Ethnomedicine and Tribal Healing Practices in India: Challenges and Possibilities of Recognition and Integration 9811942854, 9789811942853

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People, Cultures and Societies: Exploring and Documenting Diversities

Sunita Reddy Nemthianngai Guite Bamdev Subedi Editors

Ethnomedicine and Tribal Healing Practices in India Challenges and Possibilities of Recognition and Integration

People, Cultures and Societies: Exploring and Documenting Diversities Series Editors Sunita Reddy, Jawaharlal Nehru University, New Delhi, Delhi, India Sanghmitra S. Acharya, School of Social Sciences, Jawaharlal Nehru University, New Delhi, Delhi, India Editorial Board Tulsi Patel, Department of Sociology, University of Delhi, New Delhi, Delhi, India Ash Narain Roy, New Delhi, India Ramesh C. Gaur, Central Library, Jawaharlal Nehru University, New Delhi, Delhi, India Robert Tian, School of Business, Huaihua University, Hunan, China Maisam Najafizada, Faculty of Medicine, Memorial University, St. John’s, NL, Canada Shalina Mehta, Panjab University, Chandigarh, Punjab, India K. K. Mishra, Motilal Nehru National Institute of Technology, Allahabad, Uttar Pradesh, India Alison L. Kahn, Stanford University Overseas Program, Oxford, UK

The series proposes to capture the diversities in people and their communities in India. It provides a unique and innovative resource for anthropological knowledge, philosophy, methods, and tools to understand, analyse and formulate sustainable, innovative solutions to address socio-cultural issues in India. India is a repository of varied cultures and diversities. With the globalisation and development process, the cultural fabric is changing. Customs, traditions, beliefs, on one hand, food habits, art and craft, weaving, dyeing, and handloom artefacts, on the other, are undergoing a metamorphosis. It is imperative to explore, understand and document the process of changing diversity and relational inequalities. The series encompasses richness in art, craft, language, dance, music, folklore, food culture and beliefs, traditions and practices. It addresses the issues of development disparities, inequality, and segregation on the axes of caste, class, religion, region, ethnicity, and gender. The series publishes methodologically rigorous and theoretically sound, critical and comparative, empirical research peer-reviewed volumes related to non-codified healing practices, gender-based violence, migration induced vulnerabilities, child abuse, social identity-based work on a national, regional and local level, welcoming case studies, as well as comparative and applied research. The series is of interest to the academicians and students in the discipline of sociology, anthropology, psychology, social work, history, philosophy, and public health, and to all of those interested in a wide-ranging overview of art, culture, and politics. It accepts monographs, edited volumes, and textbooks.

Sunita Reddy · Nemthianngai Guite · Bamdev Subedi Editors

Ethnomedicine and Tribal Healing Practices in India Challenges and Possibilities of Recognition and Integration

Editors Sunita Reddy School of Social Science, Center of Social Medicine and Community Health Jawaharlal Nehru University New Delhi, Delhi, India

Nemthianngai Guite School of Social Science, Center of Social Medicine and Community Health Jawaharlal Nehru University New Delhi, Delhi, India

Bamdev Subedi Kathmandu, Nepal

ISSN 2662-6616 ISSN 2662-6624 (electronic) People, Cultures and Societies: Exploring and Documenting Diversities ISBN 978-981-19-4285-3 ISBN 978-981-19-4286-0 (eBook) https://doi.org/10.1007/978-981-19-4286-0 © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023 This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Singapore Pte Ltd. The registered company address is: 152 Beach Road, #21-01/04 Gateway East, Singapore 189721, Singapore

Anthropos India Foundation (AIF) Anthropos India Foundation (AIF) is a trust founded in October 2011 and registered in Delhi. AIF’s aim is to promote the discipline of Anthropology, its philosophy and methods, because the subject has huge potential to engage with all spheres of life. Therefore, the trust actively peruse and encourage Applied and Action Research. Through action research the foundation particularly reach out to women, children and other marginalized sections of the society with a focus on health, education and child rights. AIF, through its work, seeks to address issues in the local/ regional context based on the ‘emic’ perspectives and practices bottom up approach to solve the problems faced by the communities. AIF carries out community-based research, provide advocacy and policy recommendations and while doing so it takes into account, local knowledge systems, the perspective of common people and work with sincere appreciation and respect towards local culture and ecology. Besides conducting community-based action research, the foundation regularly organizes guest lectures by eminent anthropologists, social scientists and maintain an e-resources to be shared through the official website. AIF also promotes Visual Anthropology through vibrant, authentic, meaningful ethnographic films and photo documentation. More details can be accessed on www.anthroposindiafoundation.com

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Preface

I am delighted to bring out this volume and hope that this will stimulate further interest among students, academicians, researchers, indigenous rights activists, planners and policy makers on the issues of recognition and integration of indigenous healing practices. The idea of this volume was conceived at the national seminar on “Indigenous Healing Practices among the Tribes: Challenges in Recognizing and Mainstreaming” held in 2016 in Jawaharlal Nehru University, New Delhi. The seminar could not have taken place without the financial support from Indian Council of Social Science Research (ICSSR). Further support came to Anthropos India Foundation (AIF) from Indira Gandhi National Centre for Arts (IGNCA) to conduct research in selected states of North East. Further support came in from ICSSR funded project to Dr. Nemthinngai Guite and myself to conduct research in North East States. The study ‘Traditional Healing Practices and Health Care Utilization among Women and Children: A Study in four North Eastern States’ was carried out during 2018–2020. This volume comprises chapters contributed by young and eminent scholars providing a robust background on many issues of indigenous healing practices among the different tribes in India based on empirical research not just by anthropologists but also from Ayurvedic doctors, public health specialists and practitioners and promoters who are conserving local health traditions. The contributors of this volume draw attention to many important aspects of ethnomedicine and indigenous healing and at the same time, share the possibilities of recognition, conservation, promotion, revitalization, integration and mainstreaming of local health traditions. Further this volume opens up avenues for further research on this theme, which has so far received scant attention. In a way this is an effort to advance the theme of recognition and integration of indigenous traditional medicine that existed across the tribal populations. We are grateful to our distinguished scholars for the deliberations and discussion on many issues of ethnomedicine and to have contributed to this volume.

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Anthropos India Foundation will take forward advocacy with the Ministry of Tribal Affairs and Ministry of Ayush to ensure the recognition and rights of the tribal healers along with other stakeholders. New Delhi, India

Sunita Reddy Founder Chair, Anthropos India Foundation

Acknowledgements

It gives us immense pleasure to express our gratitude to many people and institutions who helped us put this volume together. This book got conceived while organizing a seminar titled “Indigenous Healing Practices among the Tribes: Challenges in Recognizing and Mainstreaming”, held on 10–11 February 2017, at Jawaharlal Nehru University (JNU). We want to thank Indian Council for Social Science Research (ICSSR) and Indian Council for Medical Research (ICMR) for financially supporting the seminar. It was great teamwork with our students who helped organize this seminar; some have also contributed to this volume. Thanks to Bamdev Subedi, Tshering Lepcha, Asem Tomba, Farzana, Alok Patra, Ashwini, and Minakshi. Special thanks to our friends, Dr Harimohan and our colleague Prof. Sanghmitra Acharya for their constant support and guidance. We are also thankful to the staff and the faculty for their support from the Center of Social Medicine and Community Health, JNU. We also like to thank the staff of the Research and Development cell of JNU. We are grateful to all the authors who reposed faith in us and patiently updated the papers for submission in this edited volume. Special thanks to Prof. R. K. Mutatkar for reviewing chapters and Ms. Rosemary Sebastian for language editing. Our sincere appreciation for the three unknown reviewers for their valuable comments on the manuscript helped reorganize and revise the book. Our gratitude goes to all the healers who shared their issues, challenges during our respective fieldwork. We all hope that this book will help make policies for recognizing, mainstreaming, and integrating local health traditions, which is long and overdue on this subject. Sunita Reddy Nemthianngai Guite Bamdev Subedi

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Contents

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Introduction: Ethnomedicine and Tribal Healing Practices in India: Challenges and Possibilities of Recognition and Integration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Sunita Reddy, Bamdev Subedi, and Nemthianngai Guite

Part I 2

Historical and Critical Perspectives to Understand Ethnomedicine and Healing Practices Among the Tribes

Practice and Praxis: A Critical Look at Medical Anthropology in India . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . P. C. Joshi

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Ethnomedicine as Public Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . R. K. Mutatkar

4

Biological Diversity Act 2002, an Implementation Challenges in India: An Experience Sharing from Sikkim . . . . . . . . . . . . . . . . . . . Bharat Kumar Pradhan

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Chronicles of Exploitation: Practice and Practitioners of Ethnomedicine in Quagmire of Market Dynamics of Pharmacopoeia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Shalina Mehta and Dinesh Kumar Indigenous Healing Practices in the Himalayas: Use of Medicinal Plants and Health Development in Nepal . . . . . . . . . . . . Madhusudan Subedi

Part II 7

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35 45

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Healing Practices Among Various Tribes

Folk Healing Practices of the North-East States . . . . . . . . . . . . . . . . . . 111 Shailaja Chandra

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Understanding Aetiology of Diseases: Special Reference to Lepcha Communities of Dzongu, Sikkim . . . . . . . . . . . . . . . . . . . . . . 133 Tshering Lepcha

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Language and Traditional Healing Practice: A Study of Limbu Community . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145 Binu Sundas

10 The Nongai Dawai Khasi Healers of Meghalaya—A Tribal Understanding of the Human Potential . . . . . . . . . . . . . . . . . . . . . . . . . . 155 Sandra Albert, John Porter, and Judith Green 11 Amchi System in Ladakh: Challenges in the New World . . . . . . . . . . 167 Tashi Smanla and Shalina Mehta 12 Health Care Systems Among Broq-pa Tribe . . . . . . . . . . . . . . . . . . . . . 177 Diskit Wangmo, Rita Kumari, Nutan Kumari Jha, and A. K. Sinha 13 Ethnomedicine in Question: The Case of Tharu Healers and Healing Practices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 205 Bamdev Subedi 14 Ethics, Morality and Healing: A Bhil Perspective . . . . . . . . . . . . . . . . . 221 Minakshi Dewan Part III Revitalization and Integration of Tribal Medicine/Local Health Traditions and Intellectual Property Rights 15 Systematic Documentation and Drug Development from Local Health Traditions (LHTs) and Ethnomedical Practices (EMPs): Challenges and Way Forward . . . . . . . . . . . . . . . . . . . . . . . . . . 237 N. Srikanth and Sumeet Goel 16 Climate Change and Protection of Traditional Ethnomedical Knowledge in India: A Critical Socio-Legal Reappraisal . . . . . . . . . . 251 David Pradhan and Alok Kumar Patra 17 Intellectual Property Rights in Indigenous Medicinal Knowledge: A Case of ‘Saikot Cancer Medicine’ in Manipur . . . . . . 265 Nemthianngai Guite 18 Strengthening Capacity of Tribal Communities to Revitalise Tribal Medicine Through Research, Education and Outreach . . . . . 277 B. N. Prakash, G. Hariramamurthi, N. S. Sarin, and P. M. Unnikrishnan 19 Empowering Traditional Healers Using Modern Quality Management Tools . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 287 Debjani Roy

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20 Local Health Traditions and Preservation of National Heritage: Emphasis on Intellectual Property Rights Protection, Benefit Sharing and Mainstreaming . . . . . . . . . . . . . . . . . . 307 Sumeet Goel and N. Srikanth 21 An Expanded Health Systems Perspective on Tribal Health Knowledge and Practices: Contemporary Relevance and Challenges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 325 Ritu Priya 22 Revival of Local Health Traditions from Healers Perspectives: Urgency of Recognition and State Support . . . . . . . . . . . . . . . . . . . . . . . 347 Sunita Reddy

Editors and Contributors

About the Editors Sunita Reddy PhD in Anthropology with two decades of research teaching experience and teaching at Jawaharlal Nehru University for the past 185 years. She has published many research papers in national and international peer-reviewed journals and contributed papers in edited volumes. Her areas of research are disasters, women and child health, medical tourism, surrogacy, ethnomedicine and child abuse. She has presented more than 100 papers in national and international seminars and conferences. She served as Deputy Director (R&D), School of Social Sciences and is an Adjunct Faculty, at the Special Centre for Disaster Research, Jawaharlal Nehru University. She is the author of the book Clash of Waves: Post Tsunami Relief and Rehabilitation in Andaman and Nicobar Islands Indos Publication 2012, editor of the books Marginalisation in Globalising Delhi: Issues of Land, Livelihood and Health Springer 2016, and Editor of The Asian Tsunami and Post Disaster Aid, Springer 2018. She is the Founder and Chairperson of Anthropos India Foundation, a trust, which is a research and policy organisation and Honorary President of SATAT, a national NGO working with Women and Children in New Delhi. She participated in national debates on surrogacy on many national TV channels. She has many awards in sports and co-curricular activities too and recently received the ‘Women Empowerment Award—2021’ on International Women’s day by Delhi State Legal Services Authority and Bhagidari Jan Sahyog Samiti. Nemthianngai Guite is an Associate Professor in the Centre of Social Medicine and Community Health, School of Social Sciences, Jawaharlal Nehru University, New Delhi. She has taught in the Department of Social Work, Delhi University as an Assistant Professor from March 2005 to July 2016 (11 years). She was awarded the Fulbright Nehru Post Doctoral Fellowship by USIEF in 2016 and Shastri Mobility Programme by Shastri Indo Canadian Institute (SICI) in 2018. She has organised bi-national online conference funded by SICI (2022). She has attended national and

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international conferences, presented papers; and published in peer-reviewed journals on primary health care and indigenous medicine, Indigenous healing systems; Global Discourses on Biodiversity and Indigenous Medicinal knowledge, health care social work practice, maternal and child health and health issues concerning indigenous communities of India’s northeastern region. She authored the books Indigenous Medicine and Health Care: A Study among Paite Tribe in Manipur (2011) and Global Discourse and Local Realities towards Indigenous Medicine (2014). She undertook and completed various research projects funded by organisations like Oxfam India (2014), Save the Children (2015), IGSSS (Indo Global Social Service Society) (2015) and ICSSR (2021; 2022). Bamdev Subedi is Medical Anthropologist with interest in public health issues. He holds an M.A. in Anthropology from the Tribhuvan University and M.Phil. and Ph.D. in Social Sciences in Health from Jawaharlal Nehru University, New Delhi. He has more than a decade of working experience in the health and development sector in Nepal. His research interests include traditional medicine, medical pluralism and the political economy of health. His M.Phil. work was on the ‘Indigenous Healing Practices’ and his Ph.D. on ‘Medical Pluralism.’ He has presented a dozen papers in seminars and conferences and has published half a dozen research papers in edited volumes and research journals. Currently, he is working on his forthcoming book Medical Pluralism in Nepal.

Contributors Albert Sandra is a dermatologist and a public health professional, and currently the Director of the Indian Institute of Public Health in Shillong, in Northeast India. She has an MD in Skin and STIs from the Kasturba Medical College, Manipal. From clinical medicine, she broadened her field of interest to public health and received a Doctor of Public Health (DrPH) from the London School of Hygiene and Tropical Medicine, UK in 2014. Her research interests include health systems, health policy, skin disorders, sexual and reproductive health, malaria epidemiology, health economics and indigenous knowledge. Prof. Albert also leads the Regional Resource Hub for Health Technology Assessment in India; Department of Health Research, Ministry of Health and Family Welfare, Government of India. Chandra Shailaja had a five-decade-long career as a civil servant, posted across India. She retired as a Chief Secretary, Delhi and was also a Permanent Secretary in the Government of India. Ms Chandra was commissioned by the Health Ministry to write a report on the ‘Status of Indian Medicine and Folk Healing in India’. She was given a Fellowship at the Institute of Advanced Studies at Nantes, France and a visiting Fellowship at the Shiv Nadar University. She was recently awarded an Honorary degree of Doctor of Literature. She is an independent public policy analyst and has written or co-authored publications of OECD, WHO, IAS Nantes, the Lancet, besides over 150 opinion pieces published in leading national newspapers.

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Goel Sumeet is Research Officer (Ayurveda) in Central Council for Research in Ayurvedic Sciences, New Delhi, present deputed as Officer on Special Duty—Technical to the Secretary to Government of India Ministry of Ayush. He has experience of six years in Teaching and Research in Ayurveda (clinical research in Child health, nutritional disorders and systematic reviews and documentation and analysis of Local Health Traditions, formation of policy documents and regulations). He has published many research works and has contributed to numerous official publications of CCRAS and of the Ministry of Ayush. He has worked actively as a team member which has been responsible for visualizing, implementing and publication of COVID-19 research studies of the Ministry of Ayush, Government of India. Hariramamurthi G. is an Emeritus Professor and Head, Centre for Local Health Traditions and Policy, The University of Trans-Disciplinary Health Sciences and Technology, Bangalore. He has twenty-seven years of action research and outreach experience in the implementation of Action research, education and outreach programmes at Prarambha, FRLHT, TDU: Documentation and Promotion of Best Practices in Sustainable Agriculture in Karnataka and Tamilnadu; Documentation and Assessment of Local Health Traditions (DALHT) across 15 states of India, Home Herbal Gardens across 12 states; Community Owed Enterprises across 7 states; Exsitu Medicinal Plants Conservation Parks across 3 states of India’ Iron Deficiency Anaemia management; Certification of traditional healers. He has numerous articles/papers in peer-reviewed journals and book chapters. Joshi P. C. is serving as Pro-Vice-Chancellor at the University of Delhi (DU). He has served in the Department of Anthropology, as a Professor and a Head. He served in the Institute of Human Behaviour and Allied Sciences and at H. N. B. Garhwal University as Lecturer and Reader in past. He has been specializing in the field of medical anthropology, disaster impact assessment, Himayalan Anthropology and research methodology. He was Asia Coordinator of the European Union 6th Framework Integrated Project MICRODIS. He has published four edited books on Medical Anthropology in India. He is the recipient of the Indira Priyadarshini Vriksha Mitra National Award, Lifetime Achievement Award from Panjab University, Chandigarh and S. C. Dube Oration Award from INCAA. Lepcha Tshering is a Samvaad Consultant at the Tata Steel Foundation, Jamshedpur, Jharkhand. He has two years of teaching experience. He has a background of Master in Social Work (Community Development), M.Phil. and Ph.D. in Public Health. His areas of interest in Social Work practice with marginalized communities, Rural Community Development, Traditional Knowledge Systems, Traditional Healing Practices, Tribal Community Development and Tribal Healers Collective. He has published articles in edited books, journals and newspapers. He is a Program Advisory Council and Task Force Member under the Ministry of Tribal Affairs, Government of India Going online as a Leader (GOAL) flagship program. He served five years as a Volunteer/Representative for North-Eastern people in Delhi under Special Police Unit for North East Region.

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Mehta Shalina is retired from the Department of Anthropology, Panjab University, Chandigarh in 2016 after serving for thirty-nine years. She has published more than 80 research papers, co-edited six books, independently edited a volume of the Journal Anthropology Today: Contemporary Trends (2010). Her most recent publication is Phulkari Embroidery in Punjab that examines the intersectionality of Gender and Craft. Other co-edited books are Globalized environmentalism and environmental organizations in India-(2009); Dialogue on AIDS: Perspectives for the Indian Context (2008); and Understanding AIDS: Myths, Efforts and Achievements. Recipient of UGC Career Award in Humanities and Social Sciences; Research Associate, Environmental Institute, Houston; Exchange fellow at IIAS, Amsterdam, under Indo-Dutch Programme on Alternatives to Development, Senior Fellow–Social Science Research Council, New York. Minakshi has a Ph.D. degree in Social Medicine and Community Health. For the last 12 years, she has worked with grassroots and international development organizations in tribal health, women’s health and traditional healing. She extensively writes on social issues. She has also been published in Indian and international publications like Hindu, Deccan Herald, The Telegraph, Asia Democracy Chronicles. In addition, she has authored a non-fiction book for children. She is currently writing an adult non-fiction book for HarperCollins, India. Mutatkar R. K. joined the University of Poona, now Savitribai Phule Pune University as a lecturer in Cultural/Social Anthropology in 1960 and superannuated in 1995 as a Professor. Introduced Masters in Anthropology in 1963, under the guidance of Prof. Irawati Karve. He became the first Head of Anthropology Department in 1977 and Director, UGC sponsored Inter-disciplinary School of Health Sciences in 1994. Medical Anthropology was first introduced in India at Pune in 1974, resulting in World Anthropology Congress on Medical Anthropology in 1978. UGC Model Anthropology Curriculum in 2001 was prepared under his Chairmanship. He has been Chairman of the Indian National Confederation and Academy of Anthropologists. He published “AYUSH in Public Health” (2016), “Tribal Health and Malnutrition” (2018) and “Anthropological Paradigm for Policy and Practice” (2020). Patra Alok Kumar is currently working as an Assistant Professor in the prestigious School of Commerce and Economics, KIIT Deemed to be University. He has completed his Ph.D. from Jawaharlal Nehru University, Centre for Social Medicine and Community Health. His research focuses on the sociology of health, tribal studies, ethnographic research, indigenous knowledge system and sociological theory. His research has been published in UGC-approved and peer-reviewed academic journals. He has been awarded Gold Medal in Sociology (MA) from Central University Odisha Koraput and received UGC-NET-JRF. Pradhan Bharat Kumar is associated with Sikkim Biodiversity Board. With over 15 years of research experience, he is currently involved in sensitizing and engaging the local communities in biodiversity conservation, providing training and technical guidance to them in preparing the People’s Biodiversity register. His work on ethnomedicinal practices of the Lepcha tribe has been filmed for arte channel, a joint

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venture of Germany and France. He is a youth influencer, motivator and a strong advocate of environmental protection and climate change. Besides he is a member of the IUCN World Commission on Protected Areas and is associated with Friends For Future International, Germany as a Community Leader. He has co-authored a book A Pictorial Handbook on the Flowers of Sikkim, Volume I. Pradhan David is a Senior Research Fellow at the School of International Studies, Jawaharlal Nehru University, New Delhi. He has a background in Legal Studies and an interest in Intellectual Property Laws. He has been a Doctoral Exchange Scholar at the Faculty of Law, University of Zurich and at the University of Bern in Switzerland, and an International Teaching Fellow at the Faculty of Law, Universitas Muhammadiyah Malang in Indonesia. David belongs to the Kondh Scheduled Tribe, an ethnic indigenous community of India. Prakash B. N. is an Associate Professor at the Centre for Local Health Traditions and Policy, The University of Trans-Disciplinary Health Sciences and Technology, Bangalore. He has a background in Ayurveda, Yoga and Public Health. He has experience of 20 years as a part of developing and implementing community research and outreach programs. His works include documentation, assessment, evaluation and outreach of LHTs for public health issues, with a particular focus on primary health care, malaria, diarrhoea, anaemia are key areas of research. He also heads the Personal Certification Body accredited by the Quality Council of India, which implements the National Scheme on Voluntary Certification for Traditional Community Healthcare Providers. He has several International and National peer-reviewed publications and book chapters. Priya Ritu is a Professor at the Centre of Social Medicine and Community Health, Jawaharlal Nehru University, a medical graduate and a Ph.D. in Community Health. Her work links epidemiology, popular culture, health systems research and policy studies for holistic planning and policy formulation, specifically focused on marginalised groups, nutrition, communicable diseases and health systems development, including urban health and integrative health systems. She was AdvisorPublic Health Planning with the National Health Systems Resource Centre, member of Task Forces of the Planning Commission, Ministry of AYUSH, and National AIDS Control Organisation, founder Coordinator of the Trans-disciplinary. Roy Debjani is currently with the CDSA, THSTI, DBT, Government of India to develop and implement the Good Clinical Practice Professional Certification Scheme for the GCP professionals based on the international standard ISO 17024 for personnel certification. Prior to this, she was an Advisor in the Quality Council of India, to develop and implement the Voluntary Certification Scheme for Traditional Community Healthcare Providers for the personnel certification of the Traditional Healers. She is a trained assessor for ISO 17024, ISO 17021, ISO 17065 and Technical Expert for ISO 21001. She is empanelled as Assessor and Technical expert with National Accreditation Board for Certification Bodies and Yoga Certification Board in India and United Accreditation Foundation, USA. She has also been UGC, INSA, DAAD and Smithsonian Visiting Fellow.

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Sarin N. S. is an Ayurveda physician and public health researcher. He has an undergraduate degree in Ayurveda and a master’s degree in Public Health. His current Ph.D. research focuses on mainstreaming Ayurveda—decoding the organization and provision of primary health services, in states of India. He has several International and National peer-reviewed publications and book chapters. Sinha Anil Kishore is a Professor of Social Anthropology at the Department of Anthropology, Panjab University, Chandigarh, India. He has been teaching Social Anthropology since 1987. His major research interests include Medical Anthropology, Tribal Studies, Anthropology of Food, Panchayati Raj Institutions and Gender Studies. To his credit are more than one hundred and fifty research publications. He has authored four books; co-authored five books and edited three books. He has undertaken and successfully completed 7 major research projects funded by different agencies. Smanla Tashi is a Ph.D. research scholar at the Department of Anthropology, Panjab University. He did his Masters in Environmental Sciences from Delhi University and is currently pursuing research in the area of Cultural Anthropology. His area of interest is Environmental Anthropology, Ecotourism and its impact in the remote regions of Ladakh, and the traditional healing system. He has presented various papers on ecotourism in the Himalayan region focusing on Ladakh at various national and international seminars. His paper entitled ‘Eco-feminism: A case of Two Women Organizations in Ladakh’ is published in a book titled Women and Development in India. His Ph.D. thesis is on Cultural Habitats and Ecotourism: Development paradigms and emerging conflicts in Ladakh. Srikanth Narayanam is Director-General I/c in Central Council for Research in Ayurvedic Sciences, Ministry of Ayush, New Delhi, India, with 23 years of Research and Teaching experience. He is engaged in formulating, coordinating, implementing and monitoring various research programs including, clinical research, drug development, literary research, pharmacology research, phytochemical research, medicinal plant research, research-oriented public health care programs such as Tribal Health Care Research Project, National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke program etc. He published 332 research papers in reputed International and National Scientific Journals, Conference Proceedings etc., and edited 119 Books, Monographs and technical reports and also contributed to the development of about 14 Policy documents. He has been honoured with 8 awards. Subedi Madhusudan teaches medical and public health students at Patan Academy of Health Sciences and MA and M.Phil. students at the Central Department of Sociology, Tribhuvan University, Nepal. With a background in sociology and medical anthropology, he has authored and co-authored four books and more than 60 journal articles. His latest book published in 2018, is State, Society and Health in Nepal (Routledge) and his edited volume in 2021 is Empowering Dalits through Knowledge (Vajra Books). He is the founding General Secretary of the Nepal Sociological

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Association. His writings focus on traditional health care practices, social determinants of health, inequality, public policy, and the social and political transformation of Nepal. Sundas Binu is an Assistant Professor at the Department of Sociology, Miranda House, University of Delhi. He has a background in Sociology. He was the founding member of the Department of Social Systems and Anthropology, Sikkim Central University, Gangtok. He has published two books, and numerous chapters in edited volumes and also in peer-reviewed journals. He was awarded the Best Teacher in School of Social Sciences, 2011 while at Sikkim University and has numerous awards in Sports. His interest areas are Culture, People and Politics in Darjeeling and contribute regularly in these areas in local portals and media. He is currently working on the Contemporary Politics of Darjeeling. Unnikrishnan P. M. is an Ayurveda physician and a development researcher. He has an undergraduate degree in Ayurveda from Bharathiar University, Coimbatore and a master’s degree in Medical Anthropology from the University of Amsterdam, Netherlands. He holds a doctoral degree in International Development Studies from the Yokohama National University, Japan. Since 2010, he has been working with the United Nations University, Tokyo, Japan in various capacities in health systems and sustainability-related programs. He is also an Adjunct Professor at the SRM School of Public Health, Chennai. His research interests are AYUSH in health systems, public health, traditional knowledge epistemology, and sustainable development. He has numerous articles/ papers in peer-reviewed journals and book chapters.

Chapter 1

Introduction: Ethnomedicine and Tribal Healing Practices in India: Challenges and Possibilities of Recognition and Integration Sunita Reddy, Bamdev Subedi, and Nemthianngai Guite Abstract Introducing the theme of this volume, this chapter delves into ethnomedicine and tribal healing practices drawing insight from anthropological literature. The chapter identifies the conceptual difficulties in recognizing those healing traditions that function outside the official healthcare system, locates such traditions in the diversity of South Asian medical traditions, and challenges the narratives that characterize such traditions are unscientific, irrelevant, superstitious and dying traditions, and examines the policy initiatives of recognition and integration of such traditions. Though codified forms of traditional healing which come under AYUSH have been recognized, legitimized, and integrated into the national health system, the non-codified forms of healing, such as indigenous/folk/tribal healings, have not got a due share of recognition and patronage despite being widely practiced. Recognition and integration of such diverse forms of popular and non-codified traditions in the national healthcare system has become a perplexing issue, coupled with unclear policy directions, and a lack of sound strategies and programmatic actions. Despite the policy articulation of integrating folk/tribal healers’ services in the healthcare delivery system and ‘recognizing tribal medicine as an independent system of medicine’, folk/tribal healers struggle for official legitimacy. The certification and documentation initiatives in the past few years are significant and a ray of hope in the pursuit of recognition. Tribal medicine should be recognized and supported as a distinct form of healing and given due space in the national health system to grow and develop while keeping its distinctive identity.

S. Reddy (B) · N. Guite Centre of Social Medicine and Community Health, JNU, New Delhi, India e-mail: [email protected] B. Subedi Medical Anthropologist and Social Activist, Kathmandu, Nepal © The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023 S. Reddy et al. (eds.), Ethnomedicine and Tribal Healing Practices in India, People, Cultures and Societies: Exploring and Documenting Diversities, https://doi.org/10.1007/978-981-19-4286-0_1

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Background Ethnomedicine is understood in various ways by anthropologists: “the health-related beliefs, knowledge, and practices of a cultural group” (Ember & Ember, 2004), “ethnographic research on indigenous, usually non-Western, forms of healing” (Lambert, 2010), “the study of indigenous healing systems” (Barnard & Spencer, 2010), etc. It remains to be an important area of study in anthropology. From the beginning, anthropology has been interested in health, sickness and healing in the local context (Singer & Baer, 1995, p. 3). Early ethnologists and ethnographers were mainly driven by the curiosity of exotic rituals, cultural practices, religions and mythologies rather than illness, illness aetiology, therapeutic concepts and practices (Schröder, 1978). The motive to study these topics was to understand tribal culture rather than health, illness and medicine. This may be the reason why some scholars see problems in recognising such studies as medical anthropological studies (Young, 1982) because “ethnomedicine has classically been linked to the discipline of cultural anthropology” (Fabrega, 1990, p. 130). Shamanism, magico-religious and ritual healing dominated classical anthropological scholarship (Adlam & Holyoak, 2005; Atkinson, 1992; Ortner, 1984; Ranganathan, 2018; Subedi & Uprety, 2014; Winkelman, 2004). There have also been more provocative impressions, such as the argument that tribal or indigenous healing is “nothing more than primitive, superstitious nonsense” (Sax, 2009, p. 232) or nothing more than “the shit medicine for the poor” (Craig, 2012). Medical anthropology is a subfield of anthropology with a deep interest in sociocultural aspects of health, illness and healing among indigenous communities. Historically, supernatural healing, and not the naturalistic or empirical aspects of healing, received widespread attention (Waldstein & Adams, 2006, p. 95). Ritual, spiritual and religious aspects are interwoven with medicinal herbs, which is the basis of tribal healing. Tribal healers largely use medicinal plants for preventive, promotive and curative purposes. Many healing practices such as herbal treatment, midwifery, bonesettings, traditional massage and manipulative therapies such as ‘vessel treatment’ (Lambert, 1996) are not necessarily associated with ritualistic and spiritual aspects. In many contexts, even the shamanic healers use medicinal herbs and include therapeutic practices such as giving a healing touch, kneading, massaging and cleansing the body (Winkelman, 2004, p. 148). Though the use of medicinal plants was an integral part of tribal healing, the focus in much of ethnographic studies was on visible magico-religious, supernatural or shamanic healing (Leslie, 1976, pp. 182–183). There can be interethnic differences in medicinal plants usage because of cultural and geographical/ecological variations. Still, plants, plant parts, animal resources and mineral substances form the materia medica of indigenous healing systems. They have cultural, ritual, spiritual and religious significance. However, it is wrong to reduce indigenous healing to shamanism and symbolic healing. Shamanism as a cultural tradition has been revived in many parts of the world. It is not only seen as a healing tradition but also as a cultural expression of identity.

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Admittedly, shamanism as a healing practice plays an important role in psychosocial health. Many scholars see the therapeutic value and relevance of shamanic healing (Beery, 2017; Dalal, 2016) in “culturally appropriate psychotherapy” (Castillo, 2001, p. 82) and in mental health care in India (Kakar, 1982; Quack, 2012) and argue for the inclusion and integration of such practices in counselling and psychotherapy (Dalal, 2005; Moodley & West, 2005). Further, the interrelationship between physical and psychosocial health and the importance of emotional and spiritual dimensions of healing cannot be underestimated in view of the persistence and revival of shamanic healing practices in many parts of the world (Liu, 2004; Sang-Hun, 2007) and even in the light of the “blossoming of a neo-shamanism in the United States and Europe” (Atkinson, 1992, p. 322). The concept of illness, i.e. an individually experienced condition, is different from the concept of disease, i.e. a medically diagnosed condition. Healing, on the other hand, is “not only the remedy or cure of sickness—that is the restoration of the prior state, but also rehabilitation—the compensation for loss of health—the palliation— the mitigation in the suffering in the sick” (Hahn, 1995, p. 7). It underscores the importance of physical, emotional, spiritual and psychosocial dimensions of health, rationalising the culturally meaningful intervention. Though there can be curing without healing and healing without a cure, the comprehensive concept of health emphasises curing with healing and healing with a cure. Recognition of only herbal practices by isolating spiritual and cultural dimensions can be against the very idea of what makes indigenous healing comprehensive and holistic. Ethnomedicine, folk medicine, tribal medicine, indigenous medicine and traditional medicine are together referred to as the healing traditions of indigenous communities. They are used interchangeably, though they have a specific meaning. A brief discussion will be helpful for some clarification of these conceptual terms. Folk medicine represents the oral tradition and refers to the general population’s traditional practices, including those of tribal communities. Traditional medicinal practices, which originated and were found in a particular ethnocultural context, are described as indigenous medicines. Indigenous medicines refer to both professional (Ayurveda) and popular traditions (tribal traditions). Among the Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homoeopathy (AYUSH) systems, Unani, Naturopathy and Homeopathy did not originate in India, but these traditions were imported and indigenised. The term ‘local health tradition’ (LHT) serves as an umbrella term referring to all those therapeutic practices and health traditions of both tribal and non-tribal communities, representing the non-formal or popular sector of traditional medicine. Though LHT is the official recognition of popular traditional medicine within the country, it masks the distinct entity of tribal traditions. Ethnomedicine is often understood as the study of indigenous healing forms, which seems closer to what Dunn calls ‘local medical systems’ (Dunn, 1976). Dunn classifies medical systems into three categories based on their geographical and cultural settings: local, regional and cosmopolitan medical systems (Dunn, 1976, p. 139). Local medical systems refer to ‘folk’ medicine of small-scale societies, which is popular and non-scholarly. In Kleinman’s scheme of popular, folk and

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professional medicine, the folk sector refers to the non-professional, usually nonbureaucratic specialist arena of health care. This includes various healers (such as shamans, mediums, magicians, herbalists, bonesetters and midwives) who function informally and often on a quasi-legal or even illegal basis (Kleinman, 1980, p. 51). The popular sector consists of individual, family and social nexus arenas, and the folk sector comprises indigenous healing (Kleinman & Sung, 1979, p. 8). Hughes (1968) defines ethnomedicine as “those beliefs and practices relating to disease which are the products of indigenous cultural development and are not explicitly derived from the conceptual framework of modern medicine”. According to Nichter (1994), ethnomedicine “entails a study of the full range and distribution of health-related experience, discourse, knowledge, and practice among different strata of a population…health-related ideas, behaviours, and practices”. Many scholars expand the definition to include biomedicine as a form of ethnomedicine (Gaines, 2008; Nichter, 1994) because biomedicine is also a part of the Western cultural tradition (Foster, 1983). Though, based on scientific knowledge, biomedicine is seen as a cultural construction of the West (Gaines, 2008, p. 114). Singer and Baer (1995, p. 12) also assert that “all medical systems, including biomedicine, are cultural systems, rooted in particular social traditions and socially constructed worldviews”. Biomedicine, also known as allopathy and cosmopolitan medicine, is characterised as scientific, modern, western, conventional, regular, mainstream and is distinguished from other ethnomedicines (Fabrega, 1990; Rubel & Hass, 1990). The term ethnomedicine is often used to exclude biomedicine or “refer to the multiplicity of medical systems associated with indigenous societies as well as peasant communities and ethnic minorities in complex or state societies” (Baer et al., 2003, p. 308). Dividing ethnomedicine into professional and popular Gaines (2008, p. 118) considers biomedicine one of many professional ethnomedicines and states that professional ethnomedicine of other societies is also considered superior to popular ethnomedicine. According to Bhuyan (2015, p. 27), “ethnomedicine encompasses the whole gamut of ethnic beliefs and practices and behaviour towards health and disease as conceived in the tribal, peasant and pre-industrial societies”. Joshi and Vashist (2018, p. 228) also opine that “the term ethnomedicine should generally be used for native groups which have undocumented orally perpetuated systems of medicine and health care. Unlike the national medical systems, which are codified and documented”. In simple terms, “ethnomedicine refers to the practices of indigenous healers who rely on indigenous medicines and/or rituals to treat the sick” (Neumann & Lauro, 1982, p. 1818). The term ‘traditional medicine’ is also used as a generic term to refer to medical systems other than biomedicine. Traditional medicine by definition refers to both scholarly or textual traditions, and popular or oral traditions passed down from generation to generation. WHO first defined traditional medicine as “diverse health practices, approaches, knowledge and beliefs incorporating plant, animal and/or mineralbased medicines, spiritual therapies, manual techniques and exercises applied singularly or in combination to maintain well-being, as well as to treat, diagnose or prevent illness (WHO, 2002). Further, as “the total of the knowledge, skill, and practices based

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on the theories, beliefs, and experiences indigenous to different cultures, whether explicable or not, used in the maintenance of health as well as in the prevention, diagnosis, improvement or treatment of physical and mental illness” (WHO, 2013). The slight changes in the definition may be because traditional medicine is gaining formal orientation. This orientation departs from other non-formal popular traditions. However, even today, we need terms such as ‘scholarly’, ‘professional’, ‘erudite’, ‘codified’, ‘formal’, ‘official’ to distinguish traditional medicine from the rest of the popular traditions, which are not considered as a normative and legal type of medicine (Maclean & Bannerman, 1982, p. 1815). In many countries, traditional medicine still operates informally and remains to be regulated. WHO global report on traditional and complementary medicine 2019 uses ‘indigenous traditional medicine’ to recognise the indigenous knowledge and practices which exist in the arena of ethno-folk sector, often as unregulated or yet to be regulated forms, defined as “the sum total of knowledge and practices, whether explicable or not, used in diagnosing, preventing or eliminating physical, mental and social diseases. This knowledge or practice may rely exclusively on past experience and observation handed down orally or in writing from generation to generation. These practices are native to the country in which they are practiced” (WHO, 2019, p. 8). The report uses “indigenous traditional medicine providers” to refer to “those who practice indigenous traditional medicine, such as traditional healers, bonesetters, herbalists and traditional birth attendants. Usually, most of these practitioners have been practising at the primary health care level” (WHO, 2019, p. 48). Article 24 of the UN Declaration on the Rights of Indigenous People states that they have the right to their traditional medicines and maintain their health practices, including the conservation of their vital medicinal plants, animals and minerals. Further, it binds the Nation States to respect the rights of indigenous peoples (United Nations, 2008). Article 25(2) of C169—Indigenous and Tribal Peoples Convention, 1989 states: Health services shall, to the extent possible, be community-based. These services shall be planned and administered in cooperation with the people concerned and consider their economic, geographic, social and cultural conditions and their traditional preventive care, healing practices and medicines.

Indigenous healing is one of the essential sources of health care, and sometimes, it is the only source of help for many tribal, rural and underserved populations. However, indigenous healers receive little attention despite their immense contribution to health care in India (Bode, 2018, p. 99). The neglect and avoidance of indigenous healing practices are no more tenable because they neglect the indigenous people’s knowledge, deprive indigenous people of their rights and resources and disempower them further. Indigenous people have been marginalised because of the marginalisation of their culture, language, health traditions and health knowledge. According to Priya (this volume), indigenous healing is an understudied component in the healthcare systems, health policy and health system research. Disciplines of public health and health systems research have ignored indigenous health knowledge as a valuable resource (Ritu Priya, this volume).

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The avoidance and exclusion of this theme by public health researchers, academicians and activists indirectly means aligning with the forces that tend to disregard the importance of indigenous health knowledge. It also means inadvertently aligning with the forces that devalue and denigrate the indigenous healing practices, making popular traditions unpopular (Subedi & Joshi, 2018). “We often say that biomedicine discounts these practices, but in ceasing to devote our scholarly attention to them, we implicitly do the same” (Scherz, 2018, p. 12). Hence, we have chosen the theme of “Ethnomedicine and Tribal Healing Practices: Possibilities of Integration and Mainstreaming” for this volume to draw attention to this injustice. There is a need to reflect on what is going on in indigenous healing and take a fresh look into the possibility of harnessing indigenous health knowledge for the benefit of the marginalised community if universal coverage is to be ensured.

Indigenous Tribal People There is no single agreed-upon definition of indigenous tribal people. Durie (2003) emphasises two distinguishing features of indigenous people: an ancient relationship with the defined territory and ethnic distinctiveness. Tribal communities are also known as autochthonous, aborigines, native people or primitive people. These names are laced with biases and are often demeaning (Reddy & Subedi, 2018). The tribal people, known as adivasi or indigenous people (literally: original inhabitants), often live inside or in close proximity to the forests and remain distinct from the dominant groups in culture, language and tradition. The practice of animism, tribal language, distinct physical features, geographical isolation, simple technology and general backwardness are generally identified as the defining features of tribes (Xaxa, 1999). According to Xaxa (1999, p. 3590), “aspects of marginalisation are built into the definition of indigenous people. Only those people that have been subjected to domination or subjugation have come to constitute the component of the indigenous people”. The officially recognised 705 tribal communities in India, known as Scheduled Tribes (STs), constitute 8.6 per cent of the total population of India (Ministry of Tribal Affairs, 2017). The term ‘Scheduled Tribes’ refers to specific indigenous peoples whose status is recognised by legislation. The essential characteristics, first laid down by the Lokur Committee, for a community to be identified as STs are indications of ‘primitive’ traits, distinctive culture, shyness of contact with the community at large, geographical isolation and backwardness (Ministry of Tribal Affairs, 2010). Tribal communities fall far below the national average in health, education and poverty indices. The widespread poverty, illiteracy, malnutrition, high mortality and low life expectancy among the tribes reflect their poor socio-economic status. They are also susceptible to exploitation, alienation, atrocities and crimes. Addressing the poor health of indigenous people requires a broad approach covering a wide spectrum of interventions, including capacity building, research, respecting their rights, cultural education for health professionals, increased funding and resources

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for indigenous health, reduction in inequities accompanying globalisation and constitutional, legislative and policy changes (Durie, 2003). Tribal healing practices, developed through generations of intimate relationship with nature, rooted in the tribal culture and linked to biological diversity, are under threat. The UNESCO Universal Declaration on Cultural Diversity states that cultural diversity is necessary for humankind as biodiversity is for nature. Tribal languages and cultures, like plants and animal species, are on the verge of extinction. Many tribal cultures and languages are disappearing because their speakers are being displaced/migrated from their territories or forced to assimilate into the dominant cultures (Sundas, this volume). The disappearance of language and culture is strongly associated with the disappearance of the vast indigenous health knowledge and practices. Safeguarding indigenous culture and language is thus considered synonymous with protecting biocultural diversity. Preservation of indigenous knowledge and practices is regarded as a matter of pride for cultural heritage. The struggle for indigenous health rights is considered synonymous with the struggle for human rights. The tribal people depend upon locally available plant resources for day-to-day needs, including for food, fodder and medicine. Indigenous healers respect nature because nature provides, among other things, the medicinal herbs which they need to treat patients suffering from a range of problems. The protection of indigenous health knowledge calls for the protection of nature and biological diversity. Before and after the colonial period, the series of Forest Acts treated tribal communities as the prime destructor of forest and wildlife and a barrier to conservation efforts. Subsequently, with new acts and rules, their rights over the forest were snatched, they were displaced from their ancestral lands, and their lives and livelihoods got affected. The recent assertion is that it is not the customary use of forest and forest resources by the tribal communities but external pressures that threaten the sustainability of natural resources. The Forest Rights Act, 2006, which is considered to be progressive, recognises the historical injustice caused to the tribes and other traditional forest dwellers (Ministry of Tribal Affairs & UNDP, 2014).

South Asian Medical Traditions South Asia boasts of the cultural heritage of diverse ethnic groups, which have a rich tradition of using medicinal plants available in the diverse ecological zones. There are myriad forms of therapeutic practices prevalent among the local tribal communities. What makes the South Asian medical landscape unique is the diversity of medicines and healing practices. Such diversity in the Indian subcontinent inspired Charles Leslie to explore the realm of Asian Medical Systems (Leslie, 1976). With a deep interest in and observation of coexisting great and little traditions medicines in the Indian subcontinent, Leslie and many scholars of his time developed and expanded the concept of medical pluralism (Subedi, 2018; Sujatha, 2014). Other social science and public health disciplines also paid attention to this diversity and complexity in

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the Indian medical landscape (Banerjee, 2000; Priya & Shweta, 2010; Sujatha & Abraham, 2012). Contemporary South Asia has a plural but hierarchical medical pluralism (Hardiman & Mukharji, 2012). Biomedicine dominates due to state patronage and legitimacy. It is followed by officially legitimised/codified traditional medicines— Ayurveda, Yoga and Naturopathy, Unani, Siddha, Sowa-Rigpa and Homoeopathy (AYUSH). At the bottom fall diverse forms of non-codified traditions (including tribal medicine) or what is officially known as Local Health Traditions (LHTs) (Abraham, 2005; Hardiman & Mukharji, 2012; Lakshmi et al., 2014; Lambert, 2018; Mishra et al., 2018). This hierarchy of Indian medicine, as Bode (2018, p. 97) asserts, “are not bounded by themselves, their demarcation is a political act”. Indeed, the political force plays a dominant role in shaping medical pluralism and power relations among the coexisting medical traditions (Sujatha & Abraham, 2009). The ‘great tradition’ in medicines, often explained as scholarly codified, formal, textual, official, state-sanctioned, gets more recognition. ‘Little traditions’ medicines described as popular, non-codified, informal, oral, unofficial, subaltern, vernacular, fringe, folk, indigenous traditional medicine though researched extensively are marginalised and not officially recognised and mainstreamed so far. The contribution of this sector in health and well-being and the relevance of tribal medicine in the national healthcare system remain to be explored and established. The great tradition medicine, officially known as AYUSH in India, dominates the contemporary academic discourse. LHTs have gained prominence lately due to several non-governmental organisations, civil society networks and People’s Health Movements (Mishra et al., 2018). However, the term LHT ranges from home-based traditions, herbal medicine, faith healing, folk remedies to indigenous traditional medicine that have not yet been recognised and integrated. The ’little traditions’ medicine receives little attention despite its immense scope and coverage in the physical, psychosocial, spiritual and emotional health of the vast majority of the rural, poor and tribal populations. The richness of ‘little traditions’ in India is reflected in the diversity of therapeutic traditions among the tribal communities, with the rich biological and cultural diversity of distinct physiographic landscapes extending to the length and breadth of the country. There are 4,639 ethnic communities in India (Gangadharan & Shankar, 2009, p. 181). It is estimated that “traditional healers in India use more than 10000 different plant species, out of which approximately 7500 are used in folk, and tribal systems” (Tiwari et al., 2004, p. 516). This is far more than the plants used by the AYUSH systems. The healing practices broadly include but are not limited to the use of fresh medicinal herbs or herbal healing, bonesetting, poison healing, traditional midwifery and massage. These practices continue despite an assumption that biomedicine would replace them (Najunda et al., 2009, p. 706). Since these practices lack legal legitimacy, policy debates on recognition and integration have become even more critical, though it has received little attention from policymakers (Albert et al., 2015, p. 958). Debates and discussions are underway to recognise, revitalise, mainstream or integrate indigenous health knowledge and practices. This volume is one more addition to this discourse.

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This volume addresses some pertinent questions: What is happening to indigenous health knowledge and practices? What efforts are being made to ‘revitalise’ and ‘integrate’ it into the public healthcare system? What challenges are faced today related to social and official legitimacy and recognition of indigenous people’s rights over their health knowledge and practices? What are the possibilities of mainstreaming or integrating tribal health traditions in the present policy frameworks? Indigenous healing is also connected to natural resources, protection of plant varieties, farmers’ rights and indigenous knowledge. All these issues need to be reflected in an integrated manner. Our aim is not just to offer an understanding of indigenous healing practices among some of the tribes of the Indian subcontinent but also to locate ethnomedicine and tribal healing practices in the present policy context and the possibilities of recognition, integration and mainstreaming. The interest in natural products and herbal medicine is growing the world over. Pharmaceutical companies are interested in the indigenous medicinal plants for business opportunities with herb-based drugs and products. They intend to exploit indigenous knowledge without recognising and sharing any benefits with the indigenous people, who know about the medicinal value of natural herbs. This volume discusses some of these issues. Today, ethnomedicine stands with problems and promises of legal legitimacy, evidence and efficacy, bioprospecting and benefit sharing, conservation of nature and sustainable use of medicinal plants, indigenous people’s rights over natural resources and their culture and identity. The chapters in this volume deliberate on these themes. Further, they assess the relevance of ethnomedicinal practices for public health and look into the challenges and possibilities of recognising and integrating indigenous healing into the national health system. The volume looks at ethnomedicine and tribal healing practices from the perspective of critical medical anthropology. It examines how the dominant forces exert influence over indigenous populations and their healing systems. This volume comprises both empirical and theoretical papers on diverse issues of ethnomedicine. It examines the dominant perspectives, which have underestimated indigenous health knowledge and practices and the contribution of indigenous healing for the country’s health and well-being. Ethnomedicine, one of the theoretical orientations of medical anthropology, has become an interdisciplinary field of study (Waldstein & Adams, 2006). The interdisciplinary interest is seen in the preservation and promotion of indigenous knowledge and practices and biodiversity conservation. Anthropological, ethnobotanical and ethnopharmacological studies have established that indigenous communities have been utilising various flora, fauna and mineral substances for therapeutic use. Indigenous healers, who outnumber official traditional medicine practitioners, have served a large section of the population. The number of AYUSH practitioners is around 600,000, whereas the number of local herbal healers is around one to two million (Bode & Hariramamurthi, 2014, p. 1). The growing concern is that their number is dwindling: the younger generation is not willing to learn, mainly due to the non-recognition of their practices by the state. Indigenous people are struggling with rapid socio-economic changes, which have affected their lives and livelihoods. They are being displaced from their natural

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abode, their knowledge has been exploited, and they have been deprived of their customary rights. Their health knowledge was disregarded, practices discouraged and resource rights denied (Posey, 1996). Their health has been worsened further because of the erosion of the indigenous health knowledge and loss of their health traditions (Subedi, 2016). They are socio-economically and politically marginalised. They are often blamed for their own poverty, illiteracy and ill-health. The pervasive thinking about tribals is that they are illiterate, ignorant and superstitious. That they are poor, live in a filthy environment, do not care about their health, do nothing about living healthily, are in the primitive stage of development—and thus, they need to be taught about the importance of modern health care. Prejudices are the mindsets that see problems with tribal culture, knowledge and practices, belief and perceptions about health and illness. Tribal populations around the world are struggling with unfavorable policy changes. In many places, they are being displaced in the name of development, excluded from the decision-making process, and they have been the most affected by the adverse impacts of globalisation (Jaysawal & Saha, 2014; Kothari, 1996; Mishra, 2002; Reddy & Subedi, 2018). Tribal people are not poor but made poor, marginalised, exploited and displaced from their land. Their resources have been grabbed over the years, and development in their regions has done more harm than good. Their health indicators are bad as compared to non-tribals. Health planners and policymakers place the onus for this problem on the tribals themselves, because of their resistance to biomedicine and underutilisation of official healthcare services. The truth behind these claims of underutilisation and non-compliance by people is that indigenous people do not opt for formal health care not because of individual problems, ignorance or resistance to modern medicine but because of social hierarchy and power differentials between the providers of modern medicine and indigenous populations (Reddy, 2008, p. 68; George et al., 2020). Despite the expansion of the official healthcare system and proliferation of private drugstores, clinics and hospitals, indigenous healing still holds the strength in terms of widespread availability and the number of people served. The preference of indigenous healing over official medicine is not just because of cost and non-availability of official medicine (Sujatha, 2014; Sujatha & Abraham, 2012) but because of the ‘felt need’ of the services which official medicine does not provide (Bode & Hariramamurthi, 2014; Priya & Shweta, 2010). Indigenous people rely heavily on indigenous medicine because it is available, affordable, accessible, culturally appropriate and effective for many illnesses. For them, official medicines are not accessible and affordable, and what is available to them as official healthcare services are often of questionable quality. Health institutions such as Sub-Centres (SCs), Primary Health Centres (PHCs) and Community Health Centres (CHCs) in tribal areas function poorly, and they often suffer from the chronic shortage of essential drugs as well as shortfall and absenteeism of medical staff. Many tribal patients express disappointment with the poor quality of care they receive. Besides, they face difficulty in communicating with medical practitioners because of language and cultural barriers.

