Peasant Women and the Rediscovery of Indigenous Health Care

indian team study 1

PEASANT WOMEN AND THE REDISCOVERY OF INDIGENOUS HEALTH CARE

1. HEALTH SYSTEM IN INDIA

India is a country with many health problems. The overall state of health in India is poor. Health services as they exist in the country at present have been structured on ideas borrowed from the industrialized West. These, no doubt, were introduced by the British to serve their own interests. At the time of independence the political leadership of the country was confronted with two choices: either choosing the easier path of merely expanding the health services qualitatively along the pattern set by the British rulers or of taking the challenge of making basic qualitative and quantitative changes to relate these health services to the masses of the people as on of the means of raising their levels of living. While the political leadership had made, as early as in 1946, solemn pronouncements that the health of the villagers required special attention and the aim was to develop a National Health Scheme – which would supply free treatment and advice to all those who required it, in actual fact it went on to adopt the palpably soft line, which left health care services concentrated in urban areas. Investments were made to strengthen the existing colonial pattern – the colonial patter of health administration and the co-

lonial pattern of the provision of health services which was heavily biased against the underprivileged, against the rural population an against the preventive programme. This caused a traumatic disruption in the way of life of the people. The colonial pattern of health services created conditions which led to decay and degeneration of the pre-existing health cultures, some of which had attained in astonishingly high level of development for self-sufficiency for the alleviation of the suffering (as in the case of ayurveda in India).

The present health system relies heavily on curative medicine which traditionally is becoming more and more dependent on sophisticated diagnostic aid- symbolic of the rapid advances in industrial technology. Hospitals equipped with such aids and staffed by highly trained personnel has been goal with the utopian thought that these will gradually extend to the rural periphery. In developing countries, India included, the accent continues to be on building large hospitals and centres of medical excellence primarily concerned with health problems of an affluent minority so that the vast majority of the population get poor or no medical care at all. Even though the government meets over 90% of the cost of training a physician, about 80% of them are located in urban areas where only 20% of the population lives. There too the services of these physicians are not adequately accessible to the majority of the population, which is constituted by the weaker sections who live in slums and other depressed urban neighborhoods. Professor Banerjee of Jawaharlal Nehru University, says “as a result of this urban and privileged class orientation and the over emphasis on curative services, physicians almost willingly allowed themselves to be ‘doped’ by the high pressure sales tactics of drug firms, particularly those belonging to multinational corporations. Armed with patent rights, brand names and multiple formulations these proprietory firms have succeeded in brainwashing the profession into prescribing medicines which might cost anywhere between 100 percent to 3000 per cent above the manufacturing cost. This cost has sometimes to be borne by patients who are desperately poor and who somehow procure money at the exorbitant rates of interests from money lender to seek the services of physicians for their serious ailments. This is not the case in India alone. The drug scene all over the world is dominated by the giant multinatioal corporations. To these multinationals, the drug industry is one of the most profitable segments of the modern industrial scene. About a

score of international companies are going to share the major part of a world market in human health products/which by 1985 will total over 22,000 million dollars. Because of their vast profits and domination of the world market, pharmaceutical companies actually dictate priorities in health (or sickness) by deciding which drugs they are going to concentrate on researching and marketing. Companies will only invest in drugs which will sell widely and bring good returns. It seems the multinational pharmaceutical industry which has entrenched itself in the less developed countries inhibits the growth of indigenous enterprise.

The pharmaceutical products are however a class by themselves. A person’s need for medicine originates under adverse circumstances, and is perceived by his physician; the patients’ demand for it, both its type and quantity, is decided by the physicians, the consumer has practically no option ( to buy or not to buy, if to buy, what) in this matter. The demand is urgent and the consumer would be willing to pay any price for it, and everything else becomes a second order of priority. The consumer knows very little about the product, including its effect, favourable and unfavourable, or about the alternatives available, or their prices and relative merits. On the other hand their use involves a certain degree of uncertainty and risk, unwholesome side effects and reactions which can prove to be serious, longstanding or even fatal.

