Community-based Oral Health Traditions in Rural India – Prof. Darshan Shankar

Author: Prof. Darshan Shankar
From the book Challenging the Indian Medical Heritage, edited by Darshan Shankar and P. M. Unnikrishnan, published in 2004, Foundation books, subsidiary of Cambridge University Press

Any attempt to introduce local health traditions is handicapped from the start due to their oral nature and the seeming absence of a theoretical foundation. It would seem that the test of their efficacy lies only in empirical evidence. In other words, for the most part they are merely considered to be a somewhat more sophisticated version of the trial-and-error method based on keen local observations. It is observed that many village healers do not care to generalise about how or why their method works. This is seen as evidence that the local traditions lack the theoretical rigour of either Ayurveda or modern medicine.

One way of addressing the issue would be to assert that the local traditions are empirical manifestations of the underlying theoretical structure of the classical tradition itself. There is no doubt that village healers often use procedures the elaborate explanations of which are located in chapters and verses of Ayurvedic texts. This gives us an immediate sense of the marvellous interpenetration of the classical and village traditions ––villagers perhaps know that theoretical explanations are frequently justifications of what they are doing. It has been repeatedly found that, having observed procedures being performed by a village healer, researchers work backwards merely to find their elaborations located in the classical tradition. On the other hand, it often seems that without the visible and expert performance of the village healer, the classical tradition seems only a maze of complex theory and obscure formulae. By observing the village healer, one identifies possible wedges that might enable one to prise open the wisdom of ancient generations.

Nevertheless, it may be appropriate to insert a word of caution here. The exact modalities of the continuity between the classical and the vernacular traditions are very far from being fully established. Much mutual borrowing and enrichment has no doubt taken place. Yet any pronouncement on the precise nature of their relationship is still far away in the future and requires much more detailed scholarship.

In India this issue is, of course, part of the larger question of the relationship between the classical and the vernacular. For our purposes it is relevant only insofar as it relates to local health practices. A later chapter gives examples of how local practices of diet can be understood in terms of an Ayurvedic rationale. But even in this limited context, it is important that such investigation be pursued, even if the practitioners (at the level of the household or of the village physician) are unaware of the rationale that underlies their practice. It is equally important that such investigations are not rendered so rigid or narrow as to preclude the possibility that these practices might have been derived from an unrelated epistemology. What is vital is not so much to explain the emanation of the village system from the classical system (or vice versa), but to fulfil our need for medical pluralism; in short, to keep open all doors so that the greatest possible variety of reliable choices are available to the consumer of health services. Just as Allopathy must not be allowed to ‘squeeze out’ the native tradition, so, too, must Ayurveda and the other written traditions not be allowed to pre-empt the possibility that some local traditions may be of independent and autonomous origin. We feel it necessary to make this disclaimer before we begin our tentative explorations.

The Need for a Basis (A level)

For any kind of exploration of local traditions, it is important to take into account the disappointing state of research on folk medicine under the larger rubric of medical research. To begin with, non-codified traditions are hardly treated as medical traditions. But initial attempts at foundational research into the classical systems have been equally disappointing. Here, the issue is clearly one of failure of our public health policy. Given the size and spread of folk tradition, a thorough investigation of its roots and practices is essential in the public interest. This orientation in policy and research can be possible only if medical institutes offer courses related to the living traditions, including their philosophical origins. What needs to be studied are not merely practices but also, if only at a preliminary level, issues related to a cosmo-vision of folk medicine –– for example, the spirit in nature, the orientations of the self in space and the triangular grid of mind–nature–body. We can no longer afford to see such issues as academic. Without the local and the codified indigenous streams relating at this level to Allopathic assumptions, we simply cannot hope for any progress in the field of medical pluralism. Philosophy is not merely a convenience that can be discarded at will to attend to the putatively more ‘practical’ aspects. Theory is integral to every level of practice.

We hope, therefore, that in the future, serious research on folk medicine will become a priority of any institute devoted to the advancement of Indian medicine. For this, a ‘foundational’ approach that will enable a fresh understanding of both the classical and folk systems is the only approach that will be equal to the task. The uncovering of the epistemology of the folk is more difficult than the recovery of the classical. Even today, many aboriginal healers do not know (or care) why a certain plant heals a certain disease. In such cases it is up to the medical researcher to attempt a discovery of underlying patterns. This would require not only patience but also vigilance, for it is necessary to resist the temptation to make large generalisations that yield only short-term gains. A full investigation into the ecology of health practices must attempt to find all the links and interrelationships of such practices; in other words, their observation might require going beyond the question of health per se, to related questions of lifestyle, diet and cultural practices in general. In the process, the question of health might well lead to an exploration of a new way of ‘living out’ the relationship of the mind–body–nature triangle. In principle, at least, such issues ought not be considered entirely outside the purview of an investigation into the creative springs of the folk tradition. Health in all its ramifications –– inner, outer, sociological and cultural –– must form an integral part of the syllabi of institutes of medicine.