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Medical doctors are not in a position to understand the cultural context and socioeconomic condition of the patients. On the other hand, indigenous healers offer psychosocial, spiritual, emotional and moral support, instill hope and connect herbal medicine with food and healing with ethical behaviour and God’s blessing. They belong to the same community as their patients, share the same culture and world view and can explain illness aetiologies in a manner which understands, recognises and responds to the patients’ idiom of distress (Bode & Hariramamurthi, 2014).

Importance of Indigenous Healers and Healing Practices Indigenous healers play multiple roles than merely providing healthcare to the patients. They serve as priests, astrologers, diviners, counsellors, legal advisers, forest guards, social workers and local leaders and deal with a wide range of family and community problems. Indigenous healers have the confidence of the members of their community because they are trusted and people have strong faith in their prowess. They are the people recognised by communities as qualified or competent to provide healthcare services employing medicinal plants, animal resources, mineral substances and other methods based on the ecological, cultural, social and religious background of the people (Anyinam, 1987, p. 810). Most of the indigenous healers are praised for their moral ethics, service orientation and non-profit motives. This is important given the healthcare frauds flourishing in the modern healthcare system (Leap, 2011). Indigenous healers are found closer to homes. They are physically accessible, economically affordable and culturally acceptable. The official healthcare system does not provide many choices to the patients, which is one reason why indigenous healing holds relevance even today. Locally available indigenous traditional healers provide culturally appropriate remedies for those who suffer from physical, psychosocial and emotional problems. With the local healers’ support, vast numbers of illness episodes are managed locally. Moreover, they also deal with family problems, property loss, disputes and tension arising out of misunderstandings and bad relationships. Quack (2012, pp. 281–282) reviews the literature and finds many points presented in favour of indigenous healing. These include cultural acceptability, affordability, easy accessibility and cardinal and compassionate healer–patient relationship. Trust in the healer’s prowess, healer’s role in sociocultural life, socially meaningful diagnosis and treatment, shared cultural values between healers and patients enrich indigenous healing practices. Further, the involvement of family, friends and community in the healing process adds value. Consideration of social and spiritual aspects of life, non-threatening environment and positive atmosphere and aesthetically attractive and visually engaging settings helps in healing. A strong degree of hope and faith on the side of the patients and caretakers are also one of the reasons why so many people suffering from illness resort to indigenous healers. What is also important in indigenous healing is that the healers instil hope in their patients, facilitate family

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support and become a source of culturally appropriate coping strategies. Indigenous healing also works as health security for the indigenous people. The healers can better understand and interpret the illness, ‘an individual’s perception of a medical problem’ (Fabrega, 1999, p. 3), and provide healing, “the culturally meaningful social responses aimed at undoing or preventing the effects of disease and injury” (Fabrega, 1999). The indigenous healers are from the same communities and share a common ethos with their patients; they are equipped to deliver socioculturally sensitive health care (Bode & Hariramamurthi, 2014). They are more attuned to the cultural context and the patient’s beliefs and perceptions (Ranganathan, 2018). Joshi and Vashist (2018, p. 233) opine “cultural orientation in explaining, understanding and reciprocating idioms of distress of the sufferers by these healers lends cultural credibility to their practices”. The inclusion of indigenous healing practices in the national health system is necessary for making primary health care robust and comprehensive. Indigenous healing is basically practised at the primary healthcare level, so engaging indigenous healers in primary health care with capacity building training has been suggested as a strategy to strengthen the primary care system. According to Priya (2013, p. 214), “the primary level of care can be further divided into the home, community based and institutional services. In Traditional Medicine (TM) there are similarly three levels. The home remedies, folk practitioners and practitioners of codified systems who have learned through the guru-shishya parampara—all three constitute the LHT that work within the home and community”. Public spending on health is low and skewed to curative rather than preventive and promotive services. Out-of-pocket expenditure in health is very high in South Asian countries (Sengupta et al., 2017). People at the margins are being pushed below the poverty line due to the rising cost of health care. Official healthcare services are inadequate and are of poor quality in rural and tribal areas. The tribal population suffers more from the inequitable healthcare services, with the double burden of diseases and mounting out-of-pocket expenditures. Biomedicine does not have sureshot cures for many conditions, and people continue to rely on or are beginning to revalue indigenous healing systems (Gaines & Davis-Floyd, 2004, p. 99).

Erosion of Indigenous Health Knowledge The value of ethnomedicine and tribal healing practices has not been recognised yet. The total neglect and even attack over ethnomedicinal practices can be taken as a historical injustice to tribal medicine. Indigenous traditional healers are looked down and treated unkindly, and their health practices are denounced as harmful, unscientific and superstitious, often disregarding the positive aspects of indigenous practices. Blaming tribal people and their healers for poor health but not making any effort to upgrade their indigenous health knowledge and practices is an injustice. As

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a result, there is a substantial intergenerational loss of traditional medicinal knowledge (Bodeker & Burford, 2007, p. 3). One of the issues is that the young generation shows little interest in learning and practising indigenous healing because there is no or low economic gain from healing services and extended periods of apprenticeship. Migration of youths for education and employment, difficulty in collecting and processing wild herbs, unfavourable or prohibitive rules to enter the forest to collect herbs are other reasons. Degradation of the local environment and depletion of medicinal plants due to commercial harvesting, market influence and commodification of medicine affect indigenous healing, eroding indigenous knowledge. Healers are primarily unorganised and lack official support to learn and practice because there are no institutional mechanisms aimed at capacity building. One of the dominant narratives is that indigenous healing practices are declining, disappearing or dying. Such narratives can be challenged because these practices are living practices, constantly evolving, innovating and changing but not dying. Indigenous healers are also adopting new technology such as X-rays and pathology laboratories and struggling with the pressures to systematise, standardise and biomedicalise their practices. Biomedicalisation refers to the increasingly complex, multisited, multidirectional processes of medicalisation, extended and reconstituted through new social forms of highly technoscientific biomedicine. Dalal (2011) asserts that “the popularity of traditional healing practices has not declined in present times”. The indigenous healing practices have proved resilient in the sense that they have stood firm despite systematic neglect and “progressive marginalisation by the state” (Lambert, 2018, p. 124). Today, indigenous health knowledge and practices are occupying space in many settings, and some policy initiatives have been directed in the pursuit of recognising indigenous health knowledge and practices. The continuity of indigenous healing practices among the tribal communities affirms that these practices have an important function in health and healing.

IPR, Biopiracy and International Instrument Ethnomedicine today stands with the enormous possibility of bioprospecting and drug discovery as there is a growing interest in herbal medicine which is free from chemical hazards. The importance of medicinal herbs and herbal practices cannot be undermined, especially when people suffer from biomedical synthetic drugs, invasive procedures, overly chemicalised products and iatrogenic effects. The need for “revitalisation of local health traditions” also suggests the importance of local herbal knowledge and practices. There is commercial interest in medicinal herbs. Ethnobotanical, ethnopharmacological and genetic research contributed to the exploitation of, rather than the advancement of, indigenous knowledge and practices and empowerment of indigenous people. Pharmaceutical and biotechnological companies are interested in exploring commercially profitable, genetic and biochemical resources in indigenous medicinal

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plants, leading to the threat of biopiracy. Concerns are expressed over the appropriation of indigenous knowledge and biopiracy. WHO (2002, p. 25) also points to this possibility: …the knowledge of indigenous TM practices and products gained by researchers can be a source of substantial benefits to companies and research institutes. Increasingly, it appears that knowledge of TM is being appropriated, adapted and patented by scientists and industry, with little or no compensation to its original custodians, and without their informed consent.

As Shiva (2001) puts it, the present legal regime promotes biopiracy in the name of bioprospecting. There have been instances of appropriation of indigenous knowledge without any recognition, consent or compensation. Sengupta (2019, p. 42) characterises this phenomenon as ‘daylight robbery’. Traditional medicine and herbbased products are in high demand, resulting in patenting indigenous medicine without consent from or compensation to the original knowledge holders. In the case of indigenous healing, the actual knowledge holder may not be the practising healer because ethnomedicinal knowledge is passed from generation to generation through an oral tradition. Since indigenous knowledge is the community knowledge, the consent and compensation or equitable sharing of benefits should be with the community. Posey (1996, p. 109) writes: Intellectual property rights (IPR) serve to protect private, corporate property, but not the collective wisdom of past, present, and future generations of indigenous people and local communities. Thus, there is an increasing demand for new, alternative, or sui generis systems to enhance, protect, and honour their societies, language and cultures. Only with such legal support will the biological, ecological, agricultural and cultural diversity be conserved.

Bioprospecting, the exploration of biodiversity for commercially valuable genetic resources, is often justified because it will help utilise the active compounds of medicinal plants with pharmacological potential that will lead to the discovery of new drugs. Further, it will enhance public health to help preserve indigenous knowledge. However, the reality is that it actually helped biopiracy and exploitation of indigenous knowledge rather than protection of indigenous knowledge. Trade-Related Aspects of Intellectual Property Rights (TRIPS) facilitates the commoditisation and appropriation of indigenous bioresources and medicinal knowledge under bioprospecting. Tribal people are being exploited in the name of benefit sharing and win-win strategies. They have experienced a threat of losing control over their indigenous knowledge because they are far behind the people of non-indigenous/foreign origin in patenting and claiming IPR (Pordie, 2010). The Convention on Biological Diversity (CBD) recognises “the contribution of indigenous communities to knowledge about the utilisation of biodiversity” (Shiva, 2001, p. 122). Article 8(j) of the CBD declares that state parties are required to: … respect, preserve and maintain knowledge, innovations and practices of indigenous and local communities embodying traditional lifestyles relevant for the conservation and sustainable use of biological diversity. It further promotes the wider application with the approval and involvement of the holders of such knowledge, innovations and practices and encourages the equitable sharing of the benefits arising from the utilization of such knowledge, innovations and practices.

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The International Labour Organization Convention (no. 169) is the international policy guaranteeing rights to indigenous peoples, which declares health services a fundamental right for indigenous people. In addition, the Convention calls for government responsibility in providing community-based, culturally appropriate care, preferably from healthcare providers employed from the local community.

Challenges and Possibility of Recognition and Integration The interest in natural herbal medicine, products and services is increasing worldwide with the increase in chronic conditions and the rising cost of care. Tired of biomedical products and services, many people have started looking for an alternative. AYUSH services, Ayurvedic therapies and Yoga centres have attracted international patients, making India an attractive destination for medical tourism (Banerjee, 2004; Kaspar & Reddy, 2017). The irony is that on the one side, big companies are making money by branding themselves ‘back to nature’ and marketing herbal medicine, products and services at an exorbitant price. On the other hand, indigenous tribal healers, who hold the knowledge and know-how of nature, are being discouraged and deprived. Despite the enormous possibility of indigenous tribal medicine, there seems to be a lack of genuine effort to document, preserve, protect and promote indigenous practices in an integrated manner. The importance of plant-based or plant-originated medicine has never been less (Iwu, 2002). However, with the increase in health problems and the limitation of biomedicine to provide the appropriate care and cure for many illness conditions, the importance of herbal medicine and natural products has increased. Medicinal plants are the main strength of tribal medicine. For a sizable proportion of the developing world population, traditional medicine is the main or only source of care (WHO, 2013, p. 16). For them, primary health care is necessarily synonymous with traditional medicine. Those who do have some choice consult both biomedical practitioners and indigenous healers in the event of sickness (Maclean & Bannerman, 1982). Indigenous healing practices are part of the tribal culture, history and identity, and this is another reason it needs protection and preservation. There is a unanimous agreement that indigenous health knowledge should be protected from further erosion. The importance of ethnomedicinal plants has increased because there is an enormous possibility of drug discovery for modern pharmacopoeia. After all, the efficacy of many such plants has been established by scientific research. Many modern drugs have been derived from ethnomedicinal plants because this provides the basis for developing modern medicines. The question arises whether we want to respect the indigenous tradition in its entirety (in the holistic form) or recognise the importance of herbal traditions, isolating the ritual and spiritual aspects to suit the biomedical parameters. The current trends seem to disown the spiritual aspects of healing to scientise the indigenous traditions; for instance, bhuta vidhya (demonology) or graha chikitsa (diagnosis and treatments of mental de-arrangements) has been disowned by modern Ayurveda.

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Integration into mainstream medicine tends to disintegrate the holistic or comprehensive nature of traditional medicine. The perplexing question remains: Do we want to recognise indigenous healing as an essential source of care and protect and preserve indigenous practices as an identity or disintegrate indigenous healing through scientific/selective integration? Traditional medicine systems which come under AYUSH were recognised and are integrated into mainstream medicine. More recent is the inclusion of Sowa-Rigpa. However, the medicine practised by many different tribes is left unrecognised and unintegrated despite the possibility of some level of integration into the national health system. The integration of tribal medicine remains a vexed issue as there are no explicit policy directions in the pursuit of recognition and integration. Recognition and integration of tribal medicine in the mainstream health system will make the healthcare system more inclusive, democratic and comprehensive. Enhancing the quality of tribal medicine is critical to improving primary health care. Since the tribal population extensively relies on tribal medicine, ensuring the quality of tribal medicine, products and services can help improve their health. The spirit of universal health coverage is that the healthcare services patients want and need must be of sufficient quality. This necessitates the recognition and integration of tribal medicine and calls for improving the quality, safety and efficacy of tribal medicine. It seems unlikely that improvement of the health status of remote rural and tribal populations can happen without improving the quality of tribal medicine. Recognition of tribal medicine is also essential to respect the tribal people’s culture, heritage and identity. Many scholars have expressed the need for recognition and integration of indigenous healing practices to meet the primary healthcare needs of the population (Bode & Hariramamurthi, 2014; Dalal, 2005; Joshi & Vashist, 2018; Payyappallimana & Hariramamurthi, 2012; Priya & Shweta, 2010; Ranganathan, 2018). Dalal (2005) expressed that since traditional healing practices are culturally compatible and have wide acceptance and application throughout India, these practices need to be rejuvenated and integrated within the existing healthcare programmes to improve the well-being of the masses. Priya and Shweta (2010, p. 178) assert that LHTs and their practitioners’ existing knowledge base must be incorporated into the health system in ways that promote their rational use and the further growth of these knowledge systems.

Integration of Traditional Medicine in the National Health System The role of global and national policies and regulatory strategies is vital to recognise and integrate traditional medicine. Around the time of the 1978 Alma Ata Conference, the integration agenda of traditional practitioners got prominence in many forums across the world (Rubel & Sargent, 1979). Integration was advocated to provide universal access to primary health care utilising local resources. Recognising the

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importance of traditional medicine to meet the primary healthcare needs, the Alma Ata Declaration highlighted the wide existence of traditional medicine practitioners and traditional birth attendants. It recommended nation states to engage them in primary health care: Traditional medical practitioners and birth attendants are found in most societies. They are often part of the local community, culture and traditions, and continue to have a high social standing in many places, exerting considerable influence on local health practices. With the support of the formal health system, these indigenous practitioners can become important allies in organising efforts to improve the health of the community. Some communities may select them as community health workers. Therefore, it is worthwhile exploring the possibilities of engaging them in primary health care and training them accordingly (WHO & UNICEF, 1978).

The Alma Ata encouraged nation states to recognise and integrate the traditional medicines in their respective territories into their health system. Many nation states moved ahead with policy measures to integrate traditional medicine and legitimise traditional medicine practitioners. Though there were laudable efforts to integrate traditional medicine and practitioners, linking indigenous tribal healers with the official health system could not become a priority agenda. As an exception, some traditional healers, including traditional birth attendants, were trained and mobilised to achieve national health goals. However, the training and mobilisation were not intended to recognise and integrate the indigenous tribal healers but to seek their support in referring patients to the health institutions to meet health targets. In many instances, the training programmes were not aimed at respecting indigenous knowledge and practices but to alter them (Pigg, 1995). Neither was their knowledge recognised nor their role as healers appreciated nor were they integrated as health staff into the structure of the healthcare delivery system. Further, when the international focus shifted from traditional birth attendance to skilled birth attendance, the creation of a new structure of grassroots health staff such as Accredited Social Health Activist (ASHA) and anganwadi workers became a priority. The shifts in global policy to institutional delivery with skilled birth attendants sidelined the indigenous midwives and their birthing knowledge (Sadgopal, 2013). Since indigenous healers meet the primary healthcare needs of the people, capacity building and mobilisation would have enabled them to render quality service and meet further needs. The integration of traditional healers in the national health system remains an unfinished agenda. The first WHO Traditional Medicine Strategy (2002–05) was to facilitate member states to integrate traditional medicine with the national health system, focusing on formulating traditional medicine policies and programmes. WHO Congress on Traditional Medicine held in 2008 in Beijing restated the goal of integration of traditional medicine into national health systems and recommended that the member states establish a system of qualification, accreditation and licencing of traditional practitioners. The WHO Traditional Medicine Strategy (2014–23) also reiterated the promotion of education, qualification, accreditation or licencing of traditional medicine practices and practitioners. Indigenous communities can be better served with traditional medicine services if indigenous healers are linked with the healthcare system. Payyappallimana and

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Hariramamurthi (2012) saw the possibility of creating the relationship of complementarities between the folk and professional sector. They opine that the integration of folk practitioners at the lower end is often criticised as a one-way flow of knowledge through targeted training, exploitation of healers and biomedicalisation of traditional knowledge. They suggest a self-reliant model of health care based on local medical traditions that complement the institutionalised health delivery system. Hence, they suggest linking indigenous healers rather than integrating them as lower level staff because this does not strengthen indigenous knowledge and practices. Hyma and Ramesh’s (1994, p. 75) view is that integrating traditional healers into national health systems almost always means incorporating traditional medical knowledge by grouping and supervising its practitioners into special categories of ‘auxiliaries’. Not all are prepared to accept this. Indeed, the social status accorded to a traditional healer within a given culture is frequently likely to be higher than what can be achieved through public administration recognition and integration into the national health system as an ‘auxiliary’. As pointed out by some scholars (Ahlberg, 2017; Blaikie, 2019), integration can become a problem rather than a solution to safeguard cultural heritage and the holistic nature of indigenous medicine. Priya (2013, p. 25) writes: “The Department of AYUSH gladly supports LHT projects only if they are likely to uncover some practices not known in the AYUSH texts, which could be validated and added to the existing texts and AUS pharmaceuticals. However, the promotion of local uses, or people’s empowerment through the legitimisation of their knowledge, is generally not considered a meaningful objective”. However, if we respect the right of tribal healers to practice tribal medicine and the rights of patients to consult these healers, they must be given a space in the national health system. Integration itself has become a polysemic term because there is no agreed-upon definition/modality of integration. By integration, many assume it to mean integration of traditional medicine with biomedicine, whereby the best of traditional medicine is incorporated into the biomedical, clinical practices. The Chopra Committee report also recommended integrative medicine, making inroads to a synthesis of medicine (Ministry of Health, 1948). The National Education Policy, 2020, also intends to make the medical education system integrative, whereby all medical students must have a basic understanding of AYUSH and vice versa. Mutual understanding among different streams of health/medical knowledge is vital for integrative medicine. Integrative medicine has its importance; however, we do not subscribe to the clinical integration of AYUSH into biomedicine or the integration of tribal medicine into the AYUSH system or AYUSHisation of tribal medicine as opined by P.C. Joshi in this volume. We mean integration of tribal medicine not without but by retaining the identity of indigenous medicine. The recognition of AYUSH systems and the colocation of AYUSH practitioners in the National Rural Health Mission (NRHM) is a way of integration. Just like medicalisation of Complimentary and Alternative Medicine (CAM) or incorporation of specific CAM therapies into biomedicine cannot be termed integration, similarly, AYUSHisation of indigenous tribal healing or incorporating specific therapies or indigenous medicinal plants cannot be called

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integration. Tribal medicine as a distinct tradition and tribal healers as distinct practitioners must grow and develop within the national health system. By integration, we mean the assimilation of indigenous tribal medicine in the national health system.

Initiatives to Recognise Indigenous Traditions and Their Revitalisation in India Recognising the local acceptance of and respect for practitioners of indigenous traditions of AYUSH systems, the National Health Policy, 1983, emphasised the need to dovetail the functioning of these practitioners and integrate their services in the healthcare delivery system (MoHFW, 1983). The 2002 National Policy on Indian Systems of Medicine and Homeopathy articulated the need to revitalise LHTs (MoHFW, 2002). The policy defined LHT as the undocumented knowledge possessed by individuals, communities and tribal groups including birth attendants (dais), bonesetters, herbal healers, poison specialists as well as the knowledge on local grains, cereals, wild fruits, vegetables and locally available medicinal plants possessed by ordinary households. (MoHFW, 2002 cited in Mishra et al., 2018)

The policy first recognised the need to document and validate indigenous health knowledge that individuals, communities and tribes have. One of the visions of NRHM, now the National Health Mission (NHM), was to revitalise local health traditions and mainstream AYUSH into the public health system. The official acceptance of local health traditions itself shows the importance of non-codified, undocumented non-institutionalised traditions. A national study conducted in 18 states of India pointed out the utilisation of AYUSH by 60–90% of households in one-thirds of states, 30–60% in one-thirds households and below 30% in the remaining one-third households. In contrast, more than 80% of households of all the states reported the use of LHTs for some health reason or the other in the last three months (Priya & Shweta, 2010). Here, LHTs included the use of home remedies and local healers divided into four categories: (i) traditional health practitioners, those who practice textual tradition by learning from older members of the family or from older practitioners; (ii) folk healers, those who practice oral tradition learnt from the previous generation or from gurus and teachers, and often consulted for specific health problems, (iii) faith healers, those who use non-material means of prevention or treatment, invoking ‘spiritual’ forces to do so, and may or may not be combined with herbal medicine and (iv) Dais, traditional birth attendants (Priya & Shweta, 2010, p. 140). A similar study conducted by Mutatkar (2016) documents LHTs as practised at the household level in tribal areas and recognises the importance of LHTs (defined as home remedies, herbalists and Dais). The study also recommends Dai huts to prevent the erosion of the traditional Dai system.

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The High-Level Committee report on socio-economic, health and educational status of tribal communities of India acknowledges the importance of the role traditional healers and Dais play in indigenous health care and recommends exploring the possibility to include them in the healthcare system (Ministry of Tribal Affairs, 2014). The revitalisation of LHTs got space in the Eleventh (2007–11) and the Twelfth (2012–16) Five-Year Plans. The Twelfth Plan also asserts the need of recognising and integrating tribal medicine. The plan states: Tribals have traditionally depended on their traditional methods of healing/treatment for minor day to day ailments and the major ones too. There is a need for evolving a new strategy of combining indigenous tribal medicine with other medical systems. A systematic effort is to be made to document this traditional tribal knowledge of medicinal/herbal plants, standardising it and recognising it as an independent system of medicine. The local tribes, especially the traditional healers, can be trained and be entrusted with the responsibility of treating the people on remuneration and so on. (Planning Commission, 2012, pp. 241–242)

The recent National Health Policy (2017) explicitly recognised the role of LHTs. It recommended formal recognition of the practices and practitioners of their knowledge to deal with primary health care (MoHFW, 2017). The policy “calls for developing mechanisms for certification of ‘prior knowledge’ of Traditional Community Healthcare Providers (TCHP) and engaging them in the conservation and generation of the raw materials required, as well as creating opportunities for enhancing their skills” (MoHFW, 2017, p. 15). Accreditation and Certification of Prior Learning (ACPL) has been initiated for the indigenous traditional healers who have been practising herbal medicine for a long time. In this initiative, healers’ competencies are examined by an expert committee based on a set of criteria. The Quality Council of India, in collaboration with the Foundation for the Revitalisation of Local Health Traditions (FRLHT), Bangalore, and other institutions have started certifying traditional healers as Traditional Community Healthcare Providers (TCHPs) (Debajani Roy, and Srikant and Goel, this volume). This is an initiative towards the recognition of indigenous health knowledge and practices. Though very few herbal healers have come under this voluntary certification scheme so far, such initiatives suggest that they have the potential to be recognised and integrated. However, folk or indigenous healers are not one homogenous group, and the challenge remains to recognise and legitimise all types of healers. This indicates that integration is possible only to a certain extent because many healers specialising in psychosocial healing are barred from coming under the scheme because it may not be easy to establish/prove the efficacy and effectiveness of such practices scientifically. However, practices such as herbal healing, bonesetting, massage and traditional midwifery (the Dai tradition) hold the possibility of being validated according to the biomedical standards. The informal nature of indigenous healing also makes it difficult to be incorporated in a formal nationalised system (Joshi & Vashist, 2018, p. 236). Though there are limits to integration, initiatives and strategies that respect indigenous health knowledge and treat indigenous healers as potential allies to improve the health of the indigenous communities are essential.

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The establishment of the North Eastern Institute of Folk Medicine (NEIFM) under the Ministry of AYUSH is another important initiative. The mandate of the NEIFM is to facilitate research on indigenous medicine, validate folk medicinal practices and build the capacities of folk healers. However, the institute is not fully equipped with the necessary equipment and infrastructure, as the 50-bedded indoor hospital for research on folk medicine is not functional (Reddy, this volume). It was expected that the institute would create an interface between folk healers and research institutions to enable a proper understanding of folk medicine, but this has not been fully realised. The institute also aims to upgrade the skills and build and enhance capacities of folk medicine practitioners and protect their Intellectual Property Rights, all of which are yet to take off. The structural modality of NEIFM is dominated by AYUSH officials headed by a Homeopathy doctor, and this may not be suitable, as he is not aware of the medicinal plants. There is a need to include medical anthropologists who are known for their expertise in indigenous/folk medicine (see Joshi in this volume), can contribute by laying emphasis on tribal medicine, and help to recognise indigenous/folk system. Establishment of institutions such as NEIFM, accreditation and training to healers, can be taken as an effort towards the recognition and integration of traditional healers and their practices. However, these efforts are not sufficient to bring tribal medicine into the fold of the national health system. Tribal medicine constitutes an important area of indigenous knowledge, which is less systematised and gets less importance in teaching and research. Tribal medicine should be recognised and regulated, and necessary resources should be allocated to address the historical injustice that has been done to this aspect of medicine. The roots of codified traditional medicine lie in indigenous therapeutic knowledge and practices. A lack of respect for indigenous health knowledge is the main reason for the unwillingness to recognise and integrate tribal medicine. A state body is required, and a mechanism should be developed to oversee tribal healing practices, to change institutional perception and increase an understanding of the value of tribal medicine. The representation of tribal healers should be ensured in the regulatory body to assess the experience and expertise of healers, facilitate licencing/accreditation and maintain a code of conduct, professional ethics, quality of herbs and service delivery. State intervention is needed to ensure that tribal healing practices, herbal medicine and healers’ services are safe, efficacious and of good quality. Local-, regionaland national-level research institutes/councils for tribal medicine are necessary to promote research, validate the practices and address the issue of safety, efficacy and quality.

Organisation of the Volume This book is a collection of 22 chapters, which are organised into three sections. The first section addresses the historical and critical perspectives to understand ethnomedicine and healing practices from among the tribes. The second section is about healing practices among various tribal communities, based on empirical

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studies. The third section discusses recognition and revitalisation of local health traditions, integration of tribal medicine and Intellectual Property Rights issues. P.C. Joshi’s chapter serves as a background for the theme of the book. It traces the historical development of medical anthropology in India, shows the strengths of anthropological methodology and anthropological orientation towards the poor, minorities and marginalised sections. It argues for equal treatment for tribal medicine. Further, it looks at the hierarchical systems of medicines and the challenges posed by AYUSHisation for local health traditions and advocates that although tribal traditions may be ‘little traditions’ but they should not be belittled. They should not be treated as inferior and subordinate systems to AYUSH. R.K. Mutatkar sheds light on the importance of ethnomedicine from a public health perspective. Mutatkar sees public health in ethnomedicine because it represents people’s health and a healthcare sector which tribal communities have historically and traditionally managed. It can be encouraged by upscaling, giving them authorisation and confidence to practice. The chapter asserts the need to establish linkages between the little traditions of ethnomedicine and the great traditions of AYUSH, following Robert Redfield’s theoretical model of interaction of little tradition–great tradition with examples from Indian civilisation, and calls for research that serves the ‘human good’ and not vested commercial interests. B. K. Pradhan gives a detailed analysis of the Biological Diversity Act, 2002, and the challenges faced in its implementation, the flaws in the Act and the guidelines. The state-specific biodiversity conservation rules are barring the indigenous communities from their rights to access the forest resources, endangering their extensive conserved indigenous knowledge. He provides some practical recommendations for the effective implementation of the Biological Diversity Act. Shalina Mehta and Dinesh Kumar examine how indigenous knowledge of tribal communities on medicinal plants is appropriated and usurped by pharmaceutical industries. Ethnobotanists, medical anthropologists and people working with indigenous communities have admitted that a substantive extent of their knowledge was derived from practitioners of traditional medicinal systems living in forested regions of the world, acquired by oral traditions and practice. The tribal practitioners who live in forest regions and the knowledge they possess about medicinal plants contribute to the realm of ethno-pharmacopoeia from where pharmaceutical companies derive knowledge without giving due recognition to the original owners. This paper calls for the restoration of herbal wealth and the protection of the knowledge of the inhabitants. Taking the case of a highly valued and high-in-demand medicinal plant (Ophiocordyceps sinensis, locally known as Yarsagumba) of the Himalaya, the chapter by Madhusudan Subedi examines the informal trading network of medicinal and aromatic plants resources in Nepal. In this informal trading system, the brokers exploit local primary collectors, which has amplified the risk of over-exploitation or depletion of medicinal herbs, making indigenous people the ultimate sufferers. This chapter gives an example of how commercial interest in medicinal plants leads to overharvesting, threatening indigenous people’s precious resources. This calls for a regulatory and legal mechanism to control the informal trading system and policy measures to promote traditional healthcare practices.

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The second section, which explores healing practices among various tribes, begins with a chapter by Shailaja Chandra that explores the tribal healing practices of NorthEast India. The chapter asserts that tribal medicine is the only available source of treatment in many places of North-East India and shows a need for engaging healers to preserve forests and promote herbal gardens with state support. The scientific community can undertake scientific validation and carry out reverse pharmacological and observational studies. Further, it advocates for legitimising their knowledge by certification and protection of sui generis knowledge. Tshering Lepcha describes the role of beliefs and perceptions among the Lepcha community in Sikkim. The Lepchas of Sikkim have enormous faith in herbal medicine, formulated through trial and error and healing practices, which are gained through constant application. Lepchas believe that an illness occurs due to a disturbance to nature, deities and ancestral spirits. Health and healing involve restoring and maintaining the relationship between patients and family/community and harmony with spiritual and natural worlds. The disappearance of the language and culture of tribal communities is a matter of grave concern. The process of disappearance has been accelerated by migration and assimilation with the dominant societies. Binu Sundas takes a look at the Limbu language of the ethnic community found across the Indo–Nepal border to discuss the disappearance of traditional healing. It reveals that the language of Limbu has been pushed to the risk of extinction by the state’s “one language and one culture” policy and sheds light on how an erosion in language led to a decline of their indigenous health knowledge. Indeed, language is an essential means to transfer knowledge from the older to younger generations. Many indigenous communities are also facing the same problems. For instance, the Tibetan language is a must to sustain the Amchi practice, but the government education system in Nepal does not provide education in their mother tongues (Craig, 2008). Albert, Porter and Green explore the Khasi indigenous healers of Meghalaya and address the key component of making nongai dawai-sap, loosely translated as talent or potential: having local specificity. There are varieties of healers who treat various conditions, including physical, muscular and skeletal problems, with communityrecognised expertise. The chapter offers an understanding of how the Khasi tribal healers, their practice built on the community’s knowledge, are recognised by the community as doktor sla, plant doctor, which is different from doctor kot, or book doctor refereeing to the biomedical doctor. One important message of this chapter is that indigenous healing is not static but dynamic and constantly evolving. Tashi Smanla and Shalina Mehta on the Amchi system in Ladakh show how SowaRigpa in Ladakh is declining, though it is encouraging that it has been included under the AYUSH ministry. However, they opine that the official recognition of Amchi as a healing practice is not necessarily enough for the survival of the Amchi system. They pointed to a loss of knowledge, medicinal herbs, language and tribal culture and echoed with the argument of Blaikie (2019) that the recognition and integration of traditional medicine and mainstreaming of practitioners, though necessary for legitimate practice, may not strengthen the systems.

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Diskit Wangmo, Rita Kumari, Nutan Kumari Jha and A.K. Sinha explore the pluralistic healthcare practices among the Broq-pa tribe in Jammu and Kashmir and the challenges faced by the Broq-pa healers. The field study affirms that even in the village, the local tribal healers (faith healers and Amchi) are the primary source of treatment besides home remedies and biomedicine as a last resort. Though the traditional Amchi practices are on the decline, the state government has taken steps to train young Amchis and support them in establishing their clinics in the village, even recruiting some of them as official practitioners. They hope that these steps will help ensure access to Tibetan medical treatment across the region and the survival of this medical system in rural areas. Bamdev Subedi looks into the indigenous healing practices among the Tharu, a tribal community found across the Indo–Nepal border, and examines how deeply embedded the healing practices are with the cultural traditions and how such traditions contribute to the continuation of healing practices. The paper draws attention to some of the cultural traditions and traditional value systems that are important for protecting indigenous health knowledge and practices and advocates for a legitimate space for them in the formal healthcare system. Tribal communities have their own ethical/moral code of conduct. The chapter by Minakshi Dewan sheds light on ethics and morality in seeking care from local healers among the Bhil tribes of Udaipur, Rajasthan. She explains the concept of dharmi and adharmi (those practitioners who adhere to ethical/moral code of conduct and those who do not), which guides the Bhil community in the Udaipur district of Rajasthan in choosing between different healthcare providers. The healer’s code of ethics is getting polluted with the influence of the market and money and the commodification of healing services. Still, the majority of the healers provide services at a meagre cost (Reddy, this volume) and stick to their morals and values. The third and last section has eight chapters that examine the policy issues in local health traditions, tribal indigenous knowledge, Intellectual Property Rights and accreditations and integration. This section begins with a chapter by N. Srikanth and Sumeet Goel on systematic documentation and drug development from local health traditions. The Central Council for Research in Ayurvedic Sciences (CCRAS) is trying to document and validate LHTs and ethnomedical practices prevalent among the communities through the proactive and reactive approach. The paper discusses the process of documentation and validation of LHTs in a coordinated manner. David Pradhan and Alok Patra’s chapter focuses on the sociolegal reappraisal in climate change and protection of traditional ethnomedical knowledge. Based on literature review, it critically analyses the existing legal mechanism for the protection of traditional knowledge. It invokes international and supranational principles, national legal procedures and local praxis to provide more equitable protection of traditional knowledge in India. This paper envisions a more communitarian cultural rightsbased protection to tangible bioresources and advocates for intangible traditional knowledge against climate change-related environment and sociocultural disruption. Nemthianngai Guite takes up the case of Saikot Cancer Medicine to give insights on a tribal healer and his healing practice, which has an effective treatment for a disease condition. She presents how the media, academia and research community

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rushed after the healer when they discovered them treating cancer patients with a locally known medicinal plant, Zanlung Damdei. The case shows the strength and importance of traditional healing practices as part of indigenous knowledge and Intellectual Property Rights issues over indigenous knowledge in the present legal context. The chapter by Prakash B.N., Hariramamurthi G., Sarin N.S. and Unnikrishnan P.M. shows the effectiveness of tribal herbal knowledge and practices for the prevention and treatment of malaria. FRLHT is in the process of revitalisation of tribal medicine through research, documentation, education and outreach. It suggests employing transdisciplinary research methods based on non-conventional and whole system approaches to validate ethnomedicinal practices. Participatory and rapid assessment, endogenous development and reverse pharmacology have been tried. The chapter looks at currently available options of access and benefits sharing mechanisms that are fair and equitable to overcome the danger of biopiracy. Debajani Roy delineates the certification of healers as Traditional Community Healthcare Providers (TCHPs), a programme started by the Indira Gandhi National Open University (IGNOU), Quality Council of India and FRLHT. Voluntary certification of the TCHPs is provided, as per the ISO 17024 for personnel certification under the Voluntary Certification Scheme for the Traditional Community Healthcare Providers (VCSTCHP) in six streams of ailments, namely jaundice, common ailments, traditional bonesetting, traditional birth attendants, poisonous bites and arthritis. It is based on the international best practices of certification. Srikanth and Sumeet Goel emphasise the protection of Intellectual Property Rights, benefit sharing and mainstreaming of traditional medicine. They propose strategies and effective models to protect the rights of folk healers by evolving a national network system of centralised documentation of LHTs, like the traditional knowledge digital library, and ensuring ex-situ protection of the IPR for traditional healers. It also recommends strong linkages and networking among scientists and regulatory authorities from national biodiversity boards and patent offices. Ritu Priya shares the relevance of tribal health knowledge and practices from a health systems perspective. Her paper examines how health systems research has ignored indigenous health knowledge as a valuable resource and the challenges for protecting and promoting this knowledge for public use. She draws on the approaches adopted by various countries and proposes available options to protect and promote tribal health knowledge. The volume concludes with a chapter by Sunita Reddy, which takes a fresh look at the indigenous healing practices of North-East India based on empirical research from the ‘emic’ perspectives of the tribal and folk healers in 2018. It shares the knowledge, efforts, aspirations and challenges faced by the healers. The poor and marginalised healers provide a lifetime of knowledge and experience for the community’s welfare by delivering primary-level care. They also shared their anxiety and fears of loss of their knowledge as a result of biopiracy. The chapter ends with some recommendations the healers gave to recognise, promote and integrate their knowledge, like the creation of a ‘healing hut’.

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Concluding Remarks All over the world, patients resort to different forms of healing, even though biomedicine, accrues state patronage. The codified forms of healing like AYUSH, which are age-old traditions, got recognition only recently. The non-codified forms of healing, such as folk/tribal/indigenous/traditional healing practices, have not got a due share of recognition and patronage despite being widely used. This book starts with the contemporary debates and discussions on ethnomedicine, the lack of legitimacy of folk health traditions, and its possible role in public health. The age-old practices of folk/tribal medicine are widely utilised across the country, especially in biodiverse and inaccessible areas where the marginalised sections are largely dependent on herbal medicine and local healers’ benevolent healing practices. With the increase in the cost of modern medicine and the non-functional primary-level care in many areas, traditional healers are the only recourse. Given their simplicity, altruistic and service-oriented practices, the poorest of the poor are able to get primary-level care. The importance of traditional healers has been noted since the WHO’s recommendations were published, and some efforts have been made to recognise their work. The certification process is in place but has limitations. There is also a huge concern of loss of this knowledge due to the ageing healers’ population and concerns of loss of IPR. Few organisations and the AYUSH ministry are documenting LHTs, but some of the empirical studies show the anxiety, suspicion and mistrust of the healers about giving away their knowledge without getting any benefits. The last section of the book explores some of the efforts made so far and offers further recommendations to the national, state and local governments to take a proactive role to recognise, certify, document, preserve and promote tribal/folk healthcare practices. Further, it is essential to integrate and mainstream their knowledge and practices in situ to reach out to the community at their doorsteps. Healers as custodians of the knowledge base of the local biodiversity can only conserve bioresources. Only if we recognise and support all kinds of healing systems will we achieve sustainable health goals and health for all, given the limited resources available.

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Part I

Historical and Critical Perspectives to Understand Ethnomedicine and Healing Practices Among the Tribes

Chapter 2

Practice and Praxis: A Critical Look at Medical Anthropology in India P. C. Joshi

Abstract Medical anthropology in India has been parallel with world medical anthropology. The publication and research work in Indian medical anthropology started early; research papers and full-length monographs meticulously cover ethnomedicinal details. It has been inspired primarily by the American medical anthropological traditions. Indian medical anthropology has catered principally to the India-specific problems, as is evident in the researches coming out of India from time to time. Indian medical anthropology is keen on initiating studies on the clinical aspects of Indian spiritualism and mysticism besides subjecting Yoga to medical anthropological experimentations. Indian medical anthropology is facing the daunting task of protecting and promoting traditional medical systems. In the Indian context, while the hegemony of biomedicine remains, more recently, the hegemony of AYUSH, an acronym for Ayurveda, Yoga, Unani, Siddha and Homoeopathy, and recently added Sowa-Rigpa over the traditional healing system persist. Indian medical anthropology now has newer vistas to understand the challenges posed by Ayushisation besides the increasing threat of media corruption. The AYUSH, in the process of documenting and preserving the traditional knowledge, further patronises, and there are possibilities of not sharing the benefits with the healers’ looms large. Keywords Ayushisation · AYUSH · Medical anthropology · India · Medical hegemony

Researches and Teaching in India Medical anthropology in the Indian context is very near to completing a whole century of research on various themes covering myriad facets of the sub-field. It will not be an exaggeration to state that medical anthropology in India has been coetaneous with

P. C. Joshi (B) University of Delhi, Delhi, India e-mail: [email protected] © The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023 S. Reddy et al. (eds.), Ethnomedicine and Tribal Healing Practices in India, People, Cultures and Societies: Exploring and Documenting Diversities, https://doi.org/10.1007/978-981-19-4286-0_2

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world medical anthropology. Starting from 1923, when the first paper1 was published in the journal of Man in India. It has been steadily enriching the subject by studying, initially the tribal populations and then incorporating rural and urban areas within its ambit. The content and theoretical orientation of the sub-discipline widens with the contributions made by scholars such as S. C. Mitra, P. O. Boddings, D. N. Majumdar, P. C. Biswas, Surajit Sinha, T. N. Madan, D. N. Kakar, K. A. Hasan, and many more dedicated anthropologists (see Joshi, 2016). It is worth mentioning here that Hasan and Prasad (see Foster and Anderson, 1976) duo gave the first definition of medical anthropology when medical anthropology was beginning to separate from applied anthropology in the 1950s. The cultural diversity and ethnic heterogeneity of the Indian tribal and rural population have made India an exciting laboratory for developing and testing worthy hypotheses on human behaviour about health beliefs and health-related practices. Indian medical anthropological studies, therefore, present a mosaic of diversity of natural and supernatural beliefs, behaviour and practices from well-developed industrial, agricultural communities to simple technology holders’ rudimentary cultivators and hunting-gatherers through the pastoral shifting cultivators. In all these communities, the state-sponsored programmes have been implemented continuously for curative, preventive and promotive health care. It makes the medical anthropological canvas in India more challenging. Besides, the interaction of these traditional medical systems with the neighbouring cultures inspires and enables the acquisition of new traits, which results in a medical pluralism containing spatiotemporally diverse medical beliefs and practices. The teaching of medical anthropology, interestingly, did not initially start from any university departments in India. R. K. Mutatkar, at the suggestion of Irawati Karve, started to teach medical anthropology to the graduates at Armed Forces Medical College and L.P. Vidyarthi started giving lectures to the psychiatry and psychology students at Central Institute of Psychiatry, Ranchi (earlier called Indian Mental Hospital). D.N. Majumdar is closely collaborating with King George Medical College Lucknow and wrote a fascinating article on the theme of medical anthropology in 1932. Anthropologists and clinicians have been closely collaborating before medical anthropology emerged as a distinct sub-discipline in India. Post-10th ICAES in 1978, after the post-plenary session on medical anthropology in Pune, the endeavour to start teaching medical anthropology in the university departments seriously started, and in a series, university anthropology departments like Pune University, Delhi University, North-Eastern Hill University, Panjab University, Dibrugarh University, Garhwal University and Hyderabad University started teaching a specialised paper titled medical anthropology to their master’s students (Joshi, 2016). The works of Benjamin Paul, Carl Taylor, Charles Leslie, Arthur Kleinman, T.N. Madan, George Foster and many Biennial and Annual Review of Anthropology 1

Dr. S. C. Mitra, a teacher at Calcutta University, wrote the first paper on Cult of Godlings of East Bengal, read first in the Indian Science Congress and later published in the journal of Man in India’s inaugural volume. Incidentally, S. C. Mitra also wrote the first paper of the Journal of the Anthropological Society of Bombay on Indian Children’s Games in 1913.

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consolidated papers with the title ‘Medical Anthropology’ was already there by the time teaching in medical anthropology started in India. Besides consolidated edited works on medical anthropology, like David Landy and Charles L. Leslie were available as necessary references. Two research journals, Social Science and Medicine and Culture, Medicine and Psychiatry, provided a boost to medical anthropology in India.

Development Agenda of Medical Anthropology What separates medical anthropology from other similar disciplines is its unique attraction towards marginalised and excluded communities on the one hand and the use of people-oriented and people-friendly methods such as ethnography and participatory research on the other. Even when medical anthropologists work in an urban setting, more often than not, their research focus will be on the poor and neglected sections living in the slums and shanties. The scale for medical anthropological research has primarily been micro but holistic in the sense that it has strived to look at the health scenario from below; how people who are at the receiving end perceive and negotiate health care. The methodology of medical anthropology has been in sync with their research agenda. Therefore rather than using a questionnaire, a medical anthropologist will be more comfortable with the interview schedule, which requires the quality presence of the researcher at the scene of an investigation. Overall, the methodological focus of medical anthropology is ethnographic and participatory, more conducive to bringing forth the insider’s view and ‘emic’ perspective. For example, the research techniques such as Explanatory Model, Free Listing, Pile Sorting, Illness Narratives or Focus Group Discussions are informant-friendly and insight-generating methods.

Applied Anthropology Medical anthropology and applied anthropology are linked to each other closely. In fact, at one point in time, medical anthropological research was one of the major agendas of applied anthropology (Caudill, 1953). Indian medical anthropology likewise has taken up this agenda very seriously for quite a long time. However, Indian medical anthropological research has a clear-cut bias towards the study of India’s tribal and marginalised population. It is also quite natural because the study of tribal communities has been fascinating anthropologists from the beginning. Therefore when the anthropologist decided to pursue themes on medical anthropology, it was but natural that the illness beliefs and practices of the tribal population were a natural choice. As a result, medical anthropologists accumulated tons of data on the tribal medicinal heritage in dissertations, thesis, books, mimeograph reports, articles and research reports. The study of tribal systems of medicines had a very humble

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start, initially looking for customs and traditions linked to the situation of illness, particularly the supernatural world of ‘godlings’ focusing on one cultural group. By the nineteen-thirties, scholars like Majumdar and Biswas were well aware of the variety of tribal medicinal traditions and customs to write detailed comparative accounts. Post-independence, a large number of studies were devoted to exploring the medicinal world of Indian tribal communities. At present, there is hardly any tribal community in India whose medical system is unknown to us. The tribal medicines are not isolated titbits of beliefs and practices. These are, first of all, medical systems, in the sense that there are well-defined and developed procedures, norms, practices, and beliefs along with personnel, equipment, and apothecary. It further includes both tangible and intangible aspects: substances and medicines on one hand and knowledge and skills on the other. A holistic study of tribal medicinal heritage can be helpful in two ways. Firstly, understanding the logic and rationale of tribal medicinal heritage will make it easier to implement the exogenously originated healthcare programme. An in-depth understanding of the beliefs, perceptions, taboos, practices, and procedures about healthcare actions of a community can inform us of the direction in which the healthcare programmes need to be oriented without having any resistance from the community. Secondly, the tribal medicinal heritage consists of years of experimentation with fauna, floral and mineral substances to ameliorate sickness. This indigenously existing knowledge has the potential to benefit society at large in discovering new pharmacologically active molecules.

Medical Hegemony With all its advancements in technology and instrumentation, biomedicine is practised within the framework of the scientific environment, business model, corporate governance and the profit motive. With globalisation and privatisation resulting in the scaling up of the biomedicine’s practice, medicalisation is slowly being replaced by corporatisation, where management and health bureaucracy have taken over the clinical personnel’s powers. Medical anthropology has been critical of biomedicine’s hegemony for quite some time, and critical medical anthropology and politicaleconomic medical anthropology were mainly oriented towards looking at the factor of inequality and exploitation within the practice of biomedicines. Medical corruption,2 for instance, consist of mal-practices and unscrupulous profit-making involving clinical practice in connivance with market forces. In the Indian context, the boom in iatrogenic unwanted caesarean delivery, cardiovascular surgery and various other clinical operations done primarily to make money are causes of concern. Quite often, the hospitals in connivance with insurance agencies show interest in extending the

2

Medical corruption is defined as the profit-making tendency of the clinical agency to subject the patient to unwanted and often unnecessary medical procedures, including surgery, diagnostic tests, medication and other actions.

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patient’s stay in the hospital so that more money may be charged on account of the patient’s stay. Medical corruption is also evident in clinicians recommending many diagnostic procedures that are often not required. The connivance between clinicians and particular diagnostic agencies is well known where for each diagnosis, the recommending doctor gets a cut.3 In Income Tax raids in Bengaluru in 2017 (see URL Scroll in), it was found that the medical diagnostic centres were paying doctors for referrals. The doctors were paid to the tune of 35% for MRI referrals and 20% for CT scans and other diagnostic test referrals. The IT raid recovered billions of rupees, including evidence of foreign deposits. Prescribing branded medicines in place of generic medicines is another example of collusion between doctors and pharmaceutical companies. It is a well-known fact that pharmaceutical companies pamper and incentivise doctors to prescribe high-cost branded drugs (Kshirsagar, 2016). As patient rights are poorly executed in India, people have to pay for the medicines, often out of pocket. Medical anthropological focus on the plight of helpless patients in the Indian context has been very poor, and there is a need for medical anthropologists to address this realm on a priority basis.