It is no secret that the pre-conditions for being healthy remain a dream for more than two thirds of India’s population who live in rural areas or in the urban slums. Consequently, they and their progeny present a spectacle of diseased poverty. For this vast majority, high infant mortality, malnutrition, and infectious disease are all too common facts of life. The bitter irony is that they are the most neglected in our present system of health care, which caters to the health needs of well-to-do urban people. Even if the poor can get to a doctor the medicines remain beyond their reach. J.P. Naik shares the view that the adoption of western models of health services has inevitably led to the recent lop-sided medical facilities. What is worse, he adds, we are no longer sure that the Western model we adopted is really suited for us, especially as its basic premises are now being challenged in the West itself by thinkers like Ivan Illich.

2. INDIGENOUS MEDICAL SYSTEM

(Ayurveda)

Ayurveda has a history of over 3,000 years. Some claim Ayurveda as the father of all forms of medical practices existing today. Ayurveda has, in early times, both physicians and surgeons. There were treatises on general medicine, anatomy, gynaecology obstetrics, and surgery.

At the beginning of the Christian era, Ayurveda had spread far and wide and had influenced the systems of medicine in Egypt, Greece, Rome and Arabia. When the British came to India they introduced the Western medical system to this country and this resulted in weakening the influence of ayurvedic practice. By the end of the 19th century the indigenous systems had become static in this country and had largely fallen on the hands of untrained persons to practise ayurvedic medicine.

In 1946 the Government of India set up a committee to study indigenous systems of medicine in India and the history of ayurveda or Hindu medicine, including sidha (the classical Tamil system of medicine) and of the unani (one of the classical systems of medicine which derives from Ionian (Greek) sources. the report stated that, although both the ayurvedic and unani systems had become static, further investigation of these systems might lead to modern medical knowledge.

The committee expressed the view that, as all different systems-ayurveda, unani, modern scientific medicine, homeopathy, etc - have the prime objective of maintaining health and preventing and curing disease, the should all be properly investigated for the benefit of humanity, and integrated into a single health care system. Separate systems of Indian and modern medicine were not envisaged in the report, although the available information indicated that Indian medicine, though relatively static, still gave medical relief to over 80$ of the population.

In ayurveda, as in modern medicine, there are two major components of medical practice-preventive and curative. The preventive aspects of the practice of ayurveda consist of the following three components: personal and social hygiene, the use of rejuvenating measures to prevent ageing and decay, and the practice of Yoga to provide tranquility of mind

and complete physical relaxation. The word yoga means “union” and its exponents claim that by continuous practice of Yoga one can maintain a perfect union of body, mind and soul, leading to complete tranquility and peace. There are four main curative aspects of the practice of ayurvedic medicine: 1) Administration of medicine internally, 2) Application of medicinal preparations externally, 3) surgical measures and 4) treatment by psychosomatic measures.

In India there are at present about 50,000 institutionally qualified practitioners and about 150,000 non-institutionally qualified registered practitioners of Indian medicine, including the ayurvedic, unani, and sidha systems of medicine. In addition, it is estimated that there are another 200,000 traditional ayurvedic practitioners practising in the rural areas who are neither qualified from an institute nor registered with any state council. These practitioners receive practical in-service training from their preceptors. Most of them use only ayurvedic dispensaries.

“Unite all medical workers”, said Mao Tse Tung, “young and old, of the traditional school and western school, and organize a solid united front to strive for the development of work of people’s health,” The ultimate solution to the health problems of the developing nations is a fully integrated type of training that includes the essential principles of modern sciences, so that practitioners can serve the rural populations with efficiency and understanding and at a relatively low cost. The committee, appointed by the Government of India, ‘recommended the integration of ayurveda and modern medicine as regards education, practices and research stating that it was not only possible but most desirable in order to provide efficient medical relief to the people living in the rural areas.

There are in India at present 107 modern medical colleges admitting more than 13,000 medical students annually, and 102 ayurvedic and other indigenous medical colleges (91 ayurvedic, 10 unani, and 1 sidha) admitting about 7,000 students annually, thus making a total of 20,000 students a year. These different types of medical institution run on parallel lines with no definite commitment on their part to render service to the rural population. This can be remedied only by starting a fully integrated medical course in all existing institutions. When a large number of graduates who have done integrated studies of both modern and ayurvedic

medicines are being produced in all the teaching institutions, they can be encouraged to serve in the rural areas and to man the primary health centres. These practitioners would be able to serve the rural areas much better than graduates trained exclusively in modern medicine or ayurveda.