Discovering Oral Health Traditions (A level)

As we know, community-based, oral health traditions are embedded in the lifestyle, diet and health practices of thousands of local communities all over India. Like music and agriculture, health care also flourishes as a folk tradition. It is estimated that there are around 1.4 million folk healers as well as millions of rural (and to a much lesser extent, urban) households who possess immense knowledge of home remedies. They are also well informed about local foods, their availability and nutritional value. The health traditions of all these healers are based on local resources. According to an All India Ethno-biological Survey carried out by the Ministry of Environment and Forests, Government of India, over the period 1985-1995, around 8,000 species of wild plants were listed as being used in health care by rural and tribal communities. These account for almost 50 per cent of the known flowering plants of India (17,5000 species). Apart from plants, local animals, metals and minerals are also used.

The most fascinating features of local health traditions are their wireless (non-institutional) transmission and the fact that they are self-sustaining. They exist in millions of homes and thousands of villages, town and cities, without the aid of any institution or external source of funding. They are transmitted through family or community traditions via a person-to-person process. Folk gurus (teachers) guide their sisyas (students) in cultural and ethical codes, which evolve, adapt and alter in time. They embody the knowledge of the human mind, physiology and anatomy as well as of food and nutrition. This knowledge extends even to the pharmacological properties of plants, animals, metal and minerals. Though community health practitioners have no legal status, they enjoy much social legitimacy in their localities.

It must be noted that folk healers do not generally undertake medical service as a full-time vocation, nor are they dependent on their health services for a livelihood. The typical healer may be a farmer, a barber, a shopkeeper, a blacksmith or even a wandering monk. And while the medical services they provide are not free of charge, they are offered in an ethical and non-commercial spirit. So though the community (patient) pays the healer for his/her services following local cultural norms, the income earned is usually incidental and supplementary. This low sustenance cost is one reason why the tradition is so large, widespread and decentralised, and has over million foot-soldiers. If folk healers were to depend on such earnings for their livelihood, their numbers would have been much smaller, as not every village can sustain the livelihood needs of full-time healers.

The health traditions of a community must also be distinguished from their other health practices. A community may have several current health practices, such as the use of aspirin for headaches, but these do not fall under the ambit of tradition. Traditions comprise practices that are self-perpetuating and transmitted without the intervention of any agency or institution. They are often passed down orally or in a written form through generations of the same family or community.

An example of a seventeenth century health diet tradition of northern India is the dish made of potatoes (Solanum tuberosum; Hindi name: aloo) and methi (botanical name: Trigonella foenum-graceum). This dish is prepared by thousands of households and is referred to as methi–aloo (and not as aloo–methi). This is to stress the use of a higher proportion of methi to aloo on the logic that methi, by virtue of its ‘hot’ nature, balances the wind-producing effect of the potatoes. This example also points to the dynamic and adaptive nature of local health traditions. Potatoes are not native to India and were introduced into the country by the Portuguese in the sixteenth century. The material was studied and assessed by Ayurvedic physicians who found it to be ‘wind’ producing and advised that it be eaten in combination with other balancing materials like methi, jira (Cuminum cyminum) and hing (Ferula asafoetida).

Another example of an ancient health food tradition that is still alive and flourishing is the highly nutritious South Indian ‘idli’, a steamed cake made up of rice and lentils. The lentil used in idli is masa (Vigna mungo), which, though rich in protein (mamsa vardhaka), is also hot and acidic (usna and pitta karaka). In North India, it is only eaten in winter; were it to be eaten in summer, it would cause hyperacidity and flatulence. The South Indians, however, have overcome this problem by cleverly combining masa with rice in a certain proportion (1:3). The dish is then prepared using the fermented dough of these two materials.

Having thus eliminated the side effects of masa, the idli can be eaten throughout the year. With a healthy balance of protein, carbohydrates and vitamins, it is easy to digest and can be eaten by the old, young and even infants. The idli is an ideal health food, the preparation of which is part of a living tradition known and practised by millions. In India, one can find a tremendous range of such regional diets. While the various ethnic communities use only ecosystem-specific food resources, these are far more numerous than those documented by food and nutrition textbooks.

