independence leadership to 'modernising' India, to
promote (Western) science and technology in the
country, and to provide 'modern' health services
to all, ensured that state patronage would con
tinue to be given to allopathy, whose practitioners
had by then become a powerful lobby alongwith
the pharmaceutical industry. Only the residue of
the Swadeshi movement, and those leaders (like
Gandhi) who were fervent advocates of indigenisation, ensured the allocation of some limited
TOT
resources for the development and strengthening
of other systems of medicine.
Notwithstanding this, the status of traditional
systems is fraught with confusion and subject to
periodic swings. The major trends, however, seem
to be the following:
The 'synthesis' school of thought which argues
that the best of each system—including allopathyshould be studied and combined to create a
'National System ot Medicine' (this manifests the
heavy influence of the Chinese model). The
'purists' feel that this is both impossible and fatal
to the future of traditional medicine. Fatal because
it would result in the irrevocable decay of the nonallopathic systems, since allopathy would dominate
both theory and practice; and impossible because
the conceptual frameworks of the different systems
are inherently incompatible, and thus they cannot be
studied or evaluated using an alien methodology.
Each system must be left severely alone to go in
its own direction. Still others argue that the whole
question of 'system' is irrelevant; what is needed is
a safe, effective and affordable range of thera
peutics for use in mass health care. If traditional
medical systems have useful remedies which fit the
bill, then they should be utilised without recourse
to philosophical arguments. Finally, the 'modernists'
within traditional medicine feel that the only way to
restore their legitimacy is to apply the techniques
of modern science to research and standardise
these therapies and remove the cloak of mysticism
from about them.
These differing and sometimes warring schools
are scrabbling for a slice of an already minute cake.
The last four decades have witnessed the growth of
a plethora of indigenous medical schools, professi
onal bodies, and research centres.
At the same time, these indigenous institutions,
their teachers, students, researchers and admini
strators, generally suffer from an inferiority complex
vis-a-vis their allopathic brethren. A 'keeping up
with the Joneses' syndrome thus develops, based on
the rationale that by acquiring the characteristics of
allopathy, the indigenous systems will
regain
recognition. One example of this is the widespread
use of allopathic drugs by indigenous practitioners,
made possible by the relatively easy availability and
rapid action of these drugs. Non-allopathic practi
tioners argue that with the spread of and exposure
to allopathy, people have become impatient with
the slower-acting indigenous therapies which, if
102
properly prescribed and taken, demand more from
the patient (like dietary and life-style changes) than
allopathic treatments. This is also an interesting
comment on the marketing strategies and ethics of
the allopathic pharmaceutical industry. Another sign
is the 'me too’ phenomenon in the growing indi
genous drug industry, which is developing, produc
ing and marketing non-allopathic drugs and phar
maceuticals at a rapid rate—particularly vitamins,
tonics and restoratives.
Therefore, while the indigenous
medicine
infrastructure is larger and stronger than it was at
independence, it suffers from the same diseases
which afflict modern medicine in India—commer
cialisation, mystification, professionalisation, rising
costs and curative bias. The only difference, perhaps,
is that its controlling elite is more fragmented and
less cohesive in its functioning and goals.
What, then, is the role of the various indigen
ous system in a people's health system? Should
they all be clubbed together or does each one have
a distinct and separate role ? And what of Homeo
pathy, another imported system which has taken
firm root in India and provides an important
alternative especially in urban areas? Obviously,
all these questions must be researched and cannot
be fully answered at this point, but we can review
existing information to throw some light on them.
For instance, it is useful to look at the ways in
which people actually utilise these different systems
(where they are available) at grassroots level, to
see if these use-patterns provide some clues. A
few studies of this type were undertaken in the
'fifties and the 'sixties in Punjab, UP and Karnataka.
Interestingly, most of them found one common
thread : people's use of alternative health care
sources was highly rational. By and large, allopathy
was used for acute conditions and for those dis
eases where it offered known cures—such as TB,
malaria, and infectious diseases. Ayurvedic, Unani
and herbal treatments were sought for chronic
ailments like skin diseases where these systems
offer far more effective therapies than allopathy.
And home remedies or folk cures were resorted to
for simple self-limiting complaints like colds, coughs,
diarrhoeas and fevers. Of course several factors
like cost, distance, attitude and behaviour of the
providers influenced (perhaps more strongly than
cure-effect alone) the choices people made. But
essentially, the strengths, weaknesses and relative
benefits of each system seem to be perceived quite
clearly by people.
Socialist Health Review
Unfortunately, there is a growing
feeling
(though little documented evidence) that this
situation has undergone considerable change in the
past decade or two. One of the main reasons is
the greater penetration of allopathy into rural
areas as a result of the overproduction of MBBS
doctors who find private practice unlucrative in
the saturated city market and opt for rural areas as
comparatively profitable. This phenomenon has re
sulted not only in increased availability of allopathy
in the rural private sector, but also an exposure
to its rapid fire remedies. Thus more and more
people have been 'hooked' onto treatments which
are either wrongful applications or overuse of
valuable, even life-saving interventions. The prime
examples are the preference for injections over
oral medication and the demand for overnight cures
which bring their own costs through widespread
drug-resistance and toxic side effects.
What then are the tasks ahead of us if we
wish to rid indigenous and other systems of me
dicine of their present ills and make them part of
a radical people-based heaith care system ?
First and foremost, it is clear that no changes
within these systems nor in their role in health
care can occur without corresponding changes
in the role and nature of allopathy. The battle on
both these fronts must be based on similar stra
tegies : major structural changes in the socio-eco
nomic-political system which controls and shapes
(or distorts) all of medicine and health care.
Within the health care sector, the following
steps would then perhaps bring us closer to the
goal : first, demystification and popularization of
all medical knowledge, regardless of system. This
may in fact be easier with traditional medicine,
whose, basic concepts are closer to people's
beliefs and health culture than those of modern
medicine. Second, the trend of professionalisation
must be reversed. Since a significant part of
indigenous therapeutics is based on herbs and
dietetics, they lend themselves to decentralised
cultivation, production and distribution. Axiomatically, the commercialisation of traditional drugs
and pharmaceuticals, particularly for producting
useless vitamins and tonics, must be stopped.
This should only be permitted where the economy
of scale and geo-climatic limitations favour cen
tralised production, and that too for really useful
remedies which are needed for mass health care.
This will keep indigenous medicines within people's
reach, and discourage the growing consumerism
December 1985
which is being cultivated by vested interests in
order to market
phony, expensively-packaged
medicaments. Finally, a massive re-education of
the people is necessary to wean them from
dependence on the rapid-fire cures which unsc
rupulous practitioners (especially of allopathy) have
used to win their faith.
Finally, there is one more important issue
which must be examined with reference to indi
genous systems of medicine : the question of gender
bias. Sexism in indigenous systems isa completely
uncharted area which demands exploration. Much
has been written about the gender-biases in the
theory and practice of modern medicine, but how
do other systems view women? This question
must be studied at three levels: 1) Is there a
gender bias in the conceptualisation of women's
health and disease in other systems? 2) Is there
a sex-distinction in their therapeutics and in the
delivery of care to women? and 3) Is there
discrimination against or decimation of women
practitioners of indigenous systems, including folk
and tribal medicine? And if so, are pressures
arising from within the system, or from the spread
and influence of allopathy?
There is an urgent need to study these ques
tions and, if necessary, sensitise non-allopathic
systems to the special health problems and needs
of women. This is all the more crucial since
traditionally, popular
medical
knowledge and
wisdom was largely the preserve of women, but
this rich resource is being eroded and lost. Organ
ised medicine systematically discredits it, without
offering an adequate substitute. Thus women are
losing their traditional source of self-care (especially
poor women), but with nothing to replace it but a
growing dependence on a health system which
throws them its crumbs.
In this issue, we present articles which focus
on the debates and controversies about traditional
medicine, its role and relevance. Dhruv Mankad
attempts a dialectical analysis, using the Chinese
experience as an illustration. Sujit Das and Smarajit
Jana's analysis presents a contrasting view. Ravi
Pathak describes the grass-roots practitioners'
perspectives. We have also reproduced two articles
from Social Science and Medicine, Roger Jeffrey's
which gives an historical account of the policies
towards indigenous healers, and Catherine Mac
Donalds' which examines the political economy of
traditional systems. In addition, we present Anant
Phadke's article which looks at the role of doctor’s
103
organisations in the context of their recent struggles
(this article was held over from the previous issue).
We hope these articles will stimulate
further
discussion and research.
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Socialist Health Review
104
A DIALECTICAL APPROACH TO TRADITIONAL MEDICINE
A Lesson from the Chinese Experience
dhruv mankad
The main protagonists in the debate on traditional medicine are the ‘traditionalists' and the 'modernists'.
The former argue that traditional medicine was suppressed by the colonising powers and should now be
revived: the latter feel that traditional systems are inherently inferior to modern medicine which is more
'scientific' and therefore the best choice for the future. But both views, the author contends, are rooted in conttradictory philosophical standpoints, and attempts to find a dialectical approach, using the history and
development of Chinese medicine as an illustration. The discussion is in three parts: the first critiques both
standpoints and contains a general discussion of the dialectical approach: the second and third parts attempt
to illustrate the concrete application of this approach in Chinese medicine.
xtensive debates, often eluding any resolution,
have been going on especially in the erstwhile
colonies, regarding the exact status of traditional
medicine as a science. On the one hand it is argued
by the 'traditionalists’ that traditional medicine has
been suppressed by their respective colonisers and
this has led to its decline. It should be extended
institutional as well as financial support and
developed further. On the other hand, the 'modern
ists' argue that modern medical science has made
tremendous strides in knowledge regarding the
human body, its diseases and their treatment. Thus,
they consider it naturally superior to traditional
medicine. The former reject modern medicine as
being culturally alien and hold traditional medicine
as having exclusively developed within the culture
and thus the only appropriate system of medicine
(cultural relativism). The former favour development
of modern medicine only, as being the only scientific
medicine devoid of any cultural and ideological
factors (neutralism). Both views are rooted in two
contradictory philosophical standpoints.
In this paper, we shall endeavour to identify
the two standpoints, analyse them in the light of
the nature of scientific knowledge and find a
dialectical approach to this problematic; using
Chinese medicine as an illustration.
The paper is divided into three parts. Part I
deals with general questions on the nature of
scientific knowledge and analyses the two stand
points mentioned above and contains a general
discussion on a dialectical approach to this pro
blematic. Part II and III deal with the concrete
application of such an approach as seen in the
development of Chinese medicine. Part II deals
with the historical background and philosophical
basis of medical science in People's Republic of
December 1985
China and socio-economic and political determin
ants informing upon its development, while Part
III deals with the current implication of the policy
of combining western and traditional medicine in
the People's Republic of China.
I. Nature of Scientific Knowledge
Like any other science, medical knowledge too,
has not developed in a unilinear, orderly, from a
lower to a higher level-evolutionary fashion, but
its history reveals a zig-zag path of development
interspersed by many breaks and jumps. In other
words, science, instead of developing from a
primitive level to its modern state by a careful,
logical, screening of available 'objective' facts and
later rejection of those not found to be true, has,
having proceeded in one direction, taken an
entirely different path later. No direct, internally
consistent logical
connections may be found
between these paths. The essential aspect of these
breaks and turnabouts has been the transformation
of world-views, the sudden shifts in the attitude
towards nature and the man-nature relationship.
That is to say, these breaks are essentially philoso
phical in nature.
These breaks were the consequence of a
struggle between different, often contradictory
schools of philosophy. In this struggle, the school
which fulfilled the ideological needs of the ruling
class dominated the rest.
Now, if science is defined as a rational body of
knowledge gathered by human beings during the
social production of their material (and non-material)
conditions of existence, then science (not with a
capital S—the modern bourgeois science having an
absolutised abstracted existence in the capitalist
society) has been with human society since its very
105
inception. So has been medical science. An out
growth of animism, wherein all diseases were seen
as a result of inflictions of evil spirits, it was one of
the earliest sciences. Human being's intercourse
with nature produced on the one hand empirically
verifiable facts having an objective existence, and
a universal truth value. It also produced various
concepts, thought categories and logic specific to
natural science with which
these facts were
organised and various levels of generalisations
were achieved. These specific thoughts, categories
and logic are influenced by thought categories and
logic of thinking process in general. That is to say
that they are rooted in philosophy. In fact, for a
long time science was indeed a part of philosophy.
Now, at different points in history, both in time
and space, this non-cognitive component is influ
enced by different cultural and ideological factors
and is thus shaped differently. This may even
result in establishment of different "facts” in different
cultures. (Here one is disregarding the question of
validity and truthfulness of these 'facts'). Thus, for
example 'geomancy' the Chinese science of wind
and water which determines placement of house
and tomb with respect to features of landscape and
aesthetics of land use, has no counterpart at all in
western science (Elzinga and Jamison, 1981).
The development of both the facts—the content and
the concepts, thought categories and logic with
which they are organised—the form—takes place in
an interpenetrating, dialectical fashion, each deriv
ing support from the other. Many a times the develop
ment of facts comes into sharp conflict with the
concepts leading to either transformation of the
concepts themselves or to distortions of facts by
ideological rationalization of the conceptual form.
What happened to Ayurveda in India during the
Medieval period was the latter. The anatomical,
pathological and pharmacological insights gained
by generations of experimenting physicians were
distorted by the use of concepts like Karma
Siddhanta, divine will, and transmigra’ion of souls
etc. On the other hand, the .• cientific revolution of
the 17th century Europe was an example of tie
former when entirely new forms of logic was
developed by Comte, Descartes, Bacon, Newton
and other philosopher scientists.
While the ideological rationalization of Ayur
veda suited the purpose of the Brahmin-dominated,
varna-jati based feudalism in a decadent state, the
scientific revolution in Europe was in response to
the growing strength of the European commercial
and industrial bourgeoisie.
106
Thus the factual component and the concep
tual component of scientific knowledge exist in a
dialectial relationship, under constant tension and
under the influence of ideological and other factors
operative in the culture and the historical period of
its orgin.
This view is debated from
positivist and cultural-relativist.
two standpoints,
Positivist Standpoint
The basic tenet in positivist philosophy is that
the scientificity of a proposition lies in its anch
orage in empirical statement of facts. Therefore,
the central part of a positivist programme is to
build a theoretical structure which is understood
in term of its interlinking with empirical state
ments. It does not allow for any hypothesis which
cannot be or has not been verified empirically
and objectively. This absolutisation of empiricity
and objectivity results in a narrow delimitation
of what can be called a Science. In particular,
theories operative in premodern knowledge pro
ducing practices such as alchemy or Ayurveda
that does not match upto some piece of modern
science, fails outside its realm. They are not even
considered as hypotheses yet to be verified.
Francis Bacon advocated a ruthless rejection of
old 'idois' inherent in all the preceding knowledge
systems but his methodology reinforced all of
them by absolutising the objectivity of scientific
knowledge. The attitude of positivism towards all
the other knowledge-producing practices can be
summed up, in his own words :
"It is idle to expect any great advancement
in science from the superinducing and engrafting
of new things upon old. We must begin from
the very foundations, unless we would revolve
forever in a circle with mean and contemptible
progress" (Bacon, 1620).
This fetishism of facts has had the obvious
consequence of converting science into scienticism
with the metaphysical principles of objective con
sciousness basing itself in an alienating dichotomy
of observing subject and observed object, the
invidious hierarchy of nature which places man
at the top and legitimises an experimental inqui
sition of nature, ........... the mechanistic imperative
that says that everything that can be known should
be known and that such knowledge should be
utilised regardless of consequences (e.g. genetic
engineering unnecessary and unethical human
Socialist Health Review
experiments -DM), the extension of instrumental
domination of nature to man himself" (e.g. excessive
reliance on medical technology in health care)
(Elzinga and Jamison, 1981).
Such a perspective when applied in medicine
means that those traditional
medical sciences
which have not adopted the positivist principles of
objectivity are considered unscientific. The the
oretical concepts and prescribed therapies of these
sciences not having been tested under the modern,
laboratory -'Controlled'—conditions are rejected as
invalid. Concepts like
acupuncture
points or
tridosha in Ayurveda, which have no counterpart in
modern medical science, are considered as non
existent. Even when, as in the case of acupuncture
points, the functional if not the anatomical existence
of a point, is demonstrated, it is not accepted. Thus
the most 'advanced' scientific mode of enquiry into
nature ends up by denying nature, ifself if it does
not fit into its theoretical straitjacket.
Cultural Relativist View Point
universality of certain scientific findings independent
of geographical and cultural factors. Though it is
true that science and technology of various civili
sations should be understood on their own merits
and not as abortive developments towards modern
western science or worse as mere fiction, one
must be cautious of how one formulates this point.
"There is a danger ... of denying of the fundamental
continuity and universality of all sciences. This
could be to resurrect the ... conception of the
various non-European civilization astotally separate,
immiscible thought patterns ... a series of different
views of the natural world, irreconciliable and
unconnected.'' (Needham, 1954).
Thus, from the opposite end, the relativist
view reinforces the positivist view that pre-modern
and non-European sciences are different from
modern science and thus incompatible. They differ
only in their views regarding the relevance of these
sciences. The positivists consider them as unscien
tific and thus irrelevant, while the relativists main
tain that each are relevant only in their own culture.
From the other end, the opposite view point
considers that the general concepts of sciences, the
value promoted by them and the 'ideal' of what
constitutes valid and proper knowledge differ from
culture to culture. The cultural relativisits argue
that modern science is the, cultural artefact of the
west while ayurveda, astrology and others are
oriental sciences. Th us,,every science is considered
to be an ethnoscience, having a theory, a logic and
verification techniques.of its own, specific to itself
and thus, incommensurable. Forexample, they argue
that the efficacy of ayurveda must be assessed by
the principles laid down in ayurveda only i.e. on
its own terms, and not on the terms dictated by
modern science. They rule out any 'objective'
assessment standing outside the premises and logic
of ayurveda. They point out that "it is only when
domination over nature is considered the highest
ideal for civilization that we find western science
becoming the universal standard for measuring the
achievement in all the other cultures. However if we
take the unity of man and nature as a predominant
positive value, the Chinese and other cultures'
scientific tradition stand out as more advanced".
(Alvares, 1979).
This assumption of a basic incommensurability
also implies that one must deny the contribution of
these cultures to the universal body of knowledge,
which is international. It also imparts a closeness to
knowledge, the boundaries being limited by the
culture. In fact, modern science is 'ecumenical', in
the sense , that historically speaking science is a
product of diverse cultures -and thus a common
property of human kind. Secondly, this assumption
denies any possibility of mutual exchange, thus
legitimising elitist doctorines in each of these
sciences.
It also rationalises the doomsayer's
conservative prophecy depicting modern science an
uncontrolled and uncontrollable monster causing
all the wars and social ills of our time. The only
alternative such a view of modern science leaves is
a total withdrawal into inner reality, an escape
into 'privatised mystical experiences' aimed to
create an 'inner' revolution. Thus, positivism and
cultural relativism absolitise and/or universalise the
form of scientific and technological development
without considering the social context and the
content of the various stages of its development
While sympathising with the eagerness to do
justice with the achievements
of pre-modern
societies including those of Egypt, China and India,
one must be wary of the dangers of slipping into an
extreme form of such relativism—a position denying
the basic equality of human experience and
A dialectical approach to the problematic ass
umes that a) all knowledge is universal and
humankind's common property; b) no scientific
theory or methodology is perfect or unchanging
and thus inherently' superior; c) science develops
under the influence of a philosophical basis
December 1985
A Dialectical Approach
A 07
generated within the framework of various socio
economic, political and cultural factors in interaction.
Therefore, even though direct comparisons may be
difficult, because theoretical systems in each
cultural setting were different, nevertheless mediated
comparison is possible.
implicit world view of existing medical science—
both modern and traditional—led to an integration
and development of both the sciences. The most
notable product of this development is acupuncture.
In order to study how this happened we shall
briefly trace the history of Chinese medicine.
This could be done "by testing out the theories
of traditional sciences in the light of modern concepts,
without absolutising the latter and by studying
how and how much the former had succeded in
discovering natural processes and in putting them
in service of humanity'' (not in order to achieve
mastery over nature or human beings but for the
benefit of all). Such a view opens up a possibility
of integrating western and traditional sciences and
a mutual exchange between the two. Having evo
lved under different historical and cultural conditi
ons each embody different sets of strong points
and limitations. The aim of such an integration is
to reinforce each other's strong points and do
away witn the limitations.
Historical Background of Chinese Medicine
Such an integration can contribute to the adva
ncement of human knowledge in three ways:
— regional traditions embody useful concrete techniques, for
example traditional herbal and mineral remedies that work
without the side effects of many chemically manufactured
drugs.
— regional traditions preserve an important body of data which
can serve as a base for furthering existing fields of modern
scientific research — examples are records of astronomers and
meteorologists.
— regional traditions can open up new perspectives and avenues
for modern scientific research, as in the case of acupuncture
which has stimulated international neurophysiological research.
(e.g, work on mechanisms of pain inhibition) (Elzinga and
Jamison, 1981).
Such an endeavour demands a change in the
world view and in the attitude towards history of
science.
Only a dialectical understanding of the history
of science, its relationship with philosophy and
social context can produce the required 'break'.
Such a conscious re-evaluation of the history of
science also reveals a different future vision of an
integrated science, wherein all the pre-modern and
non-European sciences would find that their legiti
mate contributions have transformed the existing
scientific knowledge and in turn have transformed
themselves.
The most widely discussed illustration of such
a process is Chinese medicine. A change in the
108
Chinese medicine is one of the oldest known
medicines. Very little is known about its origin but like
stone age medicine elsewhere it must have begun as
a primitive medicine. Archaeological evidence shows
that the earliest inhabitatnts of the Yellow River
Valley were people of the Stone Age and like the
religious beliefs of other tribes of Stone Age,
animism and demonology must have been the cha
racteristic feature of their religion. We may safely
assume that they believed in the spirits of the
dead, and worshipped natural events like thunder,
rain etc. Their medicine too must have consisted
of witchcraft, sacrifices and oblations. The situation
changes later, during 1200-300 B.C. when their
religion enters the age of philosophy. From being
direct and immediate response to the multifarous
problems including illhealth faced by the primitive
being, it enters a stage where the Chinese human
being has formed a metaphysical view of the uni
verse, of man and nature relationship. Medicine too
is influenced by this change. Witchcraft gives way
to institutionalised medicine using processed drugs.
It is seen that during the Chou dynasty, (1100-250
B.C.) physicians incharge of internal medicine,
surgery and veterinary medicine were appointed
(Wong, 1979).
The oldest legendary figure in Chinese me
dicine is Shen Nung (2757 B.C.) who is venerated
as the father of medicine and is considered to be
the inventor of drug lore. The oldest treatise extant
is Huang Ti Nei Ching Suwen. (Yellow Eineror's Inner
Classic). Though Nei Ching s period is around 2000
BC, the treatise is supposed to have been written
around 200 BC. It is believed to have been written
by several anonymous authors over the period. It is
a theoretical exposition of the basis of health and
illness, closely related to the cosmological ideas
taking shape during the philosophical period. It lays
down the basic principles of anatomy, physiology,
etiology of diseases and their treatment (Wong,
1979).
Chinese medicine begins to assume a rational,
scientific character during the Han dynasty (200
BC-220 AD) with Tsang Kung, Chang Chung King
and Hua To as central figures. Tsang Kung lived
Socialist Health Review
around 170 BC and left records of personal obser
vation of twenty five clinical cases. Chang Chung
King's treatise of fever marks a new era in Chinese
medicine. He has described many types of fevers
including typhoid fever in thistreatise and it contains
one hundred and thirteen prescriptions. With this
treatise, the diseases were studied more from
clinical standpoint — signs and symptoms, course
of an illness, treatment and actions of a drug rather
than from the point of view of the theories of
diseases as was the case during earlier period
(Kuttumbiah 1971). This transition shows that a
scientific outlook was permeating medicine in the
grips of speculative philosophy.