Indigenous Systems of Medicines Indigenous medical systems, especially the tribal and folk medicines prevailing in the non-urban areas of India, have been receiving adequate attention from medical anthropologists from the very beginning. Ethnographically informed documentation of these medical systems in the form of causative theories, diagnostic methods, curative practices, healers and healing traditions and efficacy has been the major focus of medical anthropological research. These systems were silently providing primary health care to the people at their doorstep for generations together. After WHO focus on traditional medicines in 1975 and the Alma Ata declaration in 1978, the international community started becoming sensitive towards the supplementary potentials of these systems. Some elements of these systems were looked up as beneficial at the primary healthcare level. In India, under the efforts to explore swadeshi (indigenous) health care, Indian Systems of Medicines and Homoeopathy received state support and financial assistance. The creation of a separate Ministry of AYUSH on 9th November 2014 by the Government of India gave much-needed impetus as far as the indigenous systems of medicines are concerned. At present, the great scholarly traditions of medicine have received total support from the central and state government, and the current budget allocation for the Ministry of AYUSH is more than sixteen billion Indian rupees. The emancipation of AYUSH from the dominating influence of allopathic systems is a welcome move, but it is not good news as far 3

Cut refers to a fixed percentage of the profit given to the doctor making a referral. It is a wellestablished practice generally with the private providers but quite often with the public providers. This phenomenon has been extensively reported in the media (see Nagarajan, 2014).

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as the folk and tribal medicines are concerned. As great traditions, Indian systems like Ayurveda, Siddha, Yoga and even the Unani systems are refined and enriched regional classical systems. There has been the codification of the therapeutic procedures and compilation of the prescriptions as medical literature within the AYUSH systems. The widespread and diverse little traditions being practised by the tribal and rural communities of India, on the contrary, are mainly oral, relevant to the specific cultural context. The state patronage to AYUSH has come as a jolt to these systems, as there is an earnest attempt to look for these systems from the prism of Ayurveda, Unani, Siddha and Yoga at the cost of their individuality and uniqueness. The process of ayushisation of the local medical traditions goes against the autonomy of these systems. The tribal and folk systems are the sources of medicinal knowledge, and whether it is Ayurveda, Unani, Siddha or even allopathy, more than 60% of medicinal knowledge has been identified and used with the tribal and folk context. The folk and tribal societies were the platforms where the initial risks were taken, and medicinal use was established. Ancient Ayurvedic texts Charak Samhita has mentioned advice being given to the Ayurvedic practitioners to get in touch with the forest dwellers and shepherds to gain new knowledge about medicinal use. There is a dire need to treat the tribal and folk medical systems as independent systems in their own right rather than treating these as inferior and subordinate systems to allopathy or AYUSH. The potentials of tribal and folk medical systems as herbal medicines are well-established, but there exists a wealth of knowledge in therapeutic procedures and rituals, which have immense implications for mental health care. The Ministry of AYUSH has indeed established a National Institute of Folk Medicine at Pasighat in Arunachal Pradesh. This is a welcome step, but there is too much AYUSH interference in the functioning of this institute. Not only that the Ministry of AYUSH financially supports it, but its institutional framework is also no different than the AYUSH institutes. In the name of folk medicines that have been mere lip service to promote and develop the folk medicines. For example, if the institute is visualised as catering to something other than Ayurveda, what is the need for Ayurvedic procedures and OPD in this institute? A National Institute of Folk Medicine should have been manned and run by medical anthropologists. However, a cursory look at the staff visualised by the institute indicates a clear-cut bias against medical anthropology. From a unique institute such as the National Institute of Folk Medicines (NIFM), it is expected that the scattered knowledge on herbal and nonherbal medicines, healing rituals and procedures, healthcare behaviours would be systematically documented and subjected to relevant experimentations to establish the efficacy and potency. How are botanists and zoologists who have no clue about the indigenous communities can accomplish this task and their ethnographic knowledge? The collection of plant species alone is not sufficient unless the accompanying intangible lore is not profoundly investigated in an ethnographic fieldwork-based research style. Fortunately, the folk healers themselves are getting organised, and from all over India, there are attempts to consolidate practices and organisation of associations. For example, in Arunachal Pradesh itself, the Nybus organise themselves as professionals even though the NIFM had decided to ignore them. In Jharkhand, under the

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rubrics of Horopathy (Horo meaning man), the Santhals are organising their therapeutic knowledge and practice. In Rajasthan, the Rashtriya Guni Mission is a unique initiative for grassroots folk healers to organise themselves. The Society for Indian Medical Anthropology has been encouraging folk healers by instituting Swasthya Seva Ratna Award for nearly a decade now. The task of medical anthropology is not merely to document the traditional knowledge but go a step further by validating the folk medicines in a crude case–control manner. Since the medicines are already used in the community, medical anthropologists can document the changes that the patients report after taking the doses of medicines. Some crude clinical trials can also be attempted in collaboration with the folk healers for ascertaining the efficacy of the medicines.

Indian Medial Anthropology Versus World Medical Anthropology Indian medical anthropology has been closely related to and continuously being inspired by world medical anthropology. In the beginning, two of India’s stalwarts, namely G.S. Ghurye and K.P. Chattopadhyay, got initial training under the father of medical anthropology—WHR Rivers. Calcutta department of anthropology brought out a large number of articles in the early nineteen twenties. In a later paper by P.C Biswas, the influence of Forrest Clement can be seen. As Indian anthropologists were constantly going to Europe and America in the pre-independence period for advanced training in anthropology, it was but natural that the Euro-American scholarship greatly inspired the medical anthropological work. This continued even after India attained freedom. The post-independence era saw many foreign anthropologists with interest in medical anthropological subject matter visiting India for research. A large majority of them were interested in the study of peasant societies, and therefore, a large number of papers appeared in the arena of folk medicines. The study of Scheduled Tribe communities for medical anthropological investigations was generally not undertaken in a big way. Furthermore, while many American anthropologists decided to undertake field research to understand and explore health beliefs and practices, the European anthropologists primarily avoided India and chose to study in Nepal. With exceptions like Morris Carstairs (born in India), William Sax and a few others, we do not find many European medical anthropologists working in India. Therefore, Indian medical anthropology has primarily been influenced by American medical anthropology. Right from Carl Taylor to Charles Leslie, Mark Nichter, Joseph Alter, Jean M. Langford and many more, American influences on Indian medical anthropology have been well known. Even during the Xth International Conference of Anthropological and Ethnological Sciences, the Poona post-plenary session on medical anthropology was dominated by American medical anthropologists with Ronald Frankenberg (U.K.) and A. L. Bhasam (Australia) being the exceptions (see Mutatkar, 2013).

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Indian medical anthropology has been influenced and guided by American medical anthropology, but at the same time, Indian medical anthropological researches have mainly been catering to specific Indian problems and concerns. For example, the pioneering work by Madan (1969) on the choice of doctors in Delhi and Ghaziabad addressed India-specific concerns. The Indian medical anthropological works by Mutatkar (1978) on Leprosy and AYUSH, Vijayendra and Bhat (2004), Joshi (1993), Kar (2004), Chaudhary (1986) and many others on ethnomedicine, Krishna Kumari (2014) on reproductive health, Aribam (2015) on acute respiratory infections, Paliwal (2004) and Lamkang (2007) on HIV/AIDS, Reddy and Qadeer (2010) on medical tourism, Reddy and Patel (2015) on surrogacy and Khundongbam (2012) on diarrhoea and many more researches catered to Indian problems, especially being faced by the poor and the marginalised section of the society. In other words, while the American medical anthropological theoretical framework has been the leading guiding force for the practice of Indian medical anthropology, there is significant scope for the exploration of India-centred opportunities and problems.

Agenda for Indian Medical Anthropology India has a very well-developed tradition of spiritual practices ingrained in the mystical cults of the Hindus, Muslims, Sikhs, Jains and Buddhists. What is known to the west in the mystical and meditational practices propagated by Maharshi Mahesh Yogi, Acharya Rajneesh, Swami Prabhupad, Swami Rama and few other Gurus is only a minuscule of the spiritual heritage actively existing in India? The canvas of spiritual practices are vast, and very little is known about India’s spiritual and mystical tradition. Much less is known about the relation of the spiritual and mystical tradition and its linkages with mental health and well-being. Indian medical anthropology has a formidable task to make a systematic study of Indian spiritualism and do a collaborative study with psychologists and psychiatrists to uncover the well-being, quality of life and mental health implications. There have been sporadic experimentations on Maharshi Mahesh Yogi (Dillbeck & Orme-Johnson, 1987) and Swami Ram (Boyd, 1976), but systematic explorations of these practices and the linkage between spiritual practices and brain functioning are mainly unexplored areas. The practice of Indian Yoga has also become internationally popular, with the world celebrating International Day of Yoga on 21st June every year. Largely seen as equivalent to aerobic exercises, Yoga or summation is a process of attaining the highest state of consciousness, that is, Samadhi. Therefore, besides physiological implications, the impact of Yoga on brain functioning is a new and exciting area for Indian medical anthropologists. The agenda of Indian medical anthropologists should be to look at and investigate Yoga in all its forms—as it is practised in the world and within India. Another dimension worth researching is to study Yoga at different levels—a great and little tradition from the point of view of exploring its contribution to the quality of life and well-being.

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The health-related implications of the religious heritage of India are another unexplored area in medical anthropology. Indian religious practices are unique because the religions are practised in a syncretic and pluralistic manner. Be it Hinduism, Islam, Christianity, Buddhism and Sikhism; there are widespread traditions within which the great religions are practised. For example, let us take the Islamic salah, a combination of physical postures and sacred sounds, enacted by a Muslim five times a day. The impact of salah on physical and mental health (Sayeed & Prakash, 2013) is an unexplored research area in India. The Bhajan traditions of Hinduism, the Qawwali Sufi, Chaitanya, ISCON, Sankardev and the sabad devotional singing among Sikhs take listeners into a state of deep abreaction and the medical anthropological implications of these states are unexplored. Tantric traditions’ physical and mental health aspects are little explored, except for Bharti (1965). This research is largely unplumbed, and scientifically designed experimental studies are required to establish these ancient practices’ on physical and mental health benefits. In Indian ethos, food plays a significant role, and it is closely linked with the humoral ideology, seasons, lifestyle and body physiology. Ayurveda, a refined and codified version of the folk and little tradition beliefs and practices, pays great attention to food habits in nurturance and maintenance of health. The trigonal and tridosha theory and food intake and food prohibitions and their relations to health and wellbeing are potent subjects for medical anthropology. In the advent of lifestyle disorders gaining prominence, traditional Indian food habits, food preparations, food grammar, and food consumption need to be extensively documented and explored from the point of view of medical anthropology.

Conclusion Medical anthropology in India is confronted with the daunting task of facilitating quality health care that is accessible, affordable, available, and equitable to its masses, which are often located in urban slums and shanties, remote rural and tribal locations. In such places, the publicly funded healthcare services are poorly functional, and people are not even covered under basic primary health care. In such a situation, medical anthropology must take a middle path by identifying the indigenously available potential in health care, including traditional healing and folk medicinal practices to supplement the official health care while striving to make public health care available and appropriate for the general public. Besides physical health reflected in improving the immunisation, intake of food supplements, use of essential medicine and availing of health services like Ante Natal Care, Directly Observed Treatment Shot, National Rural Health Mission and other services, the management of mental health and well-being is an essential task for the medical anthropology. In all, the challenges for medical anthropologists in India are enormous. For better utilisation of public and traditional resources and management of health care, a pluralistic health resource utilisation model has to be designed for the un-served and marginalised section of Indian society.

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References Aribam, B. S., Joshi, P. C., & Sharma, S. (2015). Perception and management of acute respiratory tract infections in a slum cluster of Delhi. International Journal of Scientific Research., 4(6), 642–644. Bharti, A. (1965). Tantric tradition. Greenwood Press. Boyd, D. (1976). Swami. Random House. Caudill, W. (1953). Applied anthropology in medicine. In A. L. Kroeber (Ed.), Anthropology today (pp. 771–806). University of Chicago Press. Chaudhari, B. (Ed.). (1986). Tribal medicine. Inter-India Publications. Dillbeck, M. C., & Orme-Johnson, D. W. (1987). Physiological difference between transcendental meditation and rest. American Psychologist, 42, 879–881. Joshi, P. C. (1993). Culture, health and Illness; Aspects of ethnomedicine in Jaunsar-Bawar. In S. K. Biswas (Ed.), The Central Himalayan panorama (pp. 253–280). Institute of Social Research and Applied Anthropology. Joshi, P. C. (2016). Emergence of medical anthropology in India. The Eastern Anthropologist, 69(1), 1–11. Kar, R. K. (2004). Ethnomedicine and tribal health: An illustrative appraisal. In A. K. Kalla & P. C. Joshi (Eds.), Tribal health and medicine (pp. 376–390). Concept Publishing Company. Khundongbam, G., Joshi, P. C., & Singh, M. M. (2012). Perception of childhood diarrhea in Langmeidong Village, Manipur. South Asian Anthropologist, 12(2), 135–140. Krishnakumari, P., Joshi, P. C., Arun Kumar, M. C., & Singh, M. M. (2014). Women’s perception of reproductive illness in Manipur, India. Journal of Anthropology. https://doi.org/10.1155/2014/ 321480 Kshirsagar, N. A. (2016). Rational use of medicine: Cost consideration and way forward. Indian Journal of Medical Research, 144, 502–505. Madan, T. N. (1969). Who chooses modern medicine and why? Economic and Political Weekly, 4(37), 1475–1483. Mutatkar, R. K. (1978). Society and leprosy. Gandhi Memorial Leprosy Foundation. Mutatkar, R. K. (2013). Medical anthropology: Past, present and future. In H. K. Bhat, P. C. Joshi, & B. R. Vijayaendra (Eds.), Explorations in Indian medical anthropology (Vol. I, pp. 47–54). Concept Publishing Company. Nagarajan, R. (2014). Open secret: Doctors take cuts for referrals. Times of India. 28th June. https://timesofindia.indiatimes.com/india/Open-secret-Doctors-take-cuts-for-referrals/art icleshow/37350397.cms. Accessed March 22, 2019. Paliwal, M. (2004). Risk factors for HIV/AIDS among tribes of India. In A. K. Kalla & P. C. Joshi (Eds.), Tribal health and medicine (pp. 104–114). Concept Publishing Company. Reddy, S., & Qadeer, I. (2010, May 15). Medical tourism in India: Progress or predicament? Economic and Political Weekly, XLV (20). Reddy, S., & Patel, T. (2015). There are many eggs in my body: Medical markets and commodified bodies in India. Global Bioethics. https://doi.org/10.1080/11287462.2015.1112625 Sayeed, S. A., & Prakash, A. (2013). The Islamic prayer (salah/Namaaz) and Yoga togetherness in mental health. Indian Journal of Psychiatry, 55(Suppl. 2), S224–S230. Scroll in https://scroll.in/latest/860089/i-t-raids-unearth-referral-commission-nexus-between-doctorsand-diagnostic-centres-in-bengaluru. Accessed March 16, 2019. Vijayendra, B. R., & Bhat, H. K. (2004). Ethnomedicine among the Jenu Kuruba of Karnataka. In A. K. Kalla & P. C. Joshi (Eds.), Tribal health and medicine (pp. 391–402). Concept Publishing Company.

Chapter 3

Ethnomedicine as Public Health R. K. Mutatkar

Abstract Tribal healers, including Dais, are still visible and functional, despite techno-managerial policies to exterminate them. Yoga has already received international fame. Due to the side effects of modern drugs and the frustration arising thereof, Western people are turning to Asian Medical Systems in Ayurveda and Naturopathy. Ethnomedicine can become Public Health by (a) upscaling the knowledge of traditional herbalists and Dais about the great textual traditions to provide authorisation and confidence about their traditional practices. (b) Widening the curriculum and job chart of paramedics currently functional in healthcare facilities to include ethnomedicine and textual great tradition health concepts and practices. The present paper is based on ethnomedical studies in the tribal and rural blocks in Maharashtra, Madhya Pradesh, Chhattisgarh and Himachal Pradesh during 2008–2016. The paramedics and traditional healers and Dais provide healthcare services at the doorstep of the rural and tribal people, not the doctors from any system of medicine that only manages the institutional OPD. How to turn the age-old experience of the people into evidence and establish linkage with the great textual tradition has to be an agenda of ethnomedical research. Concepts of Reverse Pharmacology and biodiversity could prove helpful in such analysis. Keywords Dais · Ethnomedicine · Rural · Tribal · Reverse pharmacology

Introduction The first book with the title, ‘Medical Anthropology’, by Foster and Anderson, published in 1978, was presented to me by Barbara Anderson, while she attended the Post-International Anthropological and Ethnological Congress Symposium on Medical Anthropology hosted by us at Pune in December 1978, after the main IUAES Congress at Delhi. Ayurvedic Medicine and Traditional Chinese Medicine have been discussed in the chapter on ethnomedicine. After some years, while I met George R. K. Mutatkar (B) Professor (retd.), Savitribai Phule, Pune University, Pune, India e-mail: [email protected] © The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023 S. Reddy et al. (eds.), Ethnomedicine and Tribal Healing Practices in India, People, Cultures and Societies: Exploring and Documenting Diversities, https://doi.org/10.1007/978-981-19-4286-0_3

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Foster at the ‘Social Science and Medicine’ Journal Conference at Sitges, Spain, I asked him how he could classify Ayurvedic and Chinese Medicine as ethnomedicine, while these were great traditional and textual medical systems, he did not respond. However, he recommended me to be on the advisory editorial board of ‘Social Science and Medicine’, and contribute a guest editorial. Ethnomedicine those days was probably more discussed in terms of Shaman and witch doctors, given the causality due to supernatural forces. Although herbal and mineral medicine have always been used for treatment, the focus in ethnography has been more on visible magico-religious practices. Spiritual and miracle faith healing by gods, religious leaders and persons like Mother Teresa continues to be accepted even now. A saint is believed to possess the capacity of miracle healing of the disciples. People continue to visit temples and god-men for health and healing. Health, wealth and happiness are sought as blessings of god during prayers. Body–mind interaction and its effects on health and healing continue to be a grey area in modern science, which works on mind–body dualism. The scientific meetings on leprosy in the Christian institutions start with sermons and prayers from Bible, as Jesus healed the leper (the term leper, like the term race, is not to be used anymore). Bible kindled Mahatma Gandhi’s compassion for leprosy. As we can see, considerable time was devoted to religious prayers during the oath taking ceremony of Donald Trump as President of the USA on 20th January 2017. Coronation of the Kings and Queens have always been performed by the religious leaders to the chanting of sacred hymes from religious texts. Life cycle rituals associated with birth, marriage and death are religious in nature. Before occupying a newly constructed house, it is common practice to perform rituals by installing a figurine of Vastu-purush in the new house to pacify or ward off evil spirits to ensure the health and well-being of the occupants. The ritual-ceremony is referred to as Vastu-shant. It has been a common experience in tribal areas, whereby a village settlement or a house is temporarily abandoned by the people, in case of disease or pestilence in an epidemic proportion. We have witnessed all the tribal village population leaving the village for a few days and return after performing community rituals, followed by community meals, at the temporary settlement. We had the occasion to be the occupants of a newly constructed house in a Warli village in the hills of Jawhar tehsil in Palghar (earlier Thane) district in Western Maharashtra. Since the house remained unoccupied due to the death of the owner of the house, who constructed it, it was perceived to have evil spirits. His two wives, who were sororates and their children, continued to stay in the old house. It is thus quite clear that belief in supernatural forces and the healing materials available from the natural environment are used together for health and healing. The attitudes and practices about health and disease are part of the culture. Ethnomedicine and traditional medicine refer to terminological issues relating to folk, peasant, indigenous communities, leading to controversies, branding modern as a synonym of science and tradition as non-science or creating the duality of Western and nonWestern. It appears that laboratory-based validations alone are termed science. We had to face opposition from the Vaidyas to the term ‘traditional’ in the name of an organisation, “International/Indian Association for the Study of Traditional Asian

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Medicine” (IASTAM). At one point in time, Prof. Charles Leslie recommended (personal written communication) dropping the term ‘traditional’ to solicit better participation of the Vaidyas and Hakims in the activities of IASTAM. William Caudill made the first attempt to review the studies on Applied Anthropology in Medicine in the encyclopaedic inventory book, “Anthropology Today” edited by Kroeber (1953). Later, we discuss “Health, Culture and Community” by Paul (1955) and “Cultural Patterns and Technical Change” by Mead (1955), documenting cultural variations about the concept of body, nutrition, maternal and child health, public health, etc. Several research papers have been written in Anthropology publications detailing the therapeutic practices in tribal communities, including the names of herbs used by the people. Botanical Survey of India, under the leadership of Dr. S. K. Jain, has compiled the names of herbs used by the people for health and disease management. The Foundation for Revitalisation of Local Health Traditions (FRLHT), Bangalore, has also digitalised such information and conceptualised it as local health traditions. Although the concepts of little and great traditions initiated by Robert Redfield are commonly accepted, as also the concepts of soft and hard aspects of culture, these have not been used as analytical tools in Anthropology (Redfield, 1962).

Ethnomedicine as People’s Sector We could safely brand ethnomedicine as people’s sector in health and health care. Ethno-medicine is public health, traditionally and historically managed by the communities. Home remedies, with the use of kitchen spices, leaves, roots, flowers and fruits available in the kitchen garden in the house courtyard, in the village and the vicinity, have been using and continue to be used by the people, at least as the first defence during indisposition. As an ANM in a Himachal village exclaimed, “My kitchen is my dispensary. If I do not get relief from kitchen medicine, I take the ANM medicine from my government stock”. In Anthropology, we use ‘Primitive Society’ as a conceptual model, which protects our unique identity since no other disciplines venture into undertaking ethnographic tribal studies based on field research using qualitative methods like participant observation. (Now, the term ‘primitive’ is not used, in scientific writing, which is considered stigmatising. In U.N. terminology, the term ‘indigenous’ is used. In India, the term ‘tribal’ is used commonly, while the term in the Constitution of India as per Article 342, is ‘Scheduled Tribe’.) We have also conducted ethnographic studies of the village communities using this conceptual model. We have documented the functions of village herbalists and Dai (TBA). Redfield has discussed the cultural role of cities, whereby we know that the referrals in medicine were available in the urban centres (1962). The Vaidyas and Hakims formally trained in medicine in traditional, home-based education or a formal institutional set-up were available in urban centres or some big villages. The majority of the people in caste-peasantry villages continued health care with home remedies

48

R. K. Mutatkar

or took the help of herbalists, who provided symptomatic treatment with herbs and mineral products.

Rural Development and Health Care In 1952, with the advent of Community Development Blocks for comprehensive rural and tribal development, primary health centres were established for health care in the public sector in India. This biomedical healthcare model based on modern medicine provided the MBBS doctor for OPD at the PHC and ANM and MPW at the subcentres. PHC also had the facility of about six indoor beds. The paramedics at the subcentres have been providing maternal and child health services, curative medicine for common ailments, participating in water and sanitation and family planning programmes, besides implementing immunisation and disease control programmes. The creation of subordinate honorary positions was effected by way of CHVs, Health Guides and now ASHA. Anganwadis were primarily created for child health and education replacing Balwadi and providing some services to pregnant and lactating women and adolescent girls. Referral hospitals by way of rural hospitals at the taluka (sub-district) and district levels were also established to provide specialist services such as radiology, obstetrics and gynaecology and ophthalmology with indoor facilities. With the growth of modern medical colleges in the public and private sectors, two doctors were appointed in the PHCs. Usually, the formula for PHC, in the beginning, was one PHC for about one lakh (100,000) population, co-terminus with the population of a Taluk/Tehsil, as per recommendation of Bhore Committee, (1946) which was later modified to one PHC for 30,000 population. In tribal area, PHC was provided for 20,000 population.

AYUSH in Public Sector Under British rule, some Princely States in India had opened Ayurvedic/Unani colleges in the respective States. Accordingly, Ayurvedic/Unani dispensaries were also opened in the public sector. With the proliferation of these colleges after Independence, mainly in the private sector, as a backdoor entry to practice allopathy, some of these doctors were appointed at the PHCs as second doctors. Some of the PHCs in the tribal belts are exclusively handled by the Ayurvedic doctors since MBBS doctors are unwilling to accept these positions. In some states like Himachal Pradesh, Chhattisgarh, Madhya Pradesh and Rajasthan, there are parallel Ayurvedic/Unani dispensaries, PHCs and even districts hospitals. There are Naturopathy and Siddha system colleges and dispensaries in the Tamilnadu. Recently, the National Health Policy 2017 has strongly advocated mainstreaming the potential of AYUSH within a pluralistic system of integrative health care. In 2014, an independent AYUSH Ministry was constituted upgrading the Department of Indian Systems of Medicine

3 Ethnomedicine as Public Health

49

and Homeopathy. Public Health has yet to become a formal and focussed agenda of the AYUSH Ministry, which could incorporate ethnomedicine in public health. All medical education in all systems of medicine is treatment-oriented and not oriented to public health. The institutionally educated AYUSH practitioners feel shy of linkage with ethnomedicine since they do not want to be identified as herbalists providing symptomatic treatment with the use of herbs in raw form (Jadi-Buti).

Ethnomedicine and AYUSH Field Studies The studies referred to in this paper focus mainly on the home remedies and indigenous healers and para-professionals in the rural areas in Himachal Pradesh, Madhya Pradesh, Chhattisgarh and Maharashtra. The studies were conducted by the Maharashtra Association of Anthropological Sciences (MAAS), Pune, highlighting the few traditions or local health traditions in the respective States. The study also documented health systems or healthcare delivery in the public sector. A similar study was undertaken in Rajasthan by Society for Economic Development and Environmental Management (SEDEM), New Delhi. National Health Systems Resource Centre (NHSRC) under the leadership of Dr. Ritu Priya from the Centre of Social Medicine and Community Health, Jawaharlal Nehru University undertook studies in 18 States of India, not covered by MAAS and SEDEM, which also documented peoples’ knowledge and practices about home remedies. The studies undertaken by MAAS have been more qualitative, following the anthropological methods of field investigations covering the whole universe of the selected villages. The Rajasthan and NHSRC studies have been more quantitative and covered the providers’ perspectives and healthcare delivery systems in the public and private domain. Both Rajasthan study by SEDEM and NHSRC studies in 18 States are focused on Health Systems Research in the context of NRHM’s objective of bringing in colocation of different systems of medicine. However, since the studies were designed to understand the position of AYUSH with the ideal objective of mainstreaming AYUSH in healthcare delivery, recommendations are weighted in favour of the capacity building of paramedics and the doctors, dealing with health issues of women, children and elderly about AYUSH systems. NHSRC studies have analysed the statistics regarding the use of home remedies by the community in common ailments, use of folk healers, TBA use during pregnancy, delivery and lactation and the knowledge of medicinal plants and medicinal properties of food items. All these home remedies, medicinal plants and food items with medicinal properties, perceived by the households, have been validated using documented codified knowledge of AYUSH systems. “Here ‘validation’ was taken as verifying the content of formal providers’ prescriptions and people’s knowledge of medicinal plants and foods, as well as home remedies in light of AYUSH epistemology and documented codified knowledge” (NSHRC, 2010, 160–171). This research finding is of great value in countering the argument of treating AYUSH as unscientific or non-rational, lacking evidence, unless otherwise proved by laboratory-based clinical trials.

50

R. K. Mutatkar

A study by MAAS about the maternity practices of lady doctors from all systems of medicine indicated that all of them followed the cultural, traditional practices when they became mothers themselves. Some of them said that they followed these practices under the social pressure of mother-in-law and affectionate pressure of mother. However, informally, they also admitted that they and the babies benefitted from traditional practices or, at worst, had no harmful side effects. National multicentric ethnographic studies of plural medical systems with good case studies would provide rich data on the subject. Such studies could also be launched among the Indian Diaspora. These ethnomedical practices about maternity and child care were uniformly found in all the four states studied by MAAS in the rural areas, with slight variations in details depending on the availability of dietary products (Mutatkar, 2016: AYUSH in Public Health, Vol II). The publications by Central Council for Research in Ayurvedic Sciences (CCRAS) and Clinical Research Units (CRUs) about “An Appraisal of Tribal Folk Medicine (1999)”, “Handbook of Domestic Medicine and Common Ayurvedic Remedies”(2005) and “Handbook of common remedies in Unani System of Medicine” (2003) are valuable references. In addition to the NHSRC and SEDEM field studies, Smt. Shailaja Chandra, Former Secretary, Department of AYUSH, Government of India, undertook a review of “Status of Indian Medicine and Folk Healing” presented in two parts and has made significant recommendations about operationalising AYUSH systems as a mainstream health system. The exercise of undertaking the studies by MAAS was initiated as a result of the Steering Committee report on AYUSH for the 11th Five Year Plan and the recommendation of mainstreaming AYUSH under the National Rural Health Mission (NRHM). The Steering Committee on AYUSH for the Twelfth Five-Year Plan has made some recommendations that have a direct link with the studies reported in this paper. Research on folk healing practices as local health traditions or little traditions needs to be undertaken. In line with the Ayurved Gram concept in Chhattisgarh, AYUSH gram in the public sector has been recommended, which could link the AYUSH health centres with Panchayati Raj Institutions (PRI), Community-Based Organisations (CBO) and Self-Help Groups (SHG). The ethnographic studies conducted by MAAS in the four States align with the tradition of ethnography in anthropological research. With the rise of Medical Anthropology in the mid-seventies, field studies of health behaviour and healing practices and indigenous healers among various ethnic tribal groups and caste Hindu peasant villages have been increasing. Ethno-botany and Ethno-physiology have developed as collateral disciplines of Ethnology and Ethnography. In each of the four States studied by MAAS, joint meetings of the formal and non-formal healthcare providers and district-level and State-level health administrators were held to discuss various perspectives. The recommendations from various stakeholders at these meetings or at the individual level were encouraging and are documented in the book “AYUSH in Public Health” (Mutatkar, 2016).

3 Ethnomedicine as Public Health

51

Geographical Area and Population Selection Ethnographic studies have been conducted in Himachal Pradesh, Madhya Pradesh, Chhattisgarh and Maharashtra by collecting primary data from the villages as per the anthropological protocol of the study. • Study area and population within the states were selected in consultation with the respective State Governments. State Government had to select one district in each state, two blocks in a selected district, two PHCs in each selected block, two sub-centres under each selected PHC and two villages under each sub-centre. • The area coverage in Maharashtra was partly from rural and partly from tribal areas, from 9 blocks covering 7 districts, where an intervention project on malnutrition, ‘Adivasi Utthan Karyakram’ (AUK) (Comprehensive and Sustainable Human Development of the Tribal People of Maharashtra) was being implemented by MAAS, funded by the Tribal Development Department of the state government (Mutatkar, 2018). Tables 3.1, 3.2, 3.3, 3.4, 3.5, and 3.6 generated from the field studies undertaken by MAAS, under my supervision, in respective states, have been referred in the book, “AYUSH in Public Health: Vols. I and II (Mutatkar, 2016)”. Several Dais in four states were interviewed about their birthing experiences. The response of three senior Dais has been summarised as under: In Chhattisgarh, Baiga’s are using nearly 200 herbs for treatment. In Maharashtra, tribal areas under AUK programme 276 Vaidus are trained for processing herbs into medicine indispensable forms. They were taught to prepare Bala Teil for baby’s body massage, Shatavari Kalp for underweight children and for lactating mothers, Gandharva Haritaki as laxative and Kutajghanvati for worm infestation in children. Trainers were trained in each of the nine taluks for sustainability, and utensils were also provided for processing the herbs. The AUK programme repurchased the finished products to be a part of the Ayurvedic kit box made available in each study village. Table 3.1 State-wise selected areas: four states S. No.

Unit

Himachal Pradesh

Chhattisgarh

Madhya Pradesh

Maharashtra

1

District

Hamirpur

Bilaspur

Sagar

Pune Rural

Tribal 7 Dist

2

Blocks

2

2

2

2

9

3

CHC/PHC

4

5

5

4

14

4

THE

3

3

2

2

–

5

Homeopathy/Unani

1

–

2

–

–

6

Sub-centres

4

8

8

–

19

7

Villages

8

16

16

–

63

52

R. K. Mutatkar

Table 3.2 Home-remedies: people’s knowledge about processing the herbs to treat common ailments S. No.

Common ailments

States Chhattisgarh

Himachal Pradesh

Madhya Pradesh

Maharashtra

Herbs

Herbs

Herbs

Herbs

Product

Product

Product

1

Cough

23

30

19

17

17

13

21

2

Cold

23

30

20

7

14

11

10

3

Fever

13

09

11

06

07

04

10

4

Constipation

19

13

13

14

13

09

–

5

Vomiting

04

02

08

05

11

11

13

6

Diarrhoea

20

16

12

07

17

11

13

7

Headache

15

12

11

06

12

12

7

8

Jaundice

13

07

02

01

11

07

–

9

Body pain

09

06

15

09

12

07

14

10

Joint pain

09

06

06

03

07

09

14

11

Weakness

14

07

04

02

18

12

6

12

Injury

14

12

04

03

07

09

8

13

Gynaec problem

06

05

01

01

14

10

04

14

Bone setting

06

04

05

02

07

01

03

15

Skin Disease

11

08

03

02

13

13

05

16

Toothache

05

03

–

–

07

04

–

17

Renal Calculi 01

01

01

01

–

–

01

18

Paralysis

02

02

–

–

–

–

–

19

Diabetes

01

01

02

02

–

–

–

Homemade preparations, single or mixed herbs

In Madhya Pradesh, after the first line of health care with home remedies, the next referral choice was for the local herbalists. ANM at sub-centre and Ayurved dispensary of the government was preferred as the third referral choice depending on the nature of ailment and accessibility. The local health functionaries like ASHA, Anganwadi workers also seemed to follow the same route of referral services for themselves and their families. ANM and AWW often bypassed local herbalists, unless he was a specialist for some specific ailment like piles or paralysis. ASHA, in her case, however, consults herbalists like other village women. Mitanin (ASHA) in Chhattisgarh has close links with herbalists, locally called Baiga.

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Table 3.3 Healthcare practices about mother and child health in four states: some examples S. No.

Delivery practices and Care

States Chhattisgarh

Himachal Pradesh 12 days

Madhya Pradesh Maharashtra

1

Dai’s help 10 days

2

For easy delivery

Drinking hot Reduced diet Black tea or Milk, dates liquid (Chhuare) decoction, warm milk, tea of Jaggery, Warm khichadi

6 days

5–15 days

Cow’s Urine

Decoction of black pepper and cumin Put root of Calotropis plant (Rui) on scalp

3

After delivery

Massage by mustard oil

Massage by ghee Massage by or sesame oil medicated oil

Massage by coconut oil or mahua seed oil

4

For lactation

Dry fruit + jaggery ladoo Black gram (Udad Dal), raw papaya, milk, bargad tree extract

Pipli boiled with milk and dry fruit—jaggery ladoo – Clarified butter (ghee), suji, almond (badam), cashew nut (kaju), dates, raisin (kishmish,) jaggery, coconut, Black pepper boiled with milk and dry fruit—jaggery ladoo

Asparagus (Shatavari) with milk Earthworm cooked in milk and jaggery

Asparagus (Shatavari) roots Chutney made up of earthworm, ginger, garlic, Black pepper Rice with sesame chutney Prawn curry fortified with earthworm extract Ladoo made up of common cress (Ahaliv)

5

Breast feeding

1–3 h after birth 2–3 h after birth

½ h after birth

½ h after birth

6

Weaning food

After 5–6 months porridge

After 4–5 months 5–6 months

After six months

7

Massage of baby

Medicated mustard oil—1 year

Sesame/mustard oil 3 years Cow’s clarified butter, zau varya, nutmeg, fennel seeds, dry ginger, saffron (kesar)

Mahua oil, til oil Coconut oil

Medicated mustard oil—1 year Ubatan of turmeric

(continued)

54

R. K. Mutatkar

Table 3.3 (continued) S. No.

8

Delivery practices and Care Recovery after delivery

States Chhattisgarh

Himachal Pradesh

Madhya Pradesh Maharashtra

Dry fruit, dry ginger edible gum, jaggery ladoo

Dry fruits, clarified butter ladoo Milk, green gram pulse (mung dal), coconut, dry ginger, kamarkas, black cardamom, milk, fennel seeds Clarified butter Gudkatira

Jaggery ladoo, harira, daliya and green gram pulse (moong dal) Milk

Fenugreek (methi) ladoo, dry fruit ladoo and ladoo made up of common cress (ahaliv)

AYUSH Rajasthan Study by SEDEM Of the 105 allopathic doctors interviewed in Rajasthan from district hospitals, CHCs and PHCs, about 44% reported the use of home remedies for self and family. However, they did not prescribe home remedies or AYUSH medicines to the patients under their treatment. Some of the common home remedies reported by doctors are based on holy basil, turmeric, ginger, black pepper, honey, hot milk, ghee, lemon, garlic, clove, clove oil, salt water, ginger tea and neem leaves in various forms (2010). Smt. Shailaja Chandra has addressed this issue in her book “Status of Indian Medicine and Folk Healing” Part II by giving a resume of several surveys such as by NCAER, NFHS-2, ICMR, NSSO and CCRAS (2013, 6–13). It, however, appears that several of these surveys have been conducted in healthcare institutions giving insights about providers perspectives. It appears Central Councils of Research in Ayurved and in Unani Medicine (CCRAS and CCRUM), respectively, have documented about 5000 folklore, ethnomedical claims made by tribal people, including ethnomedical practices, use of medical plants etc. to treat wide-ranging conditions such as common cold, cough, fever, vomiting, skin diseases, digestive problems, reproductive and child health problems, wounds, bone setting, etc., (Chandra, 2013, 10–11). Smt. Shailaja Chandra’s two-volume reports, if read concurrently with the field-based reports by NHSRC, MAAS and SEDEM, provide a holistic resume of AYUSH Community Health in India. Smt. Shailaja Chandra’s reports deal with comprehensive issues about AYUSH, including pharmacy and education. MAAS has studied the ground realities of ethnomedicine in four States in the peoples’ sector, visiting several families in the villages, talking to lay people in the families, doctors, ANMs, Mitanins, ASHA, AWW, pharmacist, chemists, Dais, local herbalists and health administrators. We also had combined stakeholders’ meetings

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Table 3.4 Growth of foetus: key expert interviews of Dai S. No. Month

Status of foetal development Madhya Pradesh Gorabai

Himachal Pradesh Mahantidevi

Chhattisgarh Raniyabai

1

First

Living blood is formed A bag of blood is formed The foetus is in the as a result of the mixing form of thick blood of white male semen and female water. This blood moves. (Khoon Fatakata hai.)

2

Second

Starts becoming thick but is red

3

Third

The thick red blood Flesh starts getting shape Real flesh is formed becomes flesh, weighing and form 200 gms. “Dosau gram gath banata hai”

4

Fourth

Flesh enlarges. ‘Gath badti hai’

5

Fifth

Hands, legs and head are The baby starts playing, formed. It is soft, though i.e. turning/playing

Heartbeats start. (“Dil put put karata hai”)

6

Sixth

Baby starts moving, and the heartbeat can be prominently heard. “Bacha hilne lagta hai or dil ki dhadkan sunai deti hai”

Weight of the baby increases

Hands and legs become separate

7

Seventh The baby starts kicking and walking “Lat Marta or chalta hai”

Dangerous for the baby, hence check-up is necessary

Baby starts playing and turning (“Baccha khelta hai aur ghoomata hai”)

8

Eighth

Starts moving his hands and legs. “Hat pair chalane lagta hai”

Fully formed baby starts turning

Skin colour becomes red

9

Ninth

Fully formed baby turns and rolls in the womb. ‘Ghoomta-Phirta hai’

Baby is fully formed and Baby starts getting hair is ready for delivery by and is perfectly the end of nine months developed for delivery

The blood starts becoming flesh

Heartbeats begin in the fourth month

The blood starts becoming flesh

Head, hands, legs and eyes start forming

as equal partners, discussing health issues, keeping aside the professional interests and formal designations. We had FGDs with Mahila Mandals and discussions at Panchayat level. The perspective of the study has been from receivers’ or beneficiaries’ angle and not from providers’ angle who claim to operationalise healthcare delivery.

56

R. K. Mutatkar

Table 3.5 Parts of plants used by Baiga herbalists for treatment in Chhattisgarh S. No.

Plant Part

Pendra block Frequency

Marwahi block %

Frequency

%

1

Bark

55

34.16

20

17.6

2

Flower

2

1.24

5

4.4

3

Fruit

2

1.2

36

31.85

–

4

Gum

1

0.62

5

Node

1

0.62

6

Rhizome

2

1.24

7

Root

54

33.54

8

Seed

6

2.48

9

Stem

5

3.1

33

29.2

2

1.76

10

Tuber

15

9.31

4

3.53

11

Leaf

5

3.1

10

8.84

12

Other

13

8.07

3

2.65

161

100

113

100

Total

Strengthening of People’s Sector: Ethnomedicine as Public Health The people’s sector has been functioning since ancient times. People’s health practices gradually became great traditions of Ayurvedic classical texts compiled by intellectuals, commonly referred as Sages or Rishis, like Charak, Sushruta and Vagbhat. The people’s sector needs to be strengthened as it is organically linked with these classic texts. Ayurveda is not only herbalism, but all herbal products are linked to textual Ayurveda and other Indian Systems of Medicine, such as in Siddha and Unani systems. Healthcare practices of the people and work of Dai and herbalists are to be linked to health institutions which could be done by colocation and coordination at village and block levels under the leadership of AYUSH doctors. Ethnomedicine has been exclusively performing public health functions before health care in an institutionalised format was introduced as a health aspect of the community development programme. The experienced elders, herbalists like Vaidu, Baiga and Dai, have been traditionally performing these functions. Charak has advised learning from shepherds and cowherds who, while tending the sheep and cattle in the village forest, acquire knowledge and experience about medicinal herbs. They keenly observe the consumption of medicinal herbs by other animals, such as eating grass for purgation, or eating certain roots in case of snakebite. The paramedics and other similar personnel like ANM, MPW, AWW, ASHA in the public sector, who are front-line workers of public health in rural areas, visit people’s homes to provide health care. They link the people following ethnomedical practices

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Table 3.6 Ailments treated by Baigas of Chhattisgarh and Vaidu from Maharashtra S. No. Name of ailments

Chhattisgarh

Maharashtra

No. of herbs used Products/forms Herbs 1

Fever

8

5

6

2

Malaria

19

11

–

3

Jaundice

20

8

9

4

Bone setting

03

04

1

5

Piles

19

10

3

6

Arthritis

15

07

5

7

Cough and cold

10

04

–

8

Stomach pain

06

06

5

9

Skin disease

06

04

–

10

Toothache

01

01

4

11

Headache

02

02

1

12

Dhaat

06

04

–

13

TB

11

04

–

14

Gynaec problems

41

16

11

15

Cancer

01

01

–

16

Paralysis

14

04

1

17

Filaria

01

01

–

18

Snake/scorpion bite

03

03

10

19

Diarrhoea

01

01

13

20

Renal calculi

07

04

10

21

Worm infestation

–

–

4

22

Avoid miscarriage

–

–

3

23

For conception

–

–

5

24

To increase weight

–

–

4

25

Lactation + recovery after delivery 06

03

7

and the PHC system managing biomedical top-down services for healthcare and disease control programmes. As part of their cultural peer groups, the paramedics themselves follow ethnomedical practices for preventive, promotive and curative care, in their homes and families, failing which, use the biomedical practices learnt as employees in the public sector healthcare institutions. Chhattisgarh State, through its SHRC, took initiatives to select Mitanin (ASHA), and other paramedics, and train them by compiling standardised texts in local language about home remedies and other ethnomedical and AYUSH materials, focussing on MCH. The herbalists and Dai who have experience of home-based care could be trained about the principles of AYUSH to link practice with textual concepts. Lay people

58

R. K. Mutatkar

know the medicinal properties of food. They prescribe or proscribe certain food items during disease conditions, convalescence and health promotion during pregnancy, maternity and infant care. The tribal herbalist prescribes the same lactogenes in the raw form of roots and tubers, which are marketed by AYUSH pharmaceuticals in the processed form. The PRI statutory members, 50% of whom are now women, CBOs like Mahila Mandals, SHGs and youth groups, particularly the adolescent girls, who know and follow ethnomedicine in their homes, need to be exposed to AYUSH public health. The Anganwadi food supplements and mid-day meals could be prepared according to culture-friendly AYUSH preparations or herbal supplements. Communities living in different climatic and environmental zones with plural flora and fauna have evolved their nutritious diets in consonance with their neighbourhood environments.

Conclusion Anthropologists have a vital role to play to establish linkage between the ethnomedical, little/local traditional practices, with great textual traditions of AYUSH. Let us not feel shy of intervention research, raising the colonial bogey of value neutrality, in the name of pseudo-science. Despite the acceptance of universal values of life and human rights, silence and inaction would make our knowledge of ethnomedicine irrelevant for human good. It would only help the vested commercial interests of those with no research deliverables for policy planning and implementation, and it would not be tolerable by the spirit of the Constitution of India. Ethnomedicine would be the most significant, traditional, time tested, evidence based and people-centric ethnoscience for public health.

References Chandra, S. (2011& 2013). Status of Indian medicine & folk healing part. 1 & 2 department of AYUSH. Government of India. Department of AYUSH. (1999). An appraisal of tribal folk medicine. CCRAS, New Delhi. Department of AYUSH. (2003). Hand book of common remedies in Unani system of medicine. CCRUS, New Delhi. Department of AYUSH. (2005). Hand book of domestic medicine & common Ayurvedic medicine. CCRAS, New Delhi. Department of AYUSH. (2006). AYUSH task force report for 11 five year plan. Government of India, New Delhi. Foster, G. M., & Anderson, B. G. (1978). Medical anthropology. Wiley. Kroeber, A. L. (Ed.). (1953). Anthropology today. The University of Chicago Press. Leslie, C. (Ed.). (1980). Social science & medicine 14 B (4). Special issue: Medical pluralism: Proceedings of Pune Symposium on Medical Anthropology, Pergamon Press. Mead, M. (Ed.). (1955). Cultural patterns and technical change. UNESCO. Mutatkar, R. K. (2016). AYUSH in public health, Vol I & II. Concept Publishing Co, New Delhi.

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Mutatkar, R. K. (2018). Tribal health and malnutrition. Concept Publishing Co., New Delhi. Paul, B. (Ed.). (1955). Health, culture and community: Russel. Sage Foundation, New York. Priya, R., & Shweta, A. S. (2010). Status and role of AYUSH & local health traditions under NRHM. NHSRC, New Delhi. Planning Commission. (2006). AYUSH report of steering committee for 11th five year plan, (2007– 2012). Government of India, New Delhi. Planning Commission. (2011). AYUSH report of steering committee for 12th five year plan (2012– 2017). Government of India, New Delhi. Robert, R. (1962). Human nature and the study of society. University of Chicago Press. SEDEM report by Arun Srivastava. (2010). Assessment of AYUSH in Rajasthan after Mainstreaming. New Delhi.

Chapter 4

Biological Diversity Act 2002, an Implementation Challenges in India: An Experience Sharing from Sikkim Bharat Kumar Pradhan

Abstract Indigenous and local communities are primarily dependent on forests for food and medicine. They understand that their well-being, their identity and their children’s future rely on the conservation and sustainable use of the forest resources. However, biopiracy and ongoing developmental activities are significantly threatening the biodiversity and associated traditional knowledge of the indigenous and local communities. India enacted the Biological Diversity Act 2002 with an aim of conserving biodiversity and their sustainable use and to ensure equitable benefit sharing from the commercialisation of biodiversity and the associated TK. This paper highlights on the various issues and challenges faced in its implementation especially in the state of Sikkim. The paper also articulates on how the certain state-specific biodiversity conservation policies are barring the indigenous communities from their access right to the forest resources thereby endangering their long conserved indigenous knowledge. Keywords Biological diversity act · Convention on biological diversity · Biodiversity management committee · People’s biodiversity register · Sikkim biodiversity board · Traditional knowledge

Introduction Biodiversity is the basis of survival for entire humanity who depends on it for food, medicine, shelter, fibre, timber, etc., and transforms it into cash for livelihood security and improving the quality of life. The economic potential of biodiversity is estimated to be US$640 billion and the collective market size for herbal supplements, personal care and food products is US$65 billion, representing the largest ‘nature’-based market (Pisupati, 2018). It has tremendous potential for use in modern medicine which is known to indigenous and local communities (ILCs) throughout the world (Reid, 2009), and they have been using it to cure ailments since centuries (Garcia, B. K. Pradhan (B) Sikkim Biodiversity Board, Forest and Environment Department, Sikkim, India e-mail: [email protected] © The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023 S. Reddy et al. (eds.), Ethnomedicine and Tribal Healing Practices in India, People, Cultures and Societies: Exploring and Documenting Diversities, https://doi.org/10.1007/978-981-19-4286-0_4

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2015). The traditional knowledge (TK) about the plants has evolved through thousands of years of constant interaction of ILCs with the nature and is transmitted orally over generations. Such practices maintain a delicate balance between nature and the human, simultaneously allowing for the regeneration of natural systems (Kalpavriksh & Grain, 2009). The TK is an identity of an ILCs, and its preservation is utmost important; however, such knowledge is neither documented nor protected, rather it is shared commonly among the various communities and no particular community holds claim to the knowledge which makes it vulnerable to biopiracy. There are growing concerns over the TKs of ILCs being exploited and patented by third parties without their prior informed consent (PIC), and the accrued benefits are rarely shared with the communities to whom the knowledge originally belongs or where the knowledge originated and exists (Gupta, 2011). The TK especially in the treatment of various diseases has always been easily accessible leading to its exploitation and misappropriation in the name of research and bioprospecting. Such knowledge forms the basis for new drug discoveries thus lessening the research efforts, time and wastage of financial resources in finding the compounds within millions of varieties of plants (Reid, 2009). Nevertheless, biopiracy of such knowledge by the developed countries without compensating the knowledge holders in the developing countries raised an alarm in late 80 s leading to the adoption of Convention on Biological Diversity (CBD) in June 1992 at Rio de Janeiro by United Nation Conference on Environment and Development (UNCED). CBD is a multilateral legal instrument for promoting biodiversity conservation as well as ensuring its sustainability taking into account the equitable sharing of cost and benefit between provider and user countries and a ways and means to support innovation by the local people.1 It recognises contributions of the ILCs in the conservation and sustainable utilisation of bioresources through TK, practices and innovations; hence, it aims at incentivising the ILCs through access and benefit-sharing mechanism. The convention recognises the sovereign right of the countries over their resources vis-à-vis maintains that its conservation and sustainability lie with the owner country. It also stresses that access to genetic resources and equitable benefit sharing should be on the basis of PIC and mutually agreed terms (MAT).2 India is one of the 17 mega-biodiverse countries and accounts for 7–8% of the globally known species; it is ranked 8th in terms of species richness. It is one of the eight primary centres of origin of cultivated plants with about 375 closely related wild species, and nearly 255 breeds of animals are found in India.3 ,4 It is home to approx. 645 tribes with distinct culture and traditions, and biodiversity is intricately related to socio-cultural practices of these forest dwellers. The concept of biodiversity conservation in a participatory manner was much prevalent among these forest dwellers from ancient times, and various principles and guidelines were framed 1

https://pib.gov.in/newsite/erelcontent.aspx?relid=4475. https://unctad.org/system/files/official-document/diaepcb2014d3_ch1_en.pdf. 3 http://docplayer.net/52861362-Future-secured-national-biodiversity-authority-tel-2777-fax-web. html. 4 http://nbaindia.org/uploaded/pdf/BIOFIN%20Brochure.pdf. 2

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for the preservation of nature. Rural communities are being traditionally preserving representative patches of major ecosystems such as sacred grooves, ponds, rivers, mountains, springs and caves as an abode of deities.5 There are several instances where many people led their lives for the protection of nature and wildlife. The sacrifice of 363 Bishnois in a Chipko movement of 1730 led by Amrita Devi for protecting the ‘Khejri’ tree is a well-cited example. Our constitution also maintains that it is the responsibility of the state to protect nature as well as safeguard the interest of the community (Khan, 2016). Therefore, in India, conservation efforts are not only focused on biodiversity, but also on the rich traditions that connect human with nature (MoEFCC, 1998). However, in the present scenario, we are losing our biodiversity at a much faster pace due to various reasons such as population growth, expansion of agricultural activities, habitat degradation, climate change, unsustainable developmental activities and overexploitation. For example, the number of threatened species in India increased from 988 in 2014 to 1065 in 2017 (Sundaraju, 2019). Subsequently, we are losing our long conserved associated TK, which else could have been a ‘ways and means’ to sustainable livelihood for the upcoming generation through access and benefit-sharing mechanism. Earlier, there were no mechanisms in India to restrict the access to biological resources for research or commercialisation including Intellectual Property Rights (IPR) by the foreign entities due to which it had been the major victim of biopiracy; the case of neem and turmeric is some of the examples where India had to spend US$6 million in fighting a legal battle against US to get patent revoked on neem- and turmeric-based medicines (Biswas, 2005). Lately, it was realised to have strong legislation to put a check on biopiracy and biotrade and also to prevent the overexploitation of bioresources and misappropriation of the associated TK.