The resources that India can afford to invest in medical care could be much better used if they were shared between the modern and indigenous medical systems. Money could then be spent on the training of the indigenous body of practitioners, and in the creating of labour between the systems. Medical research has to be carried out to find out the exact competence of the indigenous practitioners. A better remittance system has to be designed which can screen the patients in an optimal way so that the indigenous practitioners can get cases which they are competent to cure and so that they remit the cases which the allopathic is better fit to handle. (Allopathic is an Indian English term of greek origin meaning “foreign” and is used to denote the Western system of medicine).

There is no reason to believe that allopathic medicine will wipe out indigenous medicine from this country. Allopathic doctors are not likely to spread out evenly through out the country, nor will there be enough of them to soon provide the mass of the population with reasonable standards of service. The present Prime Minister, Morarjee Desai has long supported ayurveda. The inability of modern medicine to deliver goods in the rural area will allow indigenous medicine to strengthen their positions.

3. CASE STUDY OF A VILLAGE IN KERALA

This study which is descriptive but not in-depth, seeks to disclose the common diseases prevalent among agricultural workers in a village,- Kumarakom. In Kerala, and the measures they follow to prevent and cure the diseases.

Kumarakom is a small village belonging to the Kottayam district in Kerala, a south Indian state. It is part of Kuttanad, one of the principal rice growing regions of the State. Kuttanad is spread over 76 low-land villages in the Allepy and Kottayam districts. Kumarakom is one of the 76 villages.

Kumarakom hamlet is mostly a waterlogged backwater area with a good number of paddy fields, known as PADASEKARAMS. There are nearly 2,000 households. The majority of the population are agricultural

workers belonging to the backward castes. The population of Kumarakom can be classified into farmers, agricultural workers, fishermen, coir workers and lime shell workers. Agricultural workers form the major part of the work force in Kumarakom. Female participants in the agricultural operations are very high. Minimum wages for women workers are Rs.7, and Rs.8 for men.

Agriculture includes mainly rice cultivation. During harvesting and sowing the workers stand knee deep in water and mud and this may be one of the reasons for widespread rheumatism there.

We visited 50 agricultural families in Kumarakom. The families generally keep their houses clean and sweep their houses and compound everyday. A family consisted of five to eight members. Children (both boys and girls) attend schools. Men and women go to work together in the morning and return home in the evening. People generally looked very healthy and we did not find any families having nutritional deficiency. One of the reasons, we feel, for this is the increasing consumption of fish by the people.

Kumarakom has a good supply of drinking water, though taps are connected only in the road. Despite this supply of water, some people drink water from stagnant ponds partly because they under- estimate the dangers. Since Kumarakom is a village surrounded by water, the people face sewage problems. This results in the spreading of gastric diseases, according to some local doctors.

The common diseases are coughs, fever, worm infections, diarrhoea, typhoid, rheumatism and jaundice. The following infrastructure of health care operates in the villages. There is a primary health centre with 2 doctors and 7 nurses, and also a private hospital, owned by a Church, with 2 doctors and nurses. Two private clinics also operate there. There is the government mobile team for health which carries out vaccinations and people said it had good effects on the health of the people. Most children were immunised against polio. Regular vaccination campaign helped to remove diseases like measles, diphtheria and poliomyelitis. Catholic sisters visit this place from the nearby town and supply free medicine. Kumarakom has three shops which supply allopathic drugs. In the world of ayurveda medicine, there are 4 Vaidyans (village medicine men) and 2 private Ayurvedic dispensaries.

All the families we talked to use and prefer modern (Allopathic) medicine because according to them it is easily available, and the families are of the belief that it is the final answer to all the diseases. Indigenous medicine (Ayurveda) is used only to cure rheumatism and jaundice. There is hardly any fast cure for jaundice in the allopathic medicine, whereas ayurvedic treatment has a sudden and complete cure. Except for these two diseases people use allopathic medicines.