The third important text is Pen Tsao which
describes useful plants, animal and mineral sub
stances and their applications. Unlike Nei Ching
it is a practical text and has undergone many
additions over the centuries as the experience of
the Chinese physicians of using herbs and minerals
accumulated. This period saw a great intellectual
flowering in China. Confucius and Han Fei belong
to this period. Though a surgeon, Hua Tu is
claimed to have discovered anaesthesia and to
have performed some major and minor operations
like laparotomy, venesection etc., this aspect of
medicine had fallen into neglect during the later
period for reasons discussed elsewhere.
Although the pharmaceutical traditions of Pen
Tsao expanded,
the Nei Ching remained less
emendable because of its classic and semireligious
status. Both, the Chinese feudal rulers and the
physicians themselves looked upon it as a divine
gift. After the Han dynasty, this resulted in Chinese
medicine, becoming not stagnant, but backward
looking toward the sources of classical antiquity and
hence continuing to develop within the thoretical
framework based on the philosophy of that period.
This backward-looking character of Chinese
medicine made it particularly vulnerable to the
cultural aggression of the imperialists during the
19th century. During the rule of various imperialist
powers overwesternization was stressed and rivalry
was set up between Chinese and Western medicine.
Maligning the formeras unscientific and a 'stumbling
block' to the development of modern medicine they
barred practitioners of traditional medicine from
city hospitals and medical colleges. The Kuomintang
government in 1929 put forward measures to
aboish Chinese medicine. Among these were "re
strictions on the practice of medicine by traditional
physicians, a ban on setting up schools of
December 1985
traditional medicine and on publishing books and
periodicals on Chinese medicine" (Li and Tsai,
1977).
It was in the face of Nationalist Blockade,
during the liberation war, that efforts were made
by the Chinese communists to utilise the locally
grown herbs. In 1940, when liberated zones were
established, this pragmatic step was taken up as
a conscious policy of utilising indigenous medicine.
(Liberated Zones were those areas in China where
the Communist-led Revolutionary Committees had
usurped political power from the Kuomintang go
vernment). This policy received official recognition
when Mao Tse-Tung in his famous speech in 1944
at the Yenan conference on culture and education,
urged the doctors to work with and elevate the
scientific level of traditional practitioners in order
to better serve the people (Mao , 1965). However,
after liberation in 1949, the communist government
continued to have traditional practitioners as auxili
aries to the modern medical forces. The directive
of unifying the two systems of medicines was
probably interpreted as giving the traditional
practitioners some training in modern medicine. It
was only in 1955, when efforts were made by
the communist party to raise the status of tradi
tional medicine. Traditional doctors were brought
to city hospitals and clinics. Special wards were
set up for acupunture and herbal medicine. Modern
doctors were urged to learn from their traditional
colleagues.
By 1958, thirteen new colleges for traditional
medicine were opened. Over 50,000 students app
renticed themselves under distinguished traditional
physicians. In 1955, a well-equipped Chinese
Medical Research Institute with both modern and
Chinese doctors on its research staff was setup.
The entire body of knowledge was to be investigated.
In other words true integration of the two
systems of medicine at theoretical as well as
practical level was the goal.
The praise and support to traditional medicine
reached its acme during the Great Leap Forward
(1958-59) period. This period was characterised
by over-enthusiastic policies of collectivisation of
individual agricultural plots,formation of communes
etc. This resulted in a reduction in the production
of foodgrains and led to subsequent famine in some
areas. With the retreat of its extreme policies,
emphasis on traditional medicine also declined.
Although the policy of combining the two kinds of
medicine showed some triumphs notably in the
A 09
fields of resetting of fractured limbs using mobile
splints. (Sheng, 1977) no major theoretical break
through towards a new synthesis was in sight.
With the advent of Great Proletarian Cultural
Revolution, traditional medicine again came to the
forefront. This period was probably the most
turbulent one in rhe contemporary history of China.
In 1966, the Chinese youth led by Mao, rebelled
against dogmatism, bureaucratism and elitism of
sections of the Chinese Communist Party, the
government and other institutions.
With the
decentralisation drive, provinces and communes
assumed
responsibility of health services. Self
reliance was the official policy,
which meant
depending upon local resources which often in
rural areas meant traditional medicine and using
locally grown herbs. Since then, by using combined
traditional and modern medicine, many break.
throughs at both theoretical as well as applied
level, have occurred especially in acupuncture
analgesia, treatment of deaf, mute and blind (Chen
1973) and in nonsurgical treatment for conditions
normally requiring surgery (e.g. perforated peptic
ulcers) using acupuncture and traditional herbal
medicine (Wu, 1977).
Thus, it should be noted that the introduction
of modern medicine in China was not as a conse
quence of a natural transition from traditional
Chinese medicine nor was it as a result of any
'inherent' superiority of modern medicine.
(It should be kept in mind that modern western
medicine in 1929 when Kuomintang sought to
suppress the traditional Chinese medicine, had in its
therapeutic armentarium a few herbal tinctures, like
Belladonna and Gum Acacia, few mineral prepar
ations like Arsenic and Mercury and dangerous
procedures like purgation and leching.) It was
forced upon the colonial people. Ideological
struggle has played a dominant part in the develop
ment of medicine everywhere and in China in
particular.
This raises an important ideological question
as to how the dominant philosophy of Chinese
communists could reconcile with that of the tradi
tional Chinese medicine. The answer lies in points
of congruency between the philosophical basis of
Traditional Chinese medicine and the Chinese
interpretation of the dialectical materialist philosophy.
Philosophical Basis of Chinese Medicine
Chinese medicine assumed a scientific character
in a period characterised by flourishing of great
110
schools of philosophy: legalism, Confucianism*
Taoism, Yin-Yang and five element school and
Naturalism. Developments in medicine have been
influenced by all of them to some extent, but its
scientific theory owes a great deal to the last three.
Although differing in many ways over their
general world-views, there are certain common
points regarding man-nature relationships, in all the
philosophical
schools of this period. Man is
conceived of not as a master of nature nor as its
slave but as an integral part of a cosmic system
having harmony and order. Confucianism admits a
hierarchy of heaven-man-earth where all the human
and earthly events are willed by heaven which
imparts to it harmony and order. In other schools,
motive force of the cosmic order is considered as
spontaneous internal self-movement rather than
mechanical impulses from outside. This tendency to
analyse phenomena in dialectcial logic is reinforced
by the Chinese language, it is claimed. Rigid 'A or
not-A' categories are avoided (Needham, 1976).
According to ancient Chinese philosophy, in a
healthy body there should be free flow of Chi (the
basic principle of the entire universe) which is
governed by the interplay cf two opposite forces,
the Yin (negative) and the Yang (positive). Disease
results from their imbalance. Yin and Yang them
selves evolved from nothingness which was the
grand beginning of the Universe. Quantitative
transformation of Yin into Yang or vice versa
causes change.
Yin and Yang subdivide into five elements —
water, fire, metal, earth and wood. Since the human
being is conceived of as a product of Heavenaccumulated Yin, and Earth-accumulated Yang, the
human being too, contains the five elements.
Yin and Yang are not considered to be absolute
and static.
The Yin and Yang concept is an example of
conceptualisation in terms of contrariness, unity
and transformation of opposites. One contemporary
Chinese author maintains that dialectics in ancient
China dealt with the interinfiltration, interdepen
dence and mutual supplementation of Yin and Yang,
the opposites of a contradiction .. (and) self
adjustment of the system, which keeps the whole
organic .... structure dynamically balanced. The
keynote of the five Elements theory is that there is
Yang in Yin and Yin in Malfunctioning together and
that, therefore neither of them alone can generate
new things. (Li Zehou 1980).
Socialist Health Review
Thus, like dialectical materialism, the philo
sophy of traditional Chinese Medicine, too deals
with
transformation, contrariness and unity of
opposites. The Chinese medicine operated within
such a conceptual framework. And with this
concept, it sought to analyse and explain various
observations regarding the human body, its diseases
and their treatment. The only tools available to
them were their five senses and the accumulated
experience. This limits the validity of the empirical
evidence available in support of such theoretical
concepts. Now, the support or its refutation, is
sought by intergrating the traditional Chinese
medicine with modern medicine. Its analytical and
experimental techniques as well as its empirical
methodology is to be utilised for the purpose.
Generally, the philosophy of traditional Chinese
medicine encouraged scientific enquiry. But histori
cally, as Chinese medicine has come under the
influence of different schools of philosophy at
different times and places, its progress has not been
a smooth one. For instance, under the influence of
Confucianism, the official philosophy of the feudal
ruling classes of China, Chinese medicine degener
ated into dogmatism. For, although all the philoso
phical schools conceptualise the contradictory
nature of reality, they differ greatly in tackling this
contradiction. Confucianism propagates balance and
harmony -the unity of opposites, Taoism opposition
and revolt—the contrariness of opposites, and
Legalism transformation of harmony into disharmony
and vice versa in a cyclic fashion. Each world view
represents a class ideology, with Confucianism being
feudal, the ruling class ideology during the classic
period (Elzinga and Jamison 1977). "Confucianism
blocked the germination of new ideas and ham
strung the development of
scientific discoveries
in China
" (Ren Jiyu 1980).
To understand how and why this process took
place we shall have to go into the socio-political
factors which influenced the rise of Confucianism,
its subsequent pernicious effects on the development
of Chinese medicine as well as the overthrow of
this ideology.
Socio-Economic and Political factors Influen
cing Development of Medicine in China
In the last section we saw that the traditional
medicine in China was developing under a theore
tical framework under the influence of Confucianism,
Taoism and Naturalism. But it was Confucianism
which set its stamp on it. Confucianism stressed
balance of opposites in a contradiction thus
December 1985
legitimising the stability and order of the feudal
hierarchy in Chinese society. It was the official ideo
logy of the feudal state, with the result that new
ideas which could disturb this balance were not
encouraged and scientific enquiry was stiffled.
"This backward trend was due primarily to the
decaying feudal relations
But stifling effect
of Confucianism on man's urge to explore also contri
buted to the virtual halt in the march of science
That feudalism held on so obstinately in China must
be accounted for in part by the drawbacks of Con
fucianism" (Ren Jiyu, 1980) In concrete terms,
it meant that analytical and experimental techniques
not only did not develop but were looked down
upon because they involved a work of manual
nature quite like that of artisans who were
considered low down in the feudal social order.
For the physician to attain any social prestige and
economic rewards, he had to be identified with the
clasicially learned literati who constituted the
social and political elite in feudal China. A similar
situation existed in medieval India also (Chattopadhyay, 1977). The prestigious Confucian doctor
was not a physician in the real sense because he
acquired the necessary knowledge by reading
medical classics and treated others only out of
humanitarian motives. Full time medical practice
as a profession was considered unworthy of gentry
status and mandarinate. Yet amongst the ordinary
folks, many practitioners continued to base their
medical practice on experience and direct obser
vation.
This has had all the adverse conseuences for
further development of medicine. It not only retarded
surgery a messy business which even medieval
European physicians left to lower class barber
surgeons, but also inhibited the development of
supportive physical and biological sciences. (Crozier,
1973).
Thus it was no wonder that the radical move
ment that developed in China after World War I,
rejected traditional medicine as a part of decadent
feudal culture and society.
Ever since then,
traditional medicine, its rejection or its support,
has become a political issue in China.
Several factors led to it being restored to a
prestigious position. Firstly, having been faced with
Nationalist blockade in the Liberated Zones, Chinese
communists were forced to rely upon the traditional
practitioners for medical care. Moreover, in the
struggle against feudalism, traditional practitioners
as artisans were considered allies of the proletariat
AAA
and the peasantry.
Having gained some useful
lessons during this period, the Chinese Communist
Party after the liberation applied them in practice.
There was an extreme shortage of trained medical
personnel and traditional practitioners were too
important a human resource to be rejected outright.
Moreover, traditional medicine, after having been
shed of its feudal ideology, was put forward as a
symbol of national heritage. In the struggle against
imperialism, this played an important part in rallying
the people around the communists.
During the Great Leap Forward, when there
was a drive to demystify technical expertise,
traditional medicine with its folklorist features was
particularly suited for the purpose. With 'mass line'
(the term used by the Chinese communists to
denote their stress on the wisdom of the masses—
the peasants and the workers) in ascendency,
scientific knowledge was not considered to be a
monopoly of highly educated. During the Cultural
Revolution too with its anti-expert political line,
modern medicine associated with its western trained
specialists came under severe attack and traditional
medicine of common folk-peasantry got a new boost.
Thus, the traditional physicians have now been
reinstated to a prestigious position. They are
encouraged to study modern medicine and alongwith their modern counterparts, to undertake
research in various aspects of traditional medicine,
using modern scientific methods.
In concrete terms
the integrated medicine
now being practised is drastically different from
either its original classical form or the conventional
modern medicine.
III. Current Status of Medicine in China
Restoration of traditional medicine for the
Chinese never meant rejection of modern medicine.
Modern medicine continues to dominate all the
aspects of medical care. In medical care, training
and research, modern
scientific
methodology
continue to be applied but now
traditional
theoretical and practical diagnotic and therapeutic
knowledge is sought to be integrated with it.
For the Chinese "combining Chinese and
western medicine does not simply mean addition of
the one to the other and certainly not replacing
Western Medicine... by (its) native counterpart or
vice versa. What is meant is the organic combination
of the two medicines filling the weaknesses of the
one with the strong points of the other raising the
level of both, eventually evolving a new medical
science incorporating the best features of both '
(Li and Tsai, 1977).
Integration
in Medical Practice
In medical practice throughout China more
resources are now allocated to traditional medicine.
Special wards have been constructed in the existing
hospitals and new clinics have been set up. The
traditional doctor now has a major role in OPD and
with no loss of reputation is now calling for x-ray
films and laboratory investigations, and when
needed, western consultation Grey, 1971).
Rural health centres are staffed by both the
traditional and modern doctors both of whom
having received some training in the other system.
There is considerable co-operation between them in
day to day practice.
Barefoot doctors rely heavily upon traditional
therapeutics including acupuncture. A barefoot
doctor's manual lists around
533 traditional
medicines. (Sidel, 1973). Reports indicate that
model hospitals (usually Red Army hospitals) stress
combined use of both the systems. One hospital
reported that since 1969, 70 percent of the cases
were treated in this way (Crozier, 1973). Diseases
claimed to have been treated in this fashion include
jaundice, pulmonary tuberculosis, inflammation
of kidney (nephritis), inflammation of veins
(phlebitis) severe burns, facial paralysis and
fractures.
The most spectacular results by using com
bined traditional and modern medicine are in
conditions where previously surgery was required,
for example in perforated peptic ulcer (a condition
where due to interaction between the inner lining
of stomach and the acidic juice therein, there is
first a small ulcer on the inner lining of the stomach,
which may later burst to become a hole through
the stomach wall with gastric juice sprayed over
into the abdominal cavity causing severe inflamma
tion of the abdominal lining). In such a patient,
complaining of severe pain in abdomen, the modern
doctors ascertain the part affected and the kind
of disease the patient has by careful history taking,
clinical examination, x*ray and laboratory invest
igation. "The ability to accurately determine local
pathological changes is the advantage of Western
medicine's method of diagnosis. Where it falls
short however, is in understanding and analysing
the functioning of the patient's body as a whole.”
(Wu, 1973). The Chinese doctors then ascertain
the general status of the patient by traditional
Socialist Health Review
112
method. After a careful study, a method has been
developed using traditional and modern indicators
like temperature and pulse and so on to judge the
size of the hole and extent of fluid exuded. If
the hole is considered to be large and fluid ab
undant, then the patient is operated upon, otherwise
he or she is treated with acupuncture and herbal
medicine. (Wu, 1973).
standardised bamboo splints used traditionally
around the fracture site. Quite unlike the exten
sive immobilisation method of modern orthopedics,
this method advocates combined rest and movement.
This has resulted in better healing, and greater
recovery of function, particularly of old, complicated
fractures. The time of immobilisation is also greatly
reduced.
The other prominent breakthrough achieved by
using the combined methods is in the field of
acupuncture anesthesia and treatment of fractures.
No discussion on Chinese medicine today can
be complete without the mention of prevention
and treatment of mental illness in China. Quite
unlike the western method based on Freudian
thinking, the psychiatric care in China is based
on the belief in man's ability to change given a
sympathetic environment and education and re
education' (Sidel R, 1973), (Ho, 1974).
Theory and practice of acupuncture has under
gone significant changes as a result of self
evaluation on the basis of modern scientific concepts.
Older theories and principles not verified in practice
have been relegated to secondary importance. For
example in diagnosis and prognosis,
greater
emphasis is placed on effective acupuncture points
and their relationship to the autonomic nervous
system and less on the theoretical aspects of YinYang, the meridians and the Five Elements (though
the latter are not entirely rejected.) (Chen, 1973).
Thus, in late 1950's Chinese medical workers
reviewed their experience of acupuncture in relieving
toothache and sore 'throat. They applied the
experience to replace anesthetic drugs in minor
operations like tooth extractions and tonsillectomy
and achieved some success. The technique gradually
improved with more points being discovered. Now
success has been achieved with placing needles
only on the ear, nose and face (Chen 1973). Many
major operations like abdominal and chest surgery
have been performed using accupunture anaesthesia.
Another achievement has been in the field of
treating deafmutism and blindness, using acupunc
ture (Chen 1973). Traditionally certain points were
considered forbidden for deep insertion. But experi
ments showed that deep needling of these points
produced return of the power of speech and hearing.
Acupuncture therapy is combined with high quality
speech therapy.
Acupuncture has also been used successfully
in treatment of toothache, tonsillitis, jaundice,
epidemic influenza, voice paralysis and polio (Chen,
1973).
Similarly, in the field of treatment of fractures,
combined therapy is found to be superior (Sheng,
1977). The fracture is diagnosed using X-rays. The
broken bones are realigned using acupuncture
anasthesia. Then, the fracture is managed by tying
December 1985
Since the Cultural Revolution, with increased
emphasis on integrating traditional medicine, the
western trained doctors have altered their psychi
atric service to include traditional methods and
political techniques. The methods currently in use
are self-reliance, collective help, drugs, acupun
cture, heart to heart talks, follow-up care, community
ethos, productive labour and teachings of Mao.
Thus the process involves hospital and community
care, individual and group relationships, professi
onal and nonprofessional help, mutual help and
self-reliance and traditional and Western medicineHere again one clearly sees a tendency to avoid
stressing on either of the opposites.
Integration in Medical Research
Scientific research in China is guided by four princi
ples (Stuttmeir 1973) (1) Research must serve
production and solve practical problems generally.
(2) The indigenous, social, economical and intell
ectual — both contemporary and traditional experi
ences must be tapped. (3) Research must involve
the masses and should not be a monopoly of the
professional elite. (4) It should be an integral part
of Chinese way of life. Struggle for scientific
experiment, struggle for production and class
struggle are considered three major tasks of a
revoluntionary society. Medical research too, derives
its orientation from the above principles.
The most outstanding feature of medical research
in China is the concept of systematic co-operation
built around small research projects. Research units
having common interests work together regardless
of their affiliations. For instance, production of new
antibiotic 'Qingdmycin* according
to the New
China News Agency, was a result of combined
113
efforts of 36 agencies. The central body responsible
for [he medical research in China, the Chinese
Academy of Medical Sciences maintains linkages
with 24 different research institutes. Tne research
areas include various specialities in the medical field
like epidemiology and microbiology, surgery, pedi
atrics, pharmacology; areas in community and
social medicine like environment nutrition, labour
hygiene, labour protection, occupation health, basic
sciences like Medical Biology and traditional scien
ces like acupuncture, moxibustion and Chinese
medicine.
Research in traditional medical sciences is
organised under the Academy of Traditional Chinese
Medicine. Its areas of research include medicine,
surgery, acupuncture and pharmaceutics.
The
diseases studied successfully include asthma, bone
fractures, high blood pressure, tuberculosis of
bone, leprosy etc (Stuttmeir, 1973). The unique
feature of this Academy is the inclusion of western
trained doctors in its research staff who have under
gone training in traditional medicine.
In 1966
there were around 200 such doctors out of a total
research staff of 300 (Stuttmeir, 1973).
Another notable feature of medical research in
China, is the combined use of traditional and modern
diagnostic
and therapeutic principles. In one
instance 10 patients having a skull fracture with a
large blood clot under the skull bone were selected
on the basis of severity judged by modern diagn
ostic methods including x-rays
Then they were
treated with intravenous mannitol and Chinese
medicine. Conventionally, the blood clot would
have had to be removed surgically. But this clinical
trial showed that 9 patients recovered fully, the
blood clot having been absorbed (Qiu Xiang et al,
1981).
Medical research also includes exploring the
scientific basis of acupuncture. Based on extensive
observation and research, it has been found that
generally meridian system of traditional acupuncture
corresponds with the neural pathways. But modern
knowledge of anatomy and physiology of the
nervous system cannot fully explain the theory of
meridians. For example, on stimulating certain
parts of limbs with heat, corresponding areas of
the ears become sensitive to pain. Certain other
unexplained physiological changes
induced by
acupuncture have also been demonstrated. For
example, putting a needle through certain points in
the body of a normal person causes increase in the
number of white blood corpuscles and enhancement
114
of the process of devouring of wastes and bacteria
by these white corpuscles. Hormones too may be
playing a part in this process in which different
levels of the central nervous system have been
found to be involved. (Chen, 1973).
What is most revealing about the philosophical
aspect of medical research is that dialectical
principles are often used in achieving solution of a
research problem. For example from the orinciple
"the law of unity of opposites is the fundamental
law of the universe" in the words of a Chinese
doctor ' we drew a number of conclusions : immobi
lisation and movement are equally important,
fracture healing and functional recovery ought to
be mutually complementary ... None of these
aspects should be stressed to the neglect of the
other. On this basis we formulated... new principles
for the management of fractures ' (Sheng, 1977).
Conclusion
Medical science developed in China under the
influence of conflicting world-views, which repre
sented the ideological requirements of the ruling
classes or sections thereof. This struggle between
contradictory philosophies was reflected in the
sudden changes in direction which characterise the
uneven course of development of medicine in
China. Factors other than those intrinsic to science,
played an important often determining role in
shaping its course. The medicine that emerged
after a conscious policy of integration was applied,
reflected a change in the dominant worldview to
one which is more organismic as opposed to
mechanistic—a world-view implicit in bourgeois
science.
Science and philosophy, two dialectical poles
of a knowledge system, develop in an interpene
trating, mutually dependent fashion under the
influence of the socioeconomic and culturalideological factors operative in a particular mode
of production during a historical period. As Engels
put it :
"Natural scientists... are still under the domina
tion of philosophy. It is only a question of whether
they want to be dominated by a bad fashionable
philosophy or by a form of theoretical thought
which rests on acquaintance with the history of
thought and its achievements. Only when natural
science becomes imbued with dialectics will all the
philosophical rubbish.. . be superfluous, disappear
ing in positive science" (Engels, 1976).
Socialist Health Review
Only a conscious appraisal of the history of
medical science keeping in view the above per
spective can provide a future vision of a new
Intergrated Medicine.
In this way by emphasising equally empirical
observation and dialectical concepts, on positive
science and dialectical philosophy and by combi
ning the traditional and modern medicine, Chinese
medical science has contributed significantly to
'humanity's broad onward march.'
References
Alvares, Claude . Homo Faber : Technology and Culture in India.
China and the West — 1500 to the Present Day. Martin Nijhof,
The Hague, 1977.
Bacon, Francis : Novum Organuni, London, 1620.
Ren Jlyu: How Confucianism Evolved Into Religion in Social
Sciences in China (2) : 146, 1980.