Biological Diversity Act, 2002 In the wake of problems with patents India has experienced and to meet its international obligations under the CBD, Biological Diversity Act 2002 (BD Act 2002), synonym ABS law, was enacted by the Parliament of India. In fact, it came into existence after 10 years of signing of CBD through rigorous consultative process involving individuals, organisations, academies, etc., with a specific aim—to safeguard and secure its sovereign wealth from being misappropriated by the foreign entities and to ensure fair and equitable sharing of benefits.

5

http://nbaindia.org/uploaded/Biodiversityindia/1st_report.pdf.

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Salient Features of BD Act 2002 The salient features of BD Act 2002 are as follows6 : 1. 2. 3. 4. 5. 6. 7.

8. 9. 10. 11. 12. 13. 14.

15.

Regulating access to biological resources of the country. To conserve and sustainably use biological diversity. To secure sharing of benefits with local people as conservers and knowledge holders related to biodiversity. To respect and protect knowledge of local communities’ traditional knowledge related to biodiversity. To conserve and develop areas of importance from the stand point of biological diversity by declaring them as biological diversity heritage sites (BHS). Protection and rehabilitation of threatened species. Protect India’s rich biodiversity and associated knowledge against their use by foreign individuals or organisations without sharing benefits arising out of such use and check biopiracy. Setting up of National Biodiversity Authority (NBA), State Biodiversity Board (SBB) and Biodiversity Management Committees (BMCs). To create national, state and local biodiversity fund and its use for conservation of biodiversity. NBA and SBBs are required to consult BMCs in decision making related to bioresources/related knowledge within their jurisdiction. All foreign nationals/organisations require prior approval of NBA for obtaining biological resources and/or associated knowledge for use. Indian scientists/individuals require prior approval of NBA for transferring results of research to foreign nationals/organisations. Involvement of institutions of state government in the implementation of the BD Act through constitution of committees. Indian industry needs prior intimation to SBB to obtain bioresources. SBB has right to restrict if found to violate conservation and sustainable use and benefit sharing. Prior approval is needed from NBA for IPRs in any inventions in India or outside India.

Institutional Framework The BD Act 2002 is implemented through a decentralised 3-tier system at national, state and the local level by NBA, SBBs and the BMCs established under the provision of Sections 8, 22 and 41 of the Act. All the three institutions are statutory body that work in close coordination with each other. 1. National Biodiversity Authority 6

http://sbbsikkim.nic.in/pdf/publications/Flyers/SBD-eng.pdf.

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NBA functions as an advisory body to both the central and the state government. It advises the central government on the subject relating to the biodiversity conservation, its sustainable use and equitable benefit sharing. While to the state government, it advises on the matters related to notification of biodiversity heritage sites and their management. Simultaneously, it regulates access to biological resource and associated TK and transfer of research results by/to foreign nationals, institutions, companies and non-residential Indians. Furthermore, NBA also takes measures to oppose grant of Intellectual Property Rights to any agencies within and outside India on biological resource and associated TK obtained/derived from India (NBA, 2004). 2. State Biodiversity Board The SBB advises the state government in respect to any guidelines issued by the central government relating to biodiversity conservation, its sustainable use and equitable benefit sharing. Additionally, it regulates Indian entities accessing bioresources or associated TK for commercial purposes (NBA, 2004). 3. Biodiversity Management Committee The BMCs are responsible for promoting biodiversity conservation, ensuring their sustainable use, documentation of biodiversity including preservation of habitats, conservation of land races, folk varieties and cultivars, domesticated stocks and breeds of animals and microorganisms and chronicling of associated TK (NBA, 2004). The Act has a special provision under Section 41(2) which mandates both NBA and SBB to consult BMCs prior to allowing access to the biological resources and associated TK within the territorial jurisdiction of a BMC. Further, the BMCs can levy fee to any person for accessing biological resources under their territorial jurisdiction for commercial purpose.

Exemptions Under the Biological Diversity Act, 2002 The transfer or exchange of biological resources and related information under collaborative research projects is exempted from prior approval of NBA provided such projects conform to the policy guidelines issued by the central government. The Act further exempts Indian researchers (from accessing biological diversity purely for academic research within India), traditional practitioners, growers and the cultivators of the biological resources. It does not apply to the biological resources listed as Normally Traded As Commodities (NTAC).

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Penal Provisions Under the Biological Diversity Act, 2002 The Act has a penal provision of imprisonment as well as imposing fine to both individuals and the company. For example, person contravening the provision of Sections 3, 4 and 6 of the Act shall be imprisoned for five years or is imposed a fine of rupees ten lakhs or with both; person violating Section 7 and 24(1) is imprisoned for three years or are imposed a fine of rupees five lakh or with both (NBA, 2004). Person disregarding the direction or order of the central government, state government, National Biodiversity Authority or the State Biodiversity Board will be imposed a fine of rupees one lakh. On subsequent contravention, a fine of Rs two lakh will be imposed on the offender, and on continuous contravention, the offender will be imposed a fine of rupees two lakh per day (NBA, 2004). In case of offence being done by a company, the company along with the in-charge or the person responsible for the business will be held guilty. All offences under this Act are cognisable and non-bailable; nevertheless, the Court can take action only on receipt of complaint from authorised officers or the benefit claimers.

Sikkim State Biodiversity Board Sikkim covers only 0.2% of the total geographical area of the country, but it is one of the biodiversity hotspots. It has always been a frontrunner in taking actions when it comes to the biodiversity conservation and the environment protection. A number of initiatives have been taken up such as ban on-use of single use plastic, bursting of firecrackers, green felling of trees, burning of agricultural waste, use of chemical fertiliser, sale and use of Styrofoam products and grazing in forest areas and near waterholes. One of the significant steps taken up by the government of Sikkim is the declaration of the whole state as an Organic State in the year 2016 which was commended globally. In order to support fulfil India’s obligations under CBD and to implement the Biological Diversity Act 2002 effectively in the state, the government of Sikkim established the Sikkim State Biodiversity Board (SBB) in the year 2006 with its office at Forest and Environment Department with the initial financial support of Rs. 10.0 lakh from the central government through NBA. The board is governed by the Sikkim State Biological Diversity Rules 2006 and Sikkim State Biological Diversity (Amendment) Rules 2018 and is guided by the Board Members including the Chairperson (earlier the Chief Minister, now, the Forest Minister), Executive Chair (Principal Chief Conservator of Forest cum Principal Secretary), five ex-officio members from line departments such as Forest and Environment Department, Tourism, Agriculture, Horticulture and Animal Husbandry and five non-official members which includes scientists, retired forest officer and the TK holders. The Board Members meet from time to time to assess the activities of the Board mandated under the BD Act 2002.

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The day-to-day functioning of the SBB is managed by the Member Secretary (Conservator of Forest) who is supported by the officers from Forest Department and the staffs outsourced under the grant received from the National Biodiversity Authority. Other expense of the SBB is met up from the grant in aid received from the state government.

Biological Diversity Act 2002: Implementation Challenges in Sikkim Constitution of Biodiversity Management Committee Though the SBB was established in the year 2006, it became functional only in 2014 with the inception of MoEFCC-UNEP-GEF ABS Project in 2012 by NBA. Since then, Sikkim Biodiversity Board is primarily focusing on awareness generation and constitution of biodiversity management committees (BMCs) in the state at gram panchayat unit (GPU), municipal and the district level under various projects and funding schemes of the central as well as the state government. The current status of the BMC constitution in Sikkim is depicted in Table 4.1. The Act mandated every local body to constitute the BMCs within their territorial jurisdictions with technical support from Sikkim Biodiversity Board. Nevertheless, until mid-2019 prior to the Hon’ble National Green Tribunal decision to penalise the state government with a sum of Rs. 10.0 lakh per month in case of failure to comply with its order to complete BMC constitution and PBR preparation within a deadline of 31st January 2020, SBB was solely taking the responsibility of BMC constitution and Table 4.1 Status of BMCs and PBRs in Sikkim S. no

Funding source

Number of BMCs

No. PBRs prepared

GPU

Municipal

District

1

State grant in aid

07

–

–

12

2

State CAMPA

142

07

04

166

3

Grant in aid from NBA

07

–

–

-

4

UNEP-GEF project

25

–

–

14

5

Sikkim university under NMHS project

04

–

–

03

6

The mountain institute India

–

–

–

01

Sub-total

185

07

04

Total

196

Source Sikkim Biodiversity Board

196

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PBR preparation. Lately, SBB in coordination with Rural Development Department completed constitution of BMCs in all the GPUs, municipal areas and districts. SBB adopted an approach of BMCs constitution following sensitising the local communities and motivating them to come forward for biodiversity conservation which led to positive result as the local communities volunteer to become the member of the BMCs. Nonetheless, the Panchayat President and the concerned Forest Range Officer/Block Officers were selected as the Chairperson and the Member Secretary as per the existing rules and office order issued by the SBB. However, in some of the BMCs, the Gram Sabha selected the Member Secretary from among the local community. Hence, there is heterogeneity in the BMC composition among the GPUs in Sikkim. Additionally, DFO (Wildlife) and Assistant Conservator of Forest (Wildlife) were made the District Nodal/Asst. Nodal Officer to the Sikkim Biodiversity Board for better field coordination who assisted SBB in constitution of BMCs in some of the Gram Panchayat Units during the rationalisation process of JFMCs (Joint Forest Management Committees) and EDCs (Eco-Development Committees) in 2016. Since, the BMCs were formed by the forest officials, the members were under the impression that they would receive surplus fund for carrying out different activities just like JFMCs and EDCs. When it was realised that the mandate of the BMC is completely different from other committees, they lost their interest and left BMC well before the expiry of their tenure. Additionally, the lack of coordination among the existing BMC members greatly affected their functioning leading to the restructuring of the BMCs in many of the GPUs. A case of Hee-Gyathang BMC in Dzongu, North Sikkim, is worth citing where the local community replaced both the Chairperson and Member Secretary with the person of their choice. Post NGTs order, SBB adopted different approach where a district-level trainings were provided to the RDD field functionaries in regard to the constitution of BMCs. During the training, as the difficulties in coordinating with the forest Field Officers for being busy, overburdened and their vast area of duty came to light, the SBB gave freedom to select the member secretary for the BMC as per their work convenience. Accordingly, the BMCs were constituted during Gram Panchayat Development Programme of Panchayati Raj Institutions; nevertheless, for having more than 8 villages in some of the GPUs, representatives from all the villages were included in the BMCs leading to excess members; and it necessitated their removal which was a challenging task for SBB. Unlike in special Gram Sabha which is specifically organised for awareness generation and constitution of BMCs, in general Gram Sabha, they have other priority issues relating to the development of the village to be discussed; hence, genuine people, knowledge holders, senior citizens, etc., interested in working for the cause of biodiversity or who keeps immense interest on biodiversity were missed out or their voices were overshadowed resulting in selection of such people in BMCs, who does not possess knowledge or keep much interest on biodiversity. In most of the BMCs, the members lack specific knowledge on ABS law and also about their roles and responsibilities and sensitising them would be a major challenge for SBB because for most of them, the biodiversity conservation is not their primary concern.

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Rule 22(2) states that one third of the member of BMCs should represent women but it was practically not feasible in Sikkim especially in Lachen and Lachung as both the areas are administered by the traditional Dzumsa system and they have their own customary law governing them. In Sikkim, it is made mandatory for the BMC members to submit their identity proof such as domicile in addition to voter’s ID card to ensure that they are the permanent citizen and the voters of the particular area. Lately, it is been realised that such measure has restricted the knowledgeable and interested people from being a part of the BMC for not having the required documents or for being the voter of some other areas, especially in the case of married women.

Preparation of People’s Biodiversity Register The People’s Biodiversity Register (PBR) contains complete and locality specific information on the status, uses, history and associated TK on local biological resources in addition to the information on ecological processes affecting them, ongoing changes and forces driving changes, gainers and losers in the processes and people’s perception on sustainable management of the biological resources. PBR also recognises conservation effort of the local communities and helps them to prudently manage local biological resources (Gadgil, 2000). The main objective of preparing PBR is to ensure the fair and equitable sharing of benefits with the local communities in case of commercialisation of the biological resources and the associated TK. It also helps in conservation and protection of Intellectual Property Right of knowledge holders vis-à-vis forms a baseline for developing strategies for management of the biological resources. The various steps involved in the preparation of PBR (Gupta, 2013) are depicted in Fig. 4.1. The Act mandates the BMCs to prepare PBR involving the local community and under the technical guidance of the Biodiversity Board. In Sikkim, the preparation of PBR is completed for all the BMCs at GPU, municipal and district level in different phases (Table 4.1) with the major funding received from state CAMPA. The Sikkim Biodiversity Board adopted two approaches for preparation of PBRs in Sikkim. Approach 1 Earlier, some of the PBRs were prepared by the BMCs themselves under the technical guidance of the SBB. For some BMCs, researchers from central universities and the field staff of Forest Department with research background were identified as field facilitator; they were given intensive trainings on the process of PBR preparation. The registers prepared were technically vetted by the state-level technical support groups (TSGs) followed by validation by the SBB. Approach 2 Post-NGT’s order, the RDD identified their field functionaries as field facilitator for the preparation of the PBR, who were provided intensive online and offline trainings

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Step 1

Step 2

Step 3

Step 4

Step 5

Step 6

Step 7

B. K. Pradhan

•Biodiversity Management Committees (BMCs) constitution

•Sensitizatizing local communities and BMC on importance of biodiversity and its documentaion PBR

•Providing training to BMC members on data collection

•Data Collection through literature review, PRA excercise, FGD, house hold interview, one to one interview with village elders, knowledge holders, panchayats, NGOs and direct field observations

•Data compilation

•Data validation duly consulting technical support group (TSG)

•Printing of People’s Biodiversity Register

Fig. 4.1 Steps involved in preparation of PBR

at state, district and block level; trainings at GPU level were also provided to some of the BMCs on special request of the BMC Chairperson. Simultaneously, SBB constituted district-level TSGs, and also, the researchers and the BMC members who were involved in preparation of PBR earlier were appointed as PBR coordinators to assist the field facilitators involved in documenting the PBR and assess the biodiversity register prepared by them. The TSGs and coordinators were given trainings on the vetting process, and also, they were appraised on what kind of information a PBR should contain and how to validate the information contained in the draft PBR. After the first level of assessment of biodiversity register by the coordinators, the same were technically vetted by the district-level TSGs followed by final checking of the PBRs by the SBB. The state-level PBR Monitoring Committee were also constituted to assess the quality of the PBRs. Some of the PBRs were prepared by Sikkim University and The Mountain Institute India under their projects (Table 4.1). PBR documentation is a scientific activity and is an excellent opportunity of making people aware of science and taking the science to the grass root (Gadgil et al., 2006). The PBR preparation process requires rigorous consultation with local communities (NBA, 2013). The very first step in the process is to convey the objectives and purpose of the PBR preparation to the local communities through series of dialogues and meetings which was impossible at such times when the priority was to complete the task before the deadline set by NGT. Hence, draft PBRs were prepared for all the BMCs; however, there was least participation from the local communities

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because of which most of the key informants and the information were missed out though the facilitators were provided important tips on the methods to be followed while preparing the register and engaging the people. As per the Act, the PBR should have been prepared by the BMC which is only possible when they understand the true essence of BD Act 2002. Nonetheless, as of date, majority of the BMCs lack clear understanding about their roles and responsibilities and the importance of PBR as they were formed very recently prior to outbreak of COVID-19 disease due to which capacity building trainings could not be organised for them. Lack of awareness among the BMC members and the local communities as a whole highly impacted the quality of PBRs in Sikkim, and it ended up in document with mere lists of common species with their general information on medicinal uses, etc. Nevertheless, PBR is not merely a register with names of species and their distribution in a given area but it is a comprehensive database recording people’s traditional knowledge and insight of the status, history, ongoing changes and forces driving these changes and their adaptation strategies, current utilisation patterns of biological resources and its economic benefits to the local communities.7 The PBR preparation process is time-consuming exercise and requires experiences and skills in respect to extracting information from the knowledge holders, and the person involved should possess basic knowledge and understanding about biodiversity. But majority of the PBRs in Sikkim is prepared by unprofessional who lacked the knowledge on importance of PBR. Nevertheless, with relaxation in COVID-19 restrictions, SBB is working on improving the quality of PBRs by involving the BMCs and local communities by organising GPU level awareness programmes.

Issues Pertaining to Jurisdiction In a small state like Sikkim, where majority of the area (81%) is managed by the Forest Department, the constitution of BMC is already raising question on their jurisdiction as JFMCs are managing the reserve forest and EDCs are managing the protected areas. Though BMC will have control over the entire GPU including the agro-forestry landscape, there are issues of conflict of interest on the usufruct sharing. For example, Pokhari Sanrakshan Samiti (PSS) constituted by the Forest Department are collecting fee from the tourists visiting Tsomgo Lake (commonly Chaangu Lake) in east Sikkim and Khecheopalri Lake in west Sikkim. Both these lakes are potential biodiversity heritage site (BHS) and if the existing BMC moves a proposal to declare these lakes as BHS under the provision of the Act, who holds the authority to collect fee from the tourists?

7

https://www.keralabiodiversity.org/index.php/activities/people-s-biodiversity-management-com mittee/people-s-biodiversity-register.

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State Policy, Biological Diversity Act 2002 and the Conflict of Interest The livelihood of the tribal people living in the forest fringe depends on the forest resources, and they have been traditionally managing these resources since ages. Their relationship with the forest is inseparable; they are known for their environment-friendly practices (Madegowda & Rao, 2013) because they understand that their well-being, their identity and their children’s future depend on its conservation and sustainable use. TK accumulated over the years by them is being exploited and patented by the pharmaceutical, and when legal obligations were placed on them to share the benefits with the knowledge holders and their communities in a fair manner, they counter that TK is irrelevant in drug discovery (Dutfield, 2010). Had not there been TK, it would have taken hundreds of years for the bioprospecting companies to screen the plants for their medically active compounds and develop into a product. TK significantly reduces the cost of pharmaceutical R&D due to which pharmaceutical industries are looking increasingly at medicines and products that have been developed by the local communities (Singh et al., 2014). Sikkim has huge biological resources, the sustainable commercial exploitation of which may potentially generate revenue for the state and ensure economic well-being of the ILCs thereby reducing the state’s dependency on the central funding. However, the blanket ban on the commercial exploitation of NTFPs including medicinal plants in Sikkim has negative implications on the conservation policies and biodiversity as well because the illegal trade of the biological resources has increased multi-fold in the state in the last couple of years. The real benefits are being derived by the people from outside the state or the country as they are mobilising our local communities for illegal collection of the medicinal bioresources. The policymakers are looking only at the aspect of bioresources being commercially exploited by the local communities but have failed to understand that indigenous knowledge contributes to conservation, sustainable use and management of NTFPs; in other words, they are the real conserver and manager of the forest and the bioresources and have secured legal rights to access to biodiversity including minor forest produce, under Section 3(c, k) of the Forest Right Act 2006. However, such ban policy has jeopardised the economy of the state and the intellectual property of the ILCs which else could have been converted into cash by patenting their knowledge, simultaneously benefitting local communities and state as a whole through ABS thus meeting the broader objectives of BD Act 2002. By enforcing such policy, we have put our long conserved TK, which has potential to benefit humankind through commercialisation, at the risk of extinction. The biological resources are the renewable resources and are to be used; it is the provisional service that the humans are deriving from the ecosystem. The blanket ban on NTFP collection is nothing more than wastage of biological resources; it has not been able to check the illegal exploitation; rather, it has paved a way for biopiracy. In a mountainous state like Sikkim which shares transnational boundary with Bhutan, China and Nepal, it is impossible to check the illegal trade of the biological resources; the best solution is to allow its sustainable harvesting. The existing trans-boundary

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illegal trade of Ophiocordyceps sinensis, Paris polyphylla, etc., is the clear examples of the implementation challenges of such policies and reflects the field reality, else these species could have been considered for developing working ABS business model in the state. The ban does not apply to the cultivated medicinal plants but the demand–supply of the industries cannot be met through cultivation as we have very less land (approx. 12%) available for agriculture/medicinal plant cultivation. Lately, the authorities have realised that the real conservation can only be done by allowing the sustainable extraction of bioresource and not by imposing bans. To start with, the state government lifted the ban on commercial collection of Ophiocordyceps sinensis but the concerned agency is not able to reach at common consensus with the local communities. On the other hand, there is an increasing interest among the local entrepreneurs and nutraceuticals in commercially exploiting Seabuckthorn from Lachung and Lachen in North Sikkim. However, there is a conflict of interest between the two government agencies involved. Forest Department is of the opinion that commercial extraction of Seabuckthorn cannot be allowed unless a feasibility assessment is done, while Sikkim Biodiversity Board has already gone ahead by signing ABS agreement with the applicant after duly consulting the Dzumsa and the local BMCs of Lachen. The applicant even after following the official procedures is not able to extract Seabuckthorn for commercialisation. It does indicate that practical implementation of ABS Law is unrealistic in the state of Sikkim and is still a long way to go.

Conclusion The Biological Diversity Act 2002 is the only Act that stresses on incentivising the local communities through access and benefit sharing for their conservation effort. The Act has further recognised them as one of the implementing agency at the local level which will be possible only when they fully understand the Act and their roles and responsibilities as provisioned under the Act. However, the BMCs were constituted under pressure due to which knowledgeable and interested people were missed out from being included in the committee as a result of which problems such as lack of coordination among the BMC members and untimely restructuring of the BMCs before expiry of the tenure have become very common in Sikkim. This has highly affected the functioning of the BMCs. PBR, which is to be prepared by the BMCs, is a dynamic document that will serve as a baseline data for developing management strategies for the biological resources and also as an impact assessment tool for developmental activities. However, it was hard to find motivated people willing to take up PBR exercise and that affected the quality of the PBR and it ended up in a copy-paste document containing a mere list of common species with their general information on medicinal uses, etc. If India is to fulfil its obligation under CBD and achieve the goal of biodiversity conservation and sustainable use of its components, the process of BMC constitution and preparation of PBR should be done at its own pace to ensure maximum people’s participation.

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Further, it is worth involving the school children in PBR preparation process as biodiversity is an interesting subject for them. State Biodiversity Board is a bridge between NBA and the local communities. The effective implementation of BD Act 2002 in the state and involvement of the local communities entirely depend on SBBs understanding about the Act and its provisions. Hence, focus should be given on strengthening and capacity building of SBBs to avoid legal challenges in the future. In a small state like Sikkim, which has a limited source of revenue generation, its rich biological resources offer great potential to boost the economy of the state, and if the state has to benefit from its rich biological resources, it needs to promote its commercialisation at local, regional and global level. At the same time, it is necessary to acknowledge and recognise the diversity of wisdom and culture to fulfil the objective of conservation and sustainable use. Conservation is impossible without involving the local communities as they are the one who is always in contact with the nature due to which their relationship and understanding about the nature are constantly evolving (Kalpavriksh & Grain, 2009).

References Biswas, S. (2005, December 07). India hits back in ‘biopiracy battle’. BBC News. http://news.bbc. co.uk/2/hi/south_asia/4506382.stm. (Accessed 21 August 2019). Dutfield, G. (2010). Why traditional knowledge is important in drug discovery. Future Medicinal Chemistry, 2(9), 1405–1409. Gadgil, M. (2000). Pople’s biodiversity register: Lessons learnt. Environment, Development and Sustainability, 2, 323–332. https://doi.org/10.1023/A:1011438729881 Gadgil, M., Gokhale, Y., & Rao, P. R. S. (2006). People’s biodiversity register. SAHYADRI ENews, Issue 15. Western Ghats Biodiversity Information System, Indian Institute of Sciences, Bangalore. Garcia, J. (2015). Fighting biopiracy: the legislative protection of traditional knowledge. Berkley La Raza Law Journal, 18, 5–28. https://doi.org/10.15779/Z38M378 Gupta, V. K. (2011). Protecting Indian traditional knowledge and biopiracy. https://www. wipo.int/export/sites/www/meetings/en/2011/wipo_tkdl_del_11/pdf/tkdl_gupta.pdf. (Accessed 19 August 2019) Gupta, H. K. (2013). Institutional framework for creating biodiversity common through biodiversity management committees in India. In 14th IASC Global Conference on Commoners and the Changing Commons: Livelihoods, Environmental Security, and Shared Knowledge. Mount Fuji, Japan. Kalpavriksh & Grain. (2009). Six years of the biological diversity act in India. Kalpavriksh and GRAIN, Delhi/Pune (pp. 60). (A report compiled by Kanchi Kohli, Mashqura Fareedi and Shalini Bhutani). Khan, Z. A. (2016). Protection of biodiversity in India and Bangladesh: A legal perspective. ILI Law Review Summer Issue, 223–235. http://ili.ac.in/pdf/paper13.pdf. (Accessed 18 August 2019). Madegowda, C., & Usha, R. C. (2013). The ban of non-timber forest products collection effect on Soligas migration in Biligiri Rangaswamy temple wildlife sanctuary India. Antrocom Online Journal of Anthropology, 9(1), 105–114.

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MoEFCC. (1998). Implementation of the Article 6 of the convention on biological diversity in India. National Report, Ministry of Environment, Forest and Climate Change, Government of India. http://nbaindia.org/uploaded/Biodiversityindia/1st_report.pdf. (Accessed 26 August 2019). National Biodiversity Authority. (2004). The Biological Diversity act 2002 and Biological Diversity Rules 2004. National Biodiversity Authority, Chennai, India. National Biodiversity Authority. (2013). People’s biodiversity register: A revised guidelines. National Biodiversity Authority, Chennai, India. Pisupati, B. (2018, April 09). Economic value of Biodiversity. The Hindu Business Line. https://www.thehindubusinessline.com/opinion/economic-value-of-biodiversity/article20 419314.ece1. (Accessed 19 August 2019). Reid, J. (2009). Bio-piracy: The struggle for traditional knowledge rights. American Indian Law Review, 34(1), 77–98. https://digitalcommons.law.ou.edu/ailr/vol34/iss1/2. (Accessed 21 August 2019). Singh, R. D., Mody, S. K., Patel, H. B., Devi, S., Modi, C. M., & Kamani, D. R. (2014). Pharmaceutical biopiracy and protection of traditional knowledge. International Journal of Research and Development in Pharmacy and Life Sciences, 3(2), 866–871. Sundaraju, V. (2019). Implement the biological diversity act in its true spirit. Down To Earth: February 21. https://www.downtoearth.org.in/news/wildlife-biodiversity/implement-the-biolog ical-diversity-act-in-its-true-spirit-63320.. (Accessed 25 August 2019).

Chapter 5

Chronicles of Exploitation: Practice and Practitioners of Ethnomedicine in Quagmire of Market Dynamics of Pharmacopoeia Shalina Mehta and Dinesh Kumar

Knowledge may reinforce power and privilege but not be monopolised or commoditised for private benefits—(Herskovits, 1952: 390).

Abstract Studies have shown that the most important drugs in the pharmaceutical industry belong to the realm of ethnopharmacopoeia. It is reported that nearly 80% of the world’s population is dependent on plant and plant extracts for health care. Out of 150 proprietary drugs used in the USA, 57% contain at least one primary active compound currently or once derived from plants. For years, ethnobotanists, medical anthropologists and people working with indigenous communities have admitted that a substantive extent of this knowledge was derived from the practitioners of traditional medicinal systems living in forested regions of the world, acquired by oral traditions and practice. Modern medicine and pharmaceutical industries across the world usurped this knowledge without acknowledging its origin and giving due rights to the original owners of this immense wealth. Of late, recognitions of natural products being more effective and safer have brought further erosion of these fundamental rights of indigenous communities. This paper examines some of these violations and explores alternatives and possibilities by which these rights could be restored to the traditional practitioners and herbal wealth located in forested constituencies of its native inhabitants protected. Keywords Indigenous knowledge systems · Ethnopharmacopoeia · Ethics and patents · Commodification and marginalisation · Ethnomedical practitioners S. Mehta (B) Professor (retd.) Department of Anthropology, Panjab University, Chandigarh, India e-mail: [email protected] Senior Vice-President, United Indian Anthropology Forum, Chandigarh, India D. Kumar Social Scientist, Post Graduate Institute of Medical Education and Research, Chandigarh, India © The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023 S. Reddy et al. (eds.), Ethnomedicine and Tribal Healing Practices in India, People, Cultures and Societies: Exploring and Documenting Diversities, https://doi.org/10.1007/978-981-19-4286-0_5

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The tryst with ethnomedicine and practitioners of these systems for the first author of this paper started in 1987 from district Mandala in Madhya Pradesh. During this research journey that lasted for nearly fifteen years (1987–2003), 51 villages1 of Gonds and Baiga Adivasi were surveyed. Baigas were respected for their knowledge of herbal medicines and were the formal ethnomedicine practitioners for all the communities in the region. They had a repository of herbs that was transferred from one generation to the other through oral tradition. One may describe them as a living encyclopaedia of traditional knowledge systems. Researchers having an opportunity to work with these communities and their ethnomedicine have espoused the efficacy of these herbs used by these traditional medicine men (Elwin, 1939; Kapale, 2012; Khera, 1990; Patel, 1991; Tiwari et al., 2012).2 Most Adivasi communities also have well defined scientific and structured arrangements with defined responsibilities for health care. This is contrary to the widespread perception that Adivasi communities essentially relied upon orthodoxy, superstition and witchcraft for health care. Research narratives from the region explained that Baigas remained the original collectors of herbs from the forests. They are equipped with knowledge and skills to explore these in the natural habitat. Local communities also believed that they had divine abilities to ensure its efficacy. In this structured arrangement, the second tier is occupied by the Gunias—the local shamans or medicine men responsible for diagnosis, preliminary treatment and follow up. Most of them came from another tribal group in the region, commonly known as the Gonds. They were also addressed as Ojhas, Dwar, Panda and even Purohit. Occasionally, Gunia and Ojha make a distinction, believing that the Ojha could communicate with ancestral spirits. The widespread presumption is that they possess supernatural powers to remove any negative impact of afflictions caused by restless spirits. Anthropological epistemology tells us that customary knowledge is not available in the form of written records. It remains confined to oral traditions. The local communities view medicinal knowledge as sacrosanct. Its access is restricted and is conveyed from culturally and customarily accepted practitioners to socially accepted worthy inheritors. Thus, indigenous medicinal knowledge, though acknowledged as the common property resource of the local communities, primary right for resourcing is voluntarily acceded to only recognised agents.3 Communities in the region institutionalised indigenous healing systems in this structured arrangement respecting internal hierarchies and customary boundaries. They learn to restrict access to their individualised domains. Baigas the official medicine men and Gond Gunia never confront each other nor try to usurp each other’s 1

Unpublished thesis: Lamba (1992) Anthropological analysis of cure culture complex of Gonds of Mandla, Submitted to Panjab University Chandigarh. In the UGC career award and collection of data for this thesis, we also prepared an inventory of about forty commonly used medicinal herbs by the indigenous communities. 2 Both Gond and Baigas have continued to be the custodians of this knowledge system. In a recent study uploaded on research Gate by Shivaji Chaudhry (2017), 100 species of medicinal plants still used by these communities in Madhya Pradesh and Chhattisgarh are reported. 3 i.e. specified knowledge practitioners, e.g. Baigas and Gond Gunia in district Mandala.

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domain. However, the local trader who encroached their territories is neither bound by customs nor by ethics. They realised the medicinal value of the local herbs used by these traditional practitioners and started exploiting these reserves for profit. This is done without acknowledging or duly compensating local communities.4 Gullible Adivasi is duped. The local trader and other external agents make hay as long as these rare herbs are readily available. For centuries, the world remained immune to this blatant exploitation. Evidence suggests that Colonial administrators were first to exploit the ignorance and naivety of these small-scale societies. Indigenous knowledge systems were systematically destroyed. Colonial administrators promulgated draconian laws to debilitate practitioners of these knowledge systems. ‘The Forest Act 1865’ in India5 violated the fundamental rights of indigenous populations on their resources by declaring forests as property of the state. Any violations were called the culpable offence. Adivasi communities were not allowed to collect minor forest produce or even branches of trees for personal use. Protests and dissent compelled the colonial administration to relax by modifying the Act and bringing in “The Indian Evidence Act 1872”, which recognised practices recorded in the village administration or settlement records. Persistent protests compelled British administrators to tweak further the earlier provisions with the introduction of “The Indian Easement Act 1882”. It promised to examine the customary rights of indigenous communities. Some minor changes were made with the promise of safeguarding the private and the public rights of the individuals. However, these also remained ‘hallow enshrined provisions’. The 1927 Indian Forest Act6 once again replaced these vain promises. The rights were now deemed as privileges. This resulted in a substantive loss of freedom of the indigenous communities on their native resources. The chronicles of exploitation by enacting this provision in pre- and post-colonial India are subject to several anthropological texts (Elwin, 1939; Jewitt, 2000, 2002; Rao & Ramana, 2007; Sen, 1992). Our apathy to the indigenous knowledge system is witnessed because the Forest Act was not revised for decades after independence. Provisions for ensuring the rights of the indigenous communities were not put in place. Constitutional provisions enshrined in the 5th and 6th Schedules of the constitution did little to help ease the situation. Various tribal commissions appointed by the states and centre from time to time made some attempts to ask for stricter norms

4

In 1994, Mehta wrote: “…corrupt officials are selling ‘jungle’ after ‘jungle’ to their contractor friends. Obdurate, tribal may appear to such acts, but sentient they are to such discrimination”. (Man and Development: 1994: 86). 5 British enacted this law to take complete control of the forests and deny its original inhabitants any right over their resources. 6 The law was enacted to ‘consolidate the law related to forest, the transit of forest produce and the duty liable on timber and other forest produce’—the devil was in detail that spelt banning of collection of any item related to a tree or a plant essentially impacting livelihood of forest dwellers (for details refer to indiankanoon.org.doc accessed on 3rd August 2019). Ironically, we have continued with the essence of the clause detailed in the Act denying forest dwellers their fundamental right in whatever justly their resources.

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to ensure easy accessibility of forest products to Adivasi communities. However, most recommendations of these commissions remained on paper only. There were protests by the activists and ineffectual reference by anthropologists, but nothing-substantive emerged.7 Reasons for this indifference are writ large in our development paradigm. Indigenous populations in India, like several indigenous communities worldwide, inhabit rich forested regions and are the most important conservationists of natural biodiversity. Our development matrix guided by various international financial and conservation bodies8 declared a sizable portion of the natural habitats of the indigenous communities as protected forest areas. India is home to 187 “tribal districts defined so for the preponderance of Adivasi population in the region”. These districts cover 33.6% land area, 37% forest area and 63% dense forest cover. 23% of this area is declared protected that includes 99 national parks and 550 wildlife sanctuaries. The international conservation funding agencies convinced forest policy planners that the only way to protect endangered wildlife was to displace forest villages from the core area of the national parks. In the process, original conservators of biodiversity and indigenous knowledge systems are uprooted from their native ecosystems. To add to their misery came the Wild Life Protection Act of 1972.9 Consciously or inadvertently, it encroached on the limited access that these customary practitioners had to indigenous resources.10 It was only in 2006 that a positive move was made after the promulgation of “Scheduled Tribes and other Traditional Forest Dwellers (Recognition of Forest Rights Act 2006)”. The Act, as promulgated on 29th December 2006, categorically states: An act to recognise and vest the forest rights and occupation in forest land in forest-dwelling scheduled tribes and other traditional forest dwellers who have been residing in such forests for generations but whose rights could not be recorded; to provide for a framework for recording the forest rights so vested and nature of evidence required for such recognition and vesting in respect of forest land.

It further acknowledges: 7

We regret to add that interest of the 8.8% of India’s people has never been on the priority list of any government in Independent India. Their land was usurped in the name of industrial development. 88% of the displaced for infrastructure and development projects are Adivasi. It was only after Maoist violence in the ‘red corridor’ became synonymous with ‘tribal anger’ in the country’s central belt that a slight shift occurred. 8 World Bank, IMF, IUCN and WWF, to name only a few (for details, refer to Mehta and Weeks 2009). 9 Defined as “An act to provide for the protection of (wild animals, birds and plants) and for matters connected therewith or ancillary or incidental thereto”—under its proviso there is a wildlife advisory board that has a duty to advise the state government—in the selection of areas to be declared as sanctuaries, national parks, and closed areas and the administration thereof in relation to the measures to be taken for harmonising the needs of the tribal and other dwellers of the forest with the protection and conservation of wildlife. (nbaindia.org, accessed on 3rd August 2019). 10 Under this Act, the project tiger was started, and national parks for its protection were started. Funded by WWF, the programs ousted thousands of Adivasi from their natural habitat. Contestations that emerged as a consequence of this compelled the funding organisation to redefine its name from World Wild life Foundation to World Wide Fund for nature in India in 1987.

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AND WHEREAS the forest rights on ancestral lands and their habitat were not adequately recognised in the consolidation of forests during the colonial period as well in Independent India resulting in historical injustice to the forest-dwelling Scheduled Tribes and other traditional forest dwellers who are integral to the very survival of and sustainability of the forest eco-system. AND WHEREAS it has become necessary to address the long-standing insecurity of tenurial and access rights of forest-dwelling Scheduled Tribes and other traditional forest dwellers, including those who were forced to relocate their dwellings due to state development interventions.11 (Cf. tribal.nic.in accessed on 4th August 2019).

The restoration of these rights was decidedly not easy to attain! There was a prolonged struggle and hard-fought tussle between the peoples rights lobby and Wild Life Protectionist Lobby. It is in Clause 3(k) of this constitutional provision that the right of access to biodiversity and community right to intellectual property and traditional knowledge related to forest biodiversity and cultural diversity is given due credence. Eleven years later, most of us working on the subject understand how difficult it is for tribal communities even today to resource these rights.

Tyrannies of Validation and Documentation Chronicles of exploitation of traditional knowledge systems and, particularly, indigenous medicine are rampant worldwide. It was only in 1992 that a formal agreement for the protection of biological diversity and fair and equitable distribution of benefits accruing out of its generic use was promised.12 India became a signatory to the document in 1992 and formally ratified it in 1994. CBD, for the first time, recognised sovereign rights of states over their natural resources, authority to determine access to GR rests with national governments, subject to national legislation (Article 15.1).13 In pursuance of this agreement, India developed its Biological Diversity Act, 2002 and notified rules for biodiversity in 2004. It also amended its patent laws. It is now mandatory for companies seeking a patent for ethnobotanical products to declare their original source. The Ministry’s website claims that with a view to granting legitimacy due to the indigenous knowledge (IK), it has further amended and: implemented the major Policy/ Legal Frame Work to implement the objectives of CBD: BD Act 2002, NBSAP 2005, National Biodiversity Action Plan 2008, National Environment Policy 2006, NAPCC 2008, National Agriculture Policy 2000, National Water Policy, National Wildlife Action Plan 2002 – 2006, PPV & FR Act, 2001, Scheduled Tribes and other Traditional Forest Dwellers (Recognition of Forest Rights) Act, 2006, National Forestry 11

We have deliberately underlined this statement as it admits compulsive relocation of Adivasi communities from their ecology and distances them from their biodiversity that provided a primary source for their livelihood and medicinal plants. The statement falls short, as it makes no reference to any compensation that should be paid to these communities for living squalid lives. 12 Adopted in the year 1992 at Rio Earth Summit (http://www.unesco.org/education/pdf/RIO_ E.PDF). 13 (www.moef.nic.in accessed on 2nd Feb 2017).

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These are tall claims, but the practical or on the ground implications of this remain ambiguous. The WTO propagates TRIPS that does not recognise the provisions under CBD. Bijoy (2007: 18)14 infers: Fulfilling TRIPS is not in harmony with CBD and more often contradicts the CBD IPR regime in line with TRIPS overrides CBD obligations. Together with the new legal regimes, rather than recognising the rights of Adivasi/IP, further infringes their rights accorded in national and international laws.

The language of rules and controls is rooted in the governance paradigms of modern regimes. Simple Adivasi communities cannot comprehend its complexities and subsequent implications for their individual and community rights. Brush (1993: 660) reasons that there are three different ways by which the issue of protection of indigenous rights over biological resources is read in the texts: • Stressing the rights of the people unwillingly enmeshed in a nation-state would emphasise the use of intellectual property as a means to express ethnic autonomy and redress exploitation. It thus becomes a political question and overrides concerns of restoration of generic rights to indigenous communities (italics ours). • Another reading stressing the merits of the local knowledge would emphasise the use of the intellectual property to provide incentives for all the people to experiment with and protect all the biological resources. Arguments are driven by the logic of knowledge being a free resource and is always in the reckoning for scientific research without any control (italics ours). • And the third, in our view, the most important one is addressed to the nature of ambiguity inherent in the word indigenous, seeking clarity on “whether intellectual property is to be extended to only tribal people and ethnic minorities within nation-states or a general type of knowledge, regardless of the political and cultural status of the people who control it”. Reading of texts and their context is often problematic. Complexities get further enhanced, as the readers, interpreters and implementers of these texts and regulations are largely outsiders to the system. Individuals or communities directly impacted by it are not able to infer these ambiguities and their possible outcomes. To illustrate, we take cognisance of how the IPR debate is deliberated in the contextualisation of ethnomedicine in India. India formally started documenting an ethnological database of traditional medicinal knowledge only in the year 1982. A cursory review of the agencies involved in this augmentation process suggests that anthropological institutions and anthropologists per se are not actively engaged in this exercise. It is well established that anthropologists started recording tribal knowledge about herbs and their medicinal value in the

14

An independent researcher and activist made these comments in LEAD (Law, Environment and Development Journal, 2007, pp. 3–19).

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cure culture complex of Indigenous communities from the beginning of the twentieth century. Colonial anthropologists like Risely, Hutton, Stephen Fuchs, Verrier Elwin, Rivers and others have documented some of these products and practices. Every ethnographer working with a holistic perspective of community knowledge is expected to record these practices. Sadly, they have rarely brought their documented knowledge to the realm of formal systems. Formal documentation of ethnomedicinal plants is done by organisations like CSIR, Central Drug Institute, National Institute of Immunology, National Medicinal and Aromatic Plant Institute, National Botanical Institute, etc. Ironically, most of these organisations register indigenous knowledge about the medicinal value of these herbal plants as folklore. The metaphor of folklore is even accepted by the Traditional Knowledge Digital Library (TKDL). The digital platform is a commendable effort, but its endorsement of this heritage as folklore undermines its scientific efficacy and researched value. Researchers have persistently emphasised the need for granting parity to ‘folk knowledge’ with other Western systems of medicines (Brokensha et al., 1980). They also argue that continued use of the term Folklore is in a way dismissive of substantive properties of ‘ethnomedicine’. Casual referencing reduces it to the rubric of ‘popular’ or ‘romantic’ devoid of scientific logic. When TKDL accepted systems like Ayurveda, Unani, Siddha, and even Naturopathy, why not indigenous medicinal knowledge? Furthermore, why the community of ethnographers did not protest or even registered a complaint requires serious contemplation. Our rancour with the practising fraternity of ethnographers in India is that despite having documenting these repositories, there is hardly any concerted effort to protect the rights of these communities on these resources. It is abundantly visible that the existing TRIPS regime is in no position to protect the rights of the communities that are the original inventors. We have to refresh our memory and recall TBGRI-KANI MODEL.15 Kani is a small Adivasi community comprising about 25,000 individuals. Some of them live inside the reserved forests of Agasthya Hills that forms part of the Southern Western Ghats in Kerala’s Thiruvananthapuram district. The region is resource-rich with natural herbal plants that grow under its protective ecosystem. One of these unique species naturally grown here is argyopacha (Trichopus zeylanicus spp. Travancoricus). It has a unique fatigue-fighting ability. This particular Species is available in Sri Lanka and Thailand. However, its unique medicinal value is associated only with the plants found in Kerala’s Thiruvananthapuram district and Tirunelveli district in Tamil Nadu. The events surrounding its chance discovery by two scientists from RRL, Jammu, are well documented (for details, refer to Bijoy 2007; Suchitra 2015). We present some salient features of how this chance discovery became a classic case of lack of cultural understanding and lackadaisical handling of fundamental rights of the Adivasi community and basic rules of trade.

15

The Tropical Botanic Garden and Research Institute henceforth addressed as TBGRI.

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Chronicle of Events In 1987, Puspangadan and S. Rajasekharan, while surveying for an ethnobiology project, learnt from their Adivasi guides Mallan and Kuttimathan the value of local fruit that helped the local guides to avoid fatigue. To know more these two researchers started exploring and validating the medicinal properties of the natural herb, commonly sold under the name of Jeevan. It is derived from Withania somnifera, Piper longum and Evolvalus alsinoides. The original herb ‘ashwagandha’ is a perennial rhizomatous herb. Kani Adivasi community traditionally consumes its fruit. After ascertaining its pharmacological properties,16 the two scientists realised that it had to be converted into a poly-herbal drug for commercial production. They moved to TBGRI in Kerala in 1990. In 1994, the product was ready to get a licence. However, ‘folklore’ could not be licensed, so the product was codified in Ayurveda formulary as Divya Varhi. This was the beginning of the violation of the rights of the Kani Adivasis that were further conceded during its production and commoditisation. Arya Vaidya Pharmacy was given the right of production under a licensing arrangement with TBGRI for seven years on 10th November 1995. The terms and conditions followed for technology transfer were as per the norms of Council for Scientific and Industrial Research (CSIR). As per the norms, 60% of the royalty goes to the affiliating institute and the remaining 40% is distributed to the researcher (80% of the 40%) and the support staff (20% of the 80%). These rules violate the fundamental rights of the communities from whom primary knowledge is obtained, as no provisions are made for them. It was at this stage that the researchers and TIBGRI departed. The institute decided to make a voluntary surrender of 10% of its licence and royalty fee, and the researchers and support staff opted to forgo their share of the fee in favour of the Kani Adivasi. This voluntary surrender of institutional and research fees came to be celebrated as the TBGRI Kani model for indigenous knowledge sharing. Lack of knowledge of local institutions and social practices made this voluntary contribution problematic. The model identified ‘local Kani informers’ as the primary beneficiaries.17 The scientists failed to recognise the sacred value of the herb to the local community. As stated in the beginning, customary rights on this resource for knowledge are the exclusive prerogative of the local medicinal man called plathis, though the perennial reserve is a ‘common property resource’ of the entire community. These cultural boundaries were breached when the two Kani men 16

It contains glycolipids and polysaccharides. The Executive Committee and the Governing Body of TBGRI approved this significant departure from the accepted practice in this specific instance in 1994. This was also facilitated by Article 8(j) and Article 15.7 of the Convention on Biodiversity (CBD), which required the member countries to ensure equitable sharing of benefits accrued from the use of biodiversity and associated knowledge system—the stakeholders/knowledge providers. CBD had been ratified by India just then in February 1994 and was therefore obliged to promote its provisions despite the absence of national legislation to this effect. “Kerala Kani Samudaya Kshema Trust” (KKSS) was registered as a society in November 1997 as the institutional mechanism to receive the share in licence fee and royalty received by TBGRI from AVP (as reported by Bijoy, 2007: 3, 4).

17

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shared that knowledge with the outsiders. It was further abrogated, as the trust’s primary beneficiary was not the domain expert or the community chief but the two individuals who became an inadvertent source of knowledge provider. Cultural rights were encroached; customary boundaries trespassed. Resistance and conflict was a natural outcome! Even before the launch of commercial production, five Kani community healers in September 1995 protested to the Chief Minister of Kerala. They opposed the move for the commercialisation of their traditional knowledge. The Kerala Institute for Research, Training and Development of Scheduled Castes and Scheduled Tribes (KIRTADS) was also not favouring the commercialisation of any indigenous Herbal product without providing legal security of ownership of rights to the Adivasi community. The unsuccessful attempt made by TBGRI–Kani model, with whatever benevolent intent they may have had, came with several consequences. Once the product entered the market, large-scale exploitation of the natural resource was the expected outcome. Attempts to produce it commercially with community support also had adverse consequences: the forest department started demanding its commission and curbed even personal use by the community. The worst outcome was the registration of the product by NutriScience Innovation LLC Ltd.’s, distributor for Jeevani under the US Patent and Trade Mark office.18 It breached the terms of CBD and violated the rights of the nation-state over its resources. More importantly, it encroached upon the fundamental exclusive rights of the community to freely collect the natural product, taking away the right of ownership from the Kani Adivasis. Additionally, as stated earlier, this knowledge is invariably owned by the communities and even within by few designated individuals. The TIBGRI-Kani experiment exemplified how this presumably altruistic voluntary sharing of benefits accruing from indigenous resources resulted in the commercial exploitation of local energyboosting plants and violated unwritten customary practices that keep communities together. The profit-sharing model promoted by TIBGRI resulted in fissions in the community. It also created ruptures as this sacred knowledge that belongs to only the domain experts, the plathis. Encroaching this exclusive right is tantamount to unpardonable ritual violence.

Why Did It Happen? The primary responsibility for protecting indigenous knowledge of Adivasi communities is with the researchers responsible for generating that information. Anthropologists, along with ethnobotanists, have to take the initial responsibility. They must have advance in-depth knowledge of the community institutions and built-in hierarchies for resourcing these products. State and legislation follow the primary 18

US distributor for AVP registered jeevani as a trademark at the US patent and trademark office bearing the serial no. 7569228, on 27th April 1999.