The more and more use of the allopathic medicines by the people in Kumarakom is the result of the deep penetration of modern medicine. Modern medicine has penetrated rura1 areas together with other developments such as better communications, nutrition, and water supplies. There seems to be a mutual understanding between the people and health services, and people are generally happy about the modern medicine as applied in practice in Kumarakom. Even though modern medicine may have proved its efficacy in the eyes of the community, for some diseases ayuverdic medicine is regarded as the best. Some families complained that Ayurvedic medicine takes a long time to cure diseases.

For most people curative care is the felt need, they are even ready to go to the extent of buying expensive medicines because people in general are very much concerned about personal health. Preventive and promotional medical care is not yet considered a need to the same extent and the reason is that curative care lessens pain and discomfort and gets the patient back to work within a reasonable time.

As stated earlier, modern medicine has penetrated the rural areas of Kerala considerably. “The average income in the Indian state of Kerala is among the lowest in the nation, yet Kerala’s rural infant mortality rate is well below half the national average. Along with land reforms, the mass distribution of educational programmes, food subsidies and health services has improved the health of Kerala’s residents dramatically in spite of their penury”. (Erik P Eckholm, the picture of Health; Environmental Sources of Diseases, W W Norton, New York, 1977).

The important single factor to which the better levels of health could be attributed might well be the spread, and accessibility, of medical care system

developed in the state operates with less discrimination against lower-income groups than does those in other states. Kerala has the lowest mortality rate and the major factor which brought about the decline in mortality rates in Kerala was the expansion and spread of health facilities.

The total number of persons treated in hospitals, primary health centres and dispensaries in Kerala was 21.6 million in 1970 only slightly higher than the population of about 21 million in that year. This does not include the number of persons who had visited the ayurvedic hospitals and the 207 ayurveda dispensaries in Kerala. In 1967/68 they treated 2.4 million patients. The proportion of the total population treated in hospitals, however, would depend on the average number of illnesses for which the same person visited the hospital in the course of the year. In the absence of information on this, one may assume that the percentage of total population treated in hospitals (“The utilization ratio”) would be a reasonable and dependable indicator of the availability and utilization of medical care, and can therefore be used like other indicators such as the bed/population ratio and the population/ hospital ratio (Table 4 gives these ratios for a number of states for 1965.) This data brings out the availability and utilization of medical care in Kerala compared to some other states in India.

The improvement in the levels of health of the population of Kerala is closely related to the pattern of the medical care system developed in the state. This system, by ensuring its accessibility to the largest number of persons, has resulted in the highest utilization ratio achieved by any state in India. The Kerala pattern of development has resulted in less discrimination by the medical care system. In many states health cares is concentrated in the urban areas, thus denying equality of access to the bulk of the rural population as well. this has naturally resulted in raising the percentage of total population treated by the health care system, in Kerala, resulting in a higher utilization ratio.

Women have greater say in taking decisions that arise in the family. Women’s roles in the family are not as mothers and cooks but also as earners of bread. The decisions regarding health care at home are taken jointly by the husband and the wife. In many occasions and it is the woman who escorts the pat-

ient to the hospital.

As persons who have equa1 status with men, women have a great role in popularising indigenous medical practices at home and in the community. Women make maximum use of self-continued use of various indigenous remedial measures. Services of locally available practitioners of various systems of medicine should be used as supplement. Another supplementary community resource can be created by providing training to community-selected primary health workers, who are especially drawn from the weaker sections, and who can make available remedies from indigenous and western systems of medicine, for meeting the medical care needs. Services of full time health auxialiries may be used only to tackle more complicated cases and those which need more specialized care. Cuba and china have achieved a good system of health care using this approach. In India, Dr. Raj Arole at Jamkhed has trained village women to take care of 70% of the common illnesses of the community.

Women, as mothers traditionally, have been more concerned with the health and nutritional needs of the family members. But both men and women could promote personal hygiene such as teaching the children and adults basic and good health habits. They could motivate people to eat nutritious food that can be grown locally, with special emphasis placed on the nutritional needs of mothers and children. People should seek primary health education. Considering the infectious nature of many of the common diseases, stress should be placed upon the practices of hygiene, sanitation, etc. Water is a disease carrier and people should learn how important it is to boil water before drinking. It is not a practice to boil water before drinking it in villages. The reason for not using boiled water may be because of bad taste, but it could be avoided by scenting it with medicinal herbs to remove the taste and make it good for the body. Godbole suggests an effective and simple method for disinfection of water. “It has been shown that the storage of contaminated water in copper vessels for four to six hours makes it free from danger of contamination and that this simple effective and handy method of water treatment would be an answer to the question of supply of clean water to the rural population where the facilities of piped water supply

are not available and are not possible in the near future.” (Godbole S H S H “An effective and simple method for disinfection of water” - Indian Journal of Medical Science, Vol 25 (Oct. 1971 pp. 712-18)