Shang Tien Yu : New Developments in Fracture Treatment in
Creating New Chinese Medicine and Pharmacology, Foreign
Languages Press, Peking, pp 21-42, 1977.
Sidel, Ruth : Mental Diseases and Their Treatment in Medicine
and Public Health in People's Republic of China. Washington
DC pp 287-302, 1974.
Sidel, Victor W : Medical Personnel and Their Training in
Medicine and Public Health in People's Republic of China
Washington D C, pp 169 1973,
Stuttmeir, Richard P : Academy of Medical Science in Medicine
and Public Health in People's Republic of China Washington
DC. pp 173, 1973.
Wong, YC : Introduction to Basic Concepts in Chinese Medicine
paper presented at International Conference on History
and Philosophy at Islamabad. Hamdard XXIV (1): 27-53,
1979.
Wu
Chattopadhyay, DP: Science and Society in Ancient India
Research India Publications, Calcutta, 1977.
Hsien Chung : Non-Surgical Cure for Acute Abdominal
Diseases in Creating New Chinese Medicine and Pharmacology
Foreign Languages Press, Peking, pp 43-66, 1977.
Chen, James Y P : Acupuncture in Quinn in Joseph R (Ed),
Medicine and Public Health in People's Republic of China, U S
Department of Health. Education and Welfare, Washington
DC, 1973.
Dhruv Mankad
1877 Joshi Galli
Nipani
Belgaum Dist.
Crozier, Ralph C : Traditional Medicine as Basis for Chinese
Medical Practice in Medicine and Public Health in People's
Republic of China Washington DC pp 7, 1973.
Elzinga, Aant, and Jameson, Andrew ; Cultural Components in
the Scientific Attitude to Nature : Eastern and Western Modes?
Research Policy Institute, Lund, pp 12, 1981.
Engels, Frederick : Dialectics of
Moscow, pp 240, 1976.
Nature Progress
Publishers,
MAKING WAVES
Grey, E. Diamond : Medical Education and Care in People's
Republic of China m Journal of American Medical Association,
218 (10) : 1552-57, 1971 .
The Politics of Communications
(Radical Science I6)
Ho, David Y F : Prevention and Treatment of Mental Illness in
China in Health Care in China—An Introduction Christian Medical
Commission, Geneva, pp 173, 1974.
What kind of waves will be made in
the electronic paradise that we are
promised ? The essays in this
collection explore both the oppressive
and Hberatory possibilities of
communications technologies. They
include:
Kuttumbiah, P: The Evolution of Scientific
Longman Ltd., pp 80, 1971.
Medicine,
Orient
Li Zehou : A Re-evaluation of Confucius, Social Sciences in China
(2) : pp 119-120, 1980.
Li Chung Wei and Tsai Ching Fen : Creating New Medicine and
Pharmacology in Creating New Chinese Medicine and Pharma
cology Foreign Language Press, Peking, pp 4-5, 1977.
* Ursula Huws on women in hi-tech homeworking;
Mao Tse Tung : Selected Works, Vol 3 Foreign Languages Press,
Peking, pp 236, 1965.
Needham, Joseph : Foreword, in Science and Civilisation in China
Vol 5 Cambridge University Press, pp xxxvii, 1954.
Needham, Joseph : History and Human Values - A Chinese Pers
pective for World Science and Technology in Steve Rose, and
Hilary Roge (Eds.) The Radicalisation of Science Macmillan,
London, pp 90-117, 1976.
Qiu Xu Xiang, Huang, Juemin and Zhou Ruixian : Non-Surgical
Traditional Medicine in Extradurol Hematoma in Chinese
Medical Journal, 94 (4): 241-248, 1981.
December 1985
* Armand Mattelart on infotech and the Third World:
* Dee Dee Halleck on Nicaraguan video, 'live from the
revolution': and others.
£4.95/S6.50
from Radical Science,
26 Freegrove Road,
London N7 9RQ
AA5
POLICIES TOWARDS INDIGENOUS HEALERS IN
INDEPENDENT INDIA
roger jeffery
Policies towards indigenous healers in independent India show considerable continuities with
policies followed in the British period, varying according to the sex of the healer. Traditional birth
attendants (dais) have been offered short periods of training by the State since 1902, whereas until
recently male healers (vaids and hakims, and later homoeopaths) have been treated with official
hostility Current plans include the training of religious and ritual healers in psychiatric services as
well as the employment of indigenous healers in new community health schemes. These changes
are assessed in the context of a political economy of health services. This article is reproduced
from ‘Social Science and Medicine' 16:1835-1841, 1982.
Introduction
Many discussions of the potential role of indi
genous healers in health systems ignore the historical
dimension, apparently assuming that the proposals
are novel and practicable. No-one should make
this mistake in India, where there is the work of
Leslie and Brass to draw attention to shifts in policy
from 1820 onwards.1 In this paper I want to
elaborate on a small part of this topic by looking
at official policy with respect to indigenous healers
in the context of theories about the dynamics
of relationships between indigenous and cosmopolitian medicine.
There are, in essence, three views of these
relationships in India. The first is the naive scien
tistic: that the process is one in which the
indigenous systems are steadily giving ground to
the onward march of science, with only the areas
where Western medicine is ineffective remaining
for the indigenous practitioners. This was the
dominant view of the British doctors in India; it
remains common, though many Indian doctors
express guarded sympathy and support for the
relevance of indigenous medicine. The second view
is the agnostic anthropological, best expressed in
Leslie's phrase describing Asian medical systems as
'coexisting normative institutions', in which cultural
processes of change are not simply unidirectional
(with indigenous medicine being affected by cos
mopolitan medicine but not vice versa) but multi
directional, with no predictions of necessary future
patterns.2
The third view is the political struct
uralist one, in which the superiority of Western
medicine follows not from its scientific advances but
because it is more closely linked to the class
interests of the political leadership in the country,3
I shall explore
some
of the strengths
and
weaknesses of these positions by taking a closer
look at policies towards indigenous medicine in
116
India, tracing the links between the British period
and post-1947 policies, with particular focus on
policy proposals made (and to a lesser extent
implemented) since 1971.
Two caveats should be entered here. Firstly,
there may be no clear relationship between official
discussions of indigenous healers a nd the situation
'on the ground'. In particular the official mind tends
to see the systems of indigenous medicine as
discrete and discontinuous, whereas Leslie’s model
of healers occupying positions which shade into
one another seems more plausible.1 Secondly.
there is a great deal of regional variation, not only
pre-1947 when the Native States could follow
policies radically different from those of British India
but also since Independence, when health policies
have been constitutionally the sphere of the States.
The British Period
It is customary to see 1835 as a major turn
ing point in British attitudes to Indian culture. This
was the year of Macauley's Minute on educational
policy, where he argued that European culture
should provide the curriculum of schools and colleges.
This strengthened the opposition to schemes which
attempted a mixing of European and Indian cultures,
or were designed to restore Indian culture to its
presumed glory. In medical education it meant
that the Calcutta 'Native Medical Institution' founded
in 1822, would no longer teach aspects of Ayurveda
(the Hindu medical scriptures, especially those of
Susruta and Caraka) nor of Unani (the medical doct
rines derived from Greek medicine and more closely
linked to Muslim culture). While this move had
obvious significance, it did not mean a total ban
on such teaching, nor on co-operative relationships
between the British Raj and indigenous practitioners
as a class. As Hume has demonstrated, for example,
in Punjab the Provincial Government employed
Socialist Health Review
hakims [Unani practitioners) in the 1860s and 1870s,
usually as vaccinators and health extension workers,
and the University of the Punjab offered courses in
Ayurveda and Unani medicine until 1907.5
One reason for the tolerance displayed by the
State is that its own services, and practitioners
trained in its medical schools and colleges, had
a minimal impact before the end of the nineteenth
century. The first four medical colleges (Bombay,
Madras and Lahore following Calcutta by the 1850's)
produced too few graduates to make much impact
on the setting of practice for most indigenous healers,
and were mostly employed in the growing State
bureaucracy — in the army, the jails, the railways and
soon.6 The 1872 Census of Bengal, for example,
enumerated only 3769 physicians, surgeons and
doctors, but over 23,700 'Gobaidyas' and 'Kabirajes'
(vaids, or Ayurvedic practitioners) and over 400
hakeems.7 Prior to the establishment
of the
Indian Sanitary Commission in the 1860s there was
no commitment by the State to provide health care
services for its citizens, and there was a slow
extension of that commitment beyond plague control
and the provision of dispensaries. There was an
awareness of the strength of the indigenous groups:
plans to introduce medical registration in the 1880s
were dropped because the Western doctors were
too weak to defeat the expected hostility from the
vaids and the hakims.3
A change to greater hostility can be dated
from about the end of the century. By this time
the cream of the Western doctors in India — the
Indian Medical Service, (recruited in Britain though
5% Indian by 1 91 3) was more conscious of its claims
to a scientific legitimation; the number of Indian
medical graduates and licence-holders was substa
ntial, and they were offering a real challenge to
the primacy of indigenous healers in the major
towns; and there was the growth of a new middle
class which provided new financial opportunities
for both groups.9
The early twentieth century
saw considerable political conflict as the rising
bourgeois nationalist movement embraced the cause
of Indian cultural renaissance as well as the idea
of science. The Indian National Congress included
leading indigenous practitioners in its ranks as
well as modernisers like Nehru. Even within the
Imperial Government there were those willing to
lend their prestige to new private medical schools,
some of which combined indigenous and Western
techniques in 'integrated' courses. The general
argument used was that it was necessary to
improve the training of indigenous practitioners
December 1385
because "for many years to come they will constitute
the medical attendants of by far the largest portion
of the Indian community'' 10
As Indians gained positions in Ministries after
1919 they were expected to implement policies
based on this kind of view, but their scope was
limited by severe financial restrictions and their
impact was further reduced by pressures from the
Indian Medical Services, whose members provided
the senior medical civil servants. The new Legis
lative Councils supported the 'Indian' systems of
medicine on both patriotic and economy grounds,
but Ministers in several Provinces (e.g. Punjab
and Bombay) resisted this and used their limited
funds to attempt to bring 'modern scientific medicine
and surgery within reasonable reach of all', spending
only small sums on research into the indigenous
systems and for improved training.11 As a result,
relatively few indigenous medical colleges were
given State patronage; the schemes of medical
registration excluded those who had not received
Western medical training; and the Government of
India restricted its activities to an investigation into
the pharmacopeia of indigenous drugs.
With the rise of medical registration for the
cosmopolitan doctors after 191 2, the pressures on
indigenous medicine increased. Doctors who offended
the imported British ethical codes and collaborated
with indigenous practitioners, either in their new
colleges or in daily practice, were threatened with
deregistration. The wedge between cosmopolitan
and indigenous medicine was driven deeper by the
disputes over the recognition by the General Medical
Council in London of Indian medical degrees, which
occupied much of Indian medical politics in the
Inter-war period.1- When the Indian Medical
Association was established the early leaders, also
prominent in nationalist politics, called for the
admission of indigenous practitioners (if they were
'sincere'). By the mid-1930s, when these leaders
were being incorporated into the new Indian
Medical Council and other positions of influence,
they had already drawn back from these positions
because such policies might lead to a loss of their
international recognition. Indigenous practitioners
were first registered in Bombay in 1938, but they
were on a separate register from that of the
cosmopolitan doctors. They were accepted on the
basis of experience or apprenticeship, and only
after a 4 year delay was qualification to become the
only means of registration. The Bombay Government
was well ahead of other Governments, and even
here an amendment in
1949 weakened their
117
legislation and admitted new practitioners on the
basis of experience. Nevertheless, the Bombay Act
was held up as the model for legislation after 1974.
The inter-war period thus showed gains and
losses for indigenous practitioners. On the one
hand, there was the establishment of colleges,
rather than the less respectable guru chela form of
apprenticeship which had previously been the sole
training method. Several of these colleges were
well-funded, especially in Delhi, Madras and the
Princely States of Mysore and Hyderabad, for exa
mple. The indigenous practitioners also had the
support of the reports of special Government commi
ttees set up to consider policy towards them.1’
On the other hand, their subordinate position relative
to cosmopolitan
medicine
was reinforced by
registration patterns, and previous stategies of
raising status (e.g. by procuring a scientific facade
through joint teachir g and practice with cosmo
politan doctors) had received a severe blow. The
weakness of the indigenous practitioners was partly
a result of their own internal divisions. Not only
were there the two main groups separatee by
linguistic, theoretical and religious differences, but
there was also the newer group of homoeopaths,
established particularly strongly in Calcutta and
Bengal. In addition, each group had a variety of
career patterns, usually locally specific, with little
agreement about diagnosis or techniques. Often a
noted local teacher would prepare his own comme
ntary on the traditional texts, and a school which
grew up around one teacher would deride and
vilify
that around another.15 These
divisions
particularly affected elite practitioners, whereas the
average healer might be very different— but evide
nce about them before the 1960s is slight and
highly unreliable. Finally, there was the growing
ideological split between those who wanted integrated
teaching of cosmopolitan science and indigenous
therapeutics, and those who considered the pure
indigenous training sufficiently scientific. This divide
dominates the post Independence debates.16
Different
patterns affected female healers—
whose history still has to be told The presumption
is that all indigenous healers were male and this is
certainly implied by the medical texts and most
offical comments. However, many female healers
were recorded in the early Censuses, (see Table 1)
and some modernfieldwork reports refer to female
healers.17 To be sure, few of these would have
had access to the "high culture" learning of the elite
male practitioners, but that was true of many of the
male practitioners too. The main reason why female
healers were invisible to male enquiries was probably
that their clientele was almost entirely female. The
only group who do appear in the historical discuss
ions are the traditional birth attendants (dais), who
are recorded separately in the nineteenth century
Censuses, and in several early discussions of caste,
midwifery is described as the hereditary occupation
of the women of particular untouchable castes.ls
Apart from sporadic training by missionaries in
the middle of the nineteenth century, the first serious
attempts to train indigenous midwives came in 1902
when money raised in Queen Victoria's memory was
put into a fund for this purpose.1’ A sum of
Rs 40,000 was available each year, and training
followed a scheme first developed in Amritsar in
which the dai was paid a fee for attending the
classes and was expected to attend regularly, to
report cases, and to call in the teacher when she
had difficult deliveries. Simple examinations were
held, and the successful completion of a course
Table 1 Practitioners in selected provinces. 1901 Census
With a diploma, licence or certificate
Without any diploma etc.
Midwives
Compounders, nurses etc.
Bengal
Bombay
Madras
N.W F.P.
Punjab
UP
M
4123
1172
507
946
711
F
170
43
19
78
50
6750
M
33899
3648
17441
7198
F
1258
243
1501
665
789
—
—
6422
312
11341
1854
M
F
144
21036
1891
—
4753
M
2016
2127
2599
2602
328
315
324
9941
12517
F
Total medical
945
705
M
41912
6770
21267
11225
F
23480
2882
6609
7511
Notes: These are recorded as 'actual workers': dentists, occulists and administrative personnel (inclu
^^7*. and the figures
are included in the total but not in the other categories shown : vaccinators are included with compoun
include some feudatory States.
Socialist Health Review
118
could lead to a diploma and to registration. There are
no complete figures for the numbers being trained
in any year, but it is clear that a limit was set by the
shortage of female doctors or of public health
nurses (lady health visitors) to carry out the training.
These schemes were based on the following assump
tions; that institutional deliveries were very
unpopular amongst Indian women (they remain
so
today); that
midwifery was a hereditery
occupation amongst certain low castes (the situation
is almost certainly more complex than this); and that
the dai was expected to deal with the menial,
polluting, aspects of the delivery. Several features
made it acceptable for the State to become involved
in dai training, in particular, there was no band of
Western personnel whose interests were threatened
by such training. The dais themselves were so poor
and of such low status that they could be persuaded
into training schemes with relatively little difficulty;
and few people thought that the dai had any skills
worthy of being retained. In all these ways the male
healers were different, and this largely accounts
for the different policies pursued with respect to
them.
Policy After 1 947
One of the most obvious ways in which the
Congress Governments after 1947 followed the
precedents established by the British Raj is in the
sphere of health policies- The new Government of
India had two sets of proposals to deal with the
health problems of the new India . those provided
by the National Planning Committee, established by
Congress itself in 1938; and those of the Bhore
Committee, established in 1943 by the British to
plan for reconstruction after the War was over.
There was considerable agreement— for example in
the proposal that the health service should be free
at the point of contact for patients— but where they
differed, the post-war Governments followed Bhore
rather than the NPC. This was particularly true with
respect to the training of part time village level
health workers — a corner-stone of the NPC
proposals but toally ignored by Bhore. On relation
ships with the indigenous healers both reports
were ambivalent, but Bhore was more hostile. The
NPC resolved that
An attempt should be made to absorb the
practitioners of the Ayurveda and Unani
systems of medicine into the State health
organisation by giving them further scientific
training where necessary. Medical training in
every field should be based on scientific
method.20
December 1985
By contrast the Bhore Report pointed out that
the indigenous systems had nothing to say about
public health, preventive medicine, obstetrics or
advanced surgery, and described the systems as
archaic and out-side the onward march of world
science. Bhore's policies involved
a country-wide extension
of a system of
medicine which, in our view, must be regarded
as neither Eastern nor Western but as a corpus
of scientific knowledge and practice belonging
to the whole world and to which every country
has made its contribution. 21
Proponents of the indigenous systems were
able to exploit the ambiguities of these proposals by
claiming that science was not the preserve of the
cosmopolitan doctors since Ayurveda was already
scientific; and that only racial bias and a lack of
objectivity prevented cosmopolitan medicine from
learning from the Indian systems. 22
The debate over these issues became heated
over the first 10 years of Independent India. The
1946 Health Ministers' conference endorsed the
Bhore proposals, and ignored the NPC proposals,
with the sole exception of its resolution on indigen
ous practitioners. This was elaborated to include
expenditures on
(a) research into the indigenous systems;
(b) the
schools;
establishment
of new
colleges and
<c) the establishment of post-graduate course
in Indian medicine forgraduates in Western medicine;
(d) the absorption of vaids and hakims after
scientific training where necessary, as doctors, health
workers etc.;
(e) the inclusion of departments and practi
tioners of Indian medicine on official boards and
councils. 23
In the face of this strong political pressure,
the Government of India followed British precedents
and established a committee, under a cosmopolitan
doctor (Chopra); most State Governments were
similarly slow to act.
By 1947, then it is possible to discern three
main organised groups contesting the medical
domain in India, the cosmopolitian doctors with a
stranglehold on the medical bureaucracy, the 'pure*
indigenous
practitioners;
and the 'integrated'
practitioners. A fourth, less organised group
campaigned, at least in the 1970s, for the freedom
119
of unqualified and unregistered practitioners to
practice as cosmopolitan doctors. (This group
probably best represented the interests of the
majority of practitioners in India at the time.) The
three main groups have all failed to achieve their
own preferred solutions, and most of the issues
have recurred again and again in the main policymaking arenas. There are four main topics on which
battles have been fought: (1) whether to incorporate
indigenous
practitioners in the State medical
service, or whether to train a separate cadre of
community health workers; (2) how to register
existing practitioners and those graduating from the
indigenous colleges, and how to prevent unregistered
practice; (3) whether indigenous colleges should
include Western scientific training and an introduc
tion to cosmopolitan therapeutics; (4) whether
access to 'allopathic' medicines should be restricted
to those registered on the'Western' medical registers.
There were subsidiary issues— for example whether
State funds should be used to support training in
the indigenous systems or indigenous hospitals—
which were agreed in the early period: in fact
something under 5% of the Plan health expenditures
have been allocated to the indigenous systems of
medicine, though these allocations
have been
consistently underspent.24 I shall deal with the
four more important issues in turn.
1. The Incorporation of Indigenous Practitio
ners : The cosmopolitan doctors were opposed to any
such involvement. In the immediate post-Indepen
dence debates they had the support of Nehru and
his Health Minister (Rajkumari Amrit Kaur) in argu
ing with Bhore that all practitioners should have the
basic MBBS qualification; if they then chose to
practice other forms of medicine that would be up
to them—as is the case in the UK. in general it was
argued that it was impossible to integrate the various
systems without causing chaos. However, this was
the solution which Chopra proposed: his report
recommended that all students should be taught the
elements of all systems (like the Chinese solution,
at least during the 1970s). 25 Once again the
international standing of Indian doctors was used
as a powerful argument for rejecting such a move;
and the variety of skills and backgrounds of the
indigenous practitioners was seen as a reason why
no more than perhaps 2% of them could be used in
the national health services. While the Government
of India thus expressed its hostility, the States were
free to act on their own, since health was constitu
tionally their affair, subject to certain ill-defined
constraints with respect to standards of medical
education, and health Ministers made their autonomy
clear in 1954.-6
In addition, it was clear that the training of
auxiliary medical personnel was regarded as a
perferable alternative means of extending rural
medical care. A scheme proposed in 1952 was
discussed in the 1954 Central Council of Health and
jn general, those supporting the health auxiliaries
were those opposed to the involvement of the
indigenous practitioners.27 However, this proposal
was refined and reduced over the next few years,
until it was dropped completely.
The early 1970s saw a resurgence of discussions
concerning the inclusion of indigenous practitioners.
This followed the ‘Gharibi Hatao' election success of
Indira Gandhi in 1971. In 1972 the Minister of
Health announced a scheme to enlist registered
medical practitioners in Ayurveda, Unani, Siddha and
homoeopathy after a short period of training (4
months), to provide them with a kit containing
medicines for common ailments, and thus "to
provide medical services to the entire rural area
within as short a time as possible, say about three
to four years".28 Apparently this scheme received
the strong backing of the Prime Minister, and
sanction by the Task Force of the Planning Commi
ssion, but when the Health Minister was replaced
after nine months, little more was heard about it.
However, in retrospect, it can be seen as forerunner
of schemes proposed in 1975 by the Srivastav
Committee, and in the
plans currently being
implemented, which are loosely based on the Janata
Government proposals made in 1977. The Janata
manifesto called for the organisation of "a cadre of
medical, paramedical community health workers
(CHW) among whom the trained practitioners of
indigenous systems of medicine will be a part". 29
In practice, it was decided that the community
should choose who was to be the new CHW and
they were merely to be advised that the use of an
existing indigenous practitioner would be wise. In
fact the choice of the CHW has been a highly
political decision, heavily influenced by the doctors
who were to do the training, and it seems that
relatively few CHWs are, in fact indigenous practi
tioners, whether trained, registered or not. Once
again, the offer being made to the indigenous
practitioner (fulltime or part-time) was not very
attractive, since he would be recruited at the bottom
of the medical hierarchy. However, the training
schemes included the possibility that the CHW be
trained or equipped in indigenous techniques
Socialist Health Review
120
and
therapeutics, and some States
indigenous graduates to do the training.
recruited
There was no suggestion that the CHW should
be a trained dai, which is not surprising, given
the low estimation of these women. Nor were
women with other backgrounds chosen in spite
of the experiences of various voluntary schemes
which suggested that women were more reliable,
acceptable and suitable for this work. Instead, a
new dai training scheme was introduced, which
was essentially just a return to the earlier schemes
which had been allowed to lapse in the 1950s.
Like the CHWs, they were to be trained at the
rate of 1 per 1000 population, and there may have
been a feeling that this was the women's proper
place. Unlike the CHWs, however, the trained
dais were not to be given a regular honorarium but
only compensated if they referred women to ante
natal registration. So far no evalutation of the
dai training has appeared, though one is plan
ned for 1981.
The impact of the latest schemes is thus two
fold. On the one hand, it has meant the inclusion
of more indigenous practitioners into State employ
ment: on the other hand, it has created a new
band of practitioners who see themselves as po
tential doctors. Voluntary schemes have also been
unwilling to involve the local indigenous healers
except in a peripheral way. Once again, the stated
reasons have been that the indigenous healers are
not relevant in the services which are regarded as
high priorities — maternal and child health, or
community health services, and there is undoub
tedly some strength in this argument.