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protection that the researcher provides to the community and its precious herbal resource. Our conversations with several colleagues engaged in the field tell us that many of them are concerned with these issues, but the cost of submitting applications is prohibitive.19 The language of rules is riddled with legal invocations that social scientists alone cannot grasp easily. Given these, what one expects simple, often illiterate Adivasi to do? To put it across plainly, original owners of indigenous knowledge systems and, to some extent, the fraternity of anthropologists on their own are far from comprehending the complexities of details that are required by the system. Organised interventions by a team of ethnographers, ethnobotanists, patent and legal experts, and state representatives put together could play an important role. However, they also have to face the challenge of documenting and ensuring legitimacy to oral traditions and experiential knowledge. For them, funding constraints are a major hindrance. Some of them may offer voluntary services, but expecting all the team members to spare time and contribute to the expensive legal process looks unpragmatic and wishful. Researchers familiar with these obstacles have also questioned the legitimacy of copywriting ‘intangible culture’ (Brown, 1998).

Paradoxes of Patenting Intangible Cultures The paradigm of ethnomedicine being ‘folklore’ is rooted in the perception that it is ‘intangible’ as it is not a product of scientific certitude of experimentation and validation under laboratory conditions. It is experiential. This is a supercilious argument—nature is the most significant laboratory and users of these herbs for centuries are encyclopaedias of its efficacy and certainty. What troubles most of us is the process that ensures that these indigenous communities—the original owners of what is called ‘intangible culture’ (by Brown (1998) as stated above) get their legitimate benefits on the economic value accrued. There is enough evidence, as stated at the beginning of this paper, that contributions made by ethnomedicine and healers of the systems to ‘modern pharmacopoeia’ run into billions of dollars, and there is a negligible portion of that wealth that has ever been directly given to the indigenous communities or used for their benefit. A number of prominent anthropologists like Murray et al. (1990); Kloppenburg and Kleinman (1987); Mooney (1980, 1983); Posey (1990) have advocated that indigenous knowledge should be converted into IPR so that indigenous people can claim proportionate compensation from the pharmaceutical industry. We have already discussed the complications of the IPR regime, which makes registration of any indigenous knowledge system cost-prohibitive and complex. Then there are instances where indigenous use of a particular medicinal herb is registered as patent for treating another illness and not for which it has been indigenously used. 19 Vaver (1991) has expressed similar apprehensions in the context of advanced countries and prospering economies.

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Colonial administration also successfully eroded indigenous practices by declaring them unscientific orthodoxies to establish the dominance of the Western system of medicine (Harrison, 2001; McDonald & Steenbeek, 2015; Saini, 2016). Retrieving the origins of such practices is a herculean task in the absence of any written records. Incorporations of several of these practices in the modern IPR regimes are unthinkable. Researchers also have to confront issues of propriety—as the information, they publish in-copyright publications either becomes the property of the journal along with that of the author and is not attributed to the supplier of that information. Knopf and Holcombe (2010: 25, also endorsed by Janke 2009: 5) has drawn attention to this dilemma. She argues that once these researchers document that knowledge, they claim copyright on that information, but in reality, it belongs to the Adivasi or indigenous people participating in the study. Any royalties that may incur to the researcher as it happened in the context of Kani rightfully belongs to the Kani Adivasi and not to the researcher. Thus benevolence attributed to the researchers and the Institute is misplaced. Post-modernist discourse encourages researchers to record narratives in the voice of the narrator. However, this is not insurance against usurping that right from the respondent. It only facilitates a de jure right and not a de facto endorsement of ownership. There is also a widespread belief attributed to the statement of Thomas Jefferson 20 once said, “The greatest service which can be rendered is to add a useful plant to its culture” (cf. Brush, 1993:657), taking a cue from it Brush gives credence to the idea that biological knowledge is “common heritage to be shared for the benefits of all humanity, rather than a monopoly for private gain” (ibid). This is a moral argument that defies the logic of capitalist market economy in which ‘Profit over People’21 holds precedence. Given this primacy, the proposed idea will not only destroy ecosystems but also trample over small-scale communities. This could result in the annihilations of indigenous knowledge systems and the extinction of fragile communities that India now describes as particularly vulnerable populations (PVTG). We are already living under conditions of climate change and massive deforestation. The commercialisation of herbs for medicinal purposes is a fact. The modern medicine and pharmaceutical industry has generated huge profits from the commoditisation of these products. None of this knowledge is attributed to the communities from whom it has come. They continue to live in pecuniary and are deprived of access to many of these products as these have been patented. The control exercised by some of these companies has even outsmarted the legislative control that colonial forces had on natural resources. In such a pessimistic prologue, what is the way forward, in particular for anthropological knowledge that had direct access to this rich heritage? 20

Thomas Jefferson (1743–1826) is often described as ‘foremost American son of the Enlightenment and has authored The Declaration of Independence and several other pioneering writings. 21 This is also the title of Noam Chomsky’s famous book Profit over People: Neoliberalism and Global Order that is a telling commentary on how power in so-called democratic systems is controlled by the capitalist forces of the market economy.

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Finding Answers in Theoretical Realignments In an article published in 1993 in American Anthropologist by Brush22 (1993: 659) attempt to restructure the debate from an anthropological perspective is made. He visualises four approaches that configure anthropological understanding of ‘knowledge’. He describes these as (a) descriptive historical particularism, (b) cultural ecology, (c) cognitive anthropology (d) and human ecology. In this construct, his opinion is that the last two are more relevant for comprehending this entire debate on IPR. The arguments mooted by this approach withdraw the contextualisation of IPR from the subfield of historical particularism and cultural ecology and relocate it in the domain of cognitive and human ecology. The premise for this realignment is that historic particularism restricts itself to define peculiarities of knowledge systems23 to a specific culture. Cultural ecology, on the other hand, only addresses issues of adaptation to a given environment. At the same time, cognitive anthropology plays a stellar role in systematically documenting the structure of folk knowledge systems and their historical linkages. Human ecology goes beyond historical particularism and cultural ecology and moves from the domain of descriptive to analytical. Brush’s reasoning for locating IPR debate in the context of cognitive and human ecology approach is inspired by Atran’s (1987) premise that there is historical affinity and structural similarity between non-Western (non-literate, “pre-scientific”) and Western (literate, scientific) knowledge system. His argument is, “In showing this similarity, cognitive anthropology establishes the foundation for the syllogism at the heart of the intellectual property debate because (italics ours) indigenous and scientific knowledge share structural similarities, then specific knowledge from indigenous sources should be entitled to the same legal status as specific scientific knowledge” (Brush, 1993: 658–659). Extending this position, he believes that these approaches have taken folk knowledge in the realm of indigenous knowledge systems, thereby granting it scientific legitimacy. We are reading this text in the second decade of the twenty-first century. Introduction to this paper and the case study cited here shows that this shift within the anthropological approach has not succeeded in granting IPR valuation to indigenous knowledge. The author of this comprehensive approach is aware of the political limitations of this approach because of obscurities around the term ‘indigenous’. The kind of political polyphony it evokes in different contexts is widely debated in ethnicity and minority rights. In this mayhem, seeking recourse for ensuring legitimate rights of indigenous communities on their ‘knowledge system’ in re-aligning theoretical approaches is not yielding due dividend.

22

For details, refer to Stephen B. Brush, Indigenous Knowledge of biological Resources and Intellectual Property Rights: The role of Anthropology. American Anthropologist 95(3): 653–686. 23 Knowledge is addressed as a holistic understanding of flora, fauna, nature, weather, astronomy etc., unique to each culture and society.

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The current pharmaceutical and cosmetics market has accrued massive financial benefits from ‘indigenous knowledge systems’24 but are not willing to share any profit with the people from whom it was generated. The existing IPR regime is making it far more complicated. It has become part of the ‘top-down approach strategy that promises boardrooms or international forums without benefiting the grassroots (the actual owners of these knowledge systems). The middle-level approach is being redesignated as corporate social responsibility (CSR).25 It is left to the wisdom of the industry as to what privileges they want to transfer. When rights become privileges, then the onus of dispersal is with those who have usurped those rights. Companies are unwilling to endorse indigenous communities’ fundamental rights as the original innovators of ‘ethnomedicine’ or even ‘indigenous knowledge systems’. Traditional knowledge documented in written texts is gaining some recognition and partial rights but Adivasi knowledge26 that has remained confined to oral tradition is not able to get its due hubris. The bottom-up approach in the given circumstances is a possible way that indigenous knowledge could claim some share of the profits that multinational pharmaceutical companies are deriving from their knowledge. There is a possibility that these demands may be categorised as ‘protests’ and dismissed or curbed by the administration. Such claims are often interpreted in the texts as ‘the rise of ethnicity’. These are curbed with a heavy hand by the nation-state. There are hardly any indigenous communities that enjoy the status of a nation-state having independent control over their resources. Autonomy to claim IPR thus rests with the state and not with the communities. Finally, we address a genuine concern that emanates from the historical and pre-historical processes of migration. Indigenous knowledge also travelled with the migrants. Several indigenous communities often use a similar kind of herb for either treating the same ailment or for another kind of infirmities. The most common example is that of Indian snakeroot called Rauvolfia, commonly used in reserpine for treating blood pressure. It is found from India to Sumatra (Duke, 1985; Monachino, 1954) and is used to cure mental disorders, snakebites and several other ailments from ancient times.27 The plant is in common use across India and is addressed by different names.28 It was only in 1952 that reserpine; one of the alkaloids of the plant, 24

All India Coordinated Research Project on Ethnobotany in India reported that indigenous communities are acquainted with 9000 species that includes 7500 species used for medicinal and healing purposes. These products are likely to cater to the US$ 5 trillion markets by 2020. (cf. Venkataraman & Swarna Latha, 2008: 328). 25 Large corporate houses are shirking even this responsibility calling it unwarranted and indirect tax liability by the Indian state. 26 Reserpine, commonly used for treating blood pressure, insomnia and several other neurological disorders, is drawn on indigenous knowledge. It has a world market of $ 42 million but not a penny is contributed to the original owners of the indigenous knowledge (Posey, 1990). 27 It is recorded in the Sanskrit Ayurveda texts by the name of Sarpgandha, and Subsequent researchers also found it being used by the names Tsjovanna Amel-Podi (Rheede 1686, cf. Monachino 1954). 28 Medicinal usage of Indian Snakeroot goes back to Ayurveda that dates back to sixteenth century. Contextualising it in cognitive anthropology is substantiated by its connotation in different languages

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was isolated from its roots and used in Western medicine.29 To accord legal status to such a widely known indigenous knowledge to one community or one nation-state is problematic. However, pharmaceuticals that make million by using this knowledge should use some portion of wealth for the welfare of the people in the regions from where the product is procured.

Feasible Interventions There are no simple solutions for bringing indigenous knowledge systems and practitioners out of this quagmire of exploitation. Capitalist markets and their designs are far too complex for small communities to protect their rights. Bringing it to the domain of cognitive and human ecology approach only provides solutions for classification. Protecting the cultural and land rights of indigenous communities is certainly a way forward to protect the indigenous knowledge system. However, would these measures be enough? Relying on these channels alone will not be adequate to protect the fundamental rights of the communities on their knowledge systems. We need a proactive approach and practical legal framework both at the national and international levels. India did submit a proposal in 2000 to the TRIPS Council and the committee on trade and environment on ‘Protection of Biodiversity and TK’ seeking legal protection of Tribal knowledge and its exploitation by international commercial interests in India. We have to go a step forward and have international sanctions on companies that acquire these knowledge systems without acknowledging their source. They ought to be penalised. There is a need to provide retrospective benefits for available products resourced from indigenous knowledge systems to communities that reside in those biospheres. Many pharmaceuticals prefer to set up manufacturing units in the biodiversity zones from where they resource the herbs for specific medicines. Identifying the communities’ known to use that herb for personal or community care is not difficult to ascertain through a simple demographic procedure. After identifying beneficiaries, these pharmaceutical companies should be asked to share a minimum of 10% of the profits generated by using herb extracts with these communities. These profits could be distributed through the local governance institutions at the level of the village council (Gram Sabhas). Deforestation, displacement of indigenous communities for development purposes, dispersal of these knowledge banks because of erratic rehabilitation demands immediate intervention. Biodiversity and cultural zones have to be guarded by varying names, e.g. Chandra-Bengali; Chandra bagha, Chota Chand in Hindi; Patlalgondhi, Sarpagandhi, Shivvabhibali in Kannada, Chvan amelpodi in Tamil etc. 29 Ironically, the popular drug is being manufactured by Alchem phytoadvance. They have three manufacturing units in India and exports 90% of its supplies from here. However, they have no history of sharing profits with any local groups or regions from where the initial sample of the snakeroot was resourced.

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with equal zeal. Biopiracy has emerged as another serious challenge. Researchers are using epithets like ‘biocolonialism’, ‘genetic imperialism’, even ‘plunder’ (Venkataraman & Swarna Latha, 2008: 329), asking for free access to natural resources declaring it to be a universal resource. India has raised these concerns in 2000 in a meeting of the United Nations Conference on Trade and Development (UNCTAD) held in Geneva: Rampant biopiracy deprives holders of traditional knowledge of any benefits. Loss of biodiversity and associated traditional knowledge will deprive the world of a unique knowledge base and threaten the survival of local communities. IPRs laws must benefit all holders of multinationals spending billions of dollars on the knowledge passed on from one generation to another.

We are aware that there is a national biodiversity authority to monitor and negotiate access to the nation’s biological resources. However, it has not effectively managed the mandate that it has. It promised an equitable share in the profits from sharing indigenous knowledge systems through the district administration, but nothing has materialised. It is time to create pressure groups of experts from different disciplines and representatives of indigenous knowledge systems to seek legal and civic action. Expecting industry, bureaucracy and the existing IPR regime to transfer benefits to the local communities is like expecting pigs to fly.

References Atran, S. (1987). Origin of the species and genus concepts: An anthropological perspective. Journal of the History of Biology, 20(2), 195–279. Bijoy, C. R. (2007). Access and benefit sharing from the indigenous peoples’ perspective: The TBGRI-Kani model. Law, Environment and Development Journal, 3(1), 3–19. Brokensha, D., Warren, M., & Werner, O. (1980). Indigenous Knowledge Systems and Development. University Press of America. Brush, S. B. (1993). Indigenous knowledge of biological resources and intellectual property rights: The role of anthropology. American Anthropologist, 95(3), 653–686. Brown, M. F. (1998). Can culture be copyrighted? Current Anthropology, 39(2), 193–222. Maravi, M. K., Ahirvar B. P., & Chaudhry S. (2017). Ethno medicinal plants use by two sympatric tribes of Central India. International Journal of Advanced Herbal Science and Technology, 3(1), 37–48. Accessed on August 2, 2019. Duke, J. A. (1985). Handbook of Medicinal Herbs. CRC Press. Elwin, V. (1939). The Baiga. Harrison, M. (2001). Medicine and orientalism: Perspectives on Europe’s encounter with Indian medical systems. In B. Pati & M. Harrison (Eds.), Health, Medicine and Empire: Perspectives On Colonial India (pp. 37–87). Orient Longman Limited. Herskovits, M. J. (1952). Economic Anthropology: A Study in Comparative Economics. Knopf, A. A., & Holcombe, S. (2010). The arrogance of ethnography: Managing anthropological research knowledge. Australian Aboriginal Studies, 2, 22–32. Janke, T. (2009). More than Words: Writing, Indigenous Culture and Copyright in Australia. Australian Society of Authors. March 4. Jewitt, S. (2000). Mothering earth? Gender and environmental protection in Jharkhand, India. Journal of Peasant Studies, 27, 94–131.

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Jewitt, S. (2002). Environment, Knowledge and Gender: Local Development in India’s Jharkhand. Ashgate Publishing Company. Kapale, R. (2012). Ethnomedicinal plants used by Baiga tribals in Amarkantak Meikal Forest of Madhya Pradesh (India). Bulletin of Environment, Pharmacology and Life Sciences, 1(4), 14–15. Khera, P. D. (1990). The Baiga and the Sal Forest. The Eastern Anthropologist, 43, 241–258. Kloppenburg, J. J., & Kleinman, D. L. (1987). The plant germplasm controversy. Bio-Science, 37, 190–198. Krippner, S., & Welch, P. (1992). Spiritual Dimension of Healing: From Tribal Shamanism to Contemporary Healthcare. Irvington. Lamba, R. (1992) Anthropological analysis of cure culture complex of Gonds of Mandla [Ph.D. dissertation]. Department of Anthropology, Panjab University Chandigarh, India. McDonald, C., & Steenbeek, A. (2015). The impact of colonization and western assimilation on health and wellbeing of Canadian aboriginal people. International Journal of Regional and Local History, 10(1), 32–46. Mehta, S. (1994). Tribal situation in India: Encounters with empiricism. Man and Development, 16(4), 80–89. Mehta, S., & Weeks, P. (2009). Globalised Environmentalism and Environmental Organisations in India. Unistar Publications. Monachino, J. (1954). Rauvolfia serpentina: Its history, botany and medicinal use. Economic Botany, 8(4), 349–365. Mooney, P. R. (1980). Seeds of the Earth: A Private or Public Resource. International Coalition for Development Action. Mooney, P. R. (1983). The law of the seed: Another development and plant genetic resources. Development Dialogue, 1–2, 7–172. Murray, J., Fowler, C., & Mooney, P. (1990). Shattering: Food, Politics and the Loss of Genetic Diversity. University of Arizona Press. Patel, G. P. (1991). A Study of Traditional Healing Practices Among Baiga Tribe of Madhya Pradesh (Vol. 19, No. 1–2). Bulletin of the Tribal Research and Development Institute. Posey, D. (1990). Intellectual property rights: What is the position of ethnobiology? Journal of Ethnobiology, 10, 93–98. Rao, V. L. N., & Ramana, G. V. (2007). Indigenous knowledge, conservation and management of natural resources among primitive tribal groups of Andhra Pradesh. In V. Bhasin & M. K. Bhasin (Eds.), Anthropology Today: Trends, Scope and Applications (pp. 129–134). Kamla Raj Enterprises. Saini, A. (2016). Physicians of colonial India. Journal of Family Medicine and Primary Care, 5(3), 528–532. Sen, G. (Ed.). (1992). Indigenous Vision: People of India, Attitudes to Environment. Sage Publications. Suchitra, M. (2015) The Kani Learning: How Benefit Sharing Between a Research Institute and the Kani Tribe Went Awry. Down to Earth. June 28. https://www.downtoearth.org.in/coverage/thekani-learning-39208 Tiwari, A. P., Dubey, P. C., Khanna, K. K., & Sikarwar, R. (2012). Ethnomedicinal plants used by Baiga Tribe of Achanakmar-Amarkantak Biosphere Reserve. Journal of Tropical Medicinal Plants, 13(2), 167–175. United Nations Conference on Trade and Development. (2000). A Positive Agenda for Developing Countries, Issues for Trade Negotiations. https://unctad.org/en/docs/itcdtsb10_en.pdf Vaver, D. (1991). Some agnostic observations on intellectual property. Intellectual Property Journal, 6, 125–153. Venkataraman, K., & Swarna Latha, S. (2008). Intellectual property rights, traditional knowledge and biodiversity of India. Journal of Intellectual Property Rights, 13, 326–335. Williams, L. A. D. (2006). Ethno-medicine. West Indian Medical Journal, 55(4), 215–216.

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Chapter 6

Indigenous Healing Practices in the Himalayas: Use of Medicinal Plants and Health Development in Nepal Madhusudan Subedi

Abstract People know many aspects of their surroundings and daily lives and have learned how to survive in challenging environments. Such traditional or indigenous knowledge develops in a given community over time and continues to change over a period of time due to various internal and external factors. Nepal is the natural home of a wide range of medicinal and aromatic plants. Medicinal plants obtained from natural resources are mostly used in remote areas where allopathic health facilities are either unavailable or are less trusted by local people. This paper describes the use of various medicinal plants in the mountain region where people are very close to nature. The disappearance of traditional knowledge due to lack of proper recording and reporting system and the influence of globalised biomedicine is another concern of the paper. It also emphasises the importance of indigenous medicinal and herbal practices for research and health care in Nepal. Finally, the paper argues for government agencies in Nepal to be interested in this subject by identifying major policy issues and applying beneficial traditional healthcare practices to better health and well-being. Keywords Indigenous knowledge · Healing traditions · Healthcare practices · Policy options · Nepal

Introduction Natural resources play a crucial role in Nepal’s development and are used as firewood, fodder, food and medicine. Medicinal and aromatic plants of Nepal and India’s mountain and hill areas have been valued since time immemorable (Subedi, 2009). Such plants are vital for curing diseases in remote areas where biomedicine is not readily available, costly or people fear the side effects (Subedi, 2001). A large number of people living in the mountain region still depend upon herbalists and local healers. Most of the high-altitude grasslands are still used as summer pastures for livestock grazing (Bauer, 2004). These pastures are normally owned and governed M. Subedi (B) School of Public Health, Patan Academy of Health Sciences, Lalitpur, Nepal e-mail: [email protected] © The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023 S. Reddy et al. (eds.), Ethnomedicine and Tribal Healing Practices in India, People, Cultures and Societies: Exploring and Documenting Diversities, https://doi.org/10.1007/978-981-19-4286-0_6

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by local communities, according to local social norms and values, common beliefs, and socially and culturally shared understandings (Wallrapp et al., 2019). There is much potential for herbs in Nepal. Moreover, for people who live in high-altitude mountain areas, collecting and selling medicinal plants provide employment and income (IUCN Nepal, 2000; Olsen & Larsen, 2003; Olsen, 2005). Although Nepal does not have a precise inventory list, it is estimated that more than 2000 medicinal are available in Nepal. The medicinal plants in Nepal are used based on the traditional experience and knowledge that have been transferred from generation to generation. The knowledge represents traditional medical experience, usually unwritten but orally transmitted by employing values and practices from the local cultural context to repeatedly treat illnesses’ signs and symptoms (Gewali, 2008). In my academic and research career, I have had opportunities to visit various parts of Nepal and interact with people on the importance of medicinal and aromatic plants to local lives and livelihoods. This paper highlights the use of various medicinal plants, the gradual disappearance of such knowledge due to the influence of the globalised biomedical knowledge, hegemony, and the expected role of the state for the betterment of health and well-being in a Nepali context. The paper uses Yarsagumba—the most expensive medical fungus, as an example, to emphasise the exploitative relationship between the medicinal and aromatic plants collectors and the different types of traders. The Yarsagumba is well known to scholars of Traditional Chinese and Tibetan medicine where it is recommended for a wide range of circumstances, including impotence, asthma and cancer (Bauer, 2004; Shrestha & Bawa, 2013; Sulek, 2016).

Medicinal and Aromatic Plants in the Nepal Himalaya In many parts of the world, the use of herbal medicine is increasing dramatically. Traditional practices are more acknowledged within the medical field, people can afford them, and they are perceived as safe and effective (WHO, 2002). Nepal has significantly diverse ecosystems producing a wide range of unique and high-valued medicinal plants. Representing only 0.01% of the earth’s land area, Nepal has 2.6% of all world flowering plants. Nearly 7 000 kinds of plants are found in Nepal, of which 10% are medicinal and aromatic plants (Gurung, 2001; Koirala & Khaniya, 2009). The country is naturally rich in Ayurvedic herbals. Many of Nepal’s unique medicinal plants are rarely available in other parts of the world. Karnali Province of west Nepal is rich in non-timber forest products, and their contributions to people’s livelihoods are high (Acharya & Paudel, 2020). Due to inadequate focus on research and the domination of allopathic medicine, medicinal plants are underutilised. These plants are regularly collected from forests. Different parts of the plants are used for different purposes. Various parts of the plants like leaves, branches, bark, roots, fruits, herbs and wood have important medicinal values for different diseases. It can be collected from open lands, fallow agricultural lands, waysides

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and forestlands. Most of the medicinal and aromatic plants traded in the Himalayas region are wild, and only a few are cultivated. Naturally grown medicinal plants are cheaper as it does not require groundwork and initial investment. It is thought that wild medicinal plants are more superior to those cultivated because the former grows in a natural habitat. These medicinal plants are used mainly for cold and cough, joint pain, cuts and wounds, fever, urinary infection, control diarrhoea and dysentery, and as an analgesic. Nepal’s wealth of Himalayan herb has for a long time been known in Ayurvedic medicine all over the Indian subcontinent. It has a centuries-long solid cultural and religious belief in local customs and traditions (Koirala & Khaniya, 2008). The familiarity with such medical practices has been established and experienced through generations. The collection of herbs for export to Indian markets and manufacturing companies devoted to Ayurvedic preparation is still a fact of life for mountain dwellers. Medicinal substances for Ayurvedic doctors, faith healers, and household remedies are largely based upon Himalayan herbs. Experience-based trust in the service providers is the main reason for visiting Ayurvedic healers. At least, four types of Ayurvedic practitioners are working in Nepal: those who are not institutionally trained but have gained knowledge through their family traditions; the herbalists who practice with local medicinal plants; institutionally qualified Ayurvedic health professionals; and the graduates of allopathic medicine who trust Ayurveda as an additional option. They all emphasise Ayurveda’s preventive and promoting aspects, focusing on food habits, personal hygiene and social behaviour. Many people in Nepal believe that Ayurvedic medicines do not have side effects (Subedi, 2018). However, knowledge, experiences, technologies and recipes have not been properly recorded and, therefore, risk getting eroded along with the practitioners. Due to geographical hardship, availability of medicinal plants, and traditional beliefs and practices, many people living in areas close to the Tibetan borders trust Amchis (Tibetan medical system). The roles of Amchi are that of a physician, veterinarian and spiritual healers (Acharya & Paudel, 2020). There are two types of Amchis: the institutionally trained, and those who are trained by the family members or relatives. The government does not have official records of these medical practices, but they play an excellent role in the northern part of Nepal, especially in the Karnali region. The Amchis have an exceptional knowledge about medicinal plants and use them widely for healing purposes. This knowledge has its base in a resilient cultural heritage and a sense of admiration for a natural setting. Amchis have been paying significantly to the healthcare services of the remote mountain population. However, Nepal has not formally recognised Amchi practice, which has hampered the Amchis’ capabilities to pass on knowledge, serve communities and protect the natural environment this medicine depends on (Baur, 2004). The newer generation is having a difficult situation sustaining this practice amidst changing cultural, economic and social circumstances. Aside from Ayurveda and Amchi, there are other important traditional healthcare systems such as Homoeopathy and naturopathy. Such medical practices have been

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used through generations. A large number of prescriptions for such medical practices are derived from medicinal plants. Folk medicine employs practices and principles from the native cultural development in treating various symptoms of illness. Plants constitute a major form of medicine in such folk healing traditions. A particular plant is selected as a suitable medicine only after countless hits and trials of treatments (Gewali, 2008). Advantageous species were valued as medicine, whereas non-beneficial medicinal plants have been rejected. The valuable information about the medicinal plants and familiarity with their efficacy were thus acquired through ageless experience and practice. Folk medicine constructs an extremely local relationship with the nature or habitat from where plants are grown. Medicinal plants come from the local environment, and hence, they are familiar to both those who treat and those who are treated. Unlike the allopathic doctors in white coats from unknown places, folk healers come from the familiar community—uses of local herbs as the medicines are prescribed, which are primarily available in their natural setting. Many people develop a close social relationship with folk healers, ecology, and medicinal plants.

Trading Routes and Channels The Himalayan region of Nepal is well known for supplying medicinal and aromatic plants. The trade with medicinal and aromatic plants is historically secretive, and firm data from any source is lacking. Most of the plants collected in the Himalayas pass across either the Nepal–India border or across various places on the Nepal–China border through a network of legal or illegal routes. The major markets for medicinal and aromatic plants are located in large cities, and some of them are precisely known as the business centre of special medicinal plants (Subedi, 2009). Major supply chains take place from Nepalganj of west Nepal to various cities in India. The Indian medicinal and aromatic plant business is characterised by many small businesses and a few big businesses. These businesses are not organised for operating the market and authority to regulate the trade. In such a situation, statistical data on the actual volume of trade is not recorded and reported. However, the actors involved in this market chain are well-coordinated. Excellent casual networking of agents involved in the supply chain of medicinal plants is informally developed. Unofficially, all of these are well-linked and coordinated. Well-experienced persons involved in medicinal and aromatic plant trading have better ideas regarding the price at the local market, medicinal and aromatic plants that are most in-demand and which market can give maximum benefits. Depending upon the economic importance of different medicinal and aromatic plants, marketing channels are created and regulated. Products of high commercial importance are sold at district- and national-level markets and traded abroad. Many products used in medicinal and aromatic preparations are collected and traded from various districts in the Karnali region. Bark, fruits, herbs, leaves, roots, and wood are collected from open lands, unused agricultural lands, roadsides, and

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forests. Many of the medicinal and aromatic plants traded in Karnali are wild, and only a few are cultivated. These plants are relatively inexpensive because it does not require prior investments for production. It is assumed that uncultivated herbs are better than cultivated ones as the former grows naturally. The main demand for Nepali medicinal and aromatic plants comes from Uttar Pradesh and Delhi of India. The Indian companies generally buy from traders or brokers who are either Nepali or Indian. Nepali traders and brokers go to India and get an initial idea of the market price of various medicinal plants. Similarly, Indian wholesalers come to business markets, airports, and collection centres of Nepal. They have an informal agreement with the city-level traders, who, in turn, are in touch with a network of village-based traders and harvesters throughout the accessible parts of the country. Several wholesalers are also based in Kathmandu and use the same network of brokers to buy medicinal plants and sell them to their networks in India. Every year a substantial amount of medicinal plants is mainly traded in India (Olsen & Bhattarai, 2005). Most of the trade is made in raw materials or semiprocessed products, such as essential oil. The medicinal plants are gathered mainly by relatively poor collectors from government or community forests and traded with formal and informal chains to the Indian cities. The trade typically takes place in personal negotiations between the local traders and collectors. There are thousands of local traders engaged in such intermediate trade in Nepal. Based on mutual benefits between Nepali and traders and Indian brokers, medicinal plants are generally sold in the Indian market. Trade with Tibet of China in a few important medicinal plants has increased in recent years. The trade of medicinal plants is highly reliant on shared trust and assurance between the contractor and the initial processors or wholesaler exports. The stakeholders involved in the market chain establish close connections through personal visits, telephone and electronic mail, and private technical assistance services while harvesting various medicinal and aromatic plants. The demand for medicinal plants is high and increasing. However, the current trade practices are mostly unfair and exploitative to the people who collect from the forest and those who supply the products to the village-level brokers. Sharing of benefits among the various actors depends on the information of the current market price of these plant products.

Actors Involved in Yarsagumba Trading In the late 1990s, Ophiocordyceps sinensis (English: caterpillar fungus; locally known as Yarsagumba), a precious product, was discovered on the grassland of the Himalayas at altitudes between 3000 and 5200 m (Shrestha & Bawa, 2013). Yarsagumba is collected by millions of people in the Himalayas of India, Nepal and Bhutan each year and traded by powerful brokers as a medicinal product, mainly to China (Wallrapp et al., 2019).

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Yarsagumba trade in Nepal was legalised in 2001 with the provision of the tax of NRs. Twenty thousand per kilogram to be paid to the District Forest Office. In 2006, the tax amount was reduced to NRs. 10,000 per kilogram to the government. It is important to share that a fair amount of Yarsagumba is traded without paying tax. The available data is underreported and the only official sources of information to quantify the total amount of trade (Shrestha & Bawa, 2013). People’s livelihoods in Karnali Province heavily depend on the collection and trade of medicinal and aromatic plants. However, the market of these plants is uncertain and unregulated. The nature of the trade is characterised by large-scale distortions, fault and excessive complexities. National-level information regarding the number of Yarsagumba collectors, traders, local and international prices and other parameters is unavailable. For the proper functioning of the trade, well coordination of market forces of production, distribution and use is a must. In the case of the Yarsagumba market, the primary source of order and delivery comes from a few brokers who play a significant role in controlling and regulating the market. The most important cause for this market irregularity lies in the very nature of the market itself. The purchase and sale of Yarsagumba in Nepal are networked through different market agents spread across the country. Yarsagumba trade does not have an organised body for operating the business, and there does not exist any authorised body to standardise the trade. In such a situation, information on the actual volume of the trade taking place each year is not available. However, the actors involved in this trade are informally coordinated, and there exists networking of brokers involved in the supply chain of Yarsagumba. Informally, they are well-linked and coordinated. The district-level smart brokers have tentative national and international information regarding the current price, the most demanded type, and the marketplace to bring maximum profits. Tracing the major channels in Yarsagumba trade is a difficult task. However, it can be assessed that a systematic supply chain consists of the following actors: primary collectors, village-level brokers, district-level brokers, and national-level brokers. Finding out about the realities of different actors involved in the Yarsagumba business is complex. Researchers must depend on information from different actors to understand the problems, opportunities and challenges they face during the various stages of brokerages. The information presented in this paper was achieved by talking to Yarsagumba collectors and brokers at the village, district and national levels in the Karnali region in 2017. The collectors retail to village-level brokers of their preference who visit directly to meeting sites to conduct their trade in the nearby local marketplace. Some collectors retail their products before cleaning them. This provides fewer earnings but requires less work and effort. Other collectors clean and dry the Yarsagumba first and trade to village-level broker and increase their profit (Childs & Choedup, 2014).

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The Collectors Collection of Yarsagumba is seasonal, and harvested by thousands of poor farmers, often young boys, who go all the way through the grasses of fields in one of the world’s most harsh and rugged landscapes, at times in chilled temperatures. Depending on the international market situation, the harvesters can earn around two to three dollars for each fungus. A few years ago, only a few people who had a good connection with traders were interested in collecting medicinal plants, including Yarsagumba. Now, the number of collectors has increased a lot, and the per-person harvest of Yarsagumba has decreased considerably. It is estimated that more than 300,000 people from the Karnali zone are involved in the Yarsagumba collection, and the number of collectors is increasing every year. For the duration of the harvest, thousands of people can be seen mountain climbing higher up the snow-capped areas, carrying warm clothes, tents, and other logistics for food and mobile sheltering. Entire villages in the Dolpa and Mugu districts and adjoining areas are engaged to collect Yarsagumba. Only the small children and the elderly with health problems stay at home. Schools are closed, and other activities are slowed to allow people to harvest Yarsagumba. More than 60% of the family members are involved in the Yarsagumba collection. A few families of hereditary lamas do not collect Yarsagumba (Childs & Choedup, 2014). Parents request the school authority to provide leave for their children—even pregnant women who sometimes give birth at the camps. (Childs & Choedup, 2014). In order to share logistics to stay and feel safe within the group, people move and night stay in groups comprised of friends, relatives and reasonably known villagers. The tool required for harvesting the Yarsagumba is straightforward and cheap, and locally available. Although nominal, there is a difference between the insiders (from the district) and outsiders (outside the district) in the entrance fee to the pastures. The duration of stay in the pasture lands depends on the harvester’s skill and capability to find Yarsagumba and not on socio-economic conditions. It is important to note that the other non-timber forest products are easily accessible, bodily noticeable and simply collectable. However, the size of Yarsagumba is tiny, and its recognition in the habitat depends on, as it is said, one’s fate and prior familiarity with the species complex and the habitat. The informal committees formed at the local level collect entrance fees from the collectors who choose the local villagers’ traditional pastures. After the country’s federalisation, the local government has started to fix the entrance fee from the collectors. The generated from the entrance fee is used, for example, to support the salary of locally hired teachers and health workers, construct micro-hydropower, establish a community emergency fund for pregnant women, and build village roads and health facilities. In remote mountain areas, revenue from entrance fees has played an important contribution to local-level human and infrastructure development.

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Collecting Yarsagumba in a cold environment with low oxygen levels is an unsafe task, especially when the collectors do not wear proper shoes and have inadequate warm clothes and good quality tents while they sleep at pasture. Newspaper information shows that from cold alone, about 10–12 poor people die each year. The poorest families in the districts obtain a more significant amount of their earnings from Yarsagumba than from other sources of income. The earning sources of the poorest families are also limited in the mountain districts. The poor families’ income from farming and other types of work is considerably lower than that of the well-to-do families. The collectors use the income from Yarsagumba to buy mobile phones, solar panels, and new clothes, cover healthcare expenses and education for their children and invest in cattle or jewellery. Yarsagumba harvesting has reduced dependency on agro-pastoral activities in remote areas. It is also true that the cost paid to the primary collectors is a small portion of the cost paid by the final customers.

Village-Level Brokers The second stakeholder in the supply chain is the village-level traders who are in close contact with the collectors and buy Yarsagumba from them. It is a male-dominated activity though female also participates. Diverse kinds of business mechanisms exist in this part. The village-level brokers act as money suppliers to the collectors. Often the collectors receive an advance payment from village-level brokers to collect Yarsagumba for the upcoming season. This requires that the collector commit to supply Yarsagumba at a specific price. During the lean time when the job opportunities are scarce and agricultural returns are less, the village-level brokers provide credits to these primary collectors, who repay mainly by giving Yarsagumba during the peak time. This mutual dependence brings the primary collectors under the direct economic power of village-level brokers by advantage of this loan system. In most cases, village-level brokers get advance orders from district-level brokers. The village-level brokers make money at low-interest rates from several banks or finance companies and give loans to collectors at slightly higher interest rates during the financially tricky condition. The loan is given to the collector without collateral. The poor collectors feel easy to get such loans than fulfilling various rules and regulations from the banks and other financial institutions. The village-level brokers expedite the business and augment their earnings by taking interest-free credits from district-level brokers, buying Yarsagumba from the collectors and selling it to the district-level brokers. The village-level brokers use this tactic to get a more significant share of benefit from the Yarsagumba business. Village-level brokers are community leaders, teachers, midlevel political cadres and local business persons. From the benefit of this business, they buy plots for houses nearby roads or at the district headquarter.

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District-Level Brokers District-level brokers stay in the district headquarters. They give advance money to the village-level brokers, collect Yarsagumba from different village-level brokers, take advance from national-level brokers, sell in Tibet, visit themselves, or go to Nepalganj and Kathmandu, and sell them, national-level brokers. The Chinese border is open for a few days or two weeks for Yarsagumba to be sold in Tibet. The amount sold is underestimated. One of the reasons for data being estimated too low is that trading Yarsagumba in Tibet does not need tax clearance and that the presence of Nepali government authorities in the northern border regions is virtually nil. People who had sold Yarsagumba in Tibet mentioned that the price of Yarsagumba depends on a number of factors: bigger size is considered one of the important indicators for the price, so the Tibetan traders discourage Nepali traders if the size of Yarsagumba is smaller and they bargain a lower rate. The traders generally share their experience as: “The Tibetan traders examine and criticise our Yarsagumba so they can give lower price as far as possible. They say that these pieces are not good, it is too small. I do not want to lose my money on such small worms”. Colour is another indicator. Bright colour is considered excellent, and dark colour is considered the poor quality of Yarsagumba. Knowledge of the local language and communication skills is important if they sell in Tibet. If Yarsagumba is taken to cities like Nepalganj, Surkhet or Kathmandu, Nepal’s government’s tax clearance is mandatory. One district-level broker mentioned that Nepali traders used to buy food items, clothes, liquor and cash in Chinese currency. They had to find another broker in Kathmandu to exchange Nepali currency from the Chinese. It was a difficult task for district-level brokers, and a national-level broker would benefit from this (illegal) exchange business in Kathmandu. The Chinese have started giving Nepali currency in northern border areas, and district-level brokers are safer when selling Yarsagumba in Tibet. The district-level brokers use the Yarsagumba profit to start entrepreneurship activities in the district headquarters or other towns like Surkhet, Nepalganj or Kathmandu.

National-Level Brokers The region’s price and demands for products seem to be controlled by either the national-level traders in Kathmandu or Tibetan border areas during specific days when the borders are open for Nepalis. The price affects the quality of raw materials and the bargaining power of district-level brokers in setting a reasonable price. The national-level brokers develop links with the international market and sell Yarsagumba in Tibet, Hong Kong and Singapore. Actors fix prices on the international market, and Nepali brokers have less bargaining power. Also, brokers at the national-level use profits from the Yarsagumba trade to start entrepreneurship in Kathmandu or major towns.

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Government Regulations The government of Nepal has initiated to enforce several rules on the collection, buying and selling of medicinal and aromatic plants. The local government and informal committee at the village level have developed provisions to require collection consent before collection begins through a local tax payment system and fixes the starting date of the Yarsagumba collection. While the purpose of these systems may have been affirmative, they have resulted in a distorted money-making atmosphere that is negative from the collector’s perspective. Bribery in the regulating government agency is a complicated reality for brokers at the both village and district levels. Those with the monetary means to address government authority’s demands and political agents can benefit from the current situation. However, those without the financially capable and political linkages cannot collect at the village and district levels or legally trade Yarsagumba.

Role of State to Promote Indigenous Healing and Medicinal Plant Resources The Government of Nepal has not formally recognised the indigenous healing system and the healers as partners in the country’s formal healthcare system. There are no concrete government policies and programmes designed to appreciate, encourage and develop this informal healing system managed by traditional practitioners (Subedi, 2018). The absence of a precise legal framework relating to medicinal and aromatic plant resources in Nepal has been the key barrier for transparent business. Although several policies, plans, acts and laws related to non-timber forest products, a separate, concrete and transparent mechanism is yet to be formulated. Discrepancy, gaps and inconsistency in several policies and laws frequently cause forest user groups to be confused and uncertain about property rights. Sometimes private organisations are given special collection privileges for certain products, even in community forests. Lack of administrative information and rule for medicinal plants in community forests are the frequently mentioned barriers to using natural resources among user groups. The multifaceted set of dealings for commanding a harvesting licence system, transaction, transport and sell to other persons and places, an uninformed royalty system, lack of controlling power at the district-level restrict efficient use of medicinal and aromatic plant resources in Nepal. The market information is limited; a small number of national brokers have access to price information on the wholesale market in India and China. Therefore, they can translate their superior knowledge into market power by determining the prices paid to district-level brokers, thus, to collectors. Their possibility to control the price is further enhanced by what seems to be a communication gap between different levels of brokers.

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Herbal-based traditional medicine and its practices have been developed in Nepal as a complementary medicine only. It remains to be systematised, institutionalised and made transparent. The mindset of policymakers and planners towards traditional medicine in Nepal is, to a large extent, distrust. Natural wealth and information have neither been efficiently conserved nor utilised. Despite a ban to collect and export, medicinal and aromatic plants are being smuggled out of the country through the Nepal-India and Nepal-China border. There is a growing practice of Indian traders trading certain medicinal plants in advance from the various hill districts of Nepal. High-valued medicinal plants are being overexploited at an alarming rate. Due to habitat loss and fragmentation, natural habitats are utilised for farming and mining purposes, and the local communities face water and air pollution. Increased efforts are required to prevent further losses of highly valued plants (Acharya & Paudel, 2020). The prevailing harvesting methods of particular plants need to be clearly evaluated. The various actors involved in medicinal and aromatic plant trading should understand the importance of keeping the species sustainable. If the species are threatened, new harvesting processes must be explored and tested, considering the socio-economic status of harvesting areas. Further, the indigenous knowledge about the traditional use of healing herbs warrants special attention to ensure the reasonable sharing of the profit from the utilisation of such knowledge, innovations and practices. Hence, the development of medicinal and aromatic plants possesses an enormous potential in poverty alleviation. The extensive participation of households in Nepal’s commercial collection of medicinal and aromatic plants and its contribution to household income clearly shows its economic implication. The potential for community-based management of natural resources is likely to be high where precise rules and regulations are developed and implemented in Nepal.

Policy Options Recently, India, China and other Asian countries have begun integrating indigenous medicine with modern health care. Suppose Nepal does not adopt policies concerning traditional health care. In that case, opportunities to learn about its pharmacopoeia will be reduced, and it will discourage the use of harmful substances and promote those that are valuable. Various clinical and pharmaceutical investigations and documentation efforts are required to ensure the future importance and use of medicinal plants. Medicinal and aromatic plants have both internal and international markets. Overharvesting may lead to its diminished accessibility and availability or even disappearance (Gewali, 2008). The conservation issues of MAPs become evident when its trade endangers the continued existence of valuable plant species. Nepal must broaden the knowledge base of MAPs use and practices to encompass the entire stock of relatively harmless and effective healthcare practices to expand the prospect of health

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care. Serious efforts are needed in research, training, education and communication. Nepal should develop and implement indigenous healing and use of medicinal plants policy, including effective regulation of highly valued plants. The commercialisation of highly valued plants will provide employment, income, and necessary medicine and oil to the farmers. Cultivation and commercialisation of these plants will also widen the scope of establishing processing centres and industries related to it. It is necessary to distinguish between the cultivated herbs, and those collected from the forest. Cultivated herbs should be removed from the Forest Act. Exports cannot be increased without making cultivator-friendly export policy.

Conclusion Nepal is losing century-old cultural-based traditional healing knowledge and practices of naturally available medicinal and aromatic plants. The key challenges are lack of recognition by the government, the absence of regulatory and legal mechanisms, and very little support for research. Despite a rapid socio-economic transformation, local communities still possess substantial knowledge of plants and their uses. Nepal is facing a rapid loss of experience-based indigenous medical knowledge and practices due to their dependency on the verbal transformation of knowledge within limited persons, the impact of globalisation, biomedical hegemony, rapid land degradation and climate change. Wide-ranging authentic documentation, recording, reporting and credentials of medicinal and aromatic plants are urgent. There is a need to focus on regional-, national- and local-level research and dissemination of the use of medicinal plants share the evidence-based findings. At the same time, there is a reduction of resources due to overharvesting and a lack of a proper natural management system. This should be integrated into the holistic development initiatives in the Himalayan regions. Acknowledgements I am thankful to Professor Marit Bakke for her constructive comments and valuable suggestions on the draft version, Martin Chautari for financial support to conduct fieldwork in the Karnali region, and the editors who encouraged me to write this paper.

References Acharya, K. P., & Prakash K. P. (2020). Biodiversity in Karnali Province: Current status and conservation. Ministry of Industry, Tourism, Forest and Environment, Karnali Province Government. Bauer, K. (2004). High Frontiers: Dolpo and the changing world of Himalayan pastoralists. Columbia University Press.

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Childs, G., & Choedup, N. (2014). Indigenous management strategies and socioeconomic impacts of Yartsa Gunbu (Ophiocordyceps sinensis) harvesting in Nubri and Tsum, Nepal, Himalaya. The Journal of the Association for Nepal and Himalayan Studies, 34(1), Article 7. Gewali, M. B. (2008). Aspects of traditional medicine in Nepal. University of Toyama, Institute of Natural Medicine. Gurung, H. (2001). Foreward (P, V). In Y. C. Lama, S. K. Ghimire, & Y. Aumeeruddy-Thomas (Eds.), Medicinal Plants of Dolpo: Amchi’s knowledge and conservation. WWF. Koirala, R., & Khaniya, B. N. (2009). Present status of traditional medicines and medicinal & aromatic plants related resources & organizations in Nepal. Nepal Health Research Council. Nepal, I. U. C. N. (2000). National register of medicinal plants. IUCN, Nepal. Olsen, C. S., & Bhattarai, N. (2005). A typology of economic agents in the Himalayan plant trade. Mountain Research and Development, 25(1), 37–43. Olsen, C. S., & Larsen, H. O. (2003). Alpine medicinal plant trade and Himalayan mountain livelihood strategies. The Geographical Journal, 169(3), 243–254. Olsen, C. S. (2005). Valuation of commercial central Himalayan medicinal plants. Ambio, 34(8), 607–610. Shrestha, U. B., & Bawa, K. S. (2013). Trade, harvest and conservation of caterpillar fungus (Ophiocordyceps sinensis) in the Himalayas. Biological Conservation, 159, 514–520. Subedi, M. (2001). Medical anthropology of Nepal. Uday Books. Subedi, M. (2009). Aromatic plant trade and livelihood strategies in Rural Nepal: A case of wintergreen in Dolakha District. Occasional Papers in Sociology and Anthropology, 11, 84–103. Subedi, M. (2018). State, society and health in Nepal. Routledge. Sulek, E. R. (2016). Caterpillar fungus and the economy of sinning. On entangled relations between religious and economic in a Tibetan pastoral region of Golog, Qinghai, China. Études Mongoles Et Sibériennes, Centrasiatiques Et Tibétaines, 47, 1–18. Wallrapp, C., Keck, M., & Faust, H. (2019). Governing the yarshagumba ‘gold rush’ a comparative study of governance systems in the Kailash Landscape in India and Nepal. International Journal of the Commons, 13(1), 455–478. WHO. (2002). WHO traditional medicine strategy 2002–2005. WHO.

Part II

Healing Practices Among Various Tribes

Chapter 7

Folk Healing Practices of the North-East States Shailaja Chandra

Abstract Ethnographic literature on folk healing exists, but no comparative picture for all seven states in the North East region of India is available. Documentation was difficult, and challenges were faced in collating information, accentuated by the healers’ reluctance to create such a repository. Healers play a vital role in treating illness. However, the methods used are highly individualistic, and in particular, the dependence on prayer, incantation and the use of spiritual powers integral to faith healing, transcends dependency on medicine. If the aim is to benefit a wider public, replication is challenging. Giving legitimacy to the healers will demand that the standards for inclusion and exclusion are shared and that the credibility of the certifying process is transparent. The entitlements that accrue due to certification would also have to be declared as demands for parity will inevitably start. Alongside the protection of sui generis knowledge and meeting the requirements of the Biodiversity Act will pose a challenge for those who seek to give legitimacy to tribal and folk healing. There is a need to sensitise healers about preserving the forest and promoting herbal gardens and the scientific community to undertake scientific validation and carry out reverse pharmacological and observational studies. Keywords Northeast Region · Documentation · Healers · Legitimacy · Certification

Introduction The Northeast region of India comprises eight states: Arunachal Pradesh, Assam, Manipur, Meghalaya, Mizoram, Nagaland, Sikkim and Tripura. The region is endowed with rich biodiversity and a unique heritage of indigenous folk medicine Shailaja Chandra is Public policy analyst with a four decade long civil service background mainly focused on health and medical pluralism. S. Chandra (B) Former Secretary, Department of AYUSH, Government of India, New Delhi, India e-mail: [email protected] © The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023 S. Reddy et al. (eds.), Ethnomedicine and Tribal Healing Practices in India, People, Cultures and Societies: Exploring and Documenting Diversities, https://doi.org/10.1007/978-981-19-4286-0_7

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(Dutta & Dutta, 2005; Ripunjoy, 2013). Local knowledge about the healing properties of medicinal and other living and inert matter is extensive (Shankar et al., 2012). The Research Councils for Ayurveda and Unani medicine under the Ministry of AYUSH have spent decades studying the folk healing practices of tribal people in different regions in India (CCRAS, 2014, 2018; CCRUM, 2020). However, an account exclusively devoted to the North-Eastern region where much of the population still depends on local healers does not seem to have been documented in the contemporary context. Since it was important to do justice to those folk healing traditions, the North-Eastern Institute of Ayurveda and Folk Medicine Research (NEIAFMR) was contacted for assistance.1 The effort goes beyond simple tabulation of what was observed; it records the populations of the villages where the healers worked, their names, addresses, photographs and occasionally their mobile telephone numbers. It lists their practices which provides scope for follow-up research. Second, the repeated finding that documentation was challenging to maintain has been highlighted and seen as a critical weakness in collating information, accentuated by the healers’ own reluctance to create such a repository. Third, while it is apparent that the healers have a respectable position in tribal society, the methods used are highly individualistic, particularly the dependence on prayer, incantation, and the use of spiritual powers, which are integral to faith healing sometimes surpassing doing the medical component. These cannot be replicated easily if the aim is also to benefit a wider public. The author initiated this paper by engaging several investigators from the Northeast state universities who worked under the supervision of two senior research staff employed by the then North-Eastern Institute of Folk Medicine (NEIFM) in Arunachal Pradesh, which is renamed as North-Eastern Institute of Ayurveda & Folk Medicine Research (NEIAFMR). The author’s request was made keeping in mind the institute’s objectives including the need to survey, document, and validate folk medicine practices, remedies, and therapies to revitalise, promote, and harness local health traditions (Ministry of AYUSH, 2019). The institute was expected to create an interface between traditional/folk medicine practitioners and research institutions and help upgrade the practitioners’ skills while protecting their Intellectual Property Rights (Ministry of AYUSH, 2019; NEIFM, 2009). Depending on the feasibility, the benefits of these traditions were intended to be integrated into the mainstream healthcare system for being used in primary health care. On the Director’s suggestion, the author agreed to assign work to identified research scholars in universities located in

1

I thank Mr. Otem Dai, Director of the North Eastern Institute of Ayurveda & Folk Medicine Research (NEIAFMR) and Hemen Hazarika and K Jayaprakash, senior research fellows at NEIAFMR, for their assistance for the study on the Status of Indian Medicine and Folk Healing (Chandra, 2013), from which this paper has been developed.