Apart from the oral traditions at the household level, there are widespread health traditions that are practised on a community scale. Every village in India has a few traditional birth attendants (TBAs) or midwives. These midwives can handle breach deliveries, laterally positioned foetuses and infants with their umbilical cord displaced around the neck. They can even deliver a stillborn child. India has around 600,000 such TBAs who are maintained in villages through apprenticeships that extend from generation to generation.

Amazingly, India also has a folk orthopaedic tradition. Every cluster of 20–25 villages has a bonesetter. These bonesetters treat sprains and simple fractures, and in some parts of the country they also manage compound fractures with open wounds. There is no systematic study available on them yet, but it is obvious from the low access to hospitals available in rural India that traditional bonesetters manage most broken bones in the villages.

Local health practitioners do not just deal with general health problems. There are also community traditions relating to emergencies –– as is evident from the existence of an estimated 60,000 healers who treat poisonous and even life-threatening snakebites[1]. The traditional visa (poison) healers can distinguish a poisonous snakebite from a non-poisonous one and, further, between the bite of a krait, pit-scaled viper, Russell’s viper and a cobra, each of which merits a different treatment. In some regions they also treat those bitten by mad dogs to prevent rabies.

Finally, there are about 100,000[2] herbal healers who treat a range of common ailments, chronic conditions and even specialised conditions related to the eyes, ears, skin and muscular and nervous disorders.

All these are ‘health traditions’ because they survived, evolved and adapted themselves over centuries. There is no single medical school or agency that is responsible for the transmission of this knowledge, either at the household level or at the level of the specialised folk healer; it has spread through personal contacts.

However, there has been serious erosion in many segments of this tradition. Having become aware of this, it is necessary to develop an operational strategy that will revitalise the informal educational process as well as the community support system that has upheld the tradition for centuries. In this context it is very important to understand that any intervention that intends to strengthen community health practices must also protect their autonomy and self-reliance. It is only the local communities of India that can support both their own health traditions as well as their local transmitters. Local and central governments and Non-governmental Organisations (NGOs) can provide local communities support, but they should take care to do so without hobbling or crippling the tradition itself.

How is this to be done? India’s oral health traditions are vast, covering thousands of natural resources, plants, animals, minerals, wild vegetables and fruits. They encompass several preventive, promotive and curative health practices. It will easily take more than a century to fully document and assess the numerous and diverse health practices in every corner of the country. Yet, if these traditions are to be revitalised, it is important to prioritise certain health practices and initiate their assessment in order to generate confidence in the community regarding their value. For this, it would be essential to design an assessment methodology that is sensitive to, and takes into account, the basis of local knowledge systems. We cannot impose evaluation schemes based on paradigms that are incompatible with local epistemologies. Furthermore, different approaches may be needed for traditions related to (a) food and nutrition, (b) health customs, (c) preventive and promotive practices, and (d) curative health practices.

Historically, oral traditions have had a symbiotic relationship with the codified Indian systems of medicine (ISM) like Ayurveda, Siddha, Unani and gso-rig-pa. If these oral traditions are to be revitalised, it may be useful to restore and promote their functional relationship with these ISM. This would need a carefully worked-out strategy based on the realisation that while it would be disastrous to suffocate the oral traditions with the theoretical burden of formal medical systems, Indian medical systems as well as modern medical science could, if creatively applied, contribute to the revitalisation of our oral health traditions.

There is one other problem that would need to be addressed: the ‘ownership’ of traditional health knowledge. While it appears to be minor blip at the moment, it may become more threatening in the future. In countries outside India most problems relating to traditional knowledge and biopiracy pertain to oral health traditions. These traditions do contain valuable experiences that are vulnerable to exploitation by medical research and commerce. There is, thus, a need to spread awareness regarding the property rights of the traditional custodians of health knowledge, but in a balanced way, without creating paranoia. Model Material Transfer Agreements (MTAs) and Information Transfer Agreements (ITAs) would have to be evolved to protect the intellectual property rights of community knowledge. But this would have to be done based on the realisation that benefits from the commercialisation of a few amongst the thousands of available local health practices that are indeed commercially viable, is not going to make rural communities wealthy. The real benefits lie in the active use of these practices for self-reliance in primary health care. The need of the hour is therefore to create an environment that would foster local innovations based on local knowledge systems.

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