2. What to do about registering or bannning unqualified practitioners: The years follo
wing Independence also saw debates about the
proper course of action to follow with respect to
unqualified practitioners, with moves to outlaw their
practice being seriously considered in 1955 and
1959. The discussions in 1955 were inconclusive:
another committee was established (the Dave com
mittee) and its report in 1958 (recommending the
continuance of integrated courses and the esta
blishment of country-wide registration schemes) was
left for States to decide whether to implement. 30
The 1956 Act which re-established the Indian
Medical Council (now called the Medical Council
of India) prohibited unregistered medical practice,
but the Government of India advised State
Governments not to implement that clause. In 1972,
after a whole series of discussions in the Central
December 1985
Council of Health, States were advised to follow
Kerala's proposal to amend their legislation so that
those practising 'modern medicine' for at least 10
years would be registered on a separate list and
allowed to continue (but be barred from prescribing
dangerous drugs, doing surgery, obsterics or radio
therapy). No further unqualified practitioners would
then be allowed to practise. The Indian Medical
Association called this a "quacks' charter", and
managed to prevent any move on this front — but
they could not prevent unqualified and unregistered
practitioners from continuing to provide 'modern'
medical services.31
The 1950s and 1960s saw the slow but steady
extension of registration schemes designed to regis
ter those currently practising indigenous medicine,
but to forbid any new practitioners who had not
gained registrable qualifications. As with the model
for this legislation, the 1938 Bombay Act, there was
considerable pressure against the enforcement of
the penal clauses and moves to pass later amend
ments to include a new set of unqualified pra
ctitioners.32 Even after the 1970 Central Government
Act establishing a central policy on standardising
the registration of indigenous practitioners, some
States were still registering on the basis of expe
rience only, while others insisted on the acquisition
of a registrable qualification.33
By 1977 there
were 93 colleges providing Ayurvedic education,
with a total intake capacity of over 3600 per year;
14 Unani colleges with an intake capacity of 485
per year; and one Siddha college with 50 places a
year 31 However, the total registered as practitioners
on the basis of institutional qualifications was
much greater than this suggests. It would appear
that registration boards take a relatively lenient
view of claims to qualifications, or that there is
massive double registration (see Table 2).
Table 2.
Registered practitioners in Indian systems of medicine
and homoeopathy. 1977
Insti
tutionally
qualifed
Not
institutionally
qualified
Enlisted
Ayurveda
Unani
Siddha
Homoeopathy
117765
10262
1559
19.871
105344
20138
16569
74166
—
—
—
51397
Total
149457
216217
51397
Source : Pocket Book of Health Statistics of India 1978,
Central Bureau of Health intelligence. New Delhi. 1979.
COMMUNITY HEALTH CEl L
47/1. (First Floor) St. Marks Boat?,
Banqalcre - 560 00A.
3. Whether indigenous training should be
'pure' or 'integrated' : Immediately after Indepen
dence the supporters of 'integrated' medicine were
successful in several parts of the country in
establishing colleges and ensuring that the quali
fications of their graduates were registrable. However,
the counter-attack came fairly quickly. At the 1954
meeting of the Central Council of Health, repre
sentatives of most of the North Indian States
(including Bihar and UP, the largest) supported
the move by the Bombay Government to introduce
'pure' training in Indian medicine. Again the sup
porters pointed to the 'popularity' of the indigenous
practitioners; the tendency in the integrated courses
to spend too much time on Western medicine; the
incompatibility of the indigenous and the cosmo
politan systems; and the availability of indigenous
graduates for rural practice. The opposition argued
that science was universal; that it was a crime
allow the 'unscientific' to practise in rural areas
simply because they were cheap; that there was
an absence of senior vaids or hakims to take tea
ching positions; and that indigenous practitioners
actually used Western drugs and treatments. 25
These disputes have largely been won by the
supporters of the 'pure* school, and by 1 975 there
was increasing concern expressed by and about
the estimated 50,000 integrated practitioners, whose
anomalous position with respect to registration
and to drugs legislation left them particularly
exposed.36
However, to a considerable
extent
this was a Pyrrhic victory; most graduates appear
to perceive their training as second-rate and it
is widely argued that they actually practise using
cosmopolitan drugs. In other words, the attempt
to reach parity of status has not yet been successful.
4. How to control the ,use of 'allopathic'
drugs : Finally, in spite of an agreement in 1958
that only those with Western medical qualifications
would be permitted to prescribe the drugs listed
in the 1945 Drugs Rules, this too was not imple
mented. This was complemented by an apparent
unwillingness to make serious attempts to enforce
general controls on pharmacists and pharmaceutical
companies, so that there is little or no effective
control over access to any drugs in India. This
alone tends to nullify almost all the other decisions
with respect to indigenous healers. As Neumann
and others have shown most 'unofficial' healers,
whether registered as vaids or not, tend to prescribe
laigely from the cosmopolitan pharmacopeia.37
With relatively free access to these drugs, there are
c
linually new practitioners becoming established
on the basis cf experience.
Indian
political
culture seems to accept as legitimate the claim
that they have rights to a livelihood in this way.
One of their strongest arugments is that they pro
vide services where cosmopolitan doctors are
unwilling to go — in the rural areas. Nevertheless,
many of them actually practise in urban areas, but
through their links with politicians they seem to
be able to prevent punitive action against them
selves and to be able to make powerful political
cases for the amendment of hostile legislation.18
Conclusion
One of the difficulties of making clear assess
ments of the nature and effect of Government
policy with respect to indigenous healers is that
there is no clear line being followed. On the one
hand, it is clear that indigenous medicine is essen
tially marginalised, with many of its practitioners
part-time, dealing with a limited range of ailments,
drawing heavily on the cosmopolitan pharmacopeia
and perceiving cosmopolitan medicine as superior.
Government policy, particularly in terms of employ
ment and expenditure, reinforces this trend. On
the other hand, there is a trend towards greater
respectability, with the extension of registration
schemes, the recognition of indigenous contributions
by the international agencies and in CHW training,
and some steady expansion of employment. The
failure of attempts to suppress or control unqualified
practitioners, and the loop-holes in registration
schemes, mean that the cosmopolitan and qualified
indigenous practitioners alike are theatened by
'unfair' competition which is outside their control, so
that the formal commitment to the modernisation of
medical care in India is very different from the reality.
There seem to be a few threads which can
be drawn out of this, however. Firstly it is clear
that indigenous practitioners of all kinds do provide
an alternative which the Government has to come
to terms with whenever its legitimacy is weakened.
The greatest advances have come in the period
when the new Republic was being established;
when Congress was reasserting its supremacy after
its losses in the late 1960s; and during the Janata
regimes since 1977. Secondly, it is clear that the
alternative solution to the problem of providing
a cheap extension of Government health services
to rural areas—the employment of para-medical
personnel or community health workers — has been
preferred. This has been premissed on the idea
that they will be more controllable, and less likely
to claim the status of 'doctor—when of course
Socialist Health Review
122
this is the major complaint of the cosmopolitan
doctors and the major aim of many CHWs.
In terms of the arguments with which I opened
this paper it is clear that all of them have their
weaknesses. Indigenous practitioners are not dying
out, they are infiltrating Government and retaining
considerable popular appeal, even in urban areasOn the other hand, their impact on cosmopolitan
medicine is a great deal less than the influences the
other way, and the indigenous systems remain
subordinate. Yet to argue that cosmopolitan medi
cine alone meets the needs of the ruling class is also
inadequate, since the very political support which
the practitioners can generate by virtue of their
positions means that politicians woo them assidu
ously, even if they no longer have a coherent
ideological position which commands much support.
It is much easier to see how women healers are
being marginalised and excluded from positions
of influence than to draw clear pictures of the
nature of the changes amonst the men.
11.
Indian Statutory Commission, Memorandum submitted by the
Government of Punjab, Vol 1, Lahore, pp. 256-267, 1928.
Memorandum submitted by the Government of Bombay, pp:
374-375, 1928.
12.
Jeffery R. op. cit., 1979.
13.
Chandrachud C.N. Memories of an Indian Doctor, pp. 123-124
Bombay, 1970.
14.
These were summarised in the Indian Medical Gazette.
15.
Leslie C. op cit., p. 412, 1978.
16.
Brass P. op cit.. 1972.
17.
For example Nichter M. Practitioners and indigenous
medicine in North Karnataka Ph D. Thesis, Department of
Social Anthropology, Edinburgh University, 1978.
18.
See for example. Blunt E.A.H. Castes and Tribes of the
Northwest Provinces, New Delhi, 1969 (reprint of 1901
edition).
19.
Annual Report of the Public Health Commissioner with the
Government of India for 1927, Calcutta 1930.
20.
Handbook of the National Planning Committee, p. 152 Bombay
1946.
21.
Report of the Health Survey and Development Committee
(Chairman Sir Joseph Bhore), p. 74 New Delhi, 1946.
22.
Leslie C. op cit., 173.
23.
Report of the Proceedings of the Central Provincial Health
Ministers' Conference, 1948, p. 14. Simila 1949.
24.
Health for all Report of a joint committee established by the
I.C.M.R. and I.C S.S.R., New Delhi 1980.
25.
Brass P. op. cit. : see also Summary Proceedings of the Third
Health Ministers' Conference, New Delhi, 1950, pp. 15-37,
Calcutta, 1 952.
26.
Summary Proceedings of the Second Meeting of the Central
Health Council. Rajkot, 1954, New Delhi, 1955.
27.
Ibid.
References
1 .
Leslie C. The professionalising ideology of medical revi
valism. In Entrepreneurship and Modernisation of Occupati.
ona! Cultures in South Asia (Edited by Singer M ) Durham,
1973; Leslie C. The professionalisation of Ayurvedic and
Unani medicine. N. Y. Acad. Sci. Ser. 2 30. 1968; Leslie C.
The modernisation of Asian medical systems. In Rethin
king Modernisation (Edited by Poggie J.J and Lynch R. N.)
New York
1974; Brass P. The politics of Ayurvedic
education, in Education and Politics in India (Edited by
Rudolph L. H. and Rudolph S.l.) Delhi 1972.
28.
J. Indian Med. Ass. 60, 75-77, 1973.
Health Care Service in Rural Areas (Draft Plan), p. 1. New
Delhi. 1177.
2.
Leslie C. (Ed.) Introduction, in Asian Medical Systems
10, University of California Press, Berkeley, 1976.
p.
29.
3.
Frankenberg R. Allopathic medicine, profession and capi
talist ideology in India. Paper presented at the IXth World
Congress of Sociology, Uppsala 1978; Banerji D. Place
of the indigenous and western systems of medicine in
the health services of India. Paper presented at the IXth
World Congress of Sociology, Uppsala, 1978.
30.
Summary Proceedings of the 6th Meeting of the Central Council
of Health, Bangalore. 1958 pp. 74-84, New Delhi, 1959.
31.
J. Indian Med. Ass. ibid.
32.
Chandrachud C.N. Memories of an Indian Doctor, pp. 123124, Bombay 1970.
4.
5.
Leslie C. Pluralism and integration in the Indian and
Chinese medical systems. In Medicine in Chinese Cul
tures (Edited by Klenmann A. et. al.), pp. 408-409,
Washington DC, 1978.
33.
Summary Proceedings of the 18th Meeting of the Central
Council of Health, Bhubaneswar. 1973, Ne/v Delhi, 1974.
34.
Pocket Book of Health Statistics of India 1978, Table 25.
35.
Hume J. Rival traditions: Western medicine and yuman-itibb in the Punjab, 1849-89. Bull. Hist. Med. 51, 214 — 231,
1977.
Summary Proceedings of the Second Meeting of the Central
Council of Health, Rajkot. 1954, New Delhi, 1955.
36.
Editorial Comments. J. natn Integr, med. Ass. 17, 1975; 18,
1976. passim.
37.
Alexander C.A. and Shivaswamy M.K. Traditional healers in
a region of Mysore. Soc. Sci. Med. 5, 595-600, 1971:
Neumann A.K. et al. Role of the indigenous practitioners
in two areas of India, Soc. Sci. Med 5. 137-149, 1971.
38.
Editorial Comments Indian med. Pract. 16. 1967; 17, 1968.
6.
Leslie C. op. cit. 1974: Hindu medicine and medical educa
tion, CaIcutta Ref XXII, LXXXIII, 106-125, 1866.
7.
Census of Bengal. 1 872, Calcutta, 1874.
8.
Seal A. The Emergence of Indian Nationalism. Cambridge, 1968.
9.
Jeffery[R. Recognising India's doctors : the institutionali
sation of medical dependency, 1918-1939, Mod. Asian Stud,
13, 301-326, 1979.
10.
National Archieves of India, files in the Department of
Education, Health and Lands, July 1919, 26-51A and
April 1916, 96-99A.
December 1985
Roger Jeffery
Department of Sociology
University of Edinburgh
18 Buccleuch Place
Edinburgh EH8 9LN Scotland
123
SYSTEMS OF MEDICINE: ROLE AND RELEVANCE
sujit k das and smarajit jana
While traditional medical systems passed their peak centuries ago. modern medicine has not entirely
replaced them. The issue of traditional v/s modern medicine, the authors argue, is essentially an ideological
one, governed by political interests', this is illustrated by the variance in the official, semi-official, and
progressive views on the subject. Even the Chinese experience, the authors say, demonstrates this. Systems
of medicine, as such, in their opinion, are irrelevant in the context of a people-oriented and egalitarian health
system, in which they will comprise merely a set of therapeutics. Thus the entire debate on the role of
traditional medicine is academic.
f | *he historical development of health care in
the
western societies has been analysed and
explained in various ways. Those analyses bear
relevance to the Indian situation to the extent that
western medicine (allopathy) had been introduced
and developed by the colonial power and after
independence, it developed rapidly with State
patronage. Traditional systems, however, passed
their peak of development long ago, but existed
and persisted in Indian society.
Among the traditional systems, the oldest one,
Ayurveda, reached a very high level of development.
Ayurveda is the fore-runner of Indian scientific
development
and
the father of
materialist
philosophy. Ayurveda is a comprehensive body of
knowledge in medicalscience having well developed
or rather too highly developed theoretical foundation
based on empirical data, scientific methodology of
observation, experimentation and analysis, and
disciplined norms of practice.
Ayurveda asserts
that all things living and non-living are products
of natural matters; disease is the result of material
change in the body due to interaction with
natural matters; and therefore could be corrected to
an extent with the help of natural matters (drugs).
Charaka-Samhita declares, "There is nothing in
nature without relevance to medicine''. There is
nothing supernatural about natural and human
events. In ancient society, the dominant ideology of
the all-powerful ruling class was totally and
oppressively anti-materialist. Materialist heretics
actually had no right to live. That is why, all extant
source books of Ayurveda are found to be camou
flaged with enormous amount of metaphysical and
religious garbage with a view to project an
appearance of conforming to the dominant ideology.
(Chattopadhyay, 1977). But what now exists and is
practised as ayurveda or sidhha is not the ancient
dynamic science of ayurveda but a decadent form
which absorbed the alien metaphysical interpolations
as truth and degenerated. The other major existing
system Unani, the legacy of Greco-Arab medicine,
is no different.
The scientific basis of modern medicine devel
oped later. Starting from the 19th century, it
developed
on the shoulders of physical and
biological sciences in the 20th century —achieving a
tremendous speed after the 2nd Woild War. It
has been argued that British colonialism brought
along with it destruction and decay of the indi
genous systems of medicine (Banerji). But there is
little data available to substantiate this view. Others
claim that modern medicine did not make much
impact except with limited urban population; the
largest section of the population still depend on
indigenous systems, which is dealing more or less
satisfactorily with many of the health problems of
the local people. (Bannerman et al, 1983)
Alhough the state health care service has
been built on the principles of modern medicine
the indigenous systems including homoeopathy
have been receiving state patronage in the later
period. Budgetary allocation on the development of
indigenous systems and homoeopathy has been
increasing since the fourth plan period and the
number of their practitioners as well as infrastructure
have now reached impressive proportions.
Total No.
of Regd.
practitioners
Admission
capacity
Ayurveda
Unani
2,32.247
22,756
Sidhha
Homeopathy
Modern Med.
18 190
1,09,493
2,68,712
3,306
535
75
7,513
10,934
Hospital
Beds
Dispen
saries
9,783
627
—
2,249
4,86,805
12,027
986
426
1,782
17,455
Source: Health Statistics of India; CBHI , Ministry of Health &
Family Welfare. GOI, 1983. Figures are incomplete due
to lack of information from a few centres.
Socialist Health Review
124
To this figure if we add the number of various
paramedical personnel e.g. Pharmacists, Nurses of
different categories, MPHW, LHV, Health Assistants
and Supervisors, CHG, midwives, one may arrive at the
conclusion that India does not need any more
doctors at all for a comprehensive health care
delivery system
(ICSSR-ICMR, 1981) Still the
official view, which is inherently wary to admit
failure, is that the state health services have been
unable to meet the actual health needs and
priorities of the people, have been hospital-based
and cure-oriented neglecting
the preventive,
promotive, public health and rehabilitative aspects of
health care, and benefiting only the upper crusts
of the urban population (GOI, 198').
The Question of Different Systems
The official view :
The rising aspiration of the masses and
increasing demands of medicare from the diseaseridden people, particularly incensed by the glaring
difference in the standard of medicare between the
haves and have nots, have so far been chiefly
instrumental for increasing allocation in the state
health sector People have also become aware of
the discriminatory availability of the state service.
The government, therefore, has to admit the existing
reality which is self-condemnatory and with the
view to find a way out, advocated promotion of
indigenous and homoeopathic systems of medicine.
To provide ideological cover, a large number of
virtues of those systems have been discovered and
invoked, e g. rich heritage, glorious achievements
and cultural compatibility (GOi, 1982) The govern
ment realises that if the grievance of the larger
section is contained by providing them with low-cost
non-allopathic systems, the absolutely necessary
but costly provision of modern medicine for the
affluent urban section can be safeguarded. But,
the life-saving contributions of modern medicine
cannot be entirely withdrawn from the people.
Hence, the question of integration. It has been
recommended that the practitioners of the nonallopathic medicine must have a 'basic knowledge
of human anatomy, physiology and other necessary
medical knowledge'; research should be carried out
with modern equipmentand diagnostic methodology,
so that it becomes acceptable to the modern scienti
fic world; modern technology be introduced for the
manufacture of traditional medicine and specific
standards be adopted to ensure quality of raw
materials and manufactured products. For integration
of the indigenous and modern systems, the services
of non-allopathic practitioners should be integrated.
December 1985
at the appropriate levels, within specified areas of
responsibility and functioning, in the overall health
care delivery system (GOI, 1981 and 1982).
The leaders miss the point that if the above
measures are implemented, nothing remains of
tradition and the very indigenous character is wiped
out. They also forget that the non-allopathic systems
have litt>e to contribute towards preventive, promo
tive, public health and rehabilitative aspects of
health care. But then, their concern is not so much
for traditional systems as for availability of some
acceptable form of medicare for the uncovered
population.
The semi official view:
The study group of ICSSR — ICMR recommends
that there should be a national system of medicine
with 'synthesis', and not 'integration' of different
systems; practitioners of indigenous systems be
utilised in the national system; each system be
allowed to retain its own identity and grow according
to its own genius; in medicare institutions patients
be offered choice of systems; in course of time all
training institutions of medical and health personnel
will teach one and same system of medicare with
individual systems being offered as specialisation
courses at the post-graduate level; and in the same
breath, 'in course of lime medical graduates from
any medical college would be able to provide such
multi system care' (ICSSR — ICMR, 1981). Earlier an
official committee also recommended a national
system of medicine and health services, in keeping
with our life systems, needs and aspirations. (GOI,
1975).
It is clear that these recommendations are s •
full of self-contradictions and wishful thinking that
these cannot be taken as anything but hasty remarks.
But one point is obvious. The observers are anxious
that somehow the non-allopathic systems be support
ed and given a place, whatever that may be, in
health care service.
The WHO, has since come out as another
champion of traditional systems. Facing the reality
of shortage of personnel and provisions of MM,
and the existence of a large number of practitioners
of ’ other systems, the WHO calls for integration at
appropriate levels but also suggests selective
scientific training for personnel and scientific bio
medical research into their therapeutic materials.
The above views, while talking about cultural
compatibility, commercialisation and high cost of
modern medicine have introduced another ideological
125
pointthat health is essentially an individual responsi
bility (GOI, 1975), and that community participation
is the process by which individuals and families
assume responsibility for their own health and
welfare and for those of the community (WHOUNICEF, 1978).
The non official progressive view :
Essentially the progressive views on the question
of ncn allopathic systems evolve from their critiques
of modern medicine. There is no such thing as
medicine in general; medicine is always articulated
in a given social formation and the mode of
production of that social formation gives rise to its
corresponding medicine; thus we can only speak of
feudal medicine, capitalist medicine, or communist
medicine; thus,
modem medicine, is capitalist
medicine. It has a dual function : (a) dominance
and control, exercised to maintain the exploitative
relations of production, and (b) useful and needed
function, which is necessary in any society, to
contribute to the care and cure of the working
population. These two functions are not separate
but, rather, the control function is exerted through
the useful function (Navarro, 1 983) Modern medicine
is mechanistic and reductionist giving rise to
professionalism and mystification establishing the
domination of a class of elite health professionals
who propagate, reinforce and maintain bourgeois
ideology
(Waitzkin, 1984).
Perhaps the most
profound, impact-making critique is that of Ivan
lllich. His analysis of clinical, social and structural
iatrogenesis, leading to growing medicalisation of
life exposes the negative effects of modern medicine
in a telling manner, (lllich, 1977). Modern medicine,
based on the paradigm of clinical medicine, even
at its most progressive limits persists as an indivi
dualistic, class-biased and ideological mode of
diagnosing, treating and preventing illness, and is
necessarily inadequate as it ignores the socio
political and economic determinants (Turshen, 1977).
To obviate the negative effects of modern
medicine, a number of prescriptions have been
offered, the promotion of traditional systems of
medicine being one of them. The Chopra Commitee
(1948) recommended the use of indigenous systems
at the lower level and synthesised medicine at the
higher levels of medicare, and it has been lamented
that had these recommendations been implemented
at that time, it would have resulted in a drastically
different system of medicine. (Jesani & Prakash,
1984). Though the present official view, is veering
round to these recommedations, there appears to be
little prospect of the development of a drastically
different system of medicine. While emphasising
the alien identity of modern medicine and cultural
compatibility of indigenous medic ne, and recomm
ending maximum use of self-care procedures and
various home remedial measures, services of tradi
tional healers of various systems, and communityselected primary health workers, Banerji conceds a
central scientific core in modern medicine and
seeks its separation for correct application in Indian
care system (Banerji 1 982). Others, while deprecat
ing unnecessary polemics between different systems,
call for 'a coherent synthesis of the valid elements
of the different systems of medicine into a modern
scientific health science', and argue that simplified
scientific analysis of drugs and remedies of different
systems and their propagation among the people
will result in self-reliance of both the people and
drug availability. "Ayurveda can continue to provide
valuable ideas for reserach in basic and applied
biomedical research. But this would be possible
when Ayurveda undergoes a basic transformation.
Ayurveda has to become Ayur-Vigyan (Science)"
(Vaidya). Another intensely vigorous view is the
Report of the Committee on the Indigenoue Systems
of Medicine Even after a long period of neglect
due to absence of State patronage and well over a
century after the introduction of western medicine
which became the sole recipient of state help, the
indigenous systems of medicine were not only
serving the need of over 90% of our people, but
doing so much more effectively and economically
than western medicine" (Government of Madras,
1923) This view denounces the attempt of synthesis
by placing the indigenous remedies under scrutiny
of modern science and, asserting that the present
location of different systems is due to the political
process, urges clear identification of a system of
medicine that can meet the needs of our people
(PPST, 1984). In respect of tribal societies, it is
c’aimed that tribal medicine which is actually
based on ancient ayurveda, is competent enough to
meet the local needs and for the protection of
cultural identity and with the objective of selfreliance, entry of modern medicine should be
barred (Shankar, 1985).