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each Northeastern states. List of institutions2 was engaged in research into the tribal and folk healing practices of the Northeast. The data was collected, compiled and edited by Mr. Hemen Hazarika, Senior Research Fellow (SRF), assisted by Mr. K Jayaprakash, SRF—posted at NEIAFMR. The final report was based on details provided by the collaborating institutes and was edited by the author. Over the months (in 2012), the author held several discussions with Mr. Otem Dai and Mr. Hazarika. Since different institutions were involved in collecting the data, it was not easy to maintain uniformity. In the following section, healers from different states have been mentioned, along with their expertise and the kind of treatment they offer.

Arunachal Pradesh In the survey conducted in 2012, six districts out of sixteen in Arunachal Pradesh were covered, cutting across different ethnic groups. Many traditional healers are using local healing practices and doing bone settings. The Department of Health had begun to enrol selected traditional healers after producing supporting documents showing their community activities certified by the local administrator. Interviews and discussions were organised with the folk healers and the Gaon Burrahs (Village elders) or a head of a family to collect primary information on the utilisation patterns of local health traditions, prevailing customs and local beliefs. A rapid assessment was carried out in East Siang District in which, besides meeting herbalists and local healers, the need to document the available knowledge on folk medicine was discussed. Even so, tactful handling and persuasion were needed as the folk practitioners were worried about divulging the identity of the plants and methods used for preparing medicine.

Process of Healing In addition to the local indigenous folk healers, the researchers found many healers from other states coming to Arunachal Pradesh, especially from Assam, Nepal, West Bengal and Bihar, who were very popular locally. Traditionally, various healers are present, and folk healing is practised by herbalists, faith healers, traditional birth attendants, bonesetters, snakebite doctors and ethnoveterinary practitioners. They also use their spiritual powers to cure common ailments, and local people have faith in this approach. There was a strong belief that the medicinal effect of some herbs 2

The North Eastern Institute of Science and Technology, Jorhat, Department of Botany, Guwahati University, Department of Environmental Sciences, Mizoram University, Aizawl, Regional Research Institute Gangtok, Sikkim, Department of Life Sciences, Manipur University, Imphal, Tripura University, Suryamaninagar, Agartala, Martin Luther Christian University, Shillong, Department of Botany, Nagaland University, Nagaland.

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was enhanced through incantation. This boosted the faith of the patient as well as the practitioner. Empirical knowledge helped the herbalist diagnose certain illnesses with certainty and prescribe healing herbs for a cure, but magic also played an important role in the whole process. Common people were reported to believe that a herbalist required spiritual powers to be effective as a healer. The faith healers depended more on the power of prayer, and while deciding the diagnosis, they prayed by candlelight or by using water as a medium. The traditional birth attendants continued to serve communities living in isolated and remote areas without medical facilities. The traditional bonesetters attended to a range of bone fractures and dislocations, sprains and congenital disorders, like club-foot and chronic conditions like arthritis. To recognise the healers for their knowledge and skills, NEIAFMR, in collaboration with the Indira Gandhi National Open University (IGNOU), had also started a pilot scheme to give “Prior Learning” certification to the traditional healers in the North-East states. The details of the healers who got prior learning certification of Arunachal Pradesh are given in the box below (Table 7.1). When the study was conducted, three folk healers served in the NEIAFMR, Pasighat and approximately 15–18 patients came daily for treatment. The health assistants maintain the patient records along with the names, addresses, treatment provided and photographs. This shows the recognition of their healing practices and attempts to integrate their healing skills into mainstream healthcare services (Table 7.2).

Result of the Sub-District-Level Survey A rapid assessment of the traditional health practices was carried out in 24 villages in East Siang District, where it was found that the herbal healers attended to around 29 conditions using home remedies. The folk healers were asked to document one complete remedy for each common problem like bone fracture, diarrhoea, a gynaecological problem or for pimples and black spots on the face, constipation with burning sensation, white patches on the skin, eye pain, toothache, common jaundice, hepatitis B, urinary bladder infection, cuts and wounds, gastric ulcer, diabetes, piles, sinus, headache, ringworm, fever, snakebites.

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Table 7.1 Healer with prior learning certification S N

Name of the healers

Address

District

1

Shri Tasen Zirdo

S/O: Late TaloZirdoVill: Zirdo village Circle: New Daring PO &PS: New Daring Dist: West Siang, Along

West Siang

2

Shri Promta Tamei

Vill: Loiliang, Circle: TezuDist: Lohit Lohit (M) 8974643,531

3

Shri Chowmikita Namchoom

Vill: Pangkhawa PO: KhremDist: Lohit

Lohit

4

Shri Temken Mingki

Vill: Meka, PO: Roing (M) 9863770546 Dist: Lower Dibang Valley

Lower Dibang Valley

5

Shri Andalo Keche

Vill: Mayu; Roing. Dist: Lower Lower Dibang Valley Dibang Valley (M) 9612269585

6

Shri Taiyum Tado Nirjuli

Short Cut, Nirjuli, Near NERIST Campus Type I Colony, District: Papum pare

Papum pare District

7

Mr. Tasung Jamoh

Yagrung, Pasighat (M) 09862703302

East Siang

8

Smt. Yanung Jamoh Lego

GTC Pasighat,080,145,234,485

East Siang

9

Mr. Talut Siram

Pangivillages, P.O. Pangin 094024041807

East Siang

10

Mr. Tazom Mize

VillRiga, P: O: Boleng 09402657508

East Siang

11

Mr. Tasor Muang

Po;Ps; Vill: Panging Tarak, Boleng 09436220322

East Siang

12

Shri Talung Taamuk

Vill: Rew, 09402617625

East Siang

13

Mr. Arakang

Vill: KomkarMariang

Upper Siang

14

Mr. Atti Mekik

Vill: Adipasi P;O; Marriyang 09612543956/9402657498

Upper Siang

15

Mr. Tagum Taki

Vil: Takilalung, P:O: yagrung 07308998263

East Siang

16

Mr. Boluperme

Vill: Kongkul, P;O; Mebo 09615982139

East Siang

17

Bekpa Tyeng

Lower Dibang valley retired principal (M) 08822106544/09706971877

Lower Dibang Valley

18

Mr. Darin Perme

VillNgopok P;O; Mebo 9402649922

East Siang

19

Mr. TayiGommeng

Rani Village P;O: Pasighat 9402461271

East Siang

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Table 7.2 Folk healers serving in the NEIFM OPD SN

Name

Address

Treatment

1

Mr. Tasung Jamoh

Yagrung Basti, Pasighat, Contact No. 09862703302

Common ailment, bone setting, Paralysis, poisonous bites, etc

2

Mr. Anand Jamoh

Yagrung, Sibut, Pasighat Contact No. 09862172644

Common ailments, Jaundice, Bone setting, mother and child care, paralysis, piles, and fistula

3

Mrs. Yalak Jamoh

Yagrung, Pasighat

Common ailments related to mother and child care, skin care

Photographs

Herbal healers in Arunachal Pradesh

Plant remedies

Healer treating a patient

The 29 diseases where relief was claimed by the healers and documented by research teams were: diarrhoea, malaria, jaundice, gastric problems, sinus, piles, conjunctivitis anaemia, tonsil, asthma, common cold, cough, toothache, headache, fever, joint pain, menstruation problem, skin problem, bone fracture, cut and wounds, stomach ache, snakebite, hair fall, pimples, mouth ulcer, cancer, dandruff, spondylitis, backache.

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Patients waiting in line at NEIFM OPD

Healer showing medicinal herbs

Healer with a patient

Investigators documents an interview with a birth attendant.

Traditional healing practices used in Arunachal Pradesh represent the oldest form of treatment used by indigenous people. The researchers found that there was a belief that energy is present in all matter, and knowledge about the properties of plants is established through trial and error. This has accelerated innovation, and the knowledge and skills are passed on to succeeding generations. This knowledge gradually becomes a part of the oral knowledge of that particular community.

Assam Assam is situated in the Northeast region of India—bordering the seven states of Arunachal Pradesh, Manipur, Meghalaya, Mizoram, Nagaland, Tripura and West Bengal and two countries, viz. Bangladesh and Bhutan. Eighty-six percent of the total population lives in rural areas, which is a higher proportion than in the rest of India. Assam has a large number of ethnolinguistic tribes, mainly Boro, Borokachari, Miri, Karbi, Rabha, Lalung, Kachari, Sonwal, Garo, Hajang, Dimasa, Khasi, Jaintia, some Kuki tribes, Barmans in Chachar, Deori, Hojai, Mech, Chakma, Singpho and Khampti. The traditional healers among these tribes treat minor diseases like fever, cough, skin disease, hair fall, body pain, stomach problems, abdominal pain, gastric ailments, eye itching, constipation and teeth problems. Diseases like diabetes, TB, dysentery, cholera, piles, malaria, liver swelling,

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bone fractures and jaundice are also treated. The knowledge is passed from generation to generation, although orally, because there is no written script. The local people primarily depend on the local traditional healers for their basic health problems. The healers rarely keep written records about the patients, but occasionally it is done. In some rural villages of Assam, midwives still offer their services at the time of delivery and attend to pregnancy-related problems. However, they, too, do not maintain any records.

Raw drugs from plants and animals used in the preparation of medicine

A picture of traditional practitioner (Mr.Singheswar Shyam-Jorhat)

Picture of medicine bottles

Manipur The traditional system of healing is called Maiba-Maibi and is one of the oldest folk traditions. Maiba (male healer) and Maibi (female healer) treat patients by prescribing medicine from locally available plants, animal products, and inorganic minerals like ores and crystals. The Maiba and Maibi read the pulse of the patient to diagnose the ailment. Generally, the male patient’s right hand and the female patient’s left hand are held while reading the pulse and the index, middle and ring fingers are used for pulse examination. Manipuri people widely accept the system of traditional

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Maiba-Maibi healing practice for the treatment of white patches, jaundice, paralysis, kidney stone, measles, diabetes, white discharge, liver pain, stomach ulcer, cough, boil, snakebite, dog bite, bone fracture, mental disorder and allergies. In the rural and hilly areas of Manipur, where modern doctors are not available, the traditional Maiba and Maibi are the only experts available. The Maibis also handle deliveries. There are five types of traditional healing practices: (a) Treatment using psychotherapy: Performing rituals like chanting hymns and making offerings to the Gods. (b) Treatment using massage therapy (Pukshuba) and reflexology (Mari Shuba) (c) Treatment using physical exercise (d) Treatment using diet and food (e) Treatment using plant remedies, animal products and minerals The research showed that 80% of the population of Manipur depends on traditional medicine in rural areas where modern medical facilities are not available (Table 7.3). Table 7.3 Some traditional folk healers of Manipur S.N

Name of the healers

Address

1

Ms. Chei Chin

Female/45 yr Community/Tribe: Zou District:: Churachandpur Mob: 8974103265

2

Mr.Laishram Ibatombi Singh

Male/81 yr Community/Tribe: Meitei Address: Lamlai Bazar District:: Imphal East Mob: 9612705597

3

Mr.Oinam Ningthem Singh

Male/63 yr Community/Tribe: Meitei District: Imphal West Address: LangolLairembiLeikai Mob: 9612558587

4

Mr. Athokpam Rajendro Singh

Male/61 yr Community/Tribe: Meitei District: Top MakhaLeikai, Porompat Road, BPO-k.k.Khong, Imphal East

Photograph

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Traditional & Folk Healing Practices in Manipur

Growth is commonly known as Lairenshajik treated by traditional

A healer with his patient

Healers demonstrates the properties of folk medicine

Herbal medicine prepared by women

Meghalaya Meghalaya, the “Abode of Clouds”, has seven districts and three ethnic groups, viz. Khasi, Jaintia and Garos. They have distinct beliefs, customs, traditions and culture and are mostly dependent on agriculture and other farming activities for their livelihood. The people possess rich indigenous knowledge about healing practices that continue to be practised in rural and urban areas. These practices are passed on from generation to generation by word of mouth. Since many villages do not have access to formal healthcare services, folk healing remains popular and traditional healers play a pivotal role in providing health care. They include bonesetters, traditional birth attendants, herbal healers, veterinarians, healers who treat poisonous bites, and those who specialise in the eyes, skin, liver and mental disorders. However, traditional healing practice is slowly shrinking due to overexploitation of medicinal plants, deforestation and lack of documentation despite being widespread and popular.

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A survey was conducted covering around 10% of the villages in each block comprising both accessible villages (60%) and inaccessible villages (40%). Since most healers and villagers were illiterate, information was collected based on a semi-structured questionnaire and conducting interviews, group discussions and home visits. These meetings revealed a keenness to promote traditional medicine. In each village, the interviews started with the village headman (traditionally known as Sordar) to get an idea of the population of the villages and the number of traditional healers who were popular with the community. Traditional healers continue to be sought after and are called “Nongaidawaikynbat” in the Jaintia Hills and as “Uwaaidawaikynbat” in the Garo hills or just “Kaviraj”. All tribes have a large number of traditional healers, and this work is respected. A traditional healer named Dr John Kharduit provided treatment for burn injuries, broken bones, paralysis, arthritis, diabetes, blood pressure, rheumatism, severe spinal injuries and other complicated cases even after people lost faith in conventional medical treatment. He owns a six-bed nursing home known as “John’s Herbal Nursing Home” at Thangsning, which has a swimming pool used to treat patients suffering from a spinal injury. In 2011, nine well-known traditional healers of Khasi, Jaintia and Garo Hills were awarded honorary doctorates for public health service by Martin Luther Christian University, Meghalaya (Tables 7.4 and 7.5). Table 7.4 List of nine renowned herbal practitioners S. No

Name of healer

District

1

Dr. Boss Myrthong

Nongstoin, West Khasi Hills

2

Ms Alka Kharsati

Shillong, East Khasi Hills

3

Mr. Kriston Thabah

Pynursla, East Khasi Hills

4

Mr. Carehome Pakyntein

Jowai, Jaintia Hills

5

Dr. Vidyanish

Tura, Garo Hills

6

Dr. Bentinck

Tura, Garo Hills

7

Mr. Vincent Kharbuli

Shillong, East Khasi Hills

8

Mr. Riangkhro Laloo

Jowai, Jaintia Hills

9

Mr. John Wesley Kharduit

Thangsning, East Khasi Hills

Table 7.5 List of herbal practitioners owning hospitals S No

Name of healers

Hospital

Location

1

John Kharduit

John’s Herbal Nursing Home

Thangsning, East Khasi Hills 6

2

Delas Rani

Samaritan Herbal KhasiHospital

Mawryngkneng,East Khasi Hills

10

3

Dr. Vidyanish

Sam A’chikSikman

Tura, West Garo Hills

6

No. of beds

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Of these, the Sam A’chikSikman hospital is not registered with the Government of Meghalaya. Although traditional folk healing is widespread, it is slowly reducing in importance due to a variety of reasons. The Khasi Hills Autonomous District Council (KHADC) had passed a Bill on the 2nd March 2011 intending to codify, protect and promote Khasi Traditional Medicine according to the social customs, traditional knowledge and Khasi practices. Approximately 462 healers from Khasi and Jaintia Hills attended the programme, which aimed at sensitising the district healers about the Bill and related aspects. A survey was conducted in both accessible and inaccessible villages in three administrative blocks. A total of 39 villages were surveyed, covering a population of 16,597 comprising around 3521 households. There are 129 local health practitioners and 71 birth attendants practising in those villages, according to information gathered from the village headman/Sordar. It was also found that most of the people living in villages are likely to consult traditional healers rather than an allopathic doctor. Out of 129 traditional healers who were identified, 43 were male and 28 female. Forty of them owned a clinic in the village. The source of income of the traditional healers was not entirely dependent on their practice as they also pursued other activities like farming, teaching, business or working as labourers. Most traditional healers practised only part-time, while a few renowned healers devoted full time to healing. The medicine used by the traditional healers consisted of herbs obtained from the nearby forest or herbal gardens, or village markets. Some medicinal plants were being sourced from other districts of the state.

A Traditional healer in his clinic and registers maintained by him for keeping patient records

It was found that only 31 healers maintained documentation which included the patient’s name, village, and disease treated. Generally, however, traditional healers were not aware of the importance of documentation but only recently have begun keeping records. Data was collected through a household survey in order to get an idea of the most dominant diseases in the villages. From a total of 160 responses collected, it was observed that the most widespread ailments related to fever, cough,

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cold, headache, chest problem (104), gastrointestinal problem (82) and malaria (50), while the rest were occasional only. The preparation of medicine is primarily home-based. After collection, the medicinal plants are washed and ground into a paste. After preparation, the medicines are stored in small plastic packets or an airtight container. Most medications are prepared fresh by grinding into a paste or boiled in water to be taken orally or applied externally. On the other hand, the parts of rare medicinal plants, i.e. the seeds, bark, roots, etc., are dried, ground to a powder and stored in airtight containers. The bonesetters mainly treat fractures and dislocation of bones and cartilages caused by accidents or because of bone TB. The treatment is based on whether the symptoms are complicated or straightforward. If they are complicated or multiple, they refer the patient to the hospitals after giving first-aid. The diagnosis is based on the degree of swelling, the type of wound and the extent of difficulty in movement. Treatment consists of wrapping a bandage around the affected area after applying selected herbs and giving the patient a herbal formulation. In the case of snakebites, symptoms like the bite mark, redness of the eyes, swelling of the face, hands and legs accompanied by weakness of the body determine the diagnosis. Since the poison affects the heart, proper treatment has to be given immediately. The healers prepare a herbal paste and apply it to the area of the bite at least once a day for a week or depending on the condition. The traditional birth attendants do not use any herbs, and this was seen in all three blocks where surveys were conducted. The highest number of birth attendants were reported from Mawkyrwat, West Khasi Hills. Traditional health practitioners play a pivotal role in providing healthcare services, especially in rural areas where there is an acute paucity of healthcare facilities. With the increase in deforestation, forest fires and overexploitation of medicinal plants, there is a need to sensitise people about preserving the forest and promoting herbal gardens.

Mizoram Mizoram is a land of beauty with rolling hills, valleys, lakes and rivers and consists of eight districts inhabited by different tribes. The Lushais are the most dominant tribe besides a few others like Paihte, Lakher, Chakma and Riangs. While doing the survey, village elders, women and the local people from different areas were consulted. It was found that about 99% of the rural population in the interior parts rely on herbal medicine. Practically all raw drugs are harvested from the wild. In urban areas, it was found that some people preferred natural drugs to synthetic or allopathic medicine. Some practitioners are offering treatment as a part of family tradition with knowledge handed down from generation to generation. Some have acquired basic knowledge about traditional medicine and have begun using it for commercial purposes, but that was not widespread.

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Nagaland Nagaland has a population of 19.81 lakh and 11 districts. Traditional Naga medicinal practitioners have been treating patients for generations, and even today, they are trusted. The traditional knowledge is passed down from parents to children, but in some cases, the practitioners die before transmitting the knowledge to anyone. The knowledge being a closely guarded secret is confined to the family in most cases, and with the healer’s death, continuity can be lost. The researchers selected the folk practitioners they interviewed carefully based on their experience and the recommendations of local people. After comparing the medicinal plants used by the healers, some similarities between the healers of the two communities could be found relating to the use of plant species and their application for various diseases and disorders. The community is still totally dependent on plants found in the wild as efforts to cultivate them had not started (Table 7.6).

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Table 7.6 Details of the healers consulted Community

Name of the healers

Age

Sex

Field of expertise

Angami

Mr. Apu

40

M

All kinds of sickness Government servant

Ao

Occupation

Mr. Apa

29

M

All kinds of sickness Healer

Mr. Aku

72

M

Gastric and Kidney stone

Healer

Mrs. Tanusuo

77

F

Nerve problems and bone fracture

Healer

Mr. Katuka

72

M

Bone fracture

Healer

Mrs. Bino

42

F

Women-related problems and Bone fracture

Traditional weaver healer

Mr. Nungshiba

32

M

Sickness and poisoned

Healer

Mr. Asungba

55

M

All kinds of sickness Healer

Mr. N. lmti

71

M

Stomach Disorder

Advocate Healer

Mr. Chollen

62

M

Paralysis, sinus, appendix, piles and cancer

Healer

Mr. Akanglemba

78

M

Bone fracture

Healer

The medicine prepared by Folk Healers in Nagaland

Sikkim The Himalayan State of Sikkim joined the Indian Union in 1975 and borders Bhutan, China in the North, Nepal in the West and West Bengal to its south. The population of the state is about six lakh. The state has three distinct ethnic groups, the Lepchas, the Bhutias and the Nepalese, who have been practising traditional medicine for years. Twenty-nine traditional healers are registered with the State Medicinal Plant Board

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of the Government, and more than 100 folk healers have been practising traditional healing systems at different places in the State. “The tantrik forms of religion and medicine are believed to have been popularised by Guru Pamasambhava or Guru Rimpoche. He is considered the master of healing, and in his tantrik form as the medical Buddha, he was revered for healing mental depression and psychological problems” (Panda & Mishra, 2012, p. 369). In Sikkim, illness is treated along with worship and devotion. The folk healers believe that it will have little effect unless a medicine has been empowered by special benediction. The folk healers collect the herbs at an auspicious time because they believe this to have better efficacy (Panda & Mishra, 2012, p. 370). A publication titled Traditional Herbal Healers of Sikkim has been published as a Monograph by the State Medicinal Plants Board and the Forest, Environment & Wildlife Management Department of the Government of Sikkim. This publication contains information based on personal experiences and describes the practical aspects of traditional folk healing and the formulation of different drugs and their uses.

Lepcha Medicinal Practice The Lepchas constitute about 13% of the state’s total population inhabiting the Dzongu reserve of North Sikkim District. Among the Lepchas, the concept of health and illness is guided entirely by a belief in the supernatural powers. They mainly follow the Mahayana sect of Buddhism. They have their script and language, traditional dress and culture. The use of medicinal plants is described in the Lepcha epics called Tengyur, Namtar/Namthar and Domang. They respect some of the semidivine guardian spirits such as Lungzee. These could include a giant tree or a cluster of trees, a cave, a special hillock, or another natural object. They believe that any kind of disrespect to these items by ignoring, defiling, polluting or unholy acts, can invite suffering on the whole village or serious illness or even death to a particular individual. According to the Lepchas, the world is ruled by good and evil spirits. Natural disaster, drought, hailstorms and similar natural events, even a bad harvest are believed to be the action of evil spirits. On the other hand, good health and vitality, good harvest, and prosperity are credited to the action of good spirits. Traditionally, only the Bongthings (male Lepcha priests) and Muns (the female Lepcha priestesses) are called during sickness or funeral ceremonies. The Muns perform rituals connected with supernatural forces. Pougorip/Totola (Oroxylumindicum), a medicinal plant used in Ayurveda as an ingredient of Dashamula, also plays a vital role in Lepcha medical treatment. The Lepcha believe in the purity and chastity of this plant since it is not even touched by bees and the plant is used as a liver tonic and an antidiabetic medicine. The fruit of the plant is shaped like a huge sword. The seeds inside the fruit are flagellated like paper silk and are used in auspicious occasions and ceremonies. Chi (millet beer) also plays a significant role in Lepcha culture and is used to drink to good health.

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Bhutia Medicinal Practice “The Bhutias place great emphasis on coercive rites to exorcise and destroy demons” (Panda & Misra, 2010, p. 184). The practice of religion is in the hands of trained specialists called paus (male specialists) neyjums (female specialists), and lamas. During the curing process, a pau enters into a trance state and communicates with spirits to discover why they have afflicted the patient. Another approach is through divination using a plateful of rice. The pau shakes the plate until the symbol of the evil spirit appears in the rice. The pau performs “Phuphi” by offering money, eggs, and clothes that have been circulated three times over the patient’s head to be offered to the malignant spirit (Panda & Misra, 2010, pp. 184–185). Only the clothes are brought back from the ritual, and it is believed that patients will be cured within three days of performing the ritual. All Sikkimese settlements are adorned with prayer flags, or Dacho, which are believed to carry good fortune from every direction.

Nepali Medicinal Practice The Nepalese tribe also believes in the role of supernatural forces in the causation of illness. Dami and Jhakris performed healing rituals to treat physical and mental illnesses. The herbs such as Oroxylum indicum for hypertension, Fraxinus floribunda for gout, Panax pseudoginseng for longevity, Ephedra gerardiana for asthma, Elsholtzia blanda, Mahonia nepalensis for eye infection and eczema, and Urtica parviflora for invigoration after child-birth are considered to possess medicinal properties (Panda & Misra, 2010). Rhizome of Budo-Okhati (Astible rivularis) is considered to be suitable for lumbago. It is crushed and taken as a decoction after boiling in water or chewed like betel nut to relieve body ache. Flowers of Pandanus nepalensis are said to have aphrodisiac properties that also induce sleep. These are found at altitudes up to 1700 m and are used to adorn the hair to wine lovers. The plant’s roots taken with milk are said to prevent abortion; the flowers are said to remove headache and weakness, and the seeds are believed to cure broken hearts (Panda & Misra, 2010). The healing practices of these three ethnic groups are a mixture of personalistic and naturalistic theories of illness. According to prevalent beliefs, illnesses may be linked to transgressions of a moral or spiritual nature which involve inappropriate behaviour, violation of social norms or a breach of religious taboos. Naturalistic theories view illness as a manifestation of disharmony between the person and the environment. Perception of illness is highly culture related. During the survey, data on 44 medicinal plants was collected. Most plants were being used for rheumatoid arthritis, gout, gonorrhoea, fever, viral flu, asthma, cough and cold and indigestion. A total of 48 (39 male and 9 female) folk healers were identified in Sikkim. Half of them were illiterate and one-tenth had education up to matriculation. Their age, sex,

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educational qualifications, sources of knowledge, types of practices, experience and use of traditional knowledge were all noted. Only four out of 48 healers were of below 40 years and 17 were above the age of 60 years. More than two-third of the healers belonged to the Nepali community. Most Nepali folk healers practised according to Ayurvedic treatment principles, and one-fourth of them practised Tibetan medicine. No one knew about Siddha, Unani or Yoga practice. More than two-third healers were practising their traditional folk healing running into the third generation. Almost half of them had a monthly income in the range of Rs.1000–3000, while little less than one-fifth had earned over Rs. 9000 per month. What is notable is that 80% of the folk healers were eager to find alternative sources of income and leave their traditional vocation. Many of were not happy with their profession. An attempt was made to know how knowledge was being exchanged among the people. It was found that more than half of the healers aged 50 and above had not transferred their knowledge to anybody and less than one-third healers had instructed their sons and daughters (Panda & Mishra, 2012). “The health traditions of Sikkim’s population are linked with the ancient philosophical systems that connect the cosmic and terrestrial, between the outer and inner environment, and between the external and internal body. The people of Sikkim access folk medicine easily at little or no cost. Folk medicine is considered an effective and acceptable method of treatment. It would be difficult to alter the faith in traditional medicine, and even if allopathic drugs were available, people would need to overcome the fear of modern medicine, which is considered chemical-based, needing a doctor’s prescription and generating side effects” (Chandra, 2013).

Examples of Folk Medicine Practitioners in Sikkim Mr. Chintamoni Dabani (about 60 years) is a traditional folk healer from Chengay Lakha, East Sikkim. He acquired his knowledge from his father and has been practising herbal medicine for 40 years. He treats fever, jaundice, gastritis, wounds, burns, female disorders and infertility. The manner of treating a case of fever was observed and is recounted below: A patient who came to the healer’s house had suffered from fever and headache for two days. The healer checked the patient’s pulse and advised him to take a decoction of the Swertiachirayata stem and take it three to four times daily for three days. The patient was normal after three days without any other chemical medicine. Thirty-one medicinal plants are used frequently in traditional healing practices in Sikkim. Folk traditions are gradually declining as the new generation of young people are not volunteering to learn these healing practices as a profession. The NGOs working for traditional medicine are trying to establish an association of folk healers to preserve and promote their age-old traditions. However, because of a significant shift in the socio-economic status of people, folk medicine practices are on the wane. Scientific validation, reverse pharmacological and observational studies are required to understand their healing properties.

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Tripura Tripura has diverse ethnolinguistic groups, but the culture is quite composite. The dominant ethnic groups are Tripuris/Tripura, Riang, Jamatia, Chakma, Halam, Mog, Munda, Noatia, Garo, Orang, Kuki, Lushai, Bhil, Chaimal, Santhal and Uchai, Khasia, Lepcha and Bhutia (Government of Tripura, 2007). These groups mainly reside in remote forest areas and generally use traditional medicine. The healer’s knowledge is passed on from generation to generation through the oral tradition because there is no written script. Much of the traditional knowledge has remained confined to the local healers.

Local traditional healers in Tripura

Field investigator interview

conducting

an

Local traditional healers

The medicinal system practised by the healers in Tripura is centuries old. The healers recommend different kinds of medicine for a variety of diseases. There is no scientific documentation of the traditional formulations and nor is any written record maintained. The medicine given to the patient may be in capsule form or powdery material or tied to the body with a piece of newspaper or leaves. It may also be administered in the form of a paste, liquid or syrup. This is provided in an ordinary bottle along with instructions for use. The local villagers depended upon the traditional healers and reported that they were satisfied with the medication. There are around 95 Midwives/Dais who offer their services at delivery and attend to pregnancy-related problems.

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Conclusion and Recommendations The efforts to conserve and revive folklore in the Northeast and validate and recognise it are commendable, but they raise several policy questions. These are listed below and emanate from the findings of the research conducted: 1. There is a need to understand the dynamics of accepting the responsibility for selecting healers considered fit for “certification”. The aim of such certification needs to be spelt out. If it is to give legitimacy, how the standards for inclusion were selected and the credibility of the certifying agency would need to be transparent. 2. There is a need for clarity about entitlements that accrue as a result of certification. Sooner or later, the aspirations of those who have received certification will grow, and demands for parity or some other sort of recognition will start. At that time, the basis for the selection of healers may arise. This should be anticipated so that the process is clearly understood, and objectivity should be maintained in defining the selection criteria. 3. It is necessary to have an overall idea of where the certification would lead, as the approach should be seen in the context of what is happening in other parts of India. The Ministry of Environment & Forests and the Ministry of Tribal Affairs have had considerable experience in dealing with allied subjects of rights, entitlements and protection of sui generis knowledge and the requirements of the Biodiversity Act. The NEIFM needs to become a nucleus around which past endeavours in the area of folk healing can be collated at one place for the Northeast region. The institute should start by building networks and accessing studies and reports undertaken elsewhere and become a credible agency that understands and implements the legal requirements. 4. With an increase in deforestation, forest fires, and overexploitation of medicinal plants, there is also a need to sensitise the people about preserving the forest and promoting herbal gardens. NEIAFMR should act as a conduit for imparting such knowledge and network with exemplary institutions and organisations in each state to implement a sustained programme. 5. Scientific validation, reverse pharmacological and observational studies are required to understand the healing properties of plants and tribal and folk usage, which fall outside the codified systems of Ayurveda and Unani medicine systems. There is need to focus on those plants that are used extensively by the healers but are outside the ASU formularies. The outcomes need to be published in botanical and pharmacological journals. 6. The efforts being made to conserve and revive the folklore and give it validation and recognition are good initiatives, but the documentation has to be a continuous effort, and it is necessary to add new findings whenever these come to light. It is one thing to research what is happening and derive satisfaction that in the absence of doctors to serve in these remote areas at least, the tribal and folk healers can provide treatment for various conditions. It is quite another to accept

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that these practices can be used on sick people based on external symptoms without studying their effectiveness and safety concerns. Undoubtedly there is a need to encourage and support the efforts, but some transparent benchmarking would be needed to accept/reject claims about successful healing. Equally, if the outcomes were good and the patient felt better even in subjective terms, the therapy must continue if people have faith in it. It may be a good idea to organise an open house for each state when patients are asked about their condition before and after treatment. If competent experts undertake observational findings, the degree of improvement and patient satisfaction can be documented. Such a database would become a valuable and credible repository of the therapeutic benefits of tribal and folk healing practices.

References CCRAS. (2014). Glimpses of CCRAS R&D contributions and research oriented health care programmes in North East India. Central Council for Research in Ayurvedic Sciences, Ministry of AYUSH, Government of India. http://ccras.nic.in/sites/default/files/ebooks/Glimpse%20of% 20CCRAS.pdf CCRAS. (2018). Glimpses of CCRAS contributions (50 Glorious Years): Medicinal plants research (Vol. III). Central Council for Research in Ayurvedic Sciences, Ministry of AYUSH, Government of India. http://ccras.nic.in/sites/default/files/viewpdf/Publication/CCRAS_Glimpses% 20Volume-3.pdf CCRUM. (2020). Annual report 2019–2020. Central Council for Research in Unani Medicine, Ministry of AYUSH, Government of India. https://ccrum.res.in/writereaddata/UploadFile/ CCRUM%20Annual%20Report%20201902020%20(English)_1463.pdf Chandra, S. (2013). Status of Indian medicine and Folk healing: With a focus on integration of AYUSH medical systems in health care delivery (Part II). Department of AYUSH, Ministry of Health and Family Welfare, Government of India. https://reporttraditionalindianmedicine.blo gspot.com/p/blog-page.html Dutta, B., & Dutta, P. (2005). Potential of ethnobotanical studies in North East India: An overview. Indian Journal of Traditional Knowledge, 4, 7–14. Government of Tripura. (2007). Tripura human development report 2007. Government of Tripura. https://trci.tripura.gov.in/sites/default/files/tripura%20hdr.pdf Ministry of AYUSH. (2019). AYUSH in India-2018. Ministry of AYUSH, Government of India. http://repository-tnmgrmu.ac.in/11920/1/AYUSH_in_India_2018.pdf NEIFM. (2009). Proceeding on traditional healing practices in North East India. North Eastern Institute of Folk Medicine, Department of AYUSH, Ministry of Health & Family Welfare Government of India. file:///C:/Users/Dell/Downloads/Traditional_Healing_Practices_of_North_E.pdf Panda, A. K., & Mishra, S. (2012). Some belief, practices and prospects of folk healers of Sikkim. Indian Journal of Traditional Knowledge, 11(2), 369–373. Panda, A., & Misra, S. (2010). Health traditions of Sikkim Himalaya. Journal of Ayurveda and Integrative Medicine, 1(3), 183. https://doi.org/10.4103/0975-9476.72617 Ripunjoy, S. (2013). Indigenous knowledge on the utilization of medicinal plants by the Sonowal Kachari Tribe of Dibrugarh District in Assam, North-East India. International Research Journal of Biological Sciences, 2(4), 44–50. Shankar, R., Lavekar, G., Deb, S., & Sharma, B. (2012). Traditional healing practices and Folk medicine used by missing community of North East India. Journal of Ayurveda and Integrative Medicine, 3(3), 124–129.

Chapter 8

Understanding Aetiology of Diseases: Special Reference to Lepcha Communities of Dzongu, Sikkim Tshering Lepcha

Abstract This paper analyses the disease aetiology and the health-illness practices among the Lepcha communities of Dzongu, North Sikkim. It illustrates their unique culture and traditions. Their understanding of the etiological factors of diseases and the concepts related to health, illness and well-being varies from community to community in their respective geographical areas. Their day-to-day activities, culture, costume, religious practice and environmental factors all contribute to their health in the communities. Lepchas are the indigenous tribal population in Sikkim living alongside the Nepalis and Bhutia Communities. The study was carried out with the help of qualitative research tools and techniques and captured Lepcha’s understanding of health, illness and its disease aetiology. The objective of this paper is to understand the disease aetiology of the Lepcha community. The Lepcha community also perceives that there is a common belief regarding various benevolent and malevolent spirits. It was found that they mainly believe in supernatural powers and worship the souls or the spirits of their ancestors. They believe and perceive that ancestors’ spirit in their culture plays a significant role in ensuring good health, safety, protection and wealth of the family. When these ancestral spirits are not well respected and adored, they always cause problems for the family members and the community. They believe and perceive that the causes of illness and disease arise due to the disturbance to nature, deities and ancestral spirits. The Lepchas also do various faats (rituals) prayer to the mountain, land, river and caves. The Lepchas of Sikkim have enormous faith in herbal medicine and healing practices found through trial and error and gained through constant practices. Herbal medicine is widely practised among the tribes, and Sikkim medicinal board is promoting medicinal plants for more extensive use. Keywords Aetiology · Traditional healer · Local health practices · Lepcha · Dzongu T. Lepcha (B) Research and Development Officer, Anugyalaya Darjeeling Diocese Social Service Society, Loreto Convent Road, Darjeeling, India e-mail: [email protected] © The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023 S. Reddy et al. (eds.), Ethnomedicine and Tribal Healing Practices in India, People, Cultures and Societies: Exploring and Documenting Diversities, https://doi.org/10.1007/978-981-19-4286-0_8

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Introduction India has a vibrant tradition of indigenous medical knowledge, and the local communities use its practice to meet primary health care (Bhasin, 1989; Kakar, 1977). Every community has its own beliefs and practices regarding health and diseases. It also overviews the perception of health-illness and practices—their understanding of the etiological factors of diseases. The concepts related to health, illness and well-being vary from individual to individual and community to community in their respective geographical areas. Their day-to-day activities, culture, costume, religious practice and environmental factors all contribute to their health in the communities. The sociocultural array of the community is one of the major factors towards the availability of resources and the use of different kinds of treatment approaches (Subba, 2008). The Lepchas of Dzongu have their unique features, language, belief system, cultures and traditions. According to their perceptions and beliefs, they follow certain healing practices. These healing skills, knowledge and resources are gained from their ancestors by learning or practising and are verbally passed on from one generation to the next generation. The traditional healers1 have their distinctive specialities in treating various kinds of illnesses in the community. They chant mantras, use medicinal plants and herbs. The traditional faith healers use all these things to prevent diseases, cure illnesses and restore good health. The Oxford English Dictionary defines ‘healing’ as “to restore (a person, etc.) good health from wickedness and also to provide warmth and care (as sin, grief, disrepair, unwholesomeness, danger, destruction); to save, purify, cleanse, repair, mend” (Kakar, 1982, p, 3). The Lepchas of Dzongu also have their understanding regarding the concept of health and illness. The belief and health practices of Lepchas are mainly based on their socio-cultural and religious practices. Based on their world view, the local health practices are an account of being healthy and well-being related to the mental, social, spiritual, physical and ecological dimensions. The central conception is to maintain an optimum balance of health within the individual and between the individual, society and the whole world (Kakar, 1982; Sujatha & Abraham, 2009; Unnikrishnan & Hariramamurthi, 2012). Indigenous knowledge, traditional medicine and folk medicine have their unique features to provide holistic care to the sick and the suffering. The community people were aware of their skills and practices. They have the experiences of the healing process (Lambert, 2012).

Materials and Methods This paper is based on the author’s MPhil dissertation work. The fieldwork was carried out from December 2013 up to February 2014 in North Sikkim, Upper 1

Traditional healers refer to spiritual/faith healers like Lepcha call their male faith healers as bongthing/priest and female faith healers as mun/priestess.

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Dzongu. The study was carried out with the help of qualitative research tools and techniques and captured people’s understanding of health, illness and its causation. It also captures the individual day-to-day life, food habits, usage of home remedies and medicinal plants for common ailments, faith healing practices, local health practices, community festivals, sharing of knowledge and their experiences. The author did a semi-participant study by staying in the community, collecting data and participating in their day-to-day activities. The author maintained a diary and noted day-to-day activities. The data collection tools were in-depth interviews with the respondents, healers, family members, health workers and community people. The observation technique was used to capture the healer’s performing rituals and treating the patients. The nature of the sampling technique was the snowball technique to identify the respondents and households who were having complaints of health problems and other related issues. The study focused on traditional healers to understand the perception of health and illness and their healing practices. The healers were interviewed based on their availability in the community. For the study, informed verbal consent was taken from the respondents, family members, healers and the community people. During the fieldwork, the author got prior permission to take photographs, videos and other recordings for the research purpose. The study was carried out based on the willingness of the respondents.

Study Area There are four districts in Sikkim. The study area, the Dzongu reserve zone, is located in North Sikkim. The area was mainly considered a protected area for the Lepcha Community by King Chogyal Namgayal during his reign (Bhasin, 1989). The people who belong to the other parts of Sikkim or other states had to take special permission from the concerned authority. The Lepcha communities originally belonged to Dzongu. It is a restricted area for the outside people. The King’s main purpose is to protect the community from various threats such as cultural, social, economic and political. The Lepcha tribe fully dominates this area, and their main source of income is cardamom and paddy cultivation. Apart from that, they collected forest raw materials to sustain their day-to-day life. It has a scattered population, and the PHCs cover 7084, and sub-centre covers 1526 (DLHS-3, 2007–2008). The density of population is significantly less, i.e. ten persons per square kilometres. The north district is the largest of the four districts of Sikkim, which has fewer populations than other Sikkim districts. Most of the state’s people reside near Mangan, the district headquarters, which is about 2000 ft. (610 m) above sea level. Because of all these reasons, author purposively selected this study area for the research. The field area is affluent in biodiversity, and also the government of Sikkim announced this area as a booming tourist destination for the local tourists and foreign tourists.

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Source https://www.google.co.in/search?q=map+of+north+sikkim+dzongu&biw

Indian Healthcare System The Indian healthcare systems are divided into two broad categories, namely (1) biomedicine and AYUSH that is present in written documents and has a codified professional system. (2) The second category contains the non-codified system or folk traditions, including bonesetters, traditional birth attendants, herbalists, spiritual healers, shamans and diviners. There is no written documentation and not certified institutionally. It is found, mainly in the rural areas among the ethnic

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groups, indigenous and tribal communities. They provide holistic healthcare services since it is appreciated and accepted by the community (Sujatha & Abraham, 2009; Unnikrishnan & Hariramamurthi, 2012; Priya & Shweta, 2010; Lambert, 2012).

Traditional Healing Practices of Lepcha Community Lepcha, as an indigenous tribe, is mainly belonging to Sikkim, but many of them are distributed in other areas like Darjeeling District of West Bengal, foothills of Bhutan and Ilam (Nepal), the Himalayan regions. Lepchas in their language are called to be “Mutanchi Rong Kup Rum Kup”, meaning “Beloved Children of Mother Nature and God”. The Lepcha is also derived from the word Lapchao, which means the resting or the waiting place, and even it is the place where the mass of stones is kept to show the direction during the journey (Bhasin, 1989; Plaisier, 2005). The Lepcha people strongly believe in their ritualistic practices like Rum Faat, shamanistic healing, birthing and during the death sacraments, which are performed by the male priest Bongthings. Mun is a female priest who also conducts rituals and other ceremonies. In the community, they are observed as qualified and experienced traditional practitioners who can provide services in the region. It was found that for most health problems, they use medicinal plants and herbs in the form of paste and water extracts. In some cases, they also add animal parts in their preparations. Lepchas are the people who live with nature in perfect harmony, and they are the people who believe in their sacred origin (Gurung, 2013). They are also shrewd botanists, as they have inherited knowledge about numerous medicinal plants and herbs found in the Himalayan belt. On the negative side of western medicine, many people prefer to use indigenous medicine, including medicinal and herbal medicine and spiritual cure in Sikkim. According to the Lepchas belief, ‘Rum’ means ‘Good Spirit’ and ‘Mung’ means ‘Bad Spirit’. However, it is difficult to identify whether the spirit is ‘good’ or ‘bad’ (Roy Burman, 2003).

Theoretical Concept of Illness Causation Foster (1976) describes in his paper about “disease aetiologies in non-western medical systems” that there are two basic types: ‘naturalistic’ and ‘personalistic’. In naturalistic systems, illness is explained in ‘impersonal, systemic terms’, with disease resulting from “such natural forces or conditions as cold, heat, winds, dampness, and above all, due to an upset in the balance of the basic body elements” (Foster, 1976, p, 775). Intervention is therapeutically oriented towards achieving bodily equilibrium (the humour, yin and yang, or in Ayurveda dhosas that affect the individual health condition). Individuals can maintain good health by avoiding disease-producing situations or behaviour. Personalistic systems view illness as “but

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a special case in the explanation of all misfortune” which can be attributed to the “active, purposeful intervention of an agent, who may be human (witch or sorcerer), non-human (a ghost, an ancestor, an evil spirit), or supernatural (a deity or other very powerful being)” (1976a). Murdock (1980) explained the theory of illness, which was categorised under two sub-types, ‘natural causation’ and ‘supernatural causation’. In his sub-type, natural causation, he defines that any theory, which is precise and socially accepted, accounts for ill-health due to physiological changes experienced by the patient in certain situations, which has been emerging rationally in advanced medical science. This theory again implied under various categories, which mainly describes ‘infection stresses’, ‘organic deterioration’ and ‘accident’. His second sub-types of theory mainly focused on supernatural causation, which has also been described in various parts such as ‘mystical causation’. He explains the causes due to uncertain situations, threatening conditions, contamination and supernatural vengeance. In his ‘magical causation’, he mainly deals with the causes related to sorcery, exorcism and witchcraft. His ‘animistic causation’ depicts the causes related to evil possess, soul loss and spirit aggression (Murdock, 1980). Hasan (1967) conducted a study in the North Indian village, exploring the practices and cultural aspects of health and illness. The author describes the factors contributing to the causes of health and diseases in the study area. It gives detail about the community life, environmental causes of health, sanitary practices, personal hygiene, food habits, cultural practices, community ritual practices, religious practices, healer-patients relationships, traditional medical practices, utilisation of health services, etc. The causes of illnesses are natural and supernatural, and there are various other contributing factors. Health and illness have connections with their community beliefs, customs and practices for the treatment of the patients. Their culture-based practices have positive and negative impacts on the health condition of the community people (Hasan, 1967). Bhasin (1989), in the ethnographic study conducted in North Sikkim between the two ethnic groups Lepcha and the Bhutia, focuses on the concept of disease and illness, the different treatment methods and the official health policies. It also describes how and why traditional medical knowledge is persisting between these two ethnic groups. The study showed slight differences between the two ethnic groups, having their territorial region including different beliefs and perceptions regarding the illnesses. They believe in supernatural and natural causes of illnesses. Food patterns differ from each other. Both the communities had their faith healers, and they had their ritual practices. The study also revealed the demographic data of the study area and about the ethnic groups. The findings of this study illustrated the prevalence of common diseases like diarrhoea, dysentery, worm infestations and goitre (1989a). The community people believe in the power of forests, hills/mountains and rivers and see them as Gods or the mother of a creator who protects them from all the difficulties. Roy Burman (2012) conducted his study titled “Ethno-medicine among the Bhutias and Lepchas of Sikkim” in the Kabi village, North District of Sikkim. The Lepcha and Bhutia concept of illness and disease is based on cultural, religious and

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social disturbances, leading to health issues among the community. During the study, common diseases were found, such as diarrhoea, dysentery, pneumonia and chronic diseases like tuberculosis and skin disease. The Lepcha and Bhutia are very religious in their ‘bearings’, ‘affecting the entire lifestyle’, including the ‘arena of health’ and ‘disease and cure’ (2012a, p. 122). They strongly believe in any kind of disease or illness that was caused by supernatural powers.

Perception, Beliefs and the Local Health Practices Pema (pseudonym) is a woman of 45 years old, having a history of hypertension since two to three years back. She has three children. She was a housewife and did all the household work as well as in the field. She reported having good health three years ago. She said that when she was diagnosed with the case of hypertension, her dietary pattern was changed with some restrictions in her regular diet. Because of these restrictions, she had lost her weight, and her health had gone down. She was also taking medications for hypertension. One evening the patient had come to the house where the author had stayed, and she was the relative of that family member. The patient was looking weak. During dinner, she was offered a variety of food, which the community people practised in every house when somebody came into their houses. They respect and provide delicious food to the visitors. The patient refused to take the food explaining that she was on a restricted diet due to hypertension, and for three years, she controlled her diet. The patient also said that she feels uncomfortable in her eyes which she wants to show to the traditional healer. After that, she asked the family members whether they were worshipping their pig by placing the water which their parents used to follow the rituals in the early days. While having the conversation, author also asked the patient whether she was having other problems or only related to the eye. She replied in a painful voice; I have other problems like every time I feel that something has stuck in my throat and external pressure over my neck. I feel this during sleeping and sometimes could not sleep well due to breathing difficulty.

The next early morning, it was a wonderful opportunity for the author to go to the healer’s house with the patient. The patient and the author got ready to go where they had to walk for half an hour. On the way, the patient could share the experiences of her illness with the author. After reaching the healer’s house, both the author and the patient greeted the healer and his wife and invited them inside their house. The house was dark, with the fire burning at the corner of the house. The people’s faces could be seen with the help of a kerosene lamp. The patient was asked whether she takes the local wheat beer. The patient had discontinued since she was having a health problem. The healer’s wife offered the author and the patient a cup of tea. The

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traditional healer was also looking sick, and he was suffering from a liver problem and was on medication. The healer asked about the author and the purpose of coming. The author briefly introduced himself, and the patient started explaining her complaints to the healer. After her complaints, she said that: Those days the mother of the house, where the author had stayed used to offer water to the pig, burned the dried leaves of pine and used to pray. Maybe the Dewta or spirit of ancestors (God which the grandmother was worshipping early days) has followed her by which she was not healed. I used to take the pig from the house where the author had stayed, and I believed that maybe the Dewta had come to me through the pig.

She also is questioned, Why the Dewta is following me instead of following her daughters, as it is believed that dewta follows only daughters since I was the only relative of the house where she had stayed. Earlier days’ people used to believe that if the coming generation did not follow the rituals, they used to get illnesses.

By listening to the patient’s complaints, the healer replied in a soft voice, saying that the Dewta will follow not only the daughters but also follow whom it likes. The patient then said to the healer that once she had suggested to the daughters of the house of grandmother to conduct the rituals which the family members used to do those days, but now they were not willing to conduct these rituals. The patient then asked the healer to do the rituals over the small number of seeds of uncooked rice and water that she can take and worship pig to get relieved from the problem. The healer asked the patient whether she had a pig in her house at present.