Women should seek training in the use of simple herbs for all kinds of ailments, so that it could be practiced in the community. As community workers they could study the current practices in traditional medicine and they could impart the knowledge about the traditional medicine to the community.

Indigenous medicine is definitely capable of improving the medical care available to the Indian people. But it cannot do very much to improve their health situation.

The poor health of the Indian people, is rooted in their living conditions, and in the economic system which denies the majority even a mere subsistance. Bardhan economist estimates that the percentage of rural people living under the poverty line (Rs.15/- per month in 1960-61 prices) has increased from 38 percent in 1960/61 to 54 per cent in 1968/69. This is the fundamental reason for the failure of medical systems in India. No system of medical care, however sophisticated, can do anything in such a situation. Only a radical transformation of the economic structure can produce the really forceful weapons to wage the battle against disease in India.

Table: 1

STATISTICAL ANNEXURE

NUMBER OF MEDICAL INSTITUTIONS (ALLOPATHIC) IN KERALA

Year	Total number of institutions
1957-58	369
1960-61	307
1961-66	491
1966-71	553
1971-72	571
1972-73	783
1973-74	874
1974-75	881
1975-76	885
Source: Directorate of Health Service

Table: 2

NUMBER OF MEDICAL INSTITUTIONS (INDIGENOUS MEDICINES)

AYURVEDIC IN KERALA

Ayurvedic Hospitals Ayurvedic Dispensaries

No. 1974-75 1975-76 1974-75 1975-76

(1) (2) (3) (4) (5) (6)

1 Trivandrum 8 8 32 33

2 Quilon 4 4 34 34

3 Alleppay 7 7 39 39

4 Kottayam 6 6 18 18

5 Idikky 1 1 15 15

6 Ernakulam 9 9 28 28

7 Trichur 8 8 52 52

8 Palaghat 3 3 34 34

9 Malappuram 6* 6 33 33

10 Kozhikode 5 5 33 33

11 Cannanore 6 6 56 57

63 63 374 376

---------------

* Include one mental hospital

Source: Directorate of Indigenous Medicine

Table: 3

POPULATION OF KERALA

Year

Population

1971

1976

21,347375

23,737000

Source: Census of India

Table: 4

Indian States: Population for Hospital Bed/Population Ratio & Population Treated in Hospitals, 1965.

State

Population served by

No. of beds per 100,000 Populn.

Hospitals

Dispensaries

Andhra Pradesh

Assam

Bihar

Gujarat

Jananu & Kashmir

Kerala

Madhya Pradesh

Maharashtra

Karnataka

Orissa

Punjab

Rajasthan

Tamilnadu

Uttar Pradesh

West Bengal

106,541

174,682

326,622

196,588

151,232

186,371

243,426

113,854

146,411

105,473

129,453

58,961

113,470

98,258

148,065

51,448

18,578

72,022

17,145

7,546

92,272

95,310

44,531

39,971

63,913

49,407

75,807

55,069

243,727

75,895

66.4

44.0

33.5

58.6

92.5

84.7

40.3

81.2

80.9

44.5

66.5

61.9

47.9

34.7

84.5

State	Per Capita on Health 72/73 (Rupees)	Percentage total Popln. treated in Hospitals
Andhra Pradesh	6.38	........
Assam	5.64	7.8
Bihar	4.89	........
Gujarat	9.17	........
Jammu & Kashmir	11.50	........
Kerala	8.64	80.2
Madhya Pradesh	7.26	8.2
Maharashtra	11.21	........
Karnataka	8.88	........
Orissa	6.77	47.0
Punjab	11.29	46.4
Rajasthan	8.97	45.0
Tamilnadu	9.05	53.7
Uttar Pradesh	4.87	........
West Bengal	8.68	23.8