The Chinese connexion
All these views almost uniformly draw inspira
tion from the Chinese model which is hence,
discussed separately. The Chinese policy, a few
years after revolution, of integrating the traditional
medicine and practitioners into the mainstream of
medical education and health care service, received
worldwide
publicity
and
almost
universal
Socialist Health Review
126
appreciation It has since been hailed as a success.
Attempts have, therefore, been made to introduce
this policy in several Third World countries with
disastrous failures which have later been explained
as due to difference in socio-political-economic
structure. But the actual Chinese model has seldom
been painted clearly and truthfully.
The basic aim of the Chinese health care
service in the fifties was to maintain, develop and
raise production both in rural and urban context i e
agriculture and industry. It has been repeatedly
stressed in the health policy of the government and
the party that xhe principal aim of health work is to
ensure industrial and agricultural production. This
fact may embarass the strident critics of capitalist
medicine and health care which is accused of pursuing
the very same aim. Agriculture being the mainstay
of the economy, organised rural health care is
practically non-existent,
health
personnel and
infrastructure being miserably inadequate,
the
earlier Mao Tse Tung thought has been invoked,
to rely on modern doctors is no solution. Of
course modern doctors have advantages over the
doctors of the old type, but if they do not concern
themselves with the sufferings of the people, do
not train doctors for the people, do not unite with
the thousand and more doctors and veterinarians
of the old type in the Border Region and do not
help them to make progress, then they will actually
be helping the witch doctors and showing indiffer
ence to the high human and animal mortality
rates". Mao's reference to withchraft is very real
Joshua Horn's own experience told us that the
services of
the
traditional
practitioners was
available only to the rura* elite, because they were
highly professionalized and expensive and the herbal
medicines were also very costly. The overwhelming
majority of the poor villagers had actually to depend
on the village quacks and witch doctors in pre
revolutionary China (Horn, 1971)
Integration of Chinese medicine with modern
medicine is only a part of a whole comprehensive
health care service. This policy is based on the
principles of modern medical science and operated
through indigenously available technology, and
infrastructure. 'Mass line' in preventive work and
environmental protection, emphasis to maintain
production, integration of traditional doctors for
man-power mobilisation in medicare, comprehensive
coverage of population, rapid production of health
personnel, and political dominance in health admini
stration— are the
basic
elements.
Regarding
integration, the policy adopted at the First National
December 1985
Health Conference (1950) was based on the altitude
that in view of the shortage of doctors and medicine,
Chinese traditional medicine should be utilized
(because it was there and readily available rather
than because of any inherent value it had). In the
policy of 'unity and reform' the stress was on
reform of the traditional system by the western.
When this attitude failed to bring the desired results,
the political command intervened and the campaign
for superiority of Chinese culture and glorious
tradition of Chinese medicine was launched which
enhanced the social status of the traditional
practitioner and resulted in more widespread use of
herbal remedies. "Even when herbal remedies were
not very effective,
they were of considerable
importance as they still provided the peasant with
some support, whereas if it had been decided that
only modern drugs should be used, he would have
none at all as expenses would have placed any drug
therapy out of reach. The use of herbs for the
purpose of psychological support — though not
explicitly admitted in the Chinese press — is not
much different from the wide variety of placebos
offered to patients daily in industrialised countries".
(Wilenski 1979).
From the beginning of the sixties, the enthusiasm
towards traditional systems ebbed, and profession
alism and elitism again started gaining dominance;
even the traditional practitioners were concentrated
in the larger country towns and served on the basis
of private practice Mao's intervention at this stage
on the eve of the cultural revolution reversed this
direction. In his famous June 1965 directive Mao
said, "Tell the Ministry of Public Health that it only
works for 15 per cent of the entire population. ...
The Public Health Ministry is not a people's Ministry.
It should be called the Urban Public Health Ministry
or the Public Health Ministry of the privileged or
even the Urban Public Health Ministry of the
privileged Medical education must be reformed.......
A vast amount of manpower and materials have
been diverted from mass work and are being
expended in carrying out research on the high level,
complex and difficult diseases, the so-called
pinnacles of medicine. As for the frequently occuring
illnesses, the widespread sicknesses, the commonly
existing diseases, we pay no heed or very slight
heed to their prevention or to finding improved
methods of treatment. It is not that we should ignore
the pinnacles. It is only that we should devote less
men and materials in that direction and devote a
greater amount of men and materials to solving the
urgent problems of the masses...... We should keep
in the cities those doctors who have been out of
A 27
school for a year or two and those who are lacking
in ability The remainder should be sent to the
countryside". (Mao, 1977)
The large numbers of the health professionals
since sent to work in the rural areas soon realised
that they could not handle the vast burden of rural
ill health and also they could not hope to return to
urban institutions without an alternative rural health
service. Soon emerged the barefoot doctor who is
neither a paramedic nor a doctor's auxilliary, but a
part-time doctor trained in diagnosing and treating,
without assistance, common or recurrent diseases
prevailing in the locality. The scheme succeeded for
the chief reason that medicare infrastructure had
since been organised on the basis of universal
coverage right up to super-speciality at the top most
level with efficiently functioning referral system. But
the recent trend is a shift towards greater professionalisation and medicalisation of the health system,
higher education of the barefoot doctors, greater
emphasis on higher quality of medical education
with the return to seven-year curriculum, and more
research centres, modern hospitals, specialists and
technologically sophisticated interventions (Rhode,
1983). China now takes pride in letting us know
that she, in 1982, has 9,52,000 doctors of modern
medicine compared to
2.90,000 of traditional
medicine and 2000 senior doctors of modern
medicine also trained in traditional medicine While
in the year of liberation, there were 10,000 fully
trained and 30,000 partially trained doctors of
modern medicine and 5,00,000 traditional practition
ers. (Wilenski, 1 979).
The culture issue :
Concern for Indian culture is the common issue
in the agenda of the advocates of the traditional or
integrated systems. "Perhaps the simplest and most
useful formulation of the concept of culture is to
say that it is acquired or learned system of shared
and transmittable ways of adjusting to life
situations....... A common characteristic recognized
in all treatises on culture is change, a capacity to
shift, accumulate or loose components, which makes
culture far more flexible and variable than are the
somatically determined patterns of behaviour"
(Simmons & Wolff, 1954). Culture is not a rigid
frame, inert model, or static dogma of guidelines
governing community or individual conduct. Culture
is built up on complex interactions — involving
physical, environmental, ideological, political, and
predominantly economic. Economic relations i.e.
relations of production, exchange and consumption,
find expression in cultural and social responses,
128
and changes in the economic relations bring about
profound changes in the cultural matrix. Tradition
is not culture. Tradition is the vestiges of earlier
cultural trends, and ideologically influences the
present and future trends. Just because the peasant
lives with the bullock cart for generations, he should
not be taken as culturally bound to the bullock cart,
or demands to remain so Adherence to witchcraft
and ideological allegiance to the metaphysical theory
of health and disease do have their roots in
economic relations and is a reflection of the stage
of development of the productive forces and
superstructure. While on the one hand, the capitalist
onslaught on the tribal ways of life does produce
disastrous consequences on the other, the urge
to protect the tribal identity gives rise to irrational
obscurantism which is anachronistic to progress and
inadequate to meet the need Such an urge often
leads to the proposition that western medicine is
not essential for India's particular needs and we are
entitled to a separate scientific medicine relevant to
our social-cultural-historical context (Bajaj, 1985).
A carefully planned study of health behaviour
of rural population of India has revealed "that the
response to the major medical care problems was
very much in favour of western (allopathic) system
of medicine, irrespective of social, economic,
occupational and regional considerations. Accessi
bility of such services (modern medicine) and capacity
of the patients to meet the expenses were the two
major constraining factors" fBanerji, 1974). In
contrast, the observations of studies conducted in
1951-52 in villages of Rajasthan and UP revea*
that the villagers largely rejected the western
medicine in favour of witchcraft and traditional
remedies (Carstairs and Marriot 1955). This profound
change has occurred not only due to the remarkable
curing and life-saving remedies of modern medicine
but also from economic changes in all spheres of
rural community life and consequent politicoideological changes. A study by 1 3 social scientists
in the Toushan commune health clinic of Kuangtung
province, China, concludes that incorporation of
indigenous medicine into the organised health care
service is a rational move on political, ideological,
technical, socio-medjcal and economic grounds but
conceds that 70 percent of patients opt for western
medicine. Medicine bag of the barefoot doctor
carries 80 percent drugs of modern medicine (Lee,
1982). In Shangdon province, China, the number of
x ray examinations increased by 80% in the rural
areas in 4 years ('76-80'). Of the total 4111 x-ray
machines in the province, 3824 are situated in
rural and district hospitals (Feugetal 1984). The
Socialist Health Review
assertion of cultural compatibility of traditional
medicine in India appears to be a myth. The Govern
ment of West Bengal has for some years appointed
homoeopathic and ayurvedic practitioners in the
rural health centres. In all such Centres they not
only remain idle but usually their services are utilised
for other purposes. No quantitative study is
available on the practice of use of modern drugs
and implements by the non-allopathic practitioners.
Journal of the IMA (June, 1985) published a
letter from one Dr Buch who complained that the
existing govt rules precluded him from recruiting
15 Ayurvedic graduates, who he interviewed, for a
TB hospital at Keshod, Gujarat, which had been
suffering from extreme dearth of doctors, even
though all those Ayurvedic doctors were practising
MM in the nearby villages. He lamented, "Why we
continue to waste our national resources on such
education which our youth decline to practise in
future?"
an
egalitarian
health care service.
Though
professionalism prevails in Cuba to an absurd
extent (only doctors are entitled to give injections),
still Cuba has made remarkable strides in raising
the health status of the people and the health
system is free from professional explotiation.
The other issues :
On the other hand, a rational view towards all
these elements should also be evolved. One who
vigorously attempts to expose the bias of capitalist
medicine against people's interests, may run the
risk of making a fetish of these elements. Individual
ism, mechanicism.
reductionism etc. are not
touchstones that turn everything they come into
contact with ugly. In all social functions, some
practice of mechanicim and a reductionist analysis
are inevitable at the micro level. Given the operation
of socialist analysis and policy in the health care
programme of a socialist society, at the micro-level
it is reduced to
providing treatment for sick
individuals who, having similar socio-economic
background, may happen to differ widely among
themselves in respect of physical, psychological,
behavioural characteristics as well as in the quantity
and quality ol their responses to medical interven
tion. Indeed, the situation is necessarily reduced to
taking a mechanistic, individualistic and interven
tionist approach in performing the instant task of
attending to a sick indivdual who is not only a
number as featured in the policy and programme
making at the macro-level, but also a human being
possessing a distinct personality and capable to
respond to and interact with, employing his own
judgement, the medical provisions earmaked for him
by the organised society.
Mystification : is more pronounced in the
traditional systems which draw sustenance from
metaphysical philosophy and fatalistic belief regard
ing health and disease, isolated from environmental
and
socio-economic-political
determinants. In
contrast, the body of knowledge of modern medicine
is not only universally accessible but, shorn of its
avoidable terminology, this knowledge can be and
has been mastered by
non-medical personnel.
Because of its integral relationship
with other
physical and
biological
scientific
disciplines,
modern medicine has largely been demystified at
the higher functional level. The mystification of the
practice of modern medicine is not an isolated
phenomenon but is prevailing in all other professions
including even the legal profession which does not
depend on science and technology. This mystifi
cation is a feature of market economy and an
instrument of exploitation and profit. Demystification
at the level of practice can be brought by change
in the economic relationship and not by replacing
with more mystified traditional systems.
Professionalism : which also is utilised for
profit and exploitation is similarly a feature of
commodification of medicine and has little to do
with systems of medicine. With the gradual dimunition of the commodity character of medicine, China
has curbed professionalism to a great extent. On
the
other hand, in
post-revolutionary Cuba,
professionalism has been encouraged and streng
thened in a State monopoly health system but that did
not pose any constraint in the way of establishing
December 1985
Individualism, Mechanicism, Reductionism,
Class bias. Commodification, etc : These are not
peculiar to any system but owe their roots to the
economic base and the dominant ideology. Rather it
can be conceded that modern medicine is least
endowed with these vices because it has opened up
the possibility of taking a materialistic and holistic
view of health and medicine, owing to large
expansion of the data-base and knowledge-base of
the natural sciences and social sciences; growth of
socialisation of production is bound to develop
socialisation of medicine. Choice of systems of
medicine has little relevance to this change.
The Real Issue
The real issue is to formulate, organise and
develop an egalitarian health care service — with
preventive, promotive, curative and rehabilitative
A 29
aspects. Such an ideal is realisable only in a nonexploitative economy
Doyal and Pennell have
shown that in the Capitalist economy, development
of medicine and organisation of health care follow
the needs, priorities and prerogatives of economic
relations. That is why we find changing emphasis
on public health, curative medicine, individualistic
medicine, population control and so on in different
periods. “It is ultimately profit, rather than a concern
to improve overall living standards, which is the
most important determinant of economic and social
decision-making in Caoitalist society" (Doyal &
Fennel, 1981). Rejecting the anti-technology, anti
industry and anti-modern medicine stance of Ivan
lllich. and acknowledging its positive achievements
in the health sector, they argue that modern
medicine is neither a value-free science nor an
altogether evil force, and that its till effects could
be overcome in a radically changed socio-economic
order. Indeed, the idea of changing the character
and organisation of discriminatory and exploitative
health care by choosing and introducing a particular
system of medicine, itself appears to be a
mechanistic, instrumentalist and utopian view. True,
it is conceivable that mobilising the large number of
traditional practitioners and comparatively cheaper
herbal remedies under the State sector following
the Chinese model, a large section of uncovered
population may be offered some form of medicare.
But such a view is hardly relevant in the Indian
context on two counts. One — unlike China there
is no state-monopoly control over the health system
in India and hence it is not feasible. Second — it
needs to be assessed first, if India lacks in the
necessary number of trained personnel in modern
medicine for the operation of Primary Health Care
Service of comprehensive coverages Commenting
that “the argument in favourof the use of traditiona
practitioners does not question why even modern
practitioners of private medicine have not been
properly integrated into third world health care
services", Oscar Gish stresses that the major
obstacle is not the limited resources or technological
deficiency, but the social system which places a
low value on the health care needs of the poor
(Gish, 1979).
Why then all these debates about traditional
systems ? Since the political independence of the
colonies, in the era of neocolonialism the poverty
of the third world masses continue to be a headache
of the imperialist camp. 'Economic growth' approach
was introduced stating that the primary need is
rapid increase in GNP which will necessarily trickle
downwards to alleviate poverty. After two decades
130
when this strategy failed, lately a new 'basic needs
approach’ has been advocated. Ibrahim Samater has,
in an analysis of the strategy and tactics of the
controllers of international economy, shown that
this new approach is another attempt to contain the
growing unrest among the exploited and deprived
population of the third world, and that it is also
bound to fail because without any change in the
property system, in power relations and in the
demand structure, the basic needs e.g. food-clothshelter-water-sanitation-health etc cannot be met.
The ruling class needs to uphold and maintain the
image of the state as the benevolent arbiter for the
masses and the state thereby needs to put priority
on relief and medicare. Physical ailment, debility,
death are extremely sensitive elements with political
consequences. The benevolent image of the state
distributing medical relief often atones for its other
failings. One may be poor or unemployed but when
the state is there to save him from death due to
illness, the benevolent image brightens. But this
benevolence is difficult to mediate through the
provisions of modern medicine The cost is prohibi
tive and will necessarily erode the profit margin
reducing capital accumulation. The only alternative
way appears to be the glorification of the achieve
ments of the traditional systems with a coating of
the theory of cultural compatibility. The culture of
course, refers to poor people's
ulture — not of
those who can afford to purchase modern medicine.
The vigorous promotion of traditional systems by
official and semi-official circles is not out of con
viction in the efficacy and inefficacy of traditional
and modern medicine respectively, but out of
pragmatic poli’ical considerations with the purpose
of co-opting and weakening any challenge to the
existing exploitative socio-economic order which
actually is the cause of the deprivation of the basic
needs e.g. health care. An uncritical support to this
strategy by the progressive health activists will be a
liberal humanist deviation propelled by subjectivism.
From the foregoing it is evident that choice of
a particular system or any integrated systems is of
little relevance to the demand of a people-oriented
egalitarian health system. The traditional system, at
their best, can offer a few remedies in curative
practice. A comprehensive health system will have
to be based on scientific tenets, but while the
underlying theoretical pre conceptions of scientific
will need to be critically re-examined to identify the
elements of class-bias and mechanistic paradigm,
the operative infrastructure should be explored to
resist and eliminate the commercialism, mystification,
professionalism of the medical practice. Scientific
Socialist Health Review
medicine is a product of modern science developed
in the Capitalist regime. While welcoming and
practising modern Science and Technology in all
fields of social life and economic development,
rejection of modern medicine is not only anachro
nistic but utopian.
The role of traditional systems therefore appears
to be limited to effective ^organic and functional)
remedies for medicare, employed under the same
regulatory mechanism as that of modern drugs.
Relevance of the apparently unending debate on
the choice of a suitable system of medicine is only
academic and sterile in the context of our search
for a people oriented comprehensive health caie
service.
References
Chattopadhyaya, D. Science and Society in Ancient
Research India Publication, Calcutta, 1977.
India.
Vaidya, AB Modern Medicine and Ayurveda: A synthesis for
People's Medicine, in Health Care which way to go. Op cit.
PPST Bulletin What is the role of Indigenous Medical Services
in our health-care system?, 4 (1), 64-95, 1984.
Shankar, D, Issues for Debate, Lokayan Bulletin. New Delhi, 3
(3), 50-57. 1985.
Mao Tse Tung Selected Works. Foreign Language Press. Pek
ing, 1967.
Horn. J, Away with all Pe-ts. Abridged reprint in Peoples' China.
Ed. Milton, D. Miltan, N & Schurmann, F, Penguin Books,
England, 1977.
Wilenski, P, The Delivery of Health Services in the People's
Republic of China, Int. Development Research Centre, Ottawa,
1979. This book, contains extensive' references on the
Chinese Health Policy and programmes.
Mao Tse Tung Instructions on Public Health Work. 25 June, 1965,
reprinted in People's China. Op cit, p 151-152, 1977.
Rohde, JE, Health for AH in China : Principles and Relevance for
Other Countries, in 'Practising Health fir AH' Ed. Morley, D.
Rohde, JE, & Williams, G ), Oxford Univ. Press, London
p 5-16, 1983,
Cartwright, FF A Social History of Medicine, Longman, London.
1977.
Yu Gurang Yuan, (Ej) China's Socialist Modernization. F L P,
Beijing, p 740-741. 1984,
Banerjee, D Political Dimensions of Health and Health Services,
in
"Health Care : Which Way to Go?" Ed. Bang A. and
Patel, A.J. M r C, Year not mentioned.
Simmons, LW & Wolff, HG . Social Science in Medicine. Russel
Sage Foundation, New York, p 63. 1954,
Ban.ierman, R.H Burton, J, and Ch'en Wen-Chien (Ed).
Traditional Medicine and Health Care Coverage, Introduction,
WHO. Geneva, 1983.
ICSSR-ICMR Health for AH—An Alte rnative Strategy, Ind. Inst.
of Education, Pune, p 1 62, 1 981.
Goverment of India, Statement on National Health Policy. Mini
stry of Health and Family Welfare, New Delhi, 1982.
Goverment of India, Report of the 'Working Group on Health
for All' constituted by the Planning Commission, 1981.
ICSSR-ICMR, Op cit, p 98-99.
Bajaj, JK, Towards a Non-Western Perspective on Scientific
Knowledge, PPST Bulletin, 4 (2), 97-105, 1985.
Banerji, D, Health Behaviour of Rural Populations in India :
Impact of the Primary Health Centre, Economic and Political
Weekly. Vol XIII. pp 2261-2263, 1974.
Carstairs, GM & Marriot M, Medicine and Faith in Rural
Rajasthan and Western Medicine in a village of Northern
India’ respectively, in ’Health, Culture, and Community’ (Ed
Paul, BD), Russel Sage Foundation, New York. 1955,
Lee. RPL Chinese and Western Medical Care in China's rural
communes, World Health Forum, 3 (3), 301-306, 1982.
Government of India, Report : Health Services and Medical
Education, A programme for immediate action. Ministry of
Health & Family, welfare New Delhi 1975.
Zhang Dan Feng et al. Radiological Services in Shandong
province, China, World Health Forum. 5 (1), 198 .
WHO - UNICEF, Prinary Health Caro, WHO, Geneva,
1978
WHO's opinion on indigenous sytems is found in the Te
chnical Report Series No. 622 (1978) and in many rele
vant documents.
Werner, D, Health Care in Cuba: a model service or a means of
social control or both? in Practising Health For AH Op
cit, p 17-37.
Navarro, V Radicalism, Marxism and Medicine, Int. J. of Health.
Services. 13 (2), 179-202, 1983.
Waitzkin, H, A Marxist View of Medical Care, SHR, 1 (1),4-23
1984.
Illich, I, Limits to Medicine. Rupa & Co., Bombay, 1977.
Turshen, M, The Political Ecology of Disease, Review of Radi
cal Political Economic. 9 (1). 1977 (Reprinted in Health
Bulletin I of Health and Society Group, Calcutta).
Jesani, A and Prakash, P, Political Economy of Health Care
in India, SHR 1(1), 29-44, 1984.
Banerji, D, Political Economy of Western Medicine
World Countries. Mimeo, JNU, Sept., 1982.
December 1985
in Third
Doyal, L & Pennel, I. The Political Economy of Health.
Press, London, 1981.
Pluto
Gish O, The Political Economy of Primary Care and Health by
the People — An Historical Exploration
Documentation,
Amsterdam, pp 79-85. 1979.
Samater IM, From "Growth" to "Basic Needs" - The Evolu
tion of Development Theory, Monthly Review. 36 (5)1-13,
1984.
Sujit K Das
5-3/5
Sector 111
Salt Lake
Calcutta-64
13A
A SEARCH FOR ALTERNATIVES
Organising Vaidus in Gadchiroli
ravindra r p
Gadchiroli, a predominantly tribal district in Maharashtra is currently witnessing a new experiment
in providing appropriate health care. The vaidus, local healers, of the area have come together to
revive and even reformulate an ancient system of healing which is fast vanishing in the face of ex
ploitative inappropriate medicare. A report.
xperiments in community health initiated in the
seventies have now come to stay. There have
been several attempts of evaluating such projects,
the latest being by Sumathi Nair (SHR II 2 ) With
due acknowledgement of the contributions of
these projects to community health, their limitations
are being increasingly identified. The multiplicity
of such models is low due to the requirements of
heavy inputs in terms of resources like finance,
know-how and skills, drugs, training and referrel
facilities and personnel and so on In most cases,
the political component of health/life of community
s ignored, sidetracked or played down. Most such
projects revolve around 'Allopathy' which brings
with it its inherent limitations, moreover, although
allopathy is the 'least unscientific' method, it
remains culturally alien to most people.
It has thus become imperative to search for
new alternatives, free from the above constraints.
In this article, I wish to describe one such ex
periment of organising vaidus (traditional health
workers )
undertaken
by the
'Paramparagat
Vanaushadhi Vikas Va Samshodhan Kendra' (Centre
for Development and Research in Traditional Herbal
Medicine) in the Gadchiroli district of Maharashtra.
However, neither the author nor activists of the
'Kendra'wish to claim that it is the only alternative.
It can, at best, be one of the several alternatives.
The form and content of each such attempt could
depend upon local conditions and priorities of the
experimenting group.