Source Fieldwork 2014

The healer’s wife said they should not kill the pig once they have done ritual on that and said that if they killed it, it has to be replaced with the tiny pig. The healer

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told the patient that once the person starts to worship the pig, they always have to worship; otherwise, it would not be suitable. The healer shared his experience that once the old lady had fever and toothache, she was not responding well to the other people because she failed to worship the pig. However, she became all right when she started worshipping the pig again. The patient then asked the healer what she could do in the absence of the healer to get a cure for the illnesses and asked about the burning of dry pine leaves, offering water and seeds of uncooked rice to the pig and sprinkling of water. The healer said to the patient that she could conduct the rituals in her house. The patient also told the healer about the Dewta their family members used to worship in those days. The healer replied to the patient that the mother of the house where the patient lived before marriage worshipped the Dewta of the house. The patient said to the healer that during the time of killing or bringing the small pig to transfer the Dewta, she would come to call him the healer for conducting the rituals. The patient also said that the daughters-in-law of the house do not want to do puja, but they had to follow once it was done from the time of their ancestors. The healer replied to the patient that it would not be suitable for them if they stopped once it was carried out. The patient also said that two to three years back, once, she had taken the small pig from that house, where she used to stay before marriage. The patient believed that the Dewta had come to her through that pig and said that since one month, she was not feeling well, and whenever she was asking the other healers about the cause after conducting the rituals, they only said that it was because of the Dewta. The healer’s wife said that the patient would have headaches and throat pain if it were so. The woman added that sometimes she was having headaches and throat pain in a severe form. Also, she feels that someone is pressing her neck. The patient said that once she became so severe, she was taken to the healer during night time around 9–9:30 pm, where the healer had done the rituals and then sent her back home. The patient also complained to the healer that sometimes she feels something like a piece of meat stuck in her throat. The patient said that even she had gone twice to show her problem to the monk in Gangtok, the capital. After showing it to the monk, the patient then said that she told the family members to conduct the rituals, but they disagreed. She also added that when the old persons are alive, they do not ask them about the rituals that make them difficult later on. The healer gave all the things (uncooked rice, leaves of pine and water) to the patient after conducting rituals. The patient was also taught things to recite while doing puja. She has to tell the Dewta to sit in the pig’s body and not give any burden to her body anymore and asked the patient to come for a follow-up after getting cured. The conversation between the patient, healer and the author almost took half a day to complete. The described encounter gives evidence of how the patient and the community people worship the souls of their ancestors. It also illustrates how the patients and the community people firmly believe and respect their God/Dewta and the souls of their ancestors. This case also recapitulates the perceptions and beliefs of the patient regarding her illness. It also demonstrates the inter-relationships between the patient

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and the healers among the community, which also explores the role of traditional healers or practitioners in the rural community. The patient had gone to the hospital for her health problem, but she still firmly believed that the cause for her illness was supernatural. The author observed from the field that if the health sign and symptoms are unidentified by the community people, they take treatment from the traditional healing practitioners.

Community Perception on Natural Causes of Illness It was observed that the community people that when they see the illnesses with their ‘own’ eyes or when there are an imbalance or biological changes in their body, they considered it as a natural cause. When they see a child playing with the water, they presume that the child will get cold and cough, and also, when they get wet in the rain and get a fever, they believe that it was due to getting wet in the rain. They consider the natural causes of illnesses among the children and the natural causes when adults get a fever by getting wet while working in the field. People believe the joint pain was due to eating sour food or fruits. Sometimes, they also believe that it was due to the reoccurrences of old injuries. When they suffer from gastritis, they think it was due to eating cabbage or consuming milk tea, which they take in a large amount almost six to seven times a day, or by staying empty stomach. When patients suffer from diarrhoea and dysentery, they think that it is due to eating stale food and consuming contaminated water. They also believe that people suffer from fever when working on a sunny day when they wet their heads after playing under the sun. They believe that taking extra intake of salt causes hypertension, alcohol and red meat, and also, they believe the same with liver problems. They consider that when they eat fatty things like meat, fish and alcohol and sweet items, they become vulnerable to diabetes. They assume that piles were caused by consuming a large amount of red meat in their diet and including hot spices and alcohol. These were the natural causes that were found among the community people. The community people strongly believe in natural causes. It was found that only a few people were aware of protecting themselves from these natural causes.

Conclusion Perception of health and illness differs from individual to individual and from community to community. Every individual and community perceive health and illness in their different views. They do not perceive biological agents as solely responsible for the illness. Apart from biological factors, social, economic, political, spiritual and religious factors are also perceived as the causes for a person’s ill-health. Various works of literature even show variations of perceptions on the health and

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illness of the rural population. It was also found in Dzongu, North Sikkim, where people perceive health and illness. The field data shows that people believe in natural or biological causes and supernatural causes, which make the person sick or ill and consider cultural and environmental factors. They believe and perceive that the causes of illness and disease arise due to the disturbance to nature, deities and ancestral spirits. There are various other factors, which cause illness and the occurrences of diseases (Foster, 1976; Roy Burman, 2012). The community also perceives that there is a common belief regarding various benevolent and malevolent spirits. The indigenous groups or ethnic communities (Lepchas) mainly believe in supernatural powers and worship their ancestors’ souls or spirits. They believe and perceive that ancestors’ spirit in every culture plays a significant role in ensuring good health, safety, protection and wealth of the family. When these ancestral spirits are not well respected and adored, they always cause problems to the family members and the community. The Lepcha people had a strong belief in God and the spirit of their ancestors, both the malevolent and the benevolent. They keep unique places to worship their God or the spirit of ancestors like land, fireplace, caves, stones, trees, streams, rivers, etc. When somebody disrespects these places, they get sick, and according to their belief, even God and the spirit show their darker side when people cannot appease them. They believe that they have to keep their God and the spirit of their ancestors always happy. When they do not keep them happy, natural calamities like drought, landslide, famine, various illnesses among the family and the community, etc. They always pray to God and their ancestor’s spirit; they do special rituals periodically performed by the healers to get prosperity and good health and keep their God and the spirit of the ancestors happy. It was also identified that the community people were aware of the medicinal plants and their uses. The traditional practitioners were also found in the community where people go for treatment. Mainly, they go to the traditional healers if the health problem is related to supernatural causes. Community people go first to the healers and also do pujas or rituals at their houses. If the health problem does not subside, they go to the hospital, and also, if they do not get cured with biomedicine, they approach the traditional healers. Finally, if they are not cured of the biomedicines and the traditional practitioners, they anticipate and accept it as their fate and surrender themselves to God. It was also found that people were taking both treatments from the hospital and the traditional healers. The safety and efficacy of healing practices of the healers have to be strengthened and given due importance. Even the health workers have witnessed the efficacy of the healing practices of the community healers. They either go to the traditional practitioners or for biomedical treatments. Similarly, every health service providing system has its importance and limitation for providing healthcare services to the masses. There is not only the efficacy and success, which lies in one particular health system. Sometimes, there could be severe health problems due to the false perception and treatment, which makes the person suffer.

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References Bhasin, V. (1989). Medical anthropology: Healing practices in contemporary Sikkim. In V. Bhasin (Ed.), Ecology, culture and change: Tribals of Sikkim Himalayas (pp. 59–92). Inter India Publications. Foster, G. (1976). Disease etiologies in non-western medical systems. American Anthropologist, New Series, 78(4), 733–782. Gurung, A. S. (2013). Two waves of transformation and construction of Lepcha (Mon) identity in Sikkim: An assessment of intra-community divide. In The Asian Conference on Cultural Studies (pp. 131–142). The International Academic Forum. Hasan, K. A. (1967). The cultural frontier of health in village India. Manaktalas. Kakar, D. N. (1977). Folk and modern medicine: A North India case Study. New Asian Publication. Kakar, S. (1982). Shamans, mystics, and doctors: A psychological inquiry into India and its healing traditions. Oxford University Press. Lambert, H. (2012). Medical pluralism and medical marginality: Bone doctors and the selective legitimation of therapeutic expertise in India. Social Science and Medicine, 74, 1029–1036. Murdock, G. P. (1980). Theories of illness: A world survey. University of Pittsburgh Press. Plaisier, H. (2005). A brief introduction to Lepcha orthography and literature. Bulletin of Tibetology, 41(1), 7–24. Priya, R., & Shweta, A. (2010). Status and role of AYUSH and local health traditions under the national rural health mission. NHSRC. Roy Burman, J. J. (2003). Tribal medicine: Traditional practices and changes in Sikkim. Mittal Publication. Roy Burman, J. J. (2012). Ethno-medicine among the Bhutias and Lepchas of Sikkim: Some dynamics. In S. Chaudhary (Ed.), Tribal Health and Nutrition (pp. 119–135). Rawat Publication. Subba, J. R. (2008). History culture and customs of Sikkim. Gyan Publishing House. Sujatha, V., & Abraham, L. (2009). Medicine, state and society. Economic and Political Weekly, XLIV (10), 35–43. Unnikrishnan, P., & Harirsmsmurthi, G. (2012). Local health practitioners in India: Resilience, revitalisation and reintegration. In V. Sujatha, & L. Abraham (Eds.), Medical pluralism in contemporary India (pp. 279–304). Orient Blackswan Private Limited.

Chapter 9

Language and Traditional Healing Practice: A Study of Limbu Community Binu Sundas

Abstract Traditional knowledge has emerged from long-standing traditions and practices of indigenous communities. It also includes a wide variety of knowledge, which are innate to the communities. It is transmitted orally and unlike ‘scientific knowledge’ has no formal institutions to transmit. It is therefore to a large extent not documented, and language plays a significant role in its survival and dissemination. Limbu people are an ethnic tribal community of Sikkim, is one of the constituent group which creates the umbrella Nepali or Gorkha community, have their own traditional knowledge and traditional health practices which has been transferred to different generations. The traditional healing practices among them comprise of physical and spiritual healing and is often used in combination for providing health to the people. The healers are also known to be the repository of their cultural heritage and practices. However, their culture in general and the healing practice, in particular, is facing a major challenge for its survival and sustenance. Many extrinsic forces have played a role in creating an adverse environment for its survival but the most pertinent has been the gradual demise of their language. Two important historical event in India and Nepal, the Bhasa Andolan in India for the inclusion of Nepali language in the Eighth Schedule of the Indian Constitution and the process of unification of Nepal in Nepal, resulted in the extinction (or have very few speakers) of many languages of different communities comprising the Nepali community, particularly in India. The healers among the Limbu recite the healing process in their own Limbu language; the decreasing use of language is generating an ignorant behaviour among the people towards the healing practices because of the lack of knowledge of the language. This paper will try to illustrate the intrinsic relationship language has with the traditional healing practices among the Limbu people of Sikkim. I will try to establish this correlation based on interviews and the existing literature. Keywords Traditional healing practice · Limbu · Physical and spiritual healing · Bhasa Andolan · Unification of Nepal B. Sundas (B) Department of Sociology, Miranda House, New Delhi, India e-mail: [email protected] © The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023 S. Reddy et al. (eds.), Ethnomedicine and Tribal Healing Practices in India, People, Cultures and Societies: Exploring and Documenting Diversities, https://doi.org/10.1007/978-981-19-4286-0_9

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Introduction Limbu are a community which is part of a group of people, today popularly known as Gorkhas/Nepali. However, this Gorkha community is not a homogenous group. It is constituted by an amalgamation of heterogeneous ethnic groups, with distinct cultural practices, belief systems, language, and historical moorings, brought under the common identity by historical processes. The heterogeneity of the Nepali/Gorkhali society is visible in the form of caste/ethnicity, language, religion, culture, ecological regions, economy and polity, and many other signifiers of culture. This society can be divided into four racial groups. Of the four, two groups are numerically high and two are numerically less. Indo-Aryans who are mostly Hindu caste groups and Mongoloids with Tibeto-Burman languages are in majority while the Dravidians and Proto-Australoids are the minority. The common identity of Nepali/Gorkhali is conferred upon people belonging to diverse communities like the Bahun, Chettri, Rai, Limbu, Newar, Tamang, etc. Some were followers of Hinduism, while others were animist and shamanist. They had their own principalities and were governed by their social relations and organisations. It was not until the rise of Prithivi Narayan Shah that these diverse social groups were brought under the rule of one sovereign rulers and bestowed upon the identity of being Nepali. However, when Prithivi Narayan Shah propagated Hinduism, it assimilated traits of the primitive cults based on a belief in supernatural beings. Shamans are the personifications of and have the ability to communicate with these supernatural beings. Among the Sunwar tribe, there is the puimbo or ngami, the Gurungs have pajya or khepre, the Lepchas have bonthings, the Rai have bijuwa, and the Limbus have phedangba (Pradhan, 2009). This paper tries to look at the gradual disappearance of the traditional healing practices of the Limbus by attempting a correlation with the demise of its language.

Limbu: Their History, Culture and Language The region of Kirat, in the eastern zone of Nepal, is subdivided into the Near, Central and Far regions. The Central Kirat is called the Khambuan and was predominated by the Limbus and the Rais, until the conquest of the region by the Gorkha. The history of the Limbu people is if not anything, bewildering and is linked to migration from different parts. Chemjong (1961) believed that the origin of Limbu can be traced to one of the Kirata groups migrating from China’s Sichuan Province and further found linkages with the ancient tribe called Kiralite mentioned in the Old Testament (cited in Pradhan, 2009). Risley (1894) believed that the Limbus were originally from Kashi. Limbu consider Limbuan, an area further towards the east of Khambuan and considered to be conquered with the use of bow and arrow, as their homeland. This area extends from the Arun River in the west to the Singalila range which lies along the borders of Sikkim and Darjeeling (cited in Pradhan, 2009).

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The word Limbu is also thought to be of recent origin and was used for the first time by the Gorkha ruler Prithivi Narayan Shah in 1744 A.D., and the people started to use it as their surname post-1806 A.D. The Limbu also call themselves as Yakthung or Yakthungba. According to Subba (1999), Yakthumba is composed of three Limbu words ‘Yiok’ meaning fort of a particular province and ‘Thum’ meaning a province or a country ‘Ba’ meaning a group or a race of the community of the ten Limbu leaders who divided Limbuwan into ten provinces. They are known or addressed by different titles which have different historical dimensions and paradigms. The Limbu, particularly in Sikkim, are quite often called ‘Tsong’ or ‘Chong’—a merchant—by the Bhutias and Lepchas. However, now this title has become redundant in Sikkim since the abolition of their seat in the Sikkim council after 8th May Agreement of 1973. ‘Subba’ is also a popular title used among them. It means a chief, a title conferred by the King Prithivi Narayan Shah upon the influential Limbu as a conciliatory measure after his conquest. The Subbas were primarily tax collectors. The conferring of ‘Subba’ title to the Limbu, thus, after Prithivi Narayan Shah’s assumption of the monarchical ship was a strategy to gradually usurp their land and establish political hegemony of the Gorkhas over the Limbu of Limbuwan (Subba, 1999). But nowadays, Limbu and Subba are interchangeable terms. They have a very distinct culture and tradition. They are neither Hindu nor Buddhist and follow and practice Yumaism. Yumaism or yuma religion is a systematic approach to life and living among the Limbu people. Yumaism is a belief in the matriarchy or feminine great Goddess Tagera Ningwaphuma who is considered as transcendent, immanent and the eternal being and who created the universe and all there is (Subba, 2012). There are various aspects of Yumaism which includes narratives (Mundhums or oral traditions) symbolism, beliefs and practices that are supposed to give meaning to Limbu experiences in life. This religion is still passed orally from one generation to the other through the Phedangmas. Mundhum is believed to be spiritual instructions from the ancestors passed orally to the next generation and is considered to be very significant to the Limbu tribe (ibid). They perform animal sacrifices, eat beef and worship countless deities. Their cultural practices and rituals are based on the Mundhum which is an oral tradition. It is supposed to contain everything essential for Limbu-ideologies, moral values, health practices rituals for different rites of passage, etc. It is a repository of knowledge of this worldly and the other worldly, medicinal technology, diseases, plants and animals. It is preserved by the Phedangma, Samba, Yeba, Yema, who are both their religious heads as well as health practitioners. These leaders are chosen. Limbu community have their own language. It belongs to the Tibeto-Burman language family. It is different from Devanagari script, but it is considered to be a derivative of it. It has its own script called the Kirt Sirijonga Script, and their religious leader Srijunga Hang is considered to be the inventor of it.

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Traditional Healing Practice Among the Limbu The traditional healing practice among the Limbu community is an ancient system and is connected with their sociocultural ecology. It employs the method of both spiritual and physical healings. The former is based on shamanism or spiritualism, and the latter is based on the knowledge of the herbs. However, physical healing based on herbal knowledge is relatively insignificant when compared to the practice of healing based on shamanism among the community members (Khamdhok).1 These two components are used in combination where the herbalist uses the knowledge of the herbs and the shaman work on spiritual part to take care of the evil spirits. Limbu shamans like Phedangma, Samba and Yeba or Yema. Phedangma, Samba, Yeba, Yema (the last name is female priest) are not only the traditional healers and performers of certain rituals but also the sources and authorities of Mundhums, rites and rituals, customs and manners, rules and codes of conduct (Subba, 2008). The sickness or diseases are diagnosed “either through thorough examination of illness and observation of symptoms or through invocation of deities and uses of spiritual forces. The healer who used spiritual power opts supernatural methods such as reading ‘tumdumseri’ (rice grain), ‘sirpong’ (rosary), rolling ‘wadhibo yamnumadham’ (egg), invoking and offering ‘theesok’ to ‘samudhung yepmadhungma’ and ‘samu sirays’ (pure fermented millet) or counting ‘cowries’, etc., to predict and identify the sickness of a patient. Sometimes, fowls or pigs are used and sacrificed in invoking and diagnosing sickness” (Khamdhak).2 The Limbu community has great faith in shamanism and worships departed souls, nature, different deities and ghosts. Limbu shamans believe that peoples’ lives are intimately linked to the world of supernatural beings which consists of numerous Gods, Goddesses, ghosts of the dead, spirits of animals, plants and animate and inanimate objects of nature (Limbu, 2011).3 Phedangma is believed to possess the strength and knowledge to take the dead person’s soul to heaven. They believe that illness and misfortune are caused by the negligence of the deceased soul, Gods and Goddesses and the nature. The supernatural discontent attacks the evil spirits. These supernatural forces are combated and taken care of by the shamans. Such individuals receive their power primarily through successful encounter with supernatural forces in the past (Hitchcock & Jones, 1976 cited in Rai, 2012). Diseases are seen as the relationship an individual has with the nature and the supernatural. The rice grain is an important element in the process to decipher the nature of the illness (Bhasin, 2007). The utterance of incantations is a powerful method of healing. These incantations are believed to have powers to accelerate or retard the effectiveness of the medicines, prepared at a specific time and day. Everything is said and done in the state of trance, and the people have to be attentive to what the shaman is saying, and he says all in the Limbu language, on the basis of knowledge of the Mundhum which he has 1

Khamdhak (2016). Khamdhak (2016). 3 Limbu (2011). 2

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received from his teacher in the form of oral tradition, and if it is not understood it becomes redundant. Among the Limbu community, it is believed that the power to heal, possessed by the herbalist and the shamans, is gifts of Tageraningwa Phuma (Almighty God), to be used for curing the community members off their disease and sickness. This power is not possessed by all but is conferred upon a selective few. The power to heal people “comes from something sacred deep within the healer who has been bestowed with both the divine knowledge of medication and the power of spiritualism. This is the reason why mundhums of Limbu shamans and the indigenous knowledge of medication practiced by the Limbu herbalists are kept secret” (Khamdhak).4 Mundum are oral traditions and means of cultural continuity; they are inherited and passed down from generation after generation. They are regarded as truly holy and are powerful scriptures. The corpus of Mundum is myths which are sacred, legend and mythological; they can be spiritual songs or ceremonial dialogues. This is regarded as inherited knowledge concerning the universe, creation of living beings and ancestors (Subba, 2008). The Mundhums are recited orally which narrate the different rituals while performing the various kinds of pujas. “Mundhum is a legend, folklore, prehistoric accounts, sermons and moral or philosophical exhortations in poetic language”.5 It is a scripture living in oral tradition. The Mundhum relates that Tagayara-Ningwa Fuma is the supreme Goddess who is believed to be omnipotent and eternal. The Limbus believe in good and evil spirits. The evil spirits always hover around to cause harm to them so to appease them they take the help of the priests. These shamanistic priests appease these evil spirits by chanting mantras or with the sacrificial offerings of animals and fouls. During the process of the appeasement of the spirits, no idols of Gods and Goddesses are used. The Phedangmas are historically the oldest religious priests. The vocation of the Limbu religious priests is hereditary. It is renewed from generation to generation. These Shamanistic priests do not learn the various rituals through books, but these are passed on to them orally and through practice. Because these traditions are orally passed the knowledge of language is extremely significant. Today there is extreme existential crisis faced by the community as their language is vanishing. The reason for this disappearance are numerous but two historical events, the Unification of Nepal under Prithivi Narayan Shah and the Nepali Bhasa Andolan, in India has had significant impact on its sustenance and proliferation.

Unification of Nepal Prithivi Narayan Shah was fascinated by the beauty of Nepal valley. It was rich compared to the other petty hill principalities because of agriculture, manufacturing and trade with Tibet and India. Gorkha was but a poor kingdom with no 4

Khamdhak (2016). A pragmatic glimpse at Limbu Mundhum. https://www.thefreelibrary.com/A+pragmatic+gli mpse+at+Limbu+Mundhum-a0183983014. Retrieved on 21.08.2016. 5

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trade, no mines and no manufacturers. It took Prithvi Narayan Shah twenty-five years of sustained effort to reach the Kathmandu valley. He was a clever strategist; seeking alliances where possible with the petty principalities of the Baisi and the Chaubisi, using diplomatic channels in which the Brahmins played a big role and he even married the daughter of “Hemkarna Sena of Makhwanpur” as “Makhwanpur controlled the routes between the plains and the Nepal Valley”. He became the king of Nepal valley and shifted his capital to Kathmandu on 21 March 1770. He in order to bring about a socio-political integration of the country adopted the policy of one nation, one religion and one language. Through this policy, he supported the forceful incursion of Nepali language (also known as Khas Bhasa) and Hindu religion among those people who neither professed any. However, it should be noted that the spread of the Nepali language among these people had started much earlier with the migration of caste Hindus into the regions dominated by tribal people. After unification, Nepali language enjoyed state patronage and was used for all official purposes. Further, the use of this language among the recruits of the British army also facilitated the growth and spread of the Nepali language among the non-speakers. Hamilton (1819) has noted that “it is making rapid progress in extinguishing the aboriginal dialects of the mountains” (cited in Pradhan, 2009). The Bahun-Chettri were proficient in this language by virtue of which they had claimed their legitimacy over the government jobs and had consolidated their dominance in the socio-economic and the political sphere as well. Bahun-Chettri community achieved a high status in the political arena and on the basis of their ritualistically and culturally ascribed position of being higher caste gave them an undue advantage over the others. This forced, many belonging to other castes, to migrate to different places in India in search of a better livelihood.

Nepali Bhasa Andolan in India The migrating Nepali population in India did not have the luxury to be confined within their ethnic relation and settle according to their ethnicity as they did in Nepal. People belonging to all racial stocks started staying together and the assimilation which had gathered momentum in Nepal gained further pace. In India, they had to face discrimination which led to their demand for separation from Bengal, for the first time in 1907. The demand for the recognition of Nepali language had also stimulated in close proximity along the lines of the Gorkhaland movement. The first phase of language movement started in the year 1920s in Darjeeling as a direct response to the resolution made by the Indian National Congress at Nagpur Session in 1920, where it was declared that the reorganisation of Indian provinces would be on the basis of language after the independence. The movement began with the demand of the inclusion of the Nepali language in the schools in Darjeeling. The demand was further strengthened and made more vocal after the establishment of Nepali Sahitya Sammelan in 1924 (Rai & Sundas, 2015). The Bengal government appointed a committee to look into the demand for recognition of Nepali language in schools, and this was challenged by S. W. Ladenla and Dr. Yenshing Lepcha as it posed a threat

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to Bhutia and Lepcha community which subsequently also affected the fraternity of Hillmen’s Association. Nepali language was recommended for primary schools by the Griffith Committee appointed by the Bengal government in 1927. Subsequently, the use of Nepali language was raised to higher education level as well (Subba, 1992). However, after the recognition of Nepali language, Ladenla understood that his political career would be useless without the support of the Nepalis. Therefore, he organised a meeting in 1934 and reconciled the three hill communities and accepted ‘Gorkha’ as a common ethnic term for the three hill community and Nepali as their language (Samanta, 2000). The Official Language Act of 1961 gave Nepali language the status of official language within the sub-divisions of Darjeeling, Kalimpong and Kurseong along with Bengali (Sundas, 2011). Finally, the third wave of the Nepali language movement began in 1972 with the demand for inclusion of the Nepali language in the Eight Schedule of the Indian Constitution. The demand was advanced in Dehradun in 1956 by A. S. Thapa. Nepali Bhasa Sangharsha Samiti was formed in 1969 to attain the same goal. On 31 January 1972, the Nepali Bhasa Samiti was formed for pursuing the goal as the Nepali Bhasa Sangharsha Samiti had become dysfunctional. The Nepali Bhasa Samiti was renamed All India Bhasa Samiti in June 1972,6 and it was after its establishment that serious attention regarding the recognition of Nepali language in the Indian Constitution was taken into consideration by the Indian Nepali scholars and writers. The Left Front Government of Bengal and Tripura passed a resolution in favour of recognition of Nepali language in 1977 and 1981, respectively. However, the GNLF demanded the recognition of Gorkha language in the Constitution of India with an attempt to differentiate the Indian Nepalis and their language from that of Nepal (Subba, 1992). Finally, Nepali language received a national recognition and was incorporated in the Eight Schedule of the Indian Constitution on 22 August 1992 by the 71 Amendment of the Indian Constitution (Samanta, 2000). The Nepali language movement in India was voiced by all, irrespective of them having their own language. The entire population was encouraged to identify themselves with Nepali language and to give up their association with their native language. Further with the resolution to teach Nepali language in schools and its recognition under the Indian constitution, consolidated the process of the demise of the numerous languages people spoke and one was that of the Limbu community.

Situation of Limbu Language and Their Healing Practice Turin (2011) indicates that the autochthonous languages of modern Sikkim like the Bhutia, Lepcha and Limbu are at present severely endangered. Further, UNESCO interactive atlas of world language in danger also lists Limbu as an endangered language with only 37,265 speakers in India.7 The number of people speaking 6 7

Chhetri (2016). http://www.unesco.org/languages-atlas/index.php?hl=en&page=atlasmap&cc2=NP.

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Lepcha, Bhutia and Limbu language is decreasing and children of these communities do not have command over these languages. “As competence in these traditional mother tongues has declined, however, their status have begun to shift from spoken vernacular forming a part of a lived ethnic identity, to symbolic markers of an ancestral heritage that contribute to emotional belonging” (Turin, 2011; 136–137). Subba (2012) attributes the reasons for the vanishing Limbu way of life to the strengthening of modern democratic institutions in Sikkim and in Nepal. The process of the diminishing use of Limbu language is because of the process of assimilation and the gradual hinduisation among them due to the cultural interaction with the Nepali people (Subba, 1990). The process of assimilation and enculturation disturbed the equilibrium in the traditional philosophical approach of the Limbu to life. Nepali culture became the dominant culture; as a consequence, the social and religious institutions—‘Tumyanghang’ and ‘Yehang’—gradually started to lose its relevance. The disappearance of these institutions led to the change in the social organisation of the Limbu society. In the absence of organised religious scriptures for guidance, religious and ritualistic functions were performed without supervision and guidance by the respective priests on their own volition. Further, in the absence of religious and social institutions, Limbu society and its members do not abide by the customary norms and values. This has had a greater impact on the passing of the Mundhum, and therefore, the culture and traditional practices associated with the different aspects of their life. For the passing of the Mundhum, the person must be able to understand and speak the Limbu language. Since the language is on the verge of extinction, it will be difficult to preserve this very old tradition of healing. If the language is not preserved, the traditional healing practice of the Limbu community will become obsolete. An individual in Sikkim was upset by the fact that the Nepali language has replaced their native language because of the fact that the parents themselves converse with their wards in Nepali. He said “The parents do not communicate in Limbu language at home, so the children hardly speak the language these days. My parents also did not speak the language at home as much as it should had been spoken so I am only able to understand few basic words. Further, the absence of other speakers made it difficult for me to develop upon it”.8 Another individual highlighted the importance of Limbu language along with English. However, English has become the dominant language and therefore the native language has lagged behind. Even for that matter, Nepali was taught in schools and colleges which diminished the scope of studying Limbu language. “Limbu language is must for the children as well as English language but the young people prefer English over Limbu. They study English in the colleges and schools, therefore, Limbu as language has lost all its significance”.9 As a matter of fact, people are cognizant of the significance of Nepali and English in contemporary time. They were of the opinion that the state patronage these languages received for

8

Interview with Mr. S. P. Limboo 41 years, of Lingzom in March 2013. He was optimistic though that things would change. 9 Interview with Mr. Sukraj Subba, 39 years old in March 2013.

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their proliferation by being taught in the schools and colleges has pushed, not just Limbu, but also other languages like of the Rai, Newar, etc., into oblivion. The Limbu community these days do not have many speakers, not just in Sikkim but in Darjeeling as well. The lack of speakers, along with many other extraneous developments, has acted as a deterrent to employing the services of traditional healers. An old lady narrated that it is essential to have their language speakers to experience the optimum effect of the shamans. She said that once she had employed the Phedengma but due to the lack of native language speakers the entire ritual was redundant. She had to seek the services of the Phedengma again and to understand his incantation she had to invite the language speakers from Nepal.10 She said that her language proficiency was not of the highest order as after the demise of her father they would not speak the language much at home and outside the home Nepali was commonly spoken and with more friends and interaction with people around; Nepali gradually substituted Limbu language.

Conclusion It is not just the question of the Limbu language and their healing practice but the language of such subaltern indigenous communities has disappeared under the influence of a major dominant language, thereby destroying the traditional knowledge and social capital of many indigenous communities the world over. In Sikkim, recently, the only speaker of the Majhi language, another endangered language of Sikkim, died. There are more languages included on the endangered list of UNESCO from Sikkim. Sikkim University in 2016 started the Centre for Endangered Languages to preserve and promote these endangered languages. The focus is now on five languages Rai, Mangar, Sherpa Bhujel and Gurung. There are 34 languages from the region that is included in the list of endangered among the 197 from India.11 Such centres for the protection and preservation of indigenous languages should be initiated throughout the country. Limbu language is not included in the centre as Limbu language is being taught in the colleges of Sikkim as well as in the University. However, the number of students is not many who have opted to learn the language. This is a laudable step but language cannot be preserved in isolation, and therefore, a holistic effort needs to be made to preserve language and the vast array of traditional knowledge associated with it. It becomes mandatory for the preservation of institutions like Tumyanghang and Yehang and documentation of traditional oral practice in case of Limbu society. Loss of languages will also create a homogenous community, and the heterogeneity and diversity of languages and cultural practices, which make this world so much a better place to live, will be lost.

10

Interview of an old lady, who happened to be a daughter of a Phendengma in Delhi on 1 Sept. 2016. 11 https://sites.google.com/site/centreforendangeredlanguages/.

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References Bhasin, V. (2007). Medical anthropology: Healing practices in contemporary Sikkim. http://kre publishers.com/06-Special%20Volume-Journal/T-Anth-00-Special%20Volumes/T-Anth-SI-03Anth-Today-Web/Anth-SI-03-07-Bhasin-Veena/Anth-SI-03-7-Bhasin-Veena-Tt.pdf Chhetri, R. (2016). Nepali “Bhasa Andolan”: Re-telling the story (Nepali language movement). https://www.indiangorkhas.in/2015/08/nepali-bhasa-andolan-re-telling-story.html. Retrieved on August 22, 2016. Khamdhak, B. L. (2016). Limboo indigenous knowledge of traditional healing: My first visit. http://buddhilkhamdhak.blogspot.in/p/limboo-indigenous-knowledge-of_8587.html. Retrieved on August 10, 2016. Limbu, S. (2011). Practices of resource management in a Limbu village: A study of Maunabuthuk VDC in Nepal (Thesis submitted to Centre for Development and the Environment University of Oslo, Blindern, Norway). https://www.duo.uio.no/bitstream/handle/10852/32617/1/Thesis-Sha ntixLimbu.pdf. Retrieved on August 20, 2016. Pradhan, K. (2009). The Gorkha conquests: The process and the consequences of the unification of Nepal, with particular reference to Eastern Nepal. Himal Books. Rai, S. K. (2012). Traditional healing practices in Darjeeling Himalayan region. In S. Somayaji &V. Khawas (Eds.), Environment development and social change in Himalayan region (pp. 273–283). Akansha Publishing House. Rai, A., & Sundas, B. (2015). Gorkhaland movement: A migrant’s perspective. ISARA Publication. Risley, H. H. (1894). Gazetteer of Sikhim. Bengal Secretariat Press. Subba, T. B. (1990). Flight & adaption, Tibetan refugees in the Darjeeling—Sikkim Himalaya. LTWA Publisher. Subba, T. B. (1992). Ethnicity, state and development: A case study of the Gorkhaland movement in Darjeeling. Vikas Publishing House. Subba, J. R. (1999). The Limboos of the Eastern Himalayas. Ambika Printers. Samanta, A. K. (2000). Gorkhaland movement: A study in ethnic separatism. H Publishing House. Subba, J. R. (2008). History, culture and customs of Sikkim. Gyan Publication. Subba, J. R. (2012). Yumaism, the Limboo way of life: A philosophical analysis. Vikas Publications. Sundas, B. (2011). A heady mixture: Culture, economics, health and alcohol in Darjeeling. LAP Lambert Academic Publishing. Turin, M. (2011). Results from the linguistic survey of Sikkim: Mother tongues in education. http:// digitalhimalaya.com/projectteam/turin/downloads/Sikkim_Tibetology.pdf. Retrieved on August 09, 2016.

Chapter 10

The Nongai Dawai Khasi Healers of Meghalaya—A Tribal Understanding of the Human Potential Sandra Albert, John Porter, and Judith Green

Abstract This paper refers to the key component of ‘making of’ the nongai dawai. Nongai dawai—sap—loosely translated as talent or potential, is a traditional healer of the Khasi tribe of Meghalaya. The paper explores the space in which indigenous traditional Khasi healers in Meghalaya practice. Khasi indigenous healers describe themselves as doktor sla, plant doctors, to distinguish themselves from doktor kot, or book doctors. Rhetorically, this distinction operates to carve a distinct sphere of expertise concerning the allopathic sector. Moreover, to mark claims for the specific local appropriateness of traditional practices within a shifting market of state-sponsored provision. Khasi healers are a heterogeneous group who treat various conditions, having recognised expertise in physical ailments, with no obvious correlates in biomedical systems and musculoskeletal disorders. The healers also present themselves as accommodating the deficiencies in biomedicine, including inherent generic weaknesses of allopathic care and specific local gaps in rural healthcare provision. Keywords Indigenous · Khasi · Traditional medicine · Potential · Talent · Gift

This article is reproduced with permission from IJCLP. Albert, S., Porter, J., & Green, J. (2015). Sap and the Traditional Healer: A Tribal (Khasi) Understanding of the Human Potential. Indian Journal of Career and Livelihood Planning, 4(1), 52–61. http://www.iaclp.org/yahoo_site_admin/ assets/docs/6_Sandra_Albert.73115654.pdf. S. Albert (B) Indian Institute of Public Health, Shillong, Meghalaya, India e-mail: [email protected] J. Porter Professor of International Health, London School of Hygiene and Tropical Medicine (LSHTM), London, UK J. Green Professor of Sociology, King’s College London, London, UK

© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023 S. Reddy et al. (eds.), Ethnomedicine and Tribal Healing Practices in India, People, Cultures and Societies: Exploring and Documenting Diversities, https://doi.org/10.1007/978-981-19-4286-0_10

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Meghalaya State in the north-eastern region of India has a predominantly indigenous population, with 86% identified as belonging to Scheduled Tribes (Ministry of Tribal Affairs, 2013). The main tribes are Khasi (including Jaintia) and Garo, with the former being larger (GoM, 2009). In the Khasi Hills of Meghalaya, the herbal traditional medicine practitioner among the Khasis is referred to as nongai dawai. The medicines and medicinal plants that the healers use are referred to as dawai khasi. The nongai dawai often make a distinction between themselves and the ritualistic healers, the nongkñia. This paper outlines factors contributing to the “making of” a healer nongai dawai and the healers’ understanding of what is referred to as a key component of becoming a healer, sap (translated as talent or potential). This concept of sap is a generic local term not restricted to the field of traditional healing. However, we explore its importance to Khasi understandings of the recruitment and recognition of those best suited to be healers.

Method Data for this study was collected through in-depth interviews with healers, focus group discussions with healers, interviews with key informants (including policymakers and local elders), and non-participant observations. Observations such as healer interactions with patients, medical plant suppliers and other healers, and clinic facilities and herbal gardens helped improve the understanding of the context. It also assisted in corroborating what was said in the interviews. For instance, observation of interactions of healers with patients and between healers and their peers further verified accounts provided during interviews. In-depth interviews were held with 24 healers (seven female, 17 male). They were selected following discussions with key informants, such as office bearers of grassroots organisations of healers and researchers familiar with indigenous healers, to develop criteria for inclusion and exclusion. Well-known healers with at least five years of practice and who worked fairly full time were included. Healers with expertise in a single disorder and those who practised occasionally or infrequently were excluded, as were those who specialised exclusively in mental health (nongkñia) or as traditional birth attendants. Based on key informants, peers, and the community, healers were identified from different districts using the snowballing technique (Biernacki & Waldorf, 1981). After the interviews, three focused group discussions, two with six participants each and a third with 13 participants lasting between 1.5 and 2.5 h, were conducted. In all, 25 healers participated in a focused group discussion (FGD), of whom 13 were interviewed before participating in the FGD. This amounted to 36 healers: only interviews 11, interview plus FGD 13, only FGD 12. While this paper draws predominantly on the interviews and focus group discussions with healers, it also references data from key informant interviews, described in more detail elsewhere (Albert & Porter, 2015). Audio recordings were made of all in-depth interviews and focus group discussions after obtaining the informed consent of the participants. Data was collected between April and December 2012.

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The challenges posed by language in cross-cultural research settings have been well-documented (Green et al., 2010; Larkin et al., 2007; Pitchforth & van Teijlingen, 2005). In this study, the involvement of bilingual, indigenous research assistants who conducted the interviews and translated them reduced the problem of translation to some extent. All interviews and focus group discussions were audio-recorded. They were transcribed and translated into English by the interviewer. When participants used difficult words to translate, they were retained as-is, and a possible meaning was typed in parentheses. This was later rechecked, and the translation arrived after consultation with knowledgeable persons in the community. An additional step to reduce translation errors was to get about half the Khasi transcripts and their English translations compared and checked by a bilingual elder. The qualitative data collected was analysed using a thematic content analysis that incorporated the grounded theory approach (Green & Thorogood, 2009). The first set of codes informed further data collection as well as fine-tuning the topic guides. As analysis progressed, codes were modified, regrouped, and categorised. For example, references to sap (talent) were initially line coded as rationalising the practice of tribal medicine. However, observing that it was frequently used both within and between transcripts became an in-vivo code and an analytical theme. In this paper, the codes following extracts from transcripts are presented as follows: focus group discussion (FGD), Khasi healer (KH) or key informant interview (KI), gender (F or M), and the transcript number (e.g. KH 001). Unless otherwise specified, all quotes are from interviews.

Results Both men and women practised tribal medicine and were well known in the community as practitioners. Of the healers interviewed, six had no formal school or college education, while 10 had seven or more years of formal education, including four who had a bachelor’s or diploma qualification. Out of the 24 healers interviewed, 16 healers practised from the clinic adjacent to their homes or far away. Their experience ranged from seven to 25 years. Most healers obtained medicinal plants from nearby forests or sometimes from more distant forests in other districts. More than half of them (14/24) relied on a network of suppliers and or assistants who collected medicinal plants for them. A majority of the tribal healers in this study were Christian (21/24), and they often were quick to distance and differentiate themselves from the ritualistic healers. The latter is usually associated with indigenous religions.

How Do They Become Healers? Ancestry Ancestors were reported to have played a significant role in the transference of knowledge and skills by most healers in this study. Most healers (15/24 interviews) reported

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having an older family member, usually a parent, grandparent, or uncle who was a traditional healer. The introduction and exposure of the healers to tribal medicine began within the family. Then there was a gradual progression from assisting to taking over or continuing with the practices of the forebears. Thus, for some, it was reportedly an obvious “career” option from an early age. However, in some instances, despite having assisted parents or grandparents in the craft, a few reported that they had not initially considered traditional medicine as a career. Their training occurred inadvertently through helping and assisting the ancestor. Even me, I did not dream that I would become a traditional healer [the healer had initially chosen a different career: running a beauty parlour]. My grandmother and grandfather were both traditional healers. After my grandfather died, my grandmother took over. However, she was not in good health for most of the time due to her old age. Whenever people came to her for treatment, she would always ask me to go and prepare medicines for them. As time passed, people started recognising me and started looking for me whenever they came for treatment at our house. Eventually, I thought this was what I wanted to do, and I told myself - when people benefit from what I did, why should I stop. I think that is how I became a traditional healer. FGD3, KH 019, F

One healer claimed to learn and inherited her talents from an ancestor in the distant past who had not trained her in a tangible, practical sense. Claims to a link with a skilled ancestor were reported to provide this healer with some confidence and perhaps credibility within society and among peers. My talent/skills (sap) are a gift from God (jingai U blei). It is not that I had or went for any training from my mother’s clan, who is not my real mother. However, I inherited my talent/skills from her. KH 018, F

In these accounts, sap is typically referenced as a tacitly understood concept that exists in the community. It was mentioned along with ancestry as a key component explaining how and why an individual became a healer.

Sap, Talent Almost all healers used the Khasi word sap in the interviews and in focus group discussions. Sap can be loosely translated as talent, gift, or skill. Healers used the concept of sap to explain the knowledge and skills they had acquired, which they found difficult to explain. It is inherited; my talents (sap) are inherited (hiar pateng) or passed down through the generations and, but I cannot explain it [laughs]. KH 004, M For me, it is passed down from my ancestors (ai pateng) for three generations, and it is also the skills/talents (ka sap ka phong) that are gifted to me by God (ai U Blei). FGD2, KH 028, M

As used by the healers, the term sap appeared to represent the abstract concept of inherent or intrinsic ability. Talent has been defined as natural aptitude or skill in the

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Oxford English Dictionary (http://oxforddictionaries.com). The words and phrases used by healers were also discussed with bilingual experts. They translated sap as “an inborn potential” or “a sort of instinct” and said it could also mean skills. It could be translated as a talent but possibly represented a lot more than just talent. There also seems to be an effective or motivational aspect to sap. References to sap were used to describe the motivation or vocation to practice tribal medicine. The recognition of sap was especially important to those who did not have an ancestry of healing. Healers reported that their initial successes contributed to their being recognised and acknowledged within the community as having the required talent/skills. They recalled that this led to verbal encouragement from patients and elders in the community to take up the role of healer. The following is an excerpt from a healer who did not have healer ancestors: However, I did not focus on it much until I reached 18 years of age, and that is when I started realising my capabilities/potential/talents (jinglah ka sap) for treating people. My friends used to tell me that I have the talent/potential (ka sap), but I never took it seriously then because I thought it was boring. But when I was 35 years of age, I treated a man and cured him. He then forced me to take up this practice as he brought patients to me regularly and took me to several places to treat people. Because of him, I am successful and give him credit for making me realise my own potential (ka jinglah). KH 005, M On being asked if there were any means of knowing if a person had sap, a few elderly healers responded that it was possible. They claimed that they would be able to do so by observing a person in action: “Just by his touch, I will be able to understand if he is capable for this profession” [KH 005, M]. On further enquiring how one would determine if a person has sap or not, healers used examples and the steps they would take to decide, as illustrated by the following set of quotes. For example, let us take the case of a male child. On seeing a carpenter’s tools, a male child who loves carpentry would take those tools and do something with them. Likewise, we look at the person’s interests and determine the potentials. KH 004, M A master can recognise whether a person has the potential needed. We can determine a healer by observing the way of treatment, asking questions. A teacher can recognise if his student has the potential or not. KH 010, M

Sap could therefore be inferred from a person’s interest and observable behaviours. Thus, sap or talent is somewhat intangible, something that an established healer will look for before deeming someone worthy of receiving his or her knowledge and teaching. Desirable behaviours described included attitudes like concern and care for the sick. One cognitive skill attributed to sap appeared to be memorising and identifying different medicinal plants and recalling their properties as needed. He [father] once told me that if you feel/understand (sngew) that you are unable to remember all these herbs, then it is better that you do not become a traditional healer [.] If God does not give us the skills and talents we will not be able to remember everything, because in our treatment there are hundreds of species of plants that we use. FDG2, KH 030, F

It was also apparent that sap was not something that healers believed would always be inherited. A few healers, especially those who professed interest in starting training institutions, did say that they needed to observe their children and see who had interest

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and potential. It was said that they would be wasting their time in training someone if the person did not have sap. Thus, by sap, the traditional healer implies that a combination of interest, talent, aptitude and potential for the job is required.

The Community and the Healer Acknowledgement and support. The healer’s success is experienced and witnessed by the patient and the community. The resulting acknowledgement of the healer’s skills raises the expectations of the community. Healers report that they are influenced by pressure from people who expect them to provide help to relieve suffering. As evident in an earlier quote, these expectations came from the community even before the healer considered the practice of tribal medicine a career. On observing a young family member assisting her relative, community members also become convinced of the novice’s healing abilities. When discussing their beginnings, healers often recollect a successful first case or cases that tested their abilities. The initial successes were recounted as factors that encouraged those without ancestral claims to persist in the healing profession. Their reputation reportedly spreads by word of mouth, and more people seek their help. Influential members in the community averred that a good reputation was crucial to a healer. Accessibility and the trust that develops within the community in the healer’s ability were considered contributory to building the reputation. …this is their strength; people have faith in them [the traditional healers] because they are there, and they [the people] feel that they are not there to exploit anyone. Secondly, the second thing is that since they are a part of society and they move freely among these people and their reputation is by word of mouth and … [citing an example of one healer] people go there and he is good, and they get cured, and that’s again by word of mouth. KI, Elder

Knowledge in the community. Closely observing the plants that more experienced healers picked from the forests, imbibing information through assisting and later using this information to help people in the community were common first steps tentatively. For those without ancestors, acquiring knowledge without an apprenticeship is possible as there is considerable knowledge of medicinal plants within the community, especially in rural areas. This knowledge within the community was corroborated and inferred from our interactions with academics and policymakers. An example is illustrated below that implies certain geographically bound existence of knowledge within communities. Yes, just anybody from this village [could treat]. When they migrate to Ri Bhoi or West Khasi on marriage or anything, they will also carry that knowledge there. So, we will always say that people from Thyroid can cure this. KI, Policymaker, Khasi Hills Autonomous District Council.

Healers also report collating information from others in the community. Many said they seek out medicinal plants outside their usual repertoire, look for medicinal

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plants in the forests that they had heard of, and try out or experiment with new medicinal plants when they were faced with unusual ailments that did not respond to their usual therapies.

Experimenting, Empiricism, and Experience Healers in rural areas, especially those engaged in agrarian occupations, reported learning from their observation of animal behaviour. They recalled situations where elders guided them in administering medicinal plants to sick animals. The observation of the effectiveness of the medicinal plants on animals was said to prompt them to give it to humans as well. Healers also reported experimenting with medications on farm animals. Invariably this progresses to a trial on themselves and/or a family member to assess efficacy in human beings before prescribing to the larger community. When snakes bit the goats, our grandfather instructed us to pluck a plant and feed it to the goats. So when a snake bit people, we went to pluck the same kind of herb and gave it to them, and they were cured. Right from childhood, people came to seek our help, and we started helping them. Now I am 68 or 70 years of age. When a goat or a cow had a fracture, I applied for medicines on them, and after that, I tried on humans. KH 012, M

It was noteworthy that some healers were aware of both the usefulness and potential limitation of animal experiments. A healer with barely seven years of school education explained that animals also fall ill like humans, with similar disorders like fever. So he would try his medication on the sick animals first and learn from the animal’s response to the herbal remedies. He also acknowledged that what works in animals may not work in humans. Therefore, he reasoned that trials on animals must proceed to self-tests and try out on a few humans before giving to the larger community. In the absence of animal experiments, herbal remedies or a new use for a particular plant are reportedly discovered after a trial on themselves and/or family members. This happens, for instance, when a particular medication fails to provide adequate relief and the healer tries out new medicinal plants for the condition. Even for coughs and stomach aches, I try different medicinal plants on my children because it is difficult to find doctors in our village at night. When there is an improvement, and they are cured, I give it to other people with similar problems. Then my neighbours came to know about it and whenever they have some kind of problem they come and take my medicines. KH 012, M

Thus, tribal medicine healers experiment in different settings. This may involve going into the forests looking for new or rare herbs and trying them out. Or it may involve trying out familiar herbs on new ailments and learning from the experience. It may involve conducting a loose cycle of uncontrolled experiments involving farm animals, pets, and humans. Although watching, imbibing, and apprenticing skills from another healer is the usual mode of early learning, the actual practice of the craft by itself reportedly adds

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to their learning. When they start practising on their own, they report becoming more aware of the nuances of healing and claim to “understand” better. It was stated that the art could not be learnt in one day: instead, it took “years of training and experience”. The following two quotes are from a healer who learnt from an ancestor and one who did not: It is the same for me like she (referring to another participant in the FGD) said. I learnt everything from my mother, and when I started treating patients, I could learn and understand even better through my experiences. FGD2, KH 031, F When I started, I did not know much about what to do, but as the years progressed, my work started to help me understand and helped me do the needful things accordingly. KH 018, F

Elements Contributing to the Making of a Healer Becoming a well-known healer in the community thus results from a combination of factors working together: the person must be recognised as having sap, a kind of innate talent, in addition to the requisite knowledge and skills obtained from ancestors or other elders. Although this knowledge builds on a particular stock of common folk knowledge of herbal remedies, the professional healer must be acknowledged by the community by their witnessing successful treatments of patients. Ancestry and community recognition of the healer’s talent are accompanied by growing self-realisation that encourages the healer to practice. These aspects have been summarised, and the interconnections are represented schematically in Fig. 10.1. The continuation of practice as a career occurs when the community’s acceptance and appreciation become evidenced by increasing demand for their services. For Khasi tribal healers, it appears important that they detect interest and aptitude as a requisite for training a person. This is especially important when the recipient is not a family member.