Gadchiroli (formerly a part of Chandrapur) is
a predominantly tribal district on
the borders
of Maharashtra with MP and AP. In the fifties'
it was a stronghold of socialists when Narayansinh
(Jike, the first tribal graduate from Vidarbha region
of Maharashtra, organised tribals around issues of
land distribution, education and atrocities by ru
ling classes. Recently, some activists of Chhatra
Yuva Sangharsha Vahini (the same group which
supports the Kendra) have succeeded in organising
132
large numbers of landless labourers and peasants
working under the Employment Guarantee Scheme
(EGS). Attempts are being made to launch a
broad-based 'Nisarg Bachao, Manav Bachao' (save
nature, save humankind) agitation to oppose the
proposed Inchampoli dam, which is expected to
cause largescale deforestation and evacuation of
many tribal villages in the nearby districts. Sukhdevbabu dike, a follower of Narayansinh dike and
an activist associated with EGS and Nisarg Bachao
has recently been elected to the Assembly from
this area. All four MLAs from this district belong
to opposition parties much due to influence of
activists in EGS and Nisarg Bachao.
The same team of Vahini activists has, for
the last three years, undertaken the task of or
ganising vaidus, with a view to evolve an alter
native system of healthcare service which can be
made available to the needy as and when required.
It is not just a revival of an ancient system
crumbling against the pace of changing times,
but an attempt to evolve a dynamic system chall
enging the monopoly and mystification of establi
shed medical system. It would be integral to the
cultural mileu of people and within their reach.
It would be a system based on experimentation,
experience sharing and an urge to serve the people
(and not for profiteering). The team is trying to
evolve democratic methods to achieve this object
without the use of foreign aid or even possibly
full-time workers. Judging by the meagre input
of time, finance and people, it would be unjust
to pass any judgement about this venture. However,
their experiences undoubtedly point towards newer
s'gn-posts in community health.
Vaidki in Gadchiroli Today
Vaidus are traditional experts in diagnosis and
treatment of diseases;
collection,
processing,
compounding and dispensing of medicines without
any economic incentives. For them, this is a noble
service, not a profession. They are mainly responsible
Socialist Health Review
for health care of poor people, patients with
chronic ailments and in tar-flung areas yet inacce
ssible to modern health services The transfer of
knowlegde is mainly from father to son or to other
worthy male member of community. In exceptional
cases, where sons are unwilling/unworthy the know
ledge is passed on to the daughter-in-law (but not
to a daughter as she belongs' to a different family).
Many vaidus, specially the educated ones, try to
enrich knowledge gained from the Guru through
experimentation and study of Ayurvedic texts.
Vaidus in this area use drugs from plant, mineral
and animal oiigin as well as mantras (chants) for
treatment of physical and psychological disorders.
They have their specialisation such as asthma,
snakebite, veterinary diseases and claim to cure
diseases untreated by modern medicine-tetanus, can
cer etc. Although it remains to be seen how many of
these claims stand scientific scrutiny, there are many
instances confirming this skill in diagnosis and
treatment. They follow several guidelines laid down
in Ayurveda regarding the day, time and season of
plant
collection,
diagnosis
of diseases and
processing of crude drugs. Some formulations used
by vaidus are referred to in Ayurvedic texts.
Current Issues confronting Vaidki
The processes of 'development' and 'moderni
sation' have disrupted the socio-economic-cultural
fabric which sustained and nurtured tribal life and
specially their system of medicine and posed grave
threats to their very existence. Like its counterparts
everywhere, Gadchiroli has witnessed massive
butchering of trees, disruption of the intricate ecobalances triggered by profit-hungry commercia
interests hand in glove with government officials.
An interesting example of modernisation' with total
disregard to people's real needs is a dairy recently
set up after destroying several acres of rich forest.
Its premises have been declared as 'prohibited area'
for outsiders. Hence vaidus are denied access to
the few medicinal plants which have managed to
survive in the compound. It's an agony to watch a
patient suffer due to non-availability of a drug
whose whereabouts are known, but which cannot
be procured. The dairy has not in any way helped
the tribals. It has only resulted in a complete
drought of milk in the villages.
Large strips of forests are burnt by contractors
for a better yield of tembhurni leaves (used for
making bidies). Mob trees, of great economic,
cultural and medicinal significance are burnt down
and truckloads of coal sent to cities. The rich,
symbiotic flora is being replaced by large scale
December 1985
plantations of monocultures of teak and eucalyptus.
Many valuable medicinal herbs have become scarce,
some extinct. Ironically, such modernisation* has
encouraged supersitious practices. Due to the
depletion of herbal medicines, many vaidus are
resorting
to more non-drug
therapies'
like
mantras, talismans, animal-sacrifices and so on.
'Development has brought to tribal towns a
new exploiting species — 'doctors' who, posing as
demi-gods, promise instant relief and cure-alls
through miraculous modern drugs, ushering in a
culture of injections and antibiotics. The 'modernophilia' has lured people to spend their meagre
resources on unnecessary (often harmful) drugs and
cultivated in them distrust for their traditional
system of medicine. (The is not to deny the utility
of modern medicine but to protest against its
present misuse).
Even then, established medical professionals
often feel threatened by the skill and knowledge of
vaidus. There was an interesting case of a veternary
doctor who extraced large sums from people and
was still unsucessful in a number
of cases.
The cases given up by him were then successfully
treated by a young, dynamic vaidu. The people
jeered at the doctor, who, in turn, lodged a com
plaint against the vaidu for practising medicine
without registration. However, the village people
unitedly stood behind the vaidu and did not
allow the
police to arrest the vaidu. With
growing assertiveness and awareness in vaidus
resulting from their organisation, more such attacks
from medical establishment are likely to follow.
Vaidus manage to earn their living in difficult
summer days by selling crude drugs to traders
who take full advantage of the situation. Arjuna
bark bought at the rate of 5-10 paise/kg is sold by
middlemen to drug companies at the rate of several
rupees/kg (that too after considerable adulteration).
The depletion of flora has forced vaidus to
spend considerably more time and energy in collect
ing medicinal plants thus making them increasingly
difficult to practise vaidki merely as a social service.
Moreover, people now tend to visit them only when
allopathic medicines fail. Even if they are completely
cured by a vaidu's medicine, they follow the
'tradition' of not paying him, vaidus too follow the
tradition of not asking for payment. In a society
where status is increasingly being equated with
money, vaidus are fast losing their respectable
place in the community. All this has distracted the
young generation from vaidki. In most cases, the
133
present generation is the last practising one.
Various taboos have further restricted the transfer of
knowledge e.g. the taboo on allowing a 'shishya'
to part with information before his guru's death.
Many learned vaidus have died without passing on
knowlege to
anybody. Thus, some
valuable
information has vanished for ever. Vaidki, today
stands on the brink of extinction.
Vaidus* Organisation
Organising vaidus has been a great challenge
for the group. Professional jealousy and mutual
suspicion, complaceny, taboos on
information
sharing, lack of lively contact with the outside
world and prejudices among vaidus obstucted them
from coming together. However, there have been
some favourable factors too. The growing realisation
of the gravity of situation by vaidus, consciousness
gained through their experiences (direct/indirect)
of organisation of EGS workers or on forest issues
the ability of activist to relate individual/professional
problems of 'development' and 'ecology' have
helped vaidus to come out of their shells and join
hands for a common cause. There have been
several camps for mutual information sharing and
frank discussion on common problems.
There are greater challenges ahead: initiating
sustaining democratic processes of decision-making
and implementation, evolving short and long-term
programmes to give an expression to their organised
might, cultivating a spirit of experimentation and
enrichment of knowledge, arranging for their
continuing education through interaction with other
vaidus and experts in the field, carrying out field
trials for verification of claims made by vaidus and
most important, helping the movement develop
independently without dependence on the activist
group and yet retain its linkage with the wider
struggles
At present, the vaidus, on their own initiative
have decided on the
following programme :
i) To spread organisation to a wider area ii) To
organise a series of camps — for information sharing
on diseases and remedies discussion on common
problems, iii) To set up a co operative for storage
and processing of crude drugs (processed drugs
fetch a much higher price) to directly bargain with
drug companies so as to eliminate the middlemen.
iv) Felicitations of senior vaidus at the hands of
reputed vaidyas (ayurvedic
practitioners)
and
making other efforts to create awareness in society
about the role of vaidus.
wherein five acres of land obtained from the forest
department under the Social Forestry Scheme will
be used for cultivation of important medicinal plants.
The cultivator will receive a small regular sum of
money from the forest department for developing a
forest on the land plus a part of the forest yield.
This experiment, if successful, would help reduce
the shortage of medicinal plants and also provide
some monetary benefit. This may help to preserve
the spirit of 'social service' intensely prevelant in
vaidus. We believe that the spirit of selflessness is
the one we wish to develop in tomorrow's society.
So. this spirit already present in Vaidus should be
encouraged. However, it is not yet clear whether it
would be possible to nurture this spirit without their
exploitation in present system.
It is difficult to say whether vaidus, long used
to confirming to a particular system of healing will
be open enough to freely discuss with others their
understanding of diseases and drugs and perform
experiments with scientific objectivity and make
suitable changes in their practice. It also remains to
be seen how formation of new forms of mystification
of knowledge, and hierarchy could be prevented.
There are no readymade solutions to these
problems. However, there is room for hope as
experiences reveal the intelligence, innovation,
scientific objectivity and passion for knowledge
hidden in semi-literate folks. Natthuji’s, is a
glorious examole. An illiterate shepherd boy, he
used to leave his cattle for grazing outside the
school building so that he could overhear alphabets
chanted by school children and revised them with
help of friends fortunate enough to attend school.
He learnt reading from the names of tins at a grocer
shop He cultivated his interest by purchasing cooks.
He had the guts to experiment on himself and
his son to gain confidence about his experiments.
Today, he is assertive enough to tell the patient to
choose between him and the doctor It is a pleasant
surprise to see him at such an age, scan through
books in search of new information. So, when
Natthuji says, "Well, it's not impossible to build and
sustain vaidu's organisation for peoples benefit",
there should be at least some reason for hope.
Ravindra RP
L U Shah College of Pharmacy
Sir Vithaldas Vidyavihar,
Juhu Road, Santacruz (W)
Bombay 400 049
The organising group wishes to try out a scheme
Socialist Health Review
134
POLITICAL-ECONOMIC-STRUCTURES - APPROACHES TO
TRADITIONAL AND MODERN MEDICAL SYSTEMS
Catherine a mcdonald
Abstract— The paper is concerned with the WHO-UNICEF suggestion to train indigenous healers to be
first-line deliverers of medical care. Rather than evaluate this proposal directly, the paper concentrates ins
tead on the factors currently influencing the relationship between indigenous and Western medicine.
A framework, viewing the potential health impact of the use of indigenous healers, is constructed
through the comparative method. 6 Data reviewed consists of monographs, journal articles, dissertations
etc., and considers historical, cultural and political theories of the status of native medicine. The
paper concludes that the politics of health care is a greater impediment to the provision of "health care
for all'' in some types of political economic systems than in others. Thus events in the health care sys
tem are seen as influenced by the larger socio political system. This article is reproduced from "Social
Science and Medicine" 15A : 101-108, 1981.
Introduction
Medical need in the developing world
The scarcity of medical service in most of the
world is one of the factors affecting the health
of the peoples of the earth. Although the out
come of medical care is greatly hampered by
poverty, associated problems of malnutrition, poor
sanitation, crowding and lack of education, the
social and economic gap between the have and
the have-not nations extends to the area thought
to limit the destructiveness of disease and ill
health. Bryant discusses this, perhaps more elo
quently than others :
Large numbers of the world's people, perhaps
more than half, have no access to health care
at all, and for many of the rest the care they
receive does not answer the problems they have.
The grim irony is that dazzling advances in bio
medical science are scarcely felt in areas where
need is greatest. Vast numbers of people are
dying of preventable and curable diseases or sur
viving with physical and intellectual impairment
for lack of even the simplest measures of modern
medicine. Whatever the desires of nations to re
ach their people with health care, the actual task
of doing so is extraordinarily difficult. It is
difficult in Malawi, one of the world's poorest
countries, and so is it difficult in the United
States, one of the word's richest... [l.pp.X S1].
Country
Expenditure
(%Budget)
Populjtionfbed
Jamaica
§9.60
11.0
240
Senegal
3.47
6.6
700
Thailand
0.60
3.4
1280
December 1985
Health expenditures vary from between 56 dollars
per inhabitant in the United Kingdom to 20 dollars
in Indonesia.
Eleven precent of
Colombia's
budget provides 3.50 dollers per inhabitant while
4.’/% of the United States government expendi
tures means 47.40 dollars per inhabitant for health
services. The meaning of this is clear in the
pieceding tabulation of number of hospital beds,
whose definition can range from a canvas cot to
an electric-powered special. The preceding and
following statistics are from Bryant 1 for the period
1S61-1964.
The discrepancy between urban and rural
areas can exacerbate the problems of providing
care. Part of this is due to personal reference:
The reluctance of doctors to leave the big
cities and go out to practice their profession
in the rural areas is a long standing basic
medical problem which Mexico has in com
mon with all other Latin American countries
[2.PP-262]
The result of this reluctance? A difference in
the rural-urban physician ratio (1 ;3000 vs 1:500).
This is not just a local phenomena. UNICEF-WHO
estimate "that in a number of developing coun
tries less than 15% of the rural population and
other underprivileged groups, such as slum dwellers,
nomads, and people in remote areas have access
to health services''. 3
•
Another reason for rural shortages of medical
services is lack of resources. Many of the under
developed countries are predominantly rural and.
as our earlier comparisons showed, lacking fin
ancial resources even for urban areas.
135
At the University in Kampala, Uganda, the
press of obstetrical patients is so great that
the average hospital stay for delivery is less
than 24 hr. At Sierra Hospital in Bangkok,
Thailand fully half of all hospital admissions,
17,000 of 34,000 in 1 year, are to the ob
stetrical service. But despite the overwhelming
numbers of obstetrical patients in these two
institutions in these countries at large, Jess
than15”<, of all babies are delivered by trained
personnel [1, pp.41 ].
Thus, the provision of medical services to
all is a problem, particularly so when the lack of
resources is coupled with attempts to provide
doctor-hospital Western-style services to rural areas.
Indigenous medicine
The previous discussion neglects the presence
of medical services in all socio-cultural units, Bryant1
and SchendeP note the influence of local healer.
and the belief in magical medicine. Bryant notesthat
accessibility of care and reduced social disfance are
also factors in their utilization
Lee1 points out
that in Hong Kong it is easier to find a Chinese prac
titioner (4506) than a modern physician (2317). By
deduction we realize, when Bryant tells us that only
15% of a nation's babies are delivered by trained
physicians, that the other 85% are assisted into this
world by someone (usually, but not always, by
someone other than the mother). Stromberg stresses
the reliance on local healers in Ghanna for the
70-80% of the population living in rural areas. He
states that the absence of modern health facilities,
in Ghana as in other countries, does not mean there
is a vacuum in the rural areas,
...as in many other countries, traditional birth
attendants, healers, herbalists, and practitioners
of various types exist in most villages and treat
many diseases and other health problems....thus
there is a health care system throughout the
country which is consonant with traditional
beliefs and practices [5,pp. 15].
WHO-UNICEF* agree and suggest the diffeient
types of indigenous healers may be trained and inte
grated into the general health system.
This solution seems like a panacea. Given the
shortage of medical dollars, personnel, and facilities,
problems of transportation, the social and cultural
acceptability of new ways, why not train indigenous
healers to care for the medical needs of their
communities ? The someone delivering 85% of two
countries' babies might benefit from training. Further
136
more, most of the medical needs of the world are
not complex :
It involves recognizing threats to health that are
visible and monotonous : malaria, diarrhea,
pneumonia, bilharziasis, hookworm, malnutrition,
tuberculosis—or problems that are less a threat
and more a personal concern : leg-ulcer, earache,
constipation, headache, broken finger, inflamed
eye [1 ,pp. 61 ].
Given the potpntial for traditional healers to
provide health care that is affordable, accessible*
culturally relevant, belongs to the people, and has
the possibility for serving as a conduit for new ideas
in areas other than medical —what factors influence
the relationship between it and modern medicine ?
There are several theoretical approaches that may
be taken. To answer the question, why not utilise
indigenous medicine, it is also necessary to investi
gate the imbeddedness of the current relationship
between modern and traditional medicines in the
social system. That is, various factors have led to
the exclusion of native healing systems from most
modern medical systems. What are these factors ?
How might they relate to the utilisation of native
medicine in a modern setting ? What happens to the
indigenous medical system as a nation Westernises
(modernizes, industrializes, develops) ? This, then,
the factors influencing the utilisation of indigenous
medicine, is the focus of this paper. But first, the
methodological issues must be discussed.
Toward a framework—the patched up design
To answer the question, what factors have
determined the status of native medicine, requires
a comparative approach. Factors thought to be
explanatory for one time and place can be shown to
be epiphenomenal and hence irrelevant in another.
We will find in the next section that the integration
of modern and traditional medicines has varied from
one country to another. Why ? Cross-national
comparisons of health systems is one method of
looking at health services organisation.0 This
approach is, however, fraught with difficulty :
Those engaged in the study of comparative
health
service systems still struggle with
problems of theory, method, and standards for
cross-national research. In addition, the available
data are too often fragmentary, unreliable, non
comparable and subject to political constraints
[7,pp. 278].
Eiling (see also Eiling and Kerr8) has introduced
a method for cross-national comparison — the method
Socialist Health Review
of contrasting case studies :
Given the controlling character of the societal
context, the concluding point of this brief
introduction to the contrasting case studies
framework will be that inferences about health
services organization may be culled broadly from
sharply contrasting systems, but it is likely that
cross-system applications can occur only bet
ween those with somewhat similar levels of
resources and similar political
structures
[6,pp. 268].
The principle behind this is elegant. The method
of difference, as expounded by John Stuart Mill is
one of his four types of evidence that can be used
as evidence for a causal relationship, or in our case,
to control for extraneous factors. It states that if
various situations have all factors in common but
one. that may be regarded as the causal factor.9
Eiling and Kerr3 found that this principle could be
used to identify countries that are over- and under
performers in health, wealth and education levels
being similar. The comparative approach will be
used here. In other words, possible explanatory
factors will be tested by the method of difference
for one set of countries; eliminating these, we
will then discuss other factors elsewhere. This
approach is not without dangers.
Campbell
and Stanley 10 discuss the dangers inherent in
experimental design. They are critical of this type
of comparison, stating that it does not control for
the selection of the groups to the initial purported
causative factor or the loss of groups from this
factor. More simply, there is little way of knowing
what additional factors are responsible for the initial
conditions. They describe a more refined variety of
this model as a patched-up design with an inelegant
accumulation of precautionary checks. The defense
of this approach is twofold : First the world refuses,
at least thus far, to be standardised to the interests
of science; second, it must be asked if the lack of
strictly comparable evidence is to limit the questions
we may ask. This is addressed by McGranahan ll,
who considers that perhaps cultural and social
diversity is too great to permit international measure
ment. He feels that the need for data in formulating
international social policy dictates continued com
parative social research. It is the wish of this author
that reports of this type, where quantification is
deemed unnecessary or impossible, are, if not totally
accepted, a stimulus to the further refinement of
hypothesis of a broad perspective.
December 1985
Factors Influencing the Use of
Indigenous Medicine
Culture and progress
Galdston1- differentiates between medicine
as the science and art of healing the sick and caring
for the well (a body of knowledge), and medicine
as the practice of that science and art (the perfor
mance of a profession). The relationship or lack of it
between traditional medicine and Western medicine
is dependent on both parts of this definition.
Medicine as a body of knowledge will be discussed
in this section; the professions of medicine in the
following section. This paper has not differentiated
between the various types of native healers or
different levels of
theoretical
complexity of
medical systems as suggested by Marchione.13
In contrast, Sigerist feels that all systems of medicine
contain basic underlying similarities:
There can be no doubt however, that primitive
medicine, as it appears within the various culture
patterns, consists of a relatively small number of
elements, which are very much the same in all
primitive cultures and vary only in their combin
ation [14, pp. 1 21 ].
Marchione 13 states that distinctions between
three types of indigenous systems may affect the
reaction to it by society and other professions. The
next part of this section demonstrates the reverse of
relationship suggested by Marchione who sees fulltime practitioners of great medicine accommodated
and given support while part-time practitioners are
ignored, and folk healers tolerated or opposed. We
discuss three systemson an equal level of complexity.
Thus this factor is controlled for. Yet, any future
attempt to integrate a native healing system into a
modernising one would be well-advised to consider
the characteristics of the native system, for more
practical and mundane reasons.
Most studies of health care systems avoid the
traditional (e.g. Weinerman 7) or give it minimal
attention, regarding it as a survival from a more
primitive, less scientific, time. Attention is focussed
on the scientific progress of medicine such as is
suggested by Galdston:
History is a progression of ideas, traced along
a circuitous path [12, pp. 3-6].
Garrison 15 is kinder and suggests that folk
medicine brings the peace of security against the
fear of the unknown. Folk medicine also has its
defenders. Dr Bocan Alpha
Ba (International
137
Conference on Health and Health Education) believes
that "traditional medicine deserves respect".16
He states that African doctors turn to traditional
arsenals when supplies of Western pharmaceuticals
are short. Green 17 comments upon the astonish
ing technical efficiency of primitive surgery, given
the most ancient instruments. Sigerist observes that
little medical progress has been shown in some
areas:
This history of the therapy of cancer is very dull.
The principles we are following today, namely
the elimination of the tumor as radically as
possible, were discovered in far remote antiquity.
Our operative methods are much more efficient
than theirs were, and besides the knife we have
X-rays and radium to destroy the tumor cells,
but we have not found any new principles yet
[18, pp. 62].
One view is that traditional structures are
inferior in all ways to modern medicine and are
used by only the poor or ignorant : Banerji.19
notes that the inhabitants of his native land prefer
allopathic (Western) medicine irrespective of social,
economic, occupational, and regional considerations.
Cost and accessibility of services were the two
major constraining factors Local healers were used
for minor illnesses or when Western medicine
failed, Lee4, however, points out that in Hong
Kong the correlation between utilization of modern
medicine and wealth (r = 0.68) was in the same
direction as between Chinese medicine and the
wealth of the area (r = 0.54). Futhermore, it seems
that people choose rationally between the two on
the basis of perceived effectiveness for symptoms.
Although the exact statistics were not provided,
the younger generation was said to make more
extensive use of Western medicine.
An approach that makes the assumed inferiority
of traditional medicines more explicit is the historical
approach. This approach stresses the evolution of
medicine, both empirically and conceptually. Garri
son15 observes that the advancement of medical
science is the history of the discovery of a number
of important principles leading to new views of
disease, to the invention of new instruments, and to
the development of a rational scientific concept of
disease, notas a demon but as an altered physiology.
Kuhn’0
critiques
this
view,
rejecting
the
accretion approach to progress while retaining the
concept of the progress of science. This approach
fails to note that most medical systems have
performed adequately for the cultural level of the
138
people. Furthermore, some have been medically
effective. Bernado Ortiz de Montello found that 16/25
of Aztec drugs produced the desired effects, 4/25
were questionable, and 5/25 were not good
enough.-1 Know lege, then, is not exclusively WesternIt strikes one as strange that the social and
psychological functions of medicine are given stress
only for the primitive versions. All medical systems
seem to function to allay fear of death and infirmity
through professionalism (elitism), and in this sphere
shamanism differs little from white-coated magic On
the social level there is evidence that the theoretical
perspective of medicine relates to its functions as an
integrative institution of society. When society is
held together by fear, medicine is synonymous with
witchcraft and magic; as religion becomes dominant.
disease and sin coincide; later, in a rationalist
society, science is the new god: from temple to
cathedral to medical center.
Another explanation for the apparent decline of
traditional medicine isclosely related. It suggests that
the populace rejects it in favor of more modern medi
cine, or is it retained due to their ignorance of
poverty ? Sigerist11 suggests that the development
of magical-religious medicine in Greece was a result
of the needs of the indigent sick. Lee* points out
that economic factors influence the distribution of
Chinese medicine. Harwood92,
Logan93, Marti
nez and Martin21. Rubel-5 and Snow26
pro-,
vide evidence of the continuing utilisation of native
healers by populations of Mexican Americans,
Arizona Blacks, Guatemalans, and Puerto Ricans,
Schendel- traces this cultural lag to superstition.
while Foster27 cites the cultural barriers to change.
However, DeWalt 2S is able to show that the use of
native curanderors (curanderas) in a Mexican village
is the result of a rational process of choice rela
ted to the nature of the illness.
How important is the progress of medicine as
a factor in determining its role in modernising
societies? Is it only the internal characteristics of
a medical system that determine its fate? A crosscultural historical study by Leslie29 sheds much
light on this topic. He shows that traditional
medicine in three countries, China, Japan, and
India, sharing somewhat similar cultural factors, had
a different fate in each. He shows also that the
Greek, Ayurvedic, and Chinese medical systems share
similar internal characteristics-they are based on
humoral theories, have standardised learned prac
tices, long periods of training, codes of ethics,
and claims to social status. Yet their incorporation
Socialist Health Review
into modernising medical systems varied. In Japan.
the ruling elite adopted modern scientific medi
cine as the legally sanctioned system. In China,
the incorporation of traditional practices into an
essentially Western system occurred. In India, a
dualistic, though not completely equalistic, system
developed. Thus, neither cultural nor internal
characteristics of medicine accountfor this difference.
Another theoretical explanation for the status
of traditional medicine is seen to be the organi
sational struggles of medical professions :
A characteristic of modernizing societies is the
co-existence of modern and traditional profe
ssions that claim to perform the same function
for the society. As a result of differential supp
ort by the dominant classes and their social
values and by the academic and political au
thorities. the modern profession occupies a
higher statification ranking than the traditional
professional [4,pp60].
The theory of professionalism, the organization
of medicine, as the explanatory factor, for the
survival or lack of survival of traditional medicine
will be discussed in the next section.
Theories of professional struggles
Much of the work in cross-national comoarisons
of health systems ignores the political-economic
level of organization intermediate between macro
processes (society) and micro-processes (persons).
One notable exception to this is the study by
Carboni30 of the formation of a geriatic speciality
in the United Kingdom which has not occurred in
the United States, to date. Carboni traces this to
the division of medical territory by the medical
profession in the UK rather than to a more rati
onal, knowledge-based division of labor, an ex
planation suggested by Stevens31, for example
This division, then, was based in political proce
sses within the profession to the end of controlling
medical resources (wealth, patients, and control
over an area of service). This approach has been
offered by Berlant33 as a framework by which
to understand the rise of allopathic medicine in
the United States. Before examining this approach,
it is necessary to mention that the view of indivi
dual practitioners may diverge from the organisa
tions perspective Blum33 found both acceptance
of the significance of local healers and rejection
of their existence by physicians in his study of a
rural Greek town. One famous healer had even
hired a physician and X-ray technician to work as
December 1985
his assistants. This occurred despite government
and professional opposition to quackery.
Berlant3’2 describes the process by which the
AMA organized and defeated its medical rivals.
He critiques Parson's characterisation of the medical
profession as a normative structure, based on
idealised beliefs, regulated by a system of social
controls, and whose function is to maintain healthy
actors to fulfil social roles. Instead, he uses an
historical approach, coupled with Max Weber's
theory of monopolisation, to show that many of
the practices of the medical profession function
to increase the power, prestige, and wealth of the
profession collectively, regardless of the benefit
to society or the individual patients. Weber s
theory of monopolisation states that :
The success of a group is a function of two
broad determinants of economic action: the
group's tactics of competition ^or of conflict)
and the conditions of competition. One major
but not exclusive condition of competition in
modern society is the state, which exercises
both authoritative and de facto domination over
groups within its territory [32, pp.17].
The tactics of the AMA will be discussed here;
the role of the state in the next section. The
elimination of external competition is accomplished
by two means, according to Berlant.32 The first,
which he sees as the dominant methodology
employed by the AMA, is to bring the "force and
prestige" of the legal and political community to
bear against competitors. This involves licensing
and educational restriction. The goal of this strategy
is to restrict financial support to one's opponents.
The second method is to challenge one's oppo
nents on ethical grounds, thus challenging their
symbolic integrity (image).
The second game, that of name calling was
practised by both sides:
The AMA <circa 1924) referred to all non
conformist healers as ''sectarian'*. Its Judicial
Council has defined this term to include any
practitioner who follows a dogma, tenet, or
principle based on the authority of its promul
gator to the exclusion of demonstration and
practice,
...Abraham Flexner, the eminent authority on
medical education, contended that homeopaths,
eclectics, physiomedicals, and osteopaths might
rightly be considered as sectarian rarher than
fraudulent practitioners, since they all believe
139
that anatomy, pathology, bacteriology, and
physiology must form the foundation of medical
education but regarded chiropractors and
mechanotherapists as no more than unconsci
onable quacks.
.. In charging that conventional practitioners laid
undue stress on chemical compounds and
surgery; these groups, with some justification,
considered regular doctors as sectarian [34,
PP.2-3],
Despite his moderate stand toward the variety
of medical practitioners, Flexner's report on medical
education (1 920-21) proved to be the coup de grace
to most non-regular medical practice. Stevens31
speaks of the reluctance of the general public
(USA) to use the modern (regular) physicians
because of their harsh treatments. They were po
pular as a status symbol among the urban rich, due
to the prestige of their European education. B urrow34
claims that the battles of the AMA to control
licensure and restrict entry to and the proliferation
of medical schools was against quackery.
Berlant views the demise of the sectarians as
casualities of the internal battles of the AMA. He
considers the number of irregular practitioners too
small to be considered a threat, at most 10% of all
practitioners. Estimates of the numbers of homoeo
pathic practitioners are 2400 between 1835 and
1840. At most, there were some 7000 sectarian
practitioners in the 1845—1860s as compared with
some 20,000 orthodox medical graduates and
another 40,000 non-degreed orthodox matriculants.
This was the real threat : the rapid expansion of
medical schools and the large number of educated
physicians. Six medical schools in the decade
1810—1820 produced 100 graduates out of 650
students; this increased so that by 1860 there were
1 3 schools comprising 4500 students and graduating
1300 in the 1850—1860 decade. 32
Berlant describes the tension between academics
and practitioners for control of the medical profession
and licensure. Medical societies were formed in the
1760s and not until 1783 was a medical school.
Harvard, the first serious candidate for establishing
the qualifications of a physician.31 The AMA, estab
lished in 1847, soon reached a compromise position
with the development of a licensure plan whereby a
diploma was not an alternative to licensure but a
pre-requisite. It then proceeded to regulate the
supply of medical schools and hence physicians 32
The growth
phenomenal :
140
of
medical
schools
had
been
In 1869 according to the Bureau of Education
theie were 72 medical colleges in the US, 59
regular, 7 homoeopathic, 5 eclectic, and one
botanic... (By 191 1 every city had their schools)
39 in Illinois, 14 in Chicago, 42 in Missouri, 43
in New York City, 27 in Indian?, 20 in Pennsyl
vania, 18 in Tennessee, 20 in Cincinnati, 11 in
Louisville...one physician for every 691 persons
in the United States contrasted with 1:1 940 in
the German Empire; 1:2120 in Austria, and
1:2834 in France (circa 1913) [1 5,pp.761-763].
The AMA responded to this by supporting two
investigations of medical education. The first, run
by a physician, raised an uproar, but created little
change. The second, headed by Flexner, led to
reform and the securing of a medical monopoly by
the AMA. Stevens 31 sees the impact of this report
as largely financial; foundation money from the
Carnegie Foundation. General Education Board
(a Rockefeller Foundation), and other sources
enabling the better schools to improve while others
declined due to lack of support.
The role of government
As discussed earlier, Weber considers the role
of the state as one important condition in the
survival of an organization. Leslie s cross national
historical account. ''The Modernization of Asian
Medical Systems'',29 stresses the influence of go
vernment policy. He shows the Japanese ruling
elite adopting modern scientific medicine as the
legally sanctioned system. The Chinese incorpor
ation of traditional medical personnel and practices
swings with the pendulum of political change
(Wolstenholme and O'Connor
: Harbison and
Myers 3C; New and New37 ; and Sidel and Sidel 3S).
In India, the ambiguity of government policy has
led to dual medical system.19 Lee4 details the
parameters of environmental support in Hong Kong.
The government employs one-quarter of the modern,
but no Chinese, physicians. Anyone can practise
Chinese medicine without a licence but there is
a registration fee of twenty-five dollars. The
practices of Chinese physicians are restricted. They
are not allowed to issue death certificates, to use
medical titles, or to use certain restricted medicines.
Schendel2 describes the incorporation of Spanish
and Aztec medicine after the conquest (Cortes)
under royal orders, and the diffusion of Aztec
pharmacopoeia into Europe. When Germany passed
a statute on June 21, 1869, abolishing some of the
physician's obligations, the result wes an increase
in the number of nature and faith healers.1
Socialist Health Review
Berlant considers that the growth of the AMA
and its monopolistic advantages were linked to the
rise of state power which was then able to
bolster the power of the profession. He then asks
what is the advantage to society of allowing
monopolization. He feels that an explanation in
terms of the public interest is not convincing in
light of the differential distribution of the benefits
of medical care and he sue gests an alternate
explanation that is reminiscent of
Duff and
Hollingshead ‘'
Particularly in the United States, the develop
ment of the medical profession has been
closely tied with the development of stratified
relationships between social groups, so that
quality medical care has tended to be a prized
scarcity and an object of class behavior
[32, pp.505].
This explanation is good but medical care as
an object of class behavior does not tell enough.
Eiling40 sees a close relationship between the
nature of society and the nature of the health
medical systems.
It can be demonstrated that there is a corres
pondence between support of the indigenous
medical system and the type of political system
Table 1. Political structures
Centralized
Decentralized
USSR
Concerted
Pluralistic
China
India
USA
Mexico
Canada
Japan
England
Hong Kong
Table 2. State support of indigenous medicine
Country
Type of
Support
Japan
China
India
USA
Symbolic
Medium
High
High
Low
Financial
Educational
Research
Practice
Low
Low
Low
High
High
High
Medium
Medium
Medium
Low
Low
Low
Legal
Licensing
Education
High
—
—
Medium
—
Low
Low
December 1985
that exists. Eiling (personal communication) has
suggested a typology of countries along two
continua — the centralised-decentralised power di
mension and the concerted-pluralistic action di
mension. Thesec oncepts refer to the general nature
of the formal (centralised decentralised) power
structure as well as to the informal (concerted,
pluralistic) dimension of power. It is possible to
assign countries to one of four cells as in Table 1.
Table 2 shows the varying degrees of support
that a medical system may receive along different
dimensions. Scores of high, medium, or low reflect act
ion taken relative to that of other countries. Symbolic
support is defined as actions taken by the govern
ment of a country to preserve indigenous medicine
as part of the heritage of a country. Japan is rated
medium, not because it has considered its medicine
a heritage29
but as compared to the United
States,there has been little persecution of indige
nous
healers41
China29
and
India19 have
recognised the cultural roots of their medicines.
Japan provides no funds to native medicine but
does require licensing of native practitioners42,
thus granting them recognition and legitimacy.
China does support traditional medicine financially
but not at the level of modern institutions.29
Licensing of medical practitioners was abolished in
China along with the leveling of other professionals,
but traditional institutions have received government
recognition. India has made some grants available
for the stuiy of Ayurvedic medicine and the
provision of services 19 A subjective guess would
be that it is less than that provided in China.
Regulations for licensing of medical practitioners
and traditional schools are currently being decided
in India (communication from Pandit Shiv Sharma,
in visit to UCONN Health Center in 1975). These
countries contrast with the United States where
non-modern forms of healing receive no support.43
How does medical care in a country relate to
the form of goverment? We see from Tables 1 and
2 that only the United States, a decentralised,
pluralistic country has provided no support to any
but the most politically powerful medical organiza
tion. This is the result of a system where health is
not a national priority, where there is no system,
program, or prioity of expenditures for health. It
appears that only centralized and/or concerted
countries refuse to allow the battles of professionals
over the carving up of the medical arena to
interfere with.the delivery of health. Bryant 1 makes
the point that health programs can also be divided
among government agencies. A few examples will
141
suffice. Current philosophy in China dictates that
the purpose of the medical and educational system
in china is to serve the people.4’ In fact, it has
been noted that one problem of Chinese education
is its overly ut litarian nature
This signifies not
the absence of professional politics but their
subordination to national policy. This has occurred
also in Russia where feldschers were employed
despite professional opposition15; in India where
Ayurvedic physicians have not been embraced by
the medical establishment-9; and in North Vietnam
were Western and Oriental medicine is being
combined 43
Conclusions
This paper has discussed some of the factors
influencing the status and utilization of native
healing practices in the modern world. Though
cultural and internal factors may affect the utility of
traditional medicine by encouraging bad practices
and discouraging new ones, it is equally certain that
this medicine of the people contains effective
practices and new ideas. Thus, the links between it
as a knowledge system and its role in medical
system has been tenuous. The role of professional
struggles in the medicial arena as the dominant
factor has been tempered by the Influence of
government where it has been able to direct medical
priorities. It has been suggested that in centralized
governments or in those where action is concerted,
the government is able to set priorities; in other
situations, such as the United States, health
priorities are the outcome of professional struggles.
From this, it is evident that the outcome of
employing traditional medical structures to meet
the health needs of the world will depend to a large
degree on its interface with professional organizsations and the type of relationship it has with the
government, either controlling or controlled.
The question, however, remains unanswered.
Why do different kinds of political systems allow
their policy or lack of it to benefit medical power
groups? Several different models of the articulation
between the medical system and the political system
exist. Krause discusses the imbeddedness of the
health system at several levels: The first is the level
of values —
First there is the issue of occupational ideology
inherent in the term profession itself. What
citizens believe the medical profession to be
determines how they act in accordance with
this belief [46, pp. 36].
142
Friedson4
agrees
with
this
view
and
criticizes the medical profession for usurping values
when their claim to power is technical expertise. We
suggested earlier that the relationship of medical
systems to political systems was not due to cultural
factors such as the state of knowledge of the
profession or acceptance by the local residents,
but rather to the nature of the relationship between
the health professions as organizations and the
form of government. We also noted that symbolic
support is one means by which a profession may
survive and obtain other types of support.
Krause4'-* also suggests that control over the
delivery of health services varies according to the
ownership and control of health service production.
This theme is explored in greater detail by Navarro,
who makes the point that physicians no longer con
trol the health system through the power of their
knowledge. Primitive, or what Navarro calls compe
titive capitalism, has given way to monopoly
capitalism : Health is the ...
... second largest industry in the country... the
flow of health insurance money through private
insurance companies in 1973 was 29 billion
dollars slightly less than half of the total
insurance — health and other — sold in this
country in that year. About 515 billion dollars
of half of that money flowed through the
commercial insurance companies... [where] we
find again a high concentration of commercial
capital [48, pp. 1 50]
Navarro continues that the same corporate
interests which control the American economy also
dominate the health sector. Although physicians
qua physicians are losing Influence as the source of
power shifits from entrepreneurial to corporate
sources, physicians still remain part of the dominant
class in terms of economic position and many are
now members of the corporate class. The medical
system is one way to reinforce the values of and
contribute support to capitalism.
Eiling (personal communication) suggests that
it is this context of the health system that in the
end determines if the utilization of traditional
medicine is to be of real value or if it is to be a
delaying action to oerpetuate second-rate medical
care. Professionalism, coupled with a stratified
society, can serve to thwart the intention of the use
of indigenous healers — the provision of better
medical care. Thus we find a rural midwife program
in Arkansas training women for rural service.11 But
Socialist Health Review
in fact this program is designed to preserve a two
class system of medicine whereby the rura* poor
mostly black, are receiving minimal care, with little
or no access to special services while the wealthy
white are treated in medical facilities by doctors
reluctant to serve the countryside. Or there is the
paradox that is now occurring in India, where the
use of indigenous practitioners will mean less
available medical care As a by product of their
struggle to achieve recognition. Ayurvedic medicine
practitioners have agreed to limit the number of
practitioners they will certify and train. The price of
legitimacy and other support is diminished service
to the population. One must question, then, the use
of indigenous healers - who is to benefit? — and
who is to gain? Their utilization cannot be separated
from the influence of the medical system and its
position in the socioeconomic and political systems
of a country.
1 .
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
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USA
A 43
GREEN REVOLUTION' AND HEALTH
Changing Patterns of Health in Nanded
x
.
•
e ■
‘
• 1
sunil dighe
The green revolution and the changing patterns of agriculture have resulted in a deterioration of the
health status of the people. The health services are a source of exploitation in one way or another. In the
meanwhile, the rich tradition of herbal medicine is disappearing through disuse, which is itself a result of
changes that have occurred in the wake of the green revolution.
"The condition of the working class is the real
basis and point of departure of all social movements
of the present because it is the highest and most
unconcealed pinnacle of the social misery existing
in our day", (Preface to The condition of the working
class in England — F. Engels).
Every major or minor change in system has
raised the hopes of improvement in the lives of the
poor and created illusions about the present
process of development. New policies have been
drafted and redrafted at the international and
national level to eradicate poverty and to change
the lives of the 45 crore poor people living below
the. poverty line. But no significant change has
taken place. As admitted by then World Bank chief
Me Namara in his 1973 Nairobi speech, the problem
of the world's 800 million poor people has
remained unsolved.
.
»•
The new approach of attacking poverty began
in 1975 on a world scale and in India also. New
schemes of rural development to eradicate pover
ty were introduced. And their health was given
importance. It was a target-oriented package pro
gramme. What is happening in the country side
since 1975 is worth studying.
Although the green revolution began in Ma
harashtra since 1965-67, its spread and growth is
now restricted. Thus the problems have increased
and the crisis is accentuated. The old picture of
village life is not found now. Alongwith the
deteriorating socio-economic system, we find the
health of the people is very much affected and
has deteriorated.
The area under study is Biloli taluka in Nan
ded district of Maharashtra. The district is divided
into eight talukas and among them Biloli has the
highest levels of irrigation. Most of the irrigation
schemes weie completed by 1975. There are three
medium irrigation schemes functioning in the area.
Total population in the district is 17,47,589 spread
144
in 1388 villages. The major crops grown are
jawar, wheat, rice, cotton, chilli, and now sugar
cane. Seedplots producing cotton seeds are situ
ated in highly
irrigated
area.
Even banana
plantations are ample in number. This area is
wellknown for producing long staple cotton Now,
four sugar factories are producing sugar and
alcohol. Out of these, one factory is in Biloli taluka-
Changing patterns of agriculture :
Effects on health
Due to changes in the cropping pattern and
switching mainly to cash crops like sugar cane
and cotton the production of foodgtains has
declined in the area So the old system of cro
pping, mixed-cropping, is disappearing. Turmeric,
another cash crop was uprooted firstly in 1972
drought and by the government policy to favour
supply of water to sugarcane. Similarly, ground
nut is not favoured by the government. In 198384 canals became dry due to water-shortage. And
though the government initially announced guaranted irrigated water to groundnut crop, only
once or twice did the canal receive water.
So all the groundnut crops of middle and poor
peasants were destroyed. The rich could irrigate
with the help of powerful electric pumpsets.
In non irrigated area chilli is still grown. But in
irrigated fields, chilli crop cannot be grown now
as the land is saturated with water which is not
suitable for growing chilli.
There is significant decline in the area under
pulses. Partly because there is no increase in the
relatively low per acre returns. Another difficulty
with the pulses is that it cannot be grown with
hybrid kharif jawar. This is a short-duration crop.
This reduction in the acreage under pulses has cost
a lot to the village poor because, pulses used to
maintain the fertility of the soil (nitrogen fixation).
And people used to have their balanced diet. As
the diet mainly consists of hybrid roti, sometimes,
rice and watery dal (mainly tuar or udid), their
Socialist Health Review
diet has not remained a balanced one as it used
to be. Other crops like sweet potatoes which
used to be poor man's emergency staple food,
have also disappeared.
Thus, we see dependence of people on cash
crops resulting in a decline in pulses production.
This change in crops pattern has increased depen
dency on high cost chemical fertilizers and upset
the traditional soil preservation mechanism and
resulted in decline in the health of the people.
Anti people forest policy
The present forest policy of the World Bank
and the government has contributed to the de'
struction of agricultural people's living conditions.
All the old variety of trees, like malwa, kath
khair, sag, bamboo are not planted by the forest
department on a large scale. Instead, subabhul
and eucalyptus are planted on a large scale with
the result, more wood is supplied to the paper
mills and groundwater shortage has increased.
Many old varieties of the tree had medicinal value
and herbs used to grow around them. Their dis
appearance has created an acute shortage of such
country medicines. Even in villages, old tamarind
trees have disappeared.
People are using less
tamarind in their diet. The effect of this new
forest policy on the ecosystem is tremendous
It has also affected agriculture, since wooden
implements depend upon the forest. The new
varieties of trees are not suitable for house con
struction or cutting the implements from wood.
Even firewood shortage has become most acute.
People burn any type of shrubs and wood for
cooking purpose even though it is unhygenic.
They have to spend more time in collecting fire
wood. Due to shortage of wood, the size of the
huts are getting smaller and narrower which is
again unhygenic. The result is diseases like asthma,
cough and other respiratoty problems are rampant.
Old chullah still exist even though tractors and
high yielding varieties are introduced by new tech
nology. The chullah creates pollution problem
within the huts.
Due to increase in the cost of living, all the
earnings of the family members are spent on
only survival. The cash economy has changed the
situation considerably in this area. As the saving
of the poor is virtually nil, for sickness expenses,
they have to borrow from landlords, rich peasants
or money-lenders.
December 1985
Plight of non-agricultural workers
Those who work on State Employment Guar
antee Scheme (EGS) as labourers, are supposed
to get as per law medicines if they become
sick on duty. They must get drinking water at
the worksite. Usually, the worksites are far away
from the villages. Most of the time, EGS workers
do not get ordinary medicines when they get
headache or fever, or if an accident takes place
even first-aid boxes are not available. At site they
get contaminated water for
drinking
which
causes waterborne diseases. This is rampant in
the area resulting in loss of several mandays due
to sickness. The law has made a provision for
shelter and cretches at worksite. But rarely are
these provided. We find infants and young babies
are looked after by small children while the mother
is working on the site. Last year a labourer died
on EGS site in a village in Biloli taluka due
to both starvation and sickness. (This matter was
discussed in the Maharashtra Assembly). The reason
was that he had not got his wages for more than
fifteen days.
The sugarcane factories also pose new pro
blems. The molasses accumulated near factory
creates pollution problem for the peasants living
near the factory. Water-pollution by the sugar
factories is so much that many deaths have taken
place in the villages near the sugar factory. Sudden
death of animals after drinking water is quite
common in the area. Even the hue and cry made
by the press and organisation does not affect the
sugarbarons and they continue to violate ail anti
pollution norms. The health condition of sugarfactory workers is equally bad. They are exposed
to pollution, chemicals and accidents due to out
dated machinery.
Certain other factors also affect the health of
the people. Adulterated edible oil has brought new
types of diseases. Sometime ago strange kinds of
jowar and
wheat (imported) were distributed
through the rationing shops. And after consuming
them there was a virtual epidemic of skin disease.
Similary. the imported wheat from US under PL
480 brought another variety of Mexican seed grass,
which has since spread all over. This has made the
land infertile and constant contact with the grass,
spreads skin allergies and allergies affecting the
respiratory system. (This is popularly known as
'Congress grass' and during 1975, Cong I Govt.
banned the word 'Congress' grass).
Due to
inflation, people tend to cut down
145
expenses on food items. For example, as the price
of edible oil has gone up, women are using less
quantities of cooking oil, not even using coconut oil
for their hair. As the prices of medicines have gone
up, ordinary tablets for usual ailments cannot be
purchased by the people. This taluka has a very
high incidence of leprosy, but only one leprosy
centre is functioning.
Imperialist technology has improved HYVjowar,
bajara, wheat and rice production in irrigated area
but no breakthrough has been so far made on
oilseeds and on HYV seeds for dryland farming.
Thus, it has limited results for total agricultural
growth in India.
Exploitative health care services
Medical facilities are available, for example in
four big villages in the taluka. In this article we will
look at two places : PHCs at Naigaon and Ketur.
About hundred villages are connected with these
centres. They are situated either at taluka head
quarters or at the villages where the most influential
local MLA, ZP president or MP is based. The
corruption at government dispensaries is so rampant
that people tend to go to private doctors or the
government doctors treat patients privately.
During the drought of 1980 and floods of 1983,
various types of epidemics spread in the area. The
government dispensaries and hospitals created such
a situation that patients were sent back on the
pretext of a scarcity of medicines.
Kashtakari
Sanghatana had to take up the issue, the doctors
and dispensary staff were gheraoed for several
hours. Only then was proper treatment given to the
patients.
At the grassroot level, village health workers
are operating. They are supposed to distribute
medicine for ordinary ailments, malaria and so on.
They are supposed to help mothers at the time
of delivery. And to report to the PHCs when cases
of epidemic or serious diseases are noticed. In the
recent drive for birth control, they have to bring
cases for family planning operations. Now it is
lucrative business for them since the government
gives monetary incentives to both patients and health
workers. But generally stocks of tablets are not
available with them or instruments are not availbale
with them So people have to qo to private doctors
paying more fees or to the quack doctors.
Tha local organisation had to take up another
issue since it affects the health of the people —
' Bhanamati” (ghost or spirit) is a usual phenomenon
146
and mostly women are ‘haunted* by this in the
villages. In reality, they are either psychic patients
or ailments developed due to insoluble personal or
domestic problems of feudal character. Many a time,
patients became victims of
superstition.
So
the local organisation had to takeup several cases
and treat them in the Hospital after prolonged
persuation. In the past five years, more cases of
bacillary dysentry, flu, malaria are reported in the
hospitals. Thus, even the health services have
become a source of exploitation and people are not
benefited though all the institutions are aided by
government and international agencies.
Health under Green Revolutions
Changes have occurred in the attitude of the
people towards health and medicine are quite
obvious.
(a) All the old herbal, country medicines have
disappeared and the trend of widespread use of
allopathic medicines has been stabilised. It is
known that the sarpgandha herb is used for
serpina tablet for blood presure or heart problems
Similarly, some old medicines based on herbs and
minerals are quite effective. But little further
research har taken place.
(b) Due to hard work, hectic life and mount
ing problems, people tend to ignore their health
unless
health problems become serious when
they go to the doctor or the dispensary. Again less
attention is paid towards the health of women and
girls in the villages.
(c) Use of outdated medicines in the dispen
saries is quite normal. As the efficacy of the
medicine is
automatically reduced, people have
again turned towards either quack doctors or
towards superstitious practices.
There are certain voluntary agencies like Oxfam
which are working in the same villages where we
are working. But they have not yet taken up any
programme
for healthservices. Except making
propaganda for family planning operations (on the
same line as the Government propaganda) they have
done nothing in the health sector. The only service
they offered to the people during floods was to
give loan on low interest rates to the affected
people and the loan was repaid by the debtors
after the harvest. The huge irrigation schemes
began only after World Bank aid arrived since the
Government had no funds to provide them under
the five year plans. So boosting irrigiation. new
Socialist Health Review
technology of HYV seeds in irrigated area, boosting
production for cash crops mainly for export,
development of infrastructure and absorbing non
farm population in service industry, creation of wellknit finance organisations and so on makes the entry
of forces of imperialism in agriculture on a sound
basis and allows the local exploiters, landlords and
rich peasants, a share of the surplus. But has it
really solved the problems of the people?
Nanded is a drought prone area. In the past
five yeais it was twice declared drought area and
twice the area was declared as being flood aff
ected. Instead of giving water for subsistence
crops, water is given mainly to cash crops. Due to
faulty man-made forest policy, the pattern of rainfall
is changing and affecting the crop production and
ultimately the ecology. All drought prone areas
eradication schemes are slowly turned into imple
menting a policy for export led growth, cash crop
growth. This is happening nationally, locally under
the guidance of imperialism. ''A major plank for
ambitious political leaders is the promise of pro
viding irrigation to newer areas. Here the chief
consideration is bringing prosperity to those pea
sants who are in a position to grow cash crops
and not tackling the droughts."
the conditions of poor people. All the benefits
have gone to the upper classes. Consequently,
economic conditions of the poor have further
worsened
This has made health of the poor
people a severe problem. The vicious circle of
poverty and health can be seen clearly in the
rural area.
What imperialism does to the system is that
it has made the system totally dependant. Future
growth and internal growth of productive forces
*s stopped or growth is stagnated. In the case of
health, it is clear that no funds are made available
for further resources and production of medicines
on specific disease or health problems. The less
costly methods of production of medicines for such
diseases are not found out. Ultimately, as agriaculture is very important to extract surplus, imp
erialist and multinationals do make high profits on
the deteriorating conditions of health. And thus
country's real wealth, the precious people, mainly
working force, has again been ignored and is sub
jected to the process of pauperisation. From slums
to farms, the fate is the same in this system.
Reference : The silent drought : Maharashtra. EPW, Jan 19, 1985.
Though agricultural production of HYV has
increased, we do not find any improvement in
Sunil Dighe
Bahadur Mansion 2nd Floor
Lady Jamshedji Road,
Shivaji Park, Bombay
MERIND
MERIND LIMITED
New India Centre, 17, Cooperage Road
BOMBAY-400 039.
December 1985
147
ORGANISING DOCTORS: TOWARDS WHAT END ?
anant phadke
Until the ‘sixties almost all doctors in India belonged to the classical middle class, owning and
controlling their instruments and cnoditions of production. But since the 'fifties more and more doctors
are entering government service. The article begins with a discussion of the role of the wage earning
doctor and suggests that the strategies for organising doctors should be based on a dear under
standing of these contradictions.
This article was held over from the issue focussing on 'People in Health Care' (SHR //:2\ due
to lack of space. The author has since added a comment on Sujit Oas's article in that issue which
is published in the Dialogue section.
Analysis of role of doctors' organisations in
social revolution in India, would require, to begin
with, some analysis of doctors as a social layer
(including an analysis of different subgroups of
doctors) in India. This, in turn, would require an
analysis of the role of doctors in the social process
of production.
Materialist analysis of position of doctors
It is generally not recognised that although a
doctor's work has its own peculiarities, it neverthe
less involves a material process of production.
Like the work of a barber or a massager, it brings
about a material change in the human body and
restores it to a 'normal level The 'raw material'
on which doctors work is very peculiar — it is a
material which thinks, has emotions and the
emotional aspect is very much in action, when the
body is impaired. This is especially true when the
illness is serious. Hence the ideological-cultural
relations that inevitably accompany any material
process of production are much more pronounced
in case of this material process of restoring an
impaired body to a 'normal' level. The ideological
role of doctors is, therefore, much more important
than that of other professionals.
Until the sixties, almost all doctors in India
belonged to the classical middle-class — owning ano
controlling their instruments (stethoscope, syringes...
etc.) and conditions of production and not employ
ing wage labour but basically living off one's own
labour. The wealth amassed by this section of the
middle-class has been through a commercial exploi
tation of consumers (patients) through professional
monopoly over and mystification of medical science
and technology; and not through the exploitation of
wage-labour. Even now majority of doctors in India
belong to this category of classical middle-class.
But since late fifties, more and more doctors are
entering into employment with the Government.
748
This social layer is a wage-earner; does not own the
instrument and conditions of its labour and
apparently is part of the white-collar working class.
But on closer examination, it would be clear that
this layer's role in the process of social production
of medical services is different from that of the
working-class and that it belongs to the new
middle-class — a peculiar product of developed
capitalist society.
New middle class
The category — "new middle class'' has been
clearly formulated, developed in recent marxist
literature. (For example, Carchedior, better,
E.
Wright) Briefly, the new middle class is a product of
developed capitalism wherein a social layer occu
pies a position midway between the capitalist
class and the working class by partly doing fun
ctions both of the capitalist class and of the
working class The
"function of the collective
worker" is geared to the production of use
values whereas that of capital is geared to the
production of surplus value; (profit, rent, interest)
and involves the work of supervision, surveilance.
Wage earning doctors (medical officers) are on
the one hand, part of the team of labourers
consisting of nurses, midwives, technicians . .etc.
doing materially useful work and like them not
owning the instruments (medical equipment) and
conditions (building and other infrastructure) of
labour. On the other hand, they also perform the
function of Capital, of supervising, extracting work
from the paiamedics. Their comparatively high
salary, therefore, includes both a wage for the
trained labour-power they sell and also part of
the surplus value for performing the function of
Capital. Along with foremen, executive engineers,
head-clerks, junior officers and the ilk, depart
mental heads in educational
institutions .....
this layer of doctors is part of the new middle
Socialist Health Review
class. The junior doctors, a transitional phase in
a doctor's life, is entrusted less with the function
of Capital and hence is closer to the trained, skilled
white collar working class The following analysis
is applicable primarily to medical officeis and only
to a certain extent to the junior doctors.
This 'contradictory class
location' of the
Medical Officers would determine a great deal their
contradictory role in the movement tov\ ards social
revolution. As wage-earners, they are ready to
unionise and fight for their demands, and this
struggle demands an alliance with the rest of the
working class against the state. But as officers,
their interests demand a break from the subordinate
working-class; a continuance of the hierarchy
within the medical system.
There is a second couple of contradictory
facets of medical officer's life — on the one hand,
there is a need in this inhuman world of com
petition for amassing money, to earn more and
more money through illegal, irrational private
practice or through corruption to compete with
and to be a part of the flock of the money
spinning community of fellow private practitioners.
(This does not apply to the junior doctors. They
do not do private practice.) On the other hand,
as wage-earners, they need to accept limitations
of a wage-earner, and are also expected to follow
the ethics of a noble profession.
The third couple of contradictory aspects of
this layer of wage-earning doctors is related to
their ideological role (In this respect, private
practitioners also share this contradiction to a
certain extent'. On the one hand, the dominant
ideology in the field of science and hence also
in the field of medicine in capitalist society is
that of technocratic scienticism i e. of looking at
health and disease as primarily a question of
interplay of germs and chemicals amenable to
drug-therapy. Added to this is a predominantly
curative and individual-oriented as oppossed to
community oriented approach to medical care. On
the other hand, the very nature of the 'raw-material'
on which the 'doctor-scientist' works demands a
holistic, humane approach and an exposure (though
in a limited and somewhat distorted fashion) to
the science of community medicine; to the national
health programmes, throws light on the limitations
of a predominantly clinical orientation.
One more set of contradictory relations con
stitute the doctor's work — on the one hand, majority
of doctors are drawn from upper-caste, urban
December 1985
background and are by and large male and hence
are biased in favour of their own social back
ground On the other hand the science of medicine
(though vitiated to a certain extent, by elitist,
sexist bias) basically transcends these narrow barri
ers and exposes medicos to universal concepts
devoid of narrow considerations.
What should be basis of doctor's organisation ?
The left has to grap these contradictions in
order to determine its strategy of organising this
layer of doctors. Secondly we should also be clear
as to what kind of medical system we want to and
can build in socialist India Should we aim at a
medical system which is in the process of freeing
itself not only from commercialism of capitalism but
also from other ills like hierarchy within medical
system, mystification of medical knowledge and
unnecessary glorification of medical profession,
uibanism, elitism, sexism, allopathic chauvinism,
scienticism... and so on? If yes, then in that case it
s wrong to appeal medical officers mainly on the
basis of their trade-union demands We should
plainly point out their contradictory interests, and
appeal them to choose, and stick to the positive,
healthy, progressive aspects of their life-situation
and organise a revolutionary union of doctors on
the basis of this comprehensive plan. It is likely
that only a small section of this new middle-class
would come with us for this comprehensive revolu
tionary change in the medical system. That can not
be helped. But to be sure, there is a definite objective
basis for at least a small section to come over to
the side of revolutionary programme.
Similarly, we need to concretely analyse the
contradictory situation of other categories of doctors
like private practitioners (classical upper middle
class) junior doctors, consultants .. etc; and base
our organizational strategy on that basis.
Unfortunately, today, there does not seem to
be a well thought out strategy in organising doctors.
On one had, medical Officers in Government service
and resident doctors are being organized primarily
on their trade-union demands. But things are not
moving much beyond this narrow focus. At certain
places. Left activists are the leading organizers of
such organizations. They do get a few cadres for
their party or group on the basis of Party's broader
(non medical) programme. Their medical programme
however does not go much beyond asking for
extension of medical services to all people. These
Leftist organisers have not been able to foster a
process of gathering medicos on the basis of a
149
comprehensive revolutionay medical programme
which asks doctors to throw away their privileges
as elite doctors in return for promise of decent,
scientific, meaningful working life.
If there is a hope that doctors — a middle class —
can be "neutralised" by catering to their trade union
demands, then it is a misplaced hope; we must also
understand that such a "neutralised ' social layer
would immediately spring into opposition if a
thorough going change in medical system is
proposed or is actually attempted. Radicalism of
many leftist doctors is directed against injustice,
irrationalities in
the broader society; but has
Penetrated only to a small extent in their own field.
How can such a leadership foster a thorough-going
change in the medical system ? A combination trade
unionism in the medical field with broader left
politics (but not inclusive of ills of the medical
system enumerated above) will fall much short of
revolutionary changes that can be made in the
existing medical system
Some attempt in the
right direction is being made in West Bengal during
and
after
the
state-wide
strike
in
1983.
Apart from trade union demands they have asked
for certain changes in the medical system, drug
industry. It is difficult to judge from here, as to
how much of their support for radical measures
is a reflection of genuine change in the attitude
of at least a sizeable number of doctors or only
expresses the wish of a few leaders or worse,
only a lip-service to radicalism in the medical field.
At the other end, many social activists cri
ticise the doctors as if doctors
barring a few
exceptions") are basically anti-people. It is true
that flourishing private practitioners, consultants,
surgeons, hospital owners would, as a social layer
be oppossed to a revolutionary change. But it is
not realized by these critics that many wage
earning doctors have a lot of problems related to
working conditions — they hardly have any say in
the policy-decisions that affect their work, are
constantly plagued by shortage of drug-supply
and other facilities, have to cow down to the local
bourgeois politicians, and at the same time are
disliked, criticized by the people for 'poor service'
for which many times they are not responsible.
These woes, like those of workers in other public
utility service, are genuine. Rather than ignoring
their problems and be content only with criticizing
their irrational, anti-people approach; why not ana
lyse these problems and show them how they are
problems of a system, how they can be eliminated
only through a thoroughgoing revolutionary change in
150
the medical system; (as part of a broad social
revolution) and offer a programme, an organization
which would help to do this? Many medical offi
cers would not be interested in joining this
organisation since they would not be prepared t°
leave many privileges that they currently enjoy.
But why not build bridges across the valley that
separates them from a people's front when there
is some objective basis in their life situation? An
approach which appeals doctors only on mora
listic grounds is a mistaken one on many grounds
and hence will not succeed in even rallying round
even that small critical mass of doctors we need
to forge in order to make any viable, sufficiently
strong clamour for a revolutionary change in the
medical sysrem.
References
Carchedi G; On the economic identification of the new middle
class; Economy and Society, 4:1
Wright E, Contradictory class locations in Capitalist Society
New Left Review, No. 9
[Please see Dialogue Section^
Anant Phadke
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Socialist Health Review
DIALOGUE
In
Defence of Mq Confusion
Imrana Quadeer
I read with interest Anant Phadke and Dhruv
Mankad's defence of their editorial policy. My
confusion only doubled when I realised that for
them a policy is meant only to be stated and not
implemented. Within a given policy framework,
should not an article be edited or published with
comments requesting the author to rewrite it?
Instead of declaring it "disjointed" etc., etc. six
months after it was published and that too because
some one else pointed out a few contradictions!
The basis of my "confusion" as Anant and
Dhruv understand it, stands out clearly from their
letter itself. While ! think that not all health analysts
have the required understanding of society at large
(including myself) and they should therefore very
consciously try to do so through the ‘ window of health"
(a point in my letter with which my critics agree
but have preferred to ignore), they choose to
believe that"a rigorous, correct understanding of Health
and Medicine would not be possible with a superficial
understanding of society". This may be the ultimate
truth but given the status of ''rigorous and correct
understanding" of the health analysts I am not
ready to take such an assumption for granted.
While they presume that within their perspective any
discussion on health and medicine "would necessarily
be based on an understanding of society irv general",
I will plead that such over-confidence only leads
one into complacency. In fact I would like to point
out that unless and until all authors of SHR are
aware of the fact that all their general theories will
be tested in the field of health (and vice versa) by
the circle of SHR readers and not in the circles of
Social Scientist or EPW readers, the tendency to
take general concepts as well as the readers for
granted cannot be checked. It is true that SHR has
not got involved into a discussion on the mode of
production or the nature of the state but it is also
true that it has neither helped us understand these
concepts through health nor clearly demonstrated
the need to grasp them for a better understanding
of the health situation. Do we, then, mention these
concepts only to establish our Marxist credentials ?
Essentially the difference of opinions between
us boils down to perspectives. For Anant and
Dhruv there are those clear headed few who know
what is "correct" and therefore have a monopoly
over marxist analysis of health. They will write about
imperialism in health in SHR and if at all necessary,
improve their understanding of imperialism in other
intellectual circles.
For me SHR is the place where through health
I must understand imperialism. I will therefore not
let superficial handing of the concept pass unnoticed
in SHR.
All this of course is not to deny my confusion
but to say that till the clear headed ones pay some
attention to its roots it is bound to grow and
grow more.
Imrana Quadeer
Centre for Social Medicine
Jawaharlal Nehru University
New Meharauli Road
NEW DELHI 110 067
One Sided Defence of Professional
Interests
Anant Phadke
Sujit Das (SHR II : 2) starts from a correct
observation that ''...little study has been made
to investigate analyse and understand the medical
profession in the perspective of concrete reality. "
But his article does not help much in a critical
analysis of doctors as a social layer but is an un
critical shame-faced defence of the interests of the
doctors. Secondly, because of lack of clarity about
the 'contradictory class location of wage-earning
doctors, he is unable to characterise them inspite
December 1985
of a long discussion (with many excursions into
sub issues).
To begin with, a word about the title of the
article. It reinforces the popular but mistaken
notion of medical profession being only doctors
forgetting other medical professionals like nurses’,
social health workers and so on. The title reflects
the perspective of the article of focussing on the
interests of the doctors.
COMMUNITY HEALTHCILL 151
47/1. (First Floor) St. Marks Road,
T&Vtf’.aTore - 560 001.
Das’s defence of the interests of the doctors
starts with his analysis of the general practitioners.
It is true that this category of doctors is not
involved in capitalist relations of 'production; but
in petty commodity relations (not 'precapitalist
mode of production') as part of a capitalist social
formation. But it does not mean that he can not
be an exploiter. Unlike retail store-keepers general
practitioners have earned wealth quite out of pro
portion to their skill, knowledge and labour. Such
doctors through their monopoly over medical know
ledge and skills have earned money through
commercial exploitation (price more than value).
It is however, true that, as pointed out by Das,
increased competition amongst j doctors and the
rise of state medical service is changing this
picture especially in bigger towns and cities. Das
is however, content with pointing out only the
problems faced by GPS. This in itself does not
tell us their possible role in social revolution and
the attitude of marxists towards this layer. He does
not mention their poor understanding of clinical
or preventive medicine, their unnecessary use of
injections to earn money, unnecessary use of drugs
(rational or irrational combinations) many a times
cursory, indifferent, attitude to patients, and so
on. Likewise other contradictory aspects of their
existence have to be brought out since it is these
contradictions which tell us about the potentialities
of change.
Confusion between two categories : Das
clarifies
that
"the present discussion dwells
largely on the doctor
in-service among the
practitioners of modern medicine" But doctors-inservice is not a homogenous category. Junior
doctors are closer to the white collar working
class, whereas the medical officers are part of the
New Middle Class. Das is unable to see this dis
tinction and thereto e discusses the 41 day strike
by medical officers and engineers in West Bengal
in 1974 and the movement of junior doctors in
1983 in the same breath, in the same section Here
again, he gives a one-sided picture which only
defends the sectional interests of the doctors con
cerned It does not give us an idea as to what
would be the role of this layer of doctors in social
revolution. The demands in the 1974-strike men
tioned by Das were "exclusive executive power
for the scientists, technologists and professionals in
the scientific and technical departments of the state
administration which were the preserve of the
generalists and parity in pay-scale with the IAS'.
These are demands of a technocracy competing
with administrative beauracracy! The most important
issues in medical care like more resources for
water and sanitation, proper training and importance
to paramedics, rational drug policy, reorientation
of medical education....these are not even men
tioned by the 1974 strike. Then why does Das
talk about the woes of these medical officers and
give importance to this strike? This inability and
unwillingness to focus on the contradictions of
this section of doctors results in only defending
the sectional interests of the New Middle Class.
From the point of view of a social revolution,
this is a fruitless exercise unless the most important
issue of fundamental restructuring of health services
are also taken up seriously (and not only for
cosmetic purpose or for winning sympathy for a
struggle basically aimed at sectional interests only).
In the junior doctors strike in 1983 however, the
doctors' demand for proper facilities in the hospitals
was also the people's need. Interests of doctors
and the people coincided on one point It is hoped
that the movement of this section of the white
collar working class would transcend more and
more purely sectional interests. Only history can
tell us whether the ''basic people's demand' of the
1983 strike were genuinely raised or primarily to
win public support for a movement for purely
sectional interests. We would like to know from
Das what efforts this organisation of junior doctors
has made to pursue these people's demands
during the last two years.
In this brief response, I would not go into
Das's discussion on professionalism, role expetation, performance. One would only say that it
suffers from the same one sided, shamefaced
defence of professional interests of doctors and
their existing role.
Let us be clear about the role of the New
Middle Class i.e medical officers (like most of the
executive engineers, bank officers and others) in
today's society, their contradictions and hence their
role in social revolution. Even after a lengthy
discussion, Das's article precisely fails in achie
ving this.
Forthcoming Issues
Sept
86
Mental Health
Health care in post ■ capitalist
societies
Primary Health Care
Dec
86
Environment
March 86
June 86
Socialist Health Review
152
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Each issue of the journal will focus on one theme, but it will also carry (i) Discus
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PIN
THE MINER OF DHAWBAD
A dawn rises in your dream,
but you go back to the longings of the coal.
Shovelling centuries back, you return
to the fiery springs
and the merry beasts of yore,
through the prehistoric dreams
of a sunlit village,
through the screaming skulls
of its grudging grandfathers
This earth lies unaware
of the acid and the dust
gathering the form of death
in your toil-torn lungs
You shovel the coal, but
your naked children howl surprised
as the train passes by the hamlet
My brother, nameless, unknown.
Even you do not know
but for you the heart of Bihar,
its head raised like a seahorse's
stop to beat
Your mind is dry,
sterile like the River Damodar
in summer noons
The Buddha of Gaya ignores your prayers.
But tommorrow a sun will rise
fjom the flickering flame
of your charred heart,
you will find your forefather's dreams
in the single staring eye of the train, burning.
1974 INDIAN SKETCHES
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