Discussion This paper presents a descriptive analysis of an under-researched group of indigenous traditional healers, the Khasi tribal healers of Meghalaya. We have described how healers account for their career choice and the factors that lead to recognising their role by the wider community. Most healers said they acquired their knowledge and skills from ancestors, but knowledge acquisition from community members and peers also took place to a limited extent. Khasi tribal medicine is learnt from the elderly healer through observation and didactics similar to folk healer traditions reported in other societies (Prince & Geissler, 2001; Rubel & Hass, 1996). Khasi healers without hereditary antecedents often embarked on a healing career by early practice on family and friends before

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Fig. 10.1 Elements contributing to the making of a tribal healer

expanding their practice to non-relatives, a transition process also reported in other ethnic groups (Rubel & Hass, 1996). Regardless of from whom knowledge and skills were acquired, a more important concept among Khasi healers was the notion of sap or innate talent. The concept has several facets like interests, aptitude and potential. These concepts reported by tribal healers have resonance with those described in the domain of career psychology. The career psychology literature refers to interest and aptitude as key constructs that form the basis of career guidance interventions (Arulmani, 2009; Gottfredson, 2003). More recently, the notion of potential as a blend of interests and aptitudes has been proposed (Arulmani, 2014). Extending this concept to the above discussion, becoming an established healer depends on several interrelated elements. These include acquiring knowledge and skills by learning from ancestors and others and a concept of sap or inherent potential that both healers and the community recognise. In homes, learning seemingly occurred in an experiential setting, initially by observing and listening, which then progressed to imitation and doing as reported elsewhere in indigenous societies (Rubel & Hass, 1996). Tribal healers also provided accounts of learning while practising through experience, empiricism and experimentation. This resonated with elements of the learning cycle described in the influential experiential learning theory (Kolb, 1984; Kolb et al., 2001). Kolb (1984, p. 41) defines learning as “the process whereby knowledge is created through experience

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transformation”. Healers reported experimenting with medicinal plant preparations on farm animals, family members and themselves before administering to others. Thus, Khasi tribal medicine is not a static system restricted to what is learnt from ancestors, but a dynamic one where healers continually “experiment” with therapies. Although not widely recognised in the literature, such dynamism in practices has also been documented among folk healers in other parts of India (Payyappallimana & Hariramamurthi, 2012). In conclusion, this paper provides Khasi indigenous perspectives on their concept of sap. Sap represents a combination of the notion of “gift”, talent, aptitude and potential. It indicates that including aptitude or potential in career guidance remains important. The study also highlights the role of the community in the manifestation of a person’s potential. Vocation was important, as were craft skills, but the recognition of the community also contributed to becoming a Khasi healer. Acknowledgements This work was supported by a Wellcome Trust Capacity Strengthening Strategic Award to the Public Health Foundation of India and a consortium of UK institutions. Ms. Darisuk Kharlyngdoh and Mr. Ivanhoe Marak, Research Assistants, diligently conducted the fieldwork. Gideon Arulmani, Associate Editor, IJCLP, helped in developing Fig. 10.1.

References Albert, S., & Porter, J. (2015). Is ‘mainstreaming AYUSH’ the right policy for Meghalaya, northeast India? BMC Complementary and Alternative Medicine, 15(288). https://doi.org/10.1186/s12906015-0818-x Arulmani, G. (2009). Tradition and modernity: The cultural preparedness framework for counselling in India? In International handbook of cross-cultural counselling: Cultural assumptions and practices worldwide (pp. 251–262). Sage. Arulmani, G. (2014). Assessment of interest and aptitude: A methodologically integrated approach. In G. Arulmani, A. Bakshi, F. Leong, & A. Watts (Eds.), Handbook of career development: International perspectives (pp. 609–630). Springer. Biernacki, P., & Waldorf, D. (1981). Snowball sampling: Problems and techniques of chain referral sampling. Sociological Methods & Research, 10(2), 141–163. GoM (Government of Meghalaya). (2009). Meghalaya human development report 2008. Shillong, India: Planning Department, Government of Meghalaya. Retrieved from http://megplanning.gov. in/MHDR/Human_De.pdf Gottfredson, L. S. (2003). The challenge and promise of cognitive career assessment. Journal of Career Assessment, 11(2), 115–135. Green, J., & Thorogood, N. (2009). Qualitative methods for health research (2nd ed.). Sage. Green, J., Pereyaslov, D., & Balabonova, D. (2010). The use of qualitative methodologies in health services/systems research in low and middle income settings a narrative literature review. Retrieved from http://curatiofoundation.org/projects/uploads/pdfFiles/Doc%2011%20L iterature%20Review%202010.pdf Kolb, D. A. (1984). Experiential learning: Experience as the source of learning and development (Vol. 1). Prentice-Hall. Kolb, D. A., Boyatzis, R. E., & Mainemelis, C. (2001). Experiential learning theory: Previous research and new directions. In R. Sternberg & L. Zhang (Eds.), Perspectives on thinking, learning, and cognitive styles (pp. 227–247). Routledge.

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Larkin, P., de Casterlé, B., & Schotsmans, P. (2007). Multilingual translation issues in qualitative research: Reflections on a metaphorical process. Qualitative Health Research, 17, 468–476. Ministry of Tribal Affairs. (2013). Demographic status of scheduled tribe population of India. Retrieved from http://www.tribal.gov.in/WriteReadData/CMS/Documents/201306110208 002203443DemographicStatusofScheduledTribePopulationofIndia.pdf Payyappallimana, U., & Hariramamurthi, G. (2012). Local health practitioners in India—Resilience, revitalisation and reintegration. In V. Sujatha & L. Abraham (Eds.), Medical pluralism in contemporary India (pp. 279–304). Orient Black Swan. Pitchforth, E., & van Teijlingen, E. (2005). International public health research involving interpreters: A case study from Bangladesh. BMC Public Health, 5. https://doi.org/10.1186/14712458-5-71 Prince, R., & Geissler, P. W. (2001). Becoming “one who treats”: A case study of a Luo healer and her grandson in western Kenya. Anthropology & Education Quarterly, 32(4), 447–471. https:// doi.org/10.1525/aeq.2001.32.4.447 Rubel, A. J., & Hass, M. R. (1996). Ethnomedicine. In C. F. Sargent & T. M. Johnson (Eds.), Medical anthropology: Contemporary theory and method (pp. 113–130). Praeger.

Chapter 11

Amchi System in Ladakh: Challenges in the New World Tashi Smanla and Shalina Mehta

A Short History of Medicine 2000 B.C.—“Here, eat this root.” 1000 B.C.—“That root is heathen, say this prayer.” 1850 A.D.—“That prayer is superstition. Drink this potion.” 1940 A.D.—“That potion is snake oil. Swallow this pill.” 1985 A.D.—“That pill is ineffective. Take this antibiotic.” 2000 A.D.—“That antibiotic is artificial. Here, eat this root.” (Author Unknown)

Abstract Amchi system of medicine is one of the oldest living and well-documented medical traditions of the world. It is practised in the regions lying in the Himalayas of India, Tibet, Bhutan, Nepal, parts of China and Mongolia. Popularly known as Sowa-Rigpa, “the art of healing” has effectively supplemented the modern healthcare system in the Ladakh region of the Himalayas. It has been added to the acronym of AYUSH recently. However, in recent times, this traditional form of healing faces challenges posed by modernisation drive across the regions of the Himalayas. The inception of globalisation has compounded the fear among the practitioners of this system even further. This paper attempts to analyse the range of difficulties the Amchi system faces both for the discipline and practitioners in Ladakh. Keywords Amchi · Sow Rigpa · Ladakh · Modernisation · Himalayas

Introduction The traditional medicine system no longer remains only in the academic arena. The rising number of health problems in society, particularly the state of Indian society, has brought the alternative medicine system back into the focus of national T. Smanla Panjab University, Chandigarh, India S. Mehta (B) Professor (retd.), Department of Anthropology, Panjab University, Chandigarh, India e-mail: [email protected] © The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023 S. Reddy et al. (eds.), Ethnomedicine and Tribal Healing Practices in India, People, Cultures and Societies: Exploring and Documenting Diversities, https://doi.org/10.1007/978-981-19-4286-0_11

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health planners. For the majority of the people in developing nations, the traditional medicine system remains the primary or only source of health care. The indigenous medicine system contributes to 80% of the world population medical needs. (Shubhrajit Mantry et al. 2014). Recent initiatives such as establishing AYUSH Ministry, encouragement to use herbal medicine for common ailments, and increasing R&D in many pharmaceutical companies engaged in producing organic and plant-based products have led to a renewed interest in the traditional medicine system. However, encouraging these measures is a sound way forward, yet, that is not sufficient to fill the wide gap that lies between the so-called modern health system and the traditional health system (Sen & Chakraborty, 2016), particularly in terms of the extent of government emphasis. By analysis from various angles, the traditional healthcare system lies subservient to its counterpart. It is often designated as ancient, redundant, culturebound and orthodox practices, which predate the modern scientific reason as applied in allopathic medicine (Young, 1976). Some scholars have reservations against using such terms synonymously (WHO, 2000; Kayne, 2009; Ober, 2003) since they feel that such notions further relegates a system of medicine that has been in practice since time immemorial. However, the impact of westernisation and globalisation of modern scientific medicine have buried the conviction that the health system followed throughout the human civilisation is rational (Bhatia et al., 1995). It is this myopic view that has led to the present health crisis in India. The way forward is to complement the allopathic health system with the traditional medicine system in our country. The present paper explores the issues concerning the traditional medicine system prevalent in Ladakh, alternatively known as the Amchi system, an offshoot of the Tibetan Medicine System (Lal et al., 2001).

History Before the emergence of Buddhism, the entire region covering Tibet, Lahaul-Spiti and Ladakh was influenced by the Bon religion (Kreeser, 2003). The shamanic healers and astrologers were the only providers of health services during that period. The role of possession shaman, in which the shaman (Lhaba or Lhamo) possessed by deities, heal the sick by sucking out disease-causing elements from the infected part of the body. The practice in these communities is still significant (Obadia, 2015). They can also heal problems purportedly caused by spirits and supernatural power. The emergence of Buddhism in the Himalayan regions has brought a new system of medicine, which later overshadowed the shamanic healing practice as the entire region more or less had converted to Buddhism (Tsewang, 1998). This new healing system is known as ‘Sowa-Rigpa’, meaning the ‘art of healing’. The system’s fundamental theoretical concept is primarily based on Buddha Shakyamuni’s central doctrine of the four

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noble truths (Hugues, 1995). According to Amchi Tsering Punchok, Sangye Menla1 taught the fundamentals of this medical system. He further adds, “We as an ardent follower of medicine, God is just developing our thesis upon his roots”. Besides Ladakh, the Sowa-Rigpa system is practised in the regions lying in the Himachal Pradesh, Tibet, Bhutan and few parts of Nepal and Arunachal Pradesh. Documented history tells us that the Tibetan medicine system can be traced back to the early seventh century when Tibet, under King sRong sTan rGampo (627–649 AD), organised the first medical conference in Tibet (Kletter & Kriechbaum, 2001). Doctors from India, China and Persia attended the conference, bringing the medical texts that were afterwards translated into Tibetan. Besides, there were many other developments towards the propagation of this system of medicine. Thus, the seventh century can be claimed as the watershed year for “systematic medicine” in Tibet (Wootton, 1998). Various Buddhist monks and scholars like Yuthok Yanthen Gompo (personal physician of King sRong Tsan Gampo of Tibet), Lotsawa Rinchen Zangpo visited India several times to learn this unique system of healing. Buddha is believed to develop this system of healing by himself 2500 years ago. The visits were either out of their curiosity or by the state patronage, but they further enriched their knowledge. Tibetan cultural notions and the Buddhist belief system underline the socioecology of Ladakh. It is one of the few remaining Himalayan areas where the Tibetan system of medicine has not only percolated but also prospered. The Ladakhi people attribute the diffusion of Sowa-Rigpa in Ladakh to the great Tibetan translator Lotsawa Rinchen Zangpo (958–1055 AD), who was very active in propagating the teachings of Buddha, notably the Mahayana Buddhism. According to Amchi Nawang Tangey, the introduction of Tibetan Buddhism was concurrent with introducing the Tibetan Medicine System. Buddhism contributes to the formation of the practice’s moral foundation, in which the therapist’s religious approach, at least in Ladakh, is still greatly encouraged (Laurent, 2007).

Disease for Amchi Veena Bhasin (2007) argues that every culture has its worldview of disease. The Western concept is isolationist in which disease causality and curative measure have nothing to do with religion and magic. However, the non-Western considers an illness as an intricate fabric that includes every aspect of life, which involves supernatural and magical powers (Foster, 1976). Buddhist philosophy regards diseases as suffering due to the disturbance of the balance between a man and the five essential elements around him. Such a broad definition of disease has been why Amchi healing system and, for that matter, the traditional medicine system is referred to as holistic (WHO, 2011). It regards the three poisons, viz. desire and attachment; anger and hatred; and close-mindedness as 1

Buddha of Medicine (Skt. Bhaisajyaguru; Tib. Sangye Menla) is an important Buddha in the Mahayana tradition.

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the fundamental evils that give rise to human suffering. These three mental poisons are believed to be the primordial cause for illness due to disruption in the balance of three humours (Nyepa Sum) translated as wind (Lung), bile (tripa), and phlegm (beken). This is entirely different from the simplified definition given by Western authors (Gerke, 2010).

Being Amchi in Ladakh Tibetan Medicine system plays a vital part in the health care of the Ladakhi communities. They are alternatively known as ‘Amchi’2 system, its knowledge has usually been passed down from father to son or daughter within the family. This is known as the rGyutpa lineage. In many cases, this knowledge system continues up to the sixth generation of unbroken family lineage. The intriguing aspect of the rGyutpa system is that most of the knowledge is being transferred orally. Further, a young practitioner will get to experience the feeling of curing a patient very closely. According to Amchi Rigzin, the extent of focus given on practical teaching in rGyutpa lineage is rarely found in any other learning system. This helps in imparting the teacher’s knowledge to students efficiently; it also helps develop a bond between teacher and student that is very important. Fresh ‘Amchis’ have to take their passing out examination orally in front of the whole village. A panel of respected senior Amchis from surrounding villages examines them (Smanla & Millard, 2011). In every village, there are usually one or sometimes two Amchi families. Their presence within the communities makes them more serviceable. The Amchi, as practised by these people, are never done with the intent of earning a livelihood. Farming is their primary source of livelihood. These Amchis perform a dual role as a healthcare provider to the community and otherwise as a farmer. Amchi knowledge and services provided by them is greatly valued. No payment is taken for treatment, but the villagers often help a village Amchi with their farm work. Occasionally, villagers assist the Amchi in the collection and preparation of the medicines. The Amchi doctor holds a higher position in society. In any gatherings of villagers, Amchis are given seats right next to the monks. They are not only medical doctors but also influential community leaders. Their opinions are frequently sought in cases of societal matters. Many Amchis are also called to conduct special prayer on occasions like Tssanthun and gya-Zhi in families. Many Amchis practise Buddhist astrology and astronomy. These subjects play an essential role within Amchi medical practice as they do within Ladakhi society in general. There is a strong relationship between Buddhist astrology and Tibetan medicine. An Amchi is required to consult the stars and other astrological signs before giving a treatment. For instance, Saturdays are considered inappropriate for any type of treatment, which requires fire or metal instruments. Likewise, an Amchi is required to keep a tab on astrology for treating a patient. 2

Word Amchi is derived from the Mongolian word Am-rjai that means “superior to all”.

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The Practice The age at which an individual commences his/her Amchi training varies. My respondent, Amchi Chosdon, started practising Amchi at the age of 21. On being asked why she chooses to be an Amchi, her prompt response was, “it is a noble deed, and it gives an immense sense of happiness to cure people, and most importantly, this noble tradition runs in my family”. Amchi Chosdon is a nun under the Drukpa sect. During her ten years of monastic life, she has studied the fundamental texts of Buddhism, Buddhist philosophies, and other treatises of Buddhism. “Becoming an Amchi was an opportunity provided to me by Kundun Drukchen (Head of Drukpa lineage)”, says Amchi Chosdon feeling obliged. She is the third in her family generation who is practising Amchi. Both the maternal uncles of Amchi Chosdon are accomplished monk-cum-Amchi. “For me as a nun, I am not bound by family attachment and social barriers, so it gives me the freedom to practice and treat people all my life. Further, a person with the monastic background can help a patient heal spiritually”. Amchi employs several spiritual techniques and prayers like recitation and meditation while visualising the great Sangye Menla (Medicine Buddha). According to Amchi Tsering, Mantra provides the rNgag, the invisible and imperceptible spiritual power to heal the sick. Amchi attributes the conferment of this power to them to Sangye Menla. rGyudzhi is the fundamental text of the Tibetan Medicine System. For a young and new practitioner, this book is the basis for building the practitioner’s foundation. Having learned the basics of Buddhist texts while in the monastery, Amchi Chosdon feels that it helped her grasp the essentials of the rGyudzhi without much difficulty. Her background knowledge also benefits her in formulating medicine ‘Sman-Drup’, during which Amchi conducts many religious rituals. “For a layman, without prior knowledge about Tibetan scripts and rituals, this becomes another hurdle to learn Tibetan Medicine,” remarks Amchi Smanla, an Amchi medical graduate from Tibetan Medical and Astrology Institute of Dharamsala. Though traditionally, a monk or a nun favours practising Amchi, it is not essentially a norm now. The fact that Amchi-cum-monk/nun constitutes only around 11 percentage of the total Amchi population in Ladakh is sufficient to explain that their presence is due only to personal choice and initiative. Amchi Chosdon is not enrolled in a formal institute, which confers a degree on completing the stipulated period. Instead, her practice is based on the traditional Guru-Shishya system, where the practitioner stays with the Master for the entire learning period. Her legitimacy of being an Amchi will be her knowledge level and a viva voce that she has to go through in the final year of her practice. A young practitioner is taught the basics of identifying and collecting the medicinal plants, which they learn by visiting the areas where it is found besides medicine formulation. Learning rGyudzhi and another medical treatise were done in the first year. In the second year, she is taught to diagnose the sick through various means like visual diagnosis, diagnosis by touching and questioning. The student is required to stay

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with their Master while examining a patient. In the subsequent period, she will be required to diagnose the patient by herself and prescribe medicine. For Amchi Smanla, the journey of his practice is somewhat different from Amchi Chosdon. He is not associated with any monastery. However, he, too, has a family lineage of Amchis. He completed his Khachupa degree in Tibetan Medicine from Dharamsala through a formal institution. He is now interned as a fellow in Men Tse Khang at Leh. “For me, in my early years as a young learner, learning the scripts of Tibetan was a bit problematic”, remarks Amchi Smanla. This was also a concern by another fellow associated with Amchi Sabha (Amchi Association in Leh). This advantage of learning from a native script for the Tibetan practitioner is causing a sense of anxiety among many Ladakhi Amchis. They fear that such intricate things might distract Ladakhi youth from choosing this as a profession. However, Amchi Chosdon negates such perception. The primary purpose of an Amchi is to assist to cure, and it does not matter who does it. Amchi Rigzin also shares this view. Amchi Punchok goes beyond this and adds that this sense of worry amongst the Amchis is a positive sign. It can be harnessed to generate a sense of competition among the Amchis in Ladakh vis-a-vis Tibetan Amchi. This will bring in more innovation and will be helpful in the development of this dying knowledge system.

Phase of Turbulence Modernisation and globalisation have adversely impacted local traditions and culture, and the traditional medicine system is no different. However, for a considerable time since its emergence in Ladakh, the Tibetan Medicine system has remained unaffected by these forces. As per Amchi Punchok, his Master (guru) visited different corners of Ladakh, which included the army camps till 1947 for treating the sick. Amchi Rigzin, who has travelled to different parts of Ladakh assisting his father, shares this view. The reasons why it survived for so long, as per the respondents, are many. Some of them are the region’s topography, such as isolation from the rest of the world and harsh climate. Secondly, villages were not connected with proper roads and had a low level of knowledge about the modern system of medicine. All these factors led to the growth of this unique healthcare system within the confinement of the mountains. Amchi Rigzin even owes its survival to the people’s faith in the system of guru shishya tradition. So, in these conditions, Amchi plays a vital role. After independence, a surge in military movements and inter-regional trade resulted in further use of modern medicines in Ladakh. Amchi Punchok says the decade after the independence was the turning point for the change in the Amchi medicine system. Firstly, it created a fear among the Ladakhi Amchi practitioner about its survival in Ladakh owing to the inflow of allopathic medicine, promoted not only by the market but also by the state. Secondly, the Tibetan government under the auspicious aegis of His Holiness the 14th Dalai Lama has worked immensely for the growth of this knowledge system among the Tibetans. In the year 1976, the first formal institute of

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Tibetan medicine was established in Dharamshala. This gave the necessary impetus for the development of Amchi, not only for the Tibetan Amchis but also encouraged the Amchi across the Himalayan region, which includes Ladakh. However, the formal degree holders are only 30–40, while the number of informal learners exceeds 150 intrigues Amchi Punchok. A significant concern of most of my respondents is the growing deterioration of morality and ethics among the Amchis. An Amchi is required to follow the noble paths of Lord Buddha. “It is not only the expertise; rather a person must be a Chang chup samba (compassionate) to be a qualified amchi”, remarks Amchi Rigzin. He further adds, “Curing a patient is the biggest merit a person earns. He/she must not expect a cost for the service they provide”. I have seen my uncle travelling to different places to serve the patients in the cold winter. Such a humane approach among the Amchis is getting rarely visible now, remarks Amchi Rigzin. He says such a gesture helps Amchi become a part of all the families and helps build a special relationship between the patient and the doctor. The present health care system does not see such an intricate relationship between patients and doctors as important. Therefore, the doctors and patients are related only as customer-seller. Such a wide gap is the biggest flaw in the modern system. Amchi Punchok argues that the current government of India’s initiative to bring ASHA workers as a bridge between doctor and patient is just a replication of traditional practices that we learned now. Likewise, there are many things to learn from this form of knowledge system. Amchi Smanla says that the modern science-based medicine system treats disease as a physical phenomenon, treated physically like erasing by an eraser, which is a narrow view. Besides medicine, a patient needs much support, including spiritual, moral, and emotional. These needs are fulfilled in the traditional medicine system. There is also a concern about the declining tradition of the Guru-Shishya system. The kind of focus a master gives on the learner is not there in the formal system. There is no effort to teach the student in an environment where Amchi can learn by mistake in front of their masters. In addition, the formal system emphasises learning the theory part while the practical part takes the back seat. In ITDM, five years for classroom learning and only one year is given on practical. In such an environment, a student hardly gets to learn.

Challenges and Concern The diminishing faith in the traditional system of medicine among the local people is a primary concern. Though there is an effort from the government to revive this system through proper recognition, much still needs to be done, argues Amchi Punchok. He specifies that the number of patients consulting an Amchi is far less than patients visiting the modern hospital. Empowering individual Amchi through various government schemes is what is needed the most, believes Amchi Smanla. “We need to have a more assertive attitude when it comes to saving this system,” says Amchi Chosdon. Amchis across Ladakh has organised itself into a formal association that reflects the

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community’s concerns, values, and aspirations collectively. Ladakh Amchi Sabha, Ladakh society for traditional medicine, and Traditional Medico-cultural Association are some well-known organisations working towards propagating this system of knowledge. Not only do they provide a platform for all the Amchis of Ladakh to voice their concern, but they also conduct medical camps, seminars and conferences in different parts of Ladakh. These organisations’ efforts eventually resulted in the informal entry of Sowa-Rigpa into the Ministry of AYUSH. Preserving the medicinal plants found in the high mountains of Ladakh is another crucial area, which needs attention. One of the reasons for its extinction is the low level of knowledge among the local people about the importance of these precious plants. His Holiness, the 14th Dalai Lama, shares this concern and urges the people to make themselves and others aware of its criticality. Another reason is the impact of climate change. The medicinal plants, which were found at lower hills, are not grown anymore. I have seen plants shifting their growth both temporally and spatially. Amchi Punchok, with whom I went for excursion and plant collection for the last eight years, blames climate change and global warming. He fears that such trends would result in the extinction of these priceless plants if continued for long. Another challenge is the commercialisation of these medicinal plants. Leh Berry’s case, a company that sells beverages made out of sea buckthorn (tser ta lulu) in Ladakh, has posed a severe threat to the plant ecology. Sea buckthorn has been a significant plant in Tibetan medicine since time immemorial. The entry of such big companies to exploit their resources will drastically affect the ecology and the Amchi medicine system. The need for documenting the vast knowledge, which lies only orally with the traditional practitioners and its history, is another crucial area to focus upon. As per respondents, there is a plethora of knowledge that remains elusive to our reach. The need is to bring forth this knowledge and make it presentable to all. Amchi organisations can be exploited for this purpose, provided the government supports them.

Conclusion Notwithstanding the growing competition from the market and in this changing environment, it is imperative to mention that there are many positive signs, which indicates that this knowledge system can survive even under cutthroat competition. Many non-governmental organisations are working collectively for the rise of this system. The fact that the Amchis are working as a network throughout the world is a thing to reckon with. In Ladakh, it is supported by all sections of society. The legal recognition of Amchi in 2012 is also a shot in the arm for those who advocate it. Many Amchis are not afraid of their existence, as they can integrate well with the modern scientific health system. Amchi Dolker, a well-known Amchi in Delhi, correlates the biomedical report for diagnosing any disease before prescribing the Amchi medicine. The traditional medicine system still enjoys a significant position

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in many communities across the world. The system is intricately linked to the socioculture of several geographies across the world. Thus, the requirement to save this cannot be negated. Further study on Amchi and their relationship to the subject of trans-divination (shamanic healing practice) need thorough study by a keen student of Anthropology. This will help in expanding our understanding of the many unexplored areas of the medical world.

References Bhasin, V. (2007). Medical anthropology: A review. Ethno-Med, 1(1), 1–20. Bhatia, et al. (1995). Traditional healers and modern medicine. Social Science and Medicine, 9(1), 15–21. Foster, G. M. (1976). Disease Etiologies in non-western medical system. American Anthropologist, 78(4), 773–782. Gerke, B. (2010). Correlating biomedical and tibetan medical terms in Amchi medical practice. In M. Schremph & S. Craig (Eds.), Medicine between science and religion (Vol. Adam, pp. 127–156). Berghaham Books. Hugues, J. (1995). Buddhism and medical ethics: A bibliographic introduction. Journal of Buddhist Ethics 2, 105–124. Kayne, S. (2009). Introduction to traditional medicine In traditional medicine: A global perspective. London Pharmaceutical Press. Kletter, C., & Kriechbaum. (2001) Tibetan medicinal plants. Medpharm Scientific Publishers, NYC. Kreesing, F. (2003). The increasing of Shaman in the contemporary Ladakh: Some preliminary observation. Asian Folklore Studies, 62, 1–25. Lal, B., Ahuja, & Gupta. (2001). Application of Seabuckthorn in Amchi system of medicine. In Singh & Khosla (Eds.), Proceedings of International Workshop on Seabuckthorn (pp. 239–242). New Delhi. Laurent, P. (2007). Buddhism in the everyday medical practice of the Ladakhi Amchi. Indian Anthropologist, 37(1), 93–116. Obadia, L. (2015). The impact of the modernisation process in the Himalayas: Tibetan and Napalese Tradition in Transition, In D. W. Kim (Ed.), Religious transformation in modern Asia: A transnational movement (pp. 139–259). Brill Publication. Australia. Ober, K. P. (2003). Mark twain and medicine: Any mummery will cure. University of Missouri Press. Saiket, S., & Chakraborty, R. (2016). Revival, modernisation and integration of Indian traditional herbal medicine in clinical practice: Important challenges and future. Journal of Traditional and Complementary Medicine, 7(2), 234–244. Shubhrajit, et al. (2014). International standards of medicinal plants. International Journal of Innovative Pharmaceutical Sciences and Research, 2(10), 2498–2532. Smanla, T., & Millard, C. (2011). The preservation and development of Amchi medicine, in Ladakh. International Journal of East Asian Science, Technology and Society, 7, 487–504. Tsewang, T. (1998). Buddhism and Bon. Bulletin of Tibetology, 2, 7–12. Young, A. (1976). Some implication of medical belief and practices for social anthropology. American Anthropologist, 78(1), 5–24. Zhang, X., & World Health Organization (WHO). (2000). General guidelines for methodologies on research and evaluation of traditional medicine. World Health Organization, 1–71.

Chapter 12

Health Care Systems Among Broq-pa Tribe Diskit Wangmo, Rita Kumari, Nutan Kumari Jha, and A. K. Sinha

Abstract This paper focuses on the challenges faced by the traditional healers to meet the health care needs and the interaction of biomedicine and traditional medicine among the Broq-pa tribe residing in lower Sham in the villages—Dah-Baima and Hanu of Khaltse block, District Leh, (Jammu & Kashmir). The objective is to investigate the extent of health care systems available and their utilisation. An empirical study was conducted based on 250 respondents, and the key informants like doctors, health workers, Amchi (local and government appointed) were also interviewed. It was found that the Broq-pa tribe is accessing different systems of medicine for their health care needs. There is a ‘hierarchy of reason’ applied to choose between the available systems of medicine. The family composition and age of the family members also contributed to the decision making and selecting the type of healing system. The case studies revealed that the traditional system of medicine was gradually declining in the region with access to the modern biomedical system of medicine, as they found it to be more effective. The study documents the reasons for acceptance or rejection of the modern (biomedical) and the traditional system of medicine. Keywords Amchi · Broq-pa · Folk healers · Lhabhanism · Rituals · Traditional medicine

Introduction The role of the region’s health sector is health promotion through the provision of therapeutic clinical and curative services. “Health services today are required to embrace an expanded mandate that is sensitive to and tends to respect the cultural

D. Wangmo Department of Anthropology, Govt. Eliezer Joldan Memorial College, Leh-Ladakh 194101, India R. Kumari · N. K. Jha · A. K. Sinha (B) Department of Anthropology, Panjab University, Chandigarh 160014, India e-mail: [email protected] © The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023 S. Reddy et al. (eds.), Ethnomedicine and Tribal Healing Practices in India, People, Cultures and Societies: Exploring and Documenting Diversities, https://doi.org/10.1007/978-981-19-4286-0_12

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needs of a people. This mandate should cater to the needs of individuals and communities for a healthier life besides opening up a number of and the broader social, political, economic and physical environmental components” (WHO, 1986). Health and health infrastructure development form an integral part of the overall socio-economic development of a nation. Primary health care is the health approach that integrates various elements governing the health of individuals and communities as they are necessary to impact the health status of the people at the community level. It comprises the chain reaction of responses and counteractions required to maintain a healthy life, especially knowing where to seek relief from pain and suffering. The costs, techniques and methods and organisations that are easily accessible to the population seeking treatment assist them in improving the living conditions of individuals, families and communities. These may include preventive, curative and rehabilitative health measures as well as community development activities. Cassel (1976) mentioned that the Rig Veda had recorded the fact that, “in the beginning, there was a desire which was the first seed of mind”. This points to the earliest desire for a healthy family, society, and consequently, a healthy country that has driven individuals and governments alike to provide curative health systems as an essential component that seems to be an undisputed association among social equality, social integration and health. The theory of ‘social support’ documented the social integration of health. Further, Wilkinson (1992) has mentioned that poverty, resulting from social and economic inequality in a given society, can be determined by the population’s health. The outcome indicators of health determine the overall standard of living of the people. Since colonial rule, medical pluralism has been part and parcel of the Indian ethos, introducing the allopathic medicine tradition into the predominantly Indian traditional medicine scenario (Bhasin, 1997). Many factors are responsible for the coexistence of several different systems of medicine and practitioners that rest on economic affordability. Other factors were the availability of modern health care, cultural propensities and religious belief systems. Moreover, asymmetric power relations and dynamism exist both within and between multiple practices and systems, which differ from one society to another. A study on the alternative resources and treatments utilised by different population groups in Ladakh observed that the patients coming to the health centre came only after receiving treatment from traditional healers. People tend to upgrade from their pre-existing practices if the economic costs are within their reach. They are usually pragmatic in trying and evaluating newer alternatives. In the case of health behaviour, the cost–benefit mode of analysis and empirical evidence motivates deciding whether or not this is to their advantage. Among the Ladakhis, although the traditional beliefs on fertility, pregnancy and abortion have remained unchanged, most childbirths that occurred during the study were institutional at the health centre or the government hospital. As there are multiple medical systems available to Ladakhis to opt from, the situation and condition of the ailing individual and family determined the course of action. There is no specific sequence of action to resort. However, the trend is to

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usually begin with home remedies and proceed to Lhaba/Lhamo, monk and Amchi as the course of the illness progresses in severity from stage to stage and finally becomes most profound. The use of traditional herbs for curing disease is common practice in the area. Usually, allopathic medicine is the last resort among the Buddhists and the Muslim population of Ladakh.

Alternative Healing Practices: Changed Scenario According to Peters (1998), the Bonpo or Buddhist healer of Tamang also reads the pulse to diagnose the attack by don. Bonpo believes that the magical spell he uses has the effect of a command: i.e. the recitation guarantees God’s compliance. There are processes of change visible currently. Mitra (2006), in his study, examined the changes that occurred in the practice of Tibetan medicine in the current situation and how successful the traditional medical system had been in tackling various health problems. Tibetan medicine has been transformed several times over time and space in terms of its practice. The Tibetan doctors use several methods of diagnosis, but currently, the religious aspect is given lesser emphasis than as was being done earlier. Tibetan medicine emphasises behavioural changes as well as medication for treatment. The merits of Tibetan medicine are that it has no side effects and provides a permanent cure by striking at the root of the ailment. In comparison, allopathic medicine provides quick relief in some cases, is economical compared to various medicine systems and is always readily available. Kressing (2003) examined the currently increased number of Shamans or traditional healers in contemporary Ladakh. He observed that “foreign pressures, like the heavy Indian military presence, the impact of the Muslims dominated State of Jammu and Kashmir (of which Ladakh is a part), and Western influences that stem from Ladakh’s popularity as a tourist destination have led to severe stress within the region. He further argues that the ‘proliferation of shamanism’ offers a wide range of possible coping strategies”.

Research Methodology The researcher conducted anthropological research to interview 250 respondents (male = 104, female = 146) in the Dah-Baima and Hanu villages of the Broqpa tribe residing in the lower Sham of District Leh, Ladakh. Dah-Baima village is divided into two settlements, namely Dah and Baima. The Broq-pa villages lie at a distance of approximately 170 km from Leh town. The study’s objectives are to investigate the availability of alternative health care systems and the extent of utilisation of each of these health care systems in the present population and explore the reasons for acceptance or rejection of any particular medical system. The researcher collected the primary data in the form of case studies

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formed from the narratives of the native Broq-pa. Apart from the villagers, the doctor, health workers, Amchi (local and government appointed) were interviewed for the present study.

The Three Sectors of Health Care Kleinman (1981) has suggested that “while looking at any complex society, one can identify the three overlapping and inter-connected sections of health care”, namely popular sector, professional sector and folk sector. Each sector has its inherent ways of explaining and treating ill-health, defining who is a healer and patient and specifying how the healer and the patient should interact during the therapeutic interface. (i) The Popular Sector The popular sector is the layman’s, non-professional and non-specialist domain, where “ill-health is first recognised, defined and health care activities are initiated. It includes all the therapeutic options that people utilise without any payment and without consulting either folk healers or medical practitioners”. In this sector, the primary health care arena is the family. “It is the initial and ultimate site of primary health care in any society. In a family, the primary providers of health care are women, usually mothers or grandmothers, who diagnose most commonly occurring illnesses and treat them with the materials at hand. People who become ill typically follow a ‘hierarchy of reason’ ranging from self-medication to consultation with others” (Fig. 12.1). The popular sector usually includes a set of beliefs on the subject of health maintenance. “These are usually a series of guidelines for specific social groups, about the ‘correct’ behaviour for preventing ill-health in an individual and the community. They include beliefs about the healthy ways of eating, drinking, sleeping, dressing, and working, praying and generally conducting one’s life”. This sector comprises several informal and unpaid healing relationships of variable duration that occur within the ailing person’s social networks, including the Fig. 12.1 Health care system internal structure. Source Kleinman (1978)

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family. All these people can be sources of advice and assistance on health matters. Their credentials are based on their own experiences rather than formal education, social status or special occult powers.

Use of Home Remedies On asking about the use of home remedies, the study found that 75% of the respondents used home remedies before taking further medication. Only 25% of the respondents were not using any home remedies and were going straight to the practitioner of modern medicine before they took any traditional medication. The statistical analysis (Table 12.1) shows that the relationship between the age of the respondents and whom they seek advice from in cases of illness is significant (P = 0.369). It means that among the younger age groups, the role of the elders and their advice was supreme. With the advancing age, people seek independent decisions and advice from various sources to cure ailments. The study found that 53.6%, 27.7%, 10.9% and 3.6% of the respondents sought the advice of medical practitioners, family members, spouses, relatives, friends and neighbours, respectively. Only 5.2% of the respondents did not seek any advice during their illness. Most of the respondents said that they had resorted to self-medication and home remedies like apricot oil for massage, soup of barley flour and meat, boiled rice, water and other herbs to cure the symptoms during the initial stages of illness. These home remedies were handed down by word of mouth and example from generation to generation. By analysing the case studies on health-seeking behaviour, the basis of causes of illness was derived, and how the respondents sought various cures like home remedies, Amchi medicine and biomedicine to treat their ailments. Also, due of adequate income, the proximity of the location of health facilities and their attitude towards health problems, influenced their choice of seeking health care services even self-made remedies and Lhaba and Lhamo therapies. There is a belief that evil eye and evil spirits caused illnesses, and the use of home remedies like ‘dukzas’ (herbal incense used to ward off the mal effects of evil eye and evil spirits) is practice. (ii) The Professional Sector It is an organised and legally recognised healing profession. It includes physicians, specialists and recognised paramedical professionals having training in modern, western or scientific medicines. It is also known as allopathy or biomedicine. In most countries, scientific medicine is the basis of the professional sectors, but as Klienman (1981) notes, the traditional medical system can also become structured and ‘professionalised’. The Ayurvedic and Unani medical colleges in India, which receive government support, are a case in point. Western scientific medicine is only a minor contributor to health care in most countries of the world. The medical workforce is often a scarce resource, with most health care-taking place in the popular and folk sectors.

0 (0)

3 (27.3)

1 (9.1)

0 (0)

11 (100.0)

Friends/neighbours

Medical practitioners

Others

Spouse

Total 39 (100.0)

2 (5.1)

2 (5.1)

25 (64.1)

0 (0)

10 (25.6)

26–35

37 (100.0)

2 (5.4)

3 (8.1)

18 (48.6)

0 (0)

14 (37.8)

36–45

Source Field work (percentages are indicated in parentheses) (P = 0.369)

7 (63.6)

16–25

Age group

Family members

Seeking advice during illness

Table 12.1 Respondents’ age and advice-seeking behaviour

43 (100.0)

2 (4.7)

2 (4.7)

29 (67.4)

1 (2.3)

9 (20.9)

46–55

47 (100.0)

2 (4.3)

7 (14.9)

22 (46.8)

3 (6.4)

13 (27.7)

56–65

43 (100.0)

2 (4.7)

6 (14.0)

22 (51.2)

3 (7.0)

10 (23.3)

66–75

25 (100.0)

2 (8.0)

4 (16.0)

12 (48.0)

2 (8.0)

5 (20.0)

76–85

5 (100.0)

1 (20.0)

1 (20.0)

3 (60.0)

0 (0)

0 (0)

86–95

250 (100.0)

13 (5.2)

26 (10.4)

134 (53.6)

9 (3.6)

68 (27.2)

Total

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According to Klienman (1981), “Health care systems of any society cannot be studied in isolation from other aspects of the society because the medical system or professional sector of health care does not exist in a social or cultural vacuum. It is an expression of and, to some extent, is a miniature model of the values and social structure of the society from which it arises. Therefore, different types of societies produce different types of medical systems that emanate from a range of attitudes towards health and illnesses depending on their inherent and dominant ideology that governs their lives. One society may see free health care as the basic right only of the poor or the very old, while another tends to see medical care as a commodity that is bought only by those who can afford it”. Thus, for understanding any medical system, “one must see it in the context of the basic values, ideology, political organisation and the economic system of the society from which it arises”.

Medical Facilities Available Among the Broq-pa The Ladakh region has two district hospitals and several Public Health Centres (PHC), Community Health Centres (CHC), allopathic dispensaries, medical subcentres and private medical sectors. The Khaltse Block has one Community Health Centre, two allopathic dispensaries, five family welfare centres, also called subcentres, and 23 medical aid centres. The government health centres have the responsibility for the delivery of health care services to the local people. There are three medical sub-centres and one allopathic dispensary available in the field area. (i) Hanu Village: The Hanu village has two areas, i.e. Hanu Gongma (upper area) and Hanu Yokma (lower area). In Hanu Gongma, the health care delivery system comprises one sub-medical centre with two medical practitioners and a helper. The villagers visit this medical sub-centre to seek treatment for illnesses or when they do not get relief with their home remedies and local Amchi. When the villagers find that their diseases are not cured at this sub-centre, they are referred to the allopathic dispensary at Hanu Yokma. There is one allopathic dispensary in Hanu Yokma (lower area), with a doctor, pharmacist, two multipurpose women health workers (nursing staff) and two helpers. Besides the dispensary, there is one traditional Amchi centre with the newly inducted Amchi practitioner into the government service. There are no private practitioners in the village except for the local Amchi healers. The allopathic dispensary has all the basic facilities with the following medical equipment: surgical equipment, autoclave, all types of disposal bin, fridge to store medicines, washing machine, weighing machine, thermometer, stethoscope, sphygmomanometer (BP apparatus) and other minor equipment (medicine tray, syringe), etc. Dah-Baima Village Dah-Baima is a combined village, coming under one Goba (head of the village), but due to distant settlement, there are two medical sub-centres. In the

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Dah medical sub-centre, there is only one health worker and one helper. In addition to the government health facilities, an Army Health Centre is working in the Baima village. Every year, the army organises health camps in these villages. The Amchi system practitioners are not available in this village. If people wish to seek Amchi medicine, they go to Skurbuchan Public Health Centre (a neighbouring village about 30 km away) and Leh.

Utilisation of Health Centres The researchers have investigated the relationship between different age groups and procurement of medical facilities by respondents from the village health centre (Table 12.2). It can be inferred (Table 12.2) that the available medical facilities at the health centre are not sufficient for treatment of prolonged and serious illnesses. On the other hand, Table 12.3 shows the relationship between different age groups and the respondents who visited the health centre in case of illness. The statistical analysis (Table 12.3) shows that the relationship between the ages of the respondents and visits to the health centre in case of illness is highly significant. This means that the younger people visit the health centre only in case of any disease. With the increase in age, the frequency of respondents’ visits to the health centre becomes significantly low, but it was interesting to note that in the age group 86–95, they all visit the health centre in case of ailments. The respondents were asked about the procurement of medicines from the health centre. The researcher asked about the constraints in adopting the modern medical system and reason for not visiting the health centre. The grounds mentioned were personal health problems such as prolonged illness, inability to walk long distances across the harsh terrain during sickness and the recurrent belief that modern medicine was not suitable or was proving to be ineffective for them. The researcher also investigated the reasons for the use of modern medical practices, their attitude towards biomedicine and the acceptance and rejection of the modern systems of medicine among the Broq-pa. On analysis, the case studies show that despite the prevalence of chronic ailments like tuberculosis, kidney disorder, vision problems, asthma, etc., respondents found the modern medical system to be more effective. The non-availability of treatment options in the village health centre and the long and challenging journey required to access better facilities at hospitals at Khaltse or Leh and the poor source of income were a hindrance to treating the ailments efficiently and within time. (iii) Folk Sector This sector is vast in simpler societies. This is because specific individuals specialise as healers who are considered sacred or secular or an amalgamation of both. These healers are not part of the official medical system and occupy an intermediate position between the popular and professional sectors. The folk healers are numerous

3 (27.3)

1 (9.1)

0 (0)

11 (100.0)

Not for serious/prolonged illness

Not satisfactory

Do not know

Total

26–35

39 (100.0)

0 (0)

1 (2.6)

12 (30.8)

26 (66.7)

Percentages are indicated in parentheses (P = 0.009)

7 (63.6)

16–25

Age group (in years)

For common ailments

Utilisation of medical services from health centre

37 (100.0)

2 (5.4)

2 (5.4)

13 (35.1)

20 (54.1)

36–45

43 (100.0)

2 (4.7)

0 (0)

23 (53.5)

18 (41.9)

46–55

Table 12.2 Respondents’ age and utilisation of medical services from the health centre 56–65

47 (100.0)

2 (4.3)

0 (0)

29 (61.7)

16 (34.0)

66–75

43 (100.0)

3 (7.0)

5 (11.6)

21 (48.8)

14 (32.6)

76–85

25 (100.0)

2 (8.0)

5 (20.0)

11 (44.0)

7 (28.0)

86–95

5 (100.0)

0 (0)

0 (0)

3 (60.0)

2 (40.0)

250 (100.0)

11 (4.4)

14 (5.6)

115 (46.0)

110 (44.0)

Total

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Table 12.3 Utilisation of health centres among various age groups Age group (in years) Visits to health centre 16–25 26–35 36–45

Total 46–55

56–65

66–75

76–85

86–95

Yes

11 39 35 (100.0) (100.0) (94.6)

42 (97.7)

43 (91.5)

41 (95.3)

19 (76.0)

5 235 (100.0) (94.0)

No

0 (0)

1 (2.3)

4 (8.5)

2 (4.7)

6 (24.0)

0 (0)

Total

11 39 37 43 47 43 25 5 250 (100.0) (100.0) (100.0) (100.0) (100.0) (100.0) (100.0) (100.0) (100.0)

0 (0)

2 (5.4)

15 (6.0)

Percentages are indicated in parentheses (P = 0.007)

and varied. They range from technical experts such as bonesetters, midwives, tooth extractors to herbalists, spiritual healers and shamans. Folk healers form a heterogeneous group and can be organised into healers’ associations, with rules of entry, codes of conduct and information sharing. Many folk healers are immersed in the socio-cultural values and worldview of communities in which they live. They are mindful of the beliefs about the origins, significance and treatment for various ill-health conditions. The traditional healer’s approach holistically deals with all aspects of the patient’s life, relationships with people, the natural environment and supernatural forces. It also includes the physical and psychological or emotional symptoms. In many non-western societies, all these aspects of ill-health are part of the balance people have among their social, natural and supernatural environments. Disturbance in any of these results in physical symptoms or emotional distress and requires the services of a folk healer. When faced with illhealth, such healers often inquire about the patient’s behaviour before the illness and if they have conflicted with other people. In several societies, the healer is aware of the families’ difficulties as they know the local gossip. This, coupled with the knowledge of the patient’s socio-economic background, may prove helpful in reaching a diagnosis. The healer can employ a ritual of divination through any number of ways practised the world over, such as cards, bones, straws, shells, unique stones and tea leaves. Such healers invoke sacred powers to explain and treat subjective feelings of guilt, shame or anger by prescribing specific ritualistic prayers, repentances or resolving interpersonal problems. In the present study, the folk sector has been divided into sub-systems of medicine, including the Amchi system, Labhanism system and Onpo (astrologer) system.

Amchi System of Medicine In Ladakhi societies, each community has its specific traditional system of medicine known as the Amchi medicine or Tibetan medicine. The meaning of Amchi Buddhists in Tibetan language used by population means ‘superior to all’. Traditionally, the

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Amchi practitioners were primarily farmers, and medical practice was a secondary occupation, and their services were free of charge. One member of every village household exhibits their gratitude by helping the Amchi during the sowing and harvesting of crops. This traditional institution is prevalent even today as the Amchi practitioners enjoy great respect and social status among trans-Himalayan Buddhist communities. While the use of allopathic medicine no doubt has increased manifold in recent decades, a large percentage of the population still relies on the traditional healing system. The “indigenous knowledge of the Amchi sustains the socio-cultural fabric of village life and is a trusted, effective, and affordable health care system” (Kala, 2005). The Amchi medicine system provides primary health care in every area. In Ladakh, it is known as Sowa Rigpa. It is based on the principles of the Tibetan health system. The concepts of Tibetan Buddhism ordain a holistic approach to health, advocating the balance of life-sustaining forces within the body. This tradition forms the basis for health care in Ladakh. “The traditional healer or Amchi is an integral component of the culture and community in which they work”. A traditional type of system has been observed to be based on myths and powers that are beyond human control and intervention, including the supernatural elements. Traditionally, it has been passed down from generation to generation. The father passes the knowledge and skills to his offspring. Nowadays, however, many aspirants are pursuing professional degrees of Amchi from reputed institutions. Stephan (2004) mentioned that in the Broq-pa society, once Amchi established social power, he easily maintained his medical control due to favourable access to the resources needed for good medical practice. Table 12.4 shows the Amchi tradition in Hanu village. The case studies concluded that all Amchis are primarily cultivators, so they have to look after many other domestic chores and therefore cannot prescribe medicines all the time. As local Amchis have no funds to pre-prepare medications, the Amchi system is gradually losing importance and recognition. The pressure of the modernised medical system is affecting his income and economic conditions a lot. Also, the local Amchis are getting older and cannot gather herbs and prepare medicines. While the younger generations are veering away from this traditional occupation.

Declining Traditional System of Medicine The traditional system of Tibetan medicine is declining in the trans-Himalayan region of India. The older Amchis have exceptional knowledge of the local flora and fauna. In contrast, many of the new Amchi do not make these medicines themselves, nor do they get a chance to visit the forest area to identify medicinal plants. Hence, they are unable to locate several of the plant species. They are dependent on the readily available Tibetan medicines prepared by pharmaceutical companies that are available off the counter. It is praiseworthy that the state government, a few NGOs and many Amchi are attempting to keep the Amchi tradition alive. New associations and Amchi schools

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Table 12.4 Amchi tradition in Hanu village First generation

Family

Village

Dates

Age

Amchi education

Teacher

Stanzin

Gangchungpa

HG

1854–1940

86

1915–1920*

–

Sonam Joldan

Sponpa

HG

1860–1954

94

1870–1880*

Rgyudpa

Aba Rigzin

Abapa

Visit

1865–1940

–

1875–1889*

Rgyudpa

Tseang Sandup

Gochung pa

HY

1882–1960

78

1895–1905*

–

Second generation Aba Konpan

Abapa

Visit

1890–1960

–

1900–1910*

Aba Rigzin

Sonam

Angbo pa

HY

1892–1976

84

1920–1930*

Tsewang Sandup

Sonam Stobdan

Gochung pa

HY

1910–1970

60

1920–1930*

Tsewang Sandup

Tsewang Tashi

Aba pa

HG

1912–1972

60

1920–1930*

Aba Konpan

Sonam Dorje

Spon pa

HG

1913–1972

59

1920–1930*

Sonam Joldan

Tundup Tsephel

Pheya pa

HG

1930–

71

1942–1954*

Sonam Dorje

Tashi Bulu

Gangchung pa

HG

1940–

61

1953–1961

Skalzang Stopges

Smanla Rigzin

Spon pa

HG

1955–

46

1960–1970*

Sonam Dorje

Tsering Tundup

Dom pa

HY

1955–

46

1964–1970

Tashi Bulu

Gangchung pa

HG

1963–

38

1996–2000

Tashi Bulu

Third generation

Fourth generation Skarma Stamphel

Date with * is only approximate but in correct relation to the others HG = H anu Gong ma, HY = Hanu Yokma Source Based on Stephan (2004)

established are trying to popularise the traditional medical system with encouraging results. Tibetan medicine seems to have attained considerable momentum in western countries, especially as they are wary of allopathic medicines. Amchi associations like the Traditional Medico-Cultural Association and the Yuthog Foundation are working on preserving and promoting Tibetan medicine. They provide health care facilities to the rural poor. NOMAD, a Leh-based NGO, is working on the revitalisation of the Tibetan medical system. The knowledge

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quintessential of traditional systems like the Tibetan medical system requires recognition, respect and understanding. Indigenous institutions, knowledge systems and traditional survival strategies seem to have little or no impact towards modernisation. The objective is to decelerate the pace of environmental degradation to attain eco-friendly economic development.

Lhabanism Healing Practice in Ladakh The practice of the spiritual healing system in Ladakh is called Lhabanism (shamanism, as mentioned by other foreign studies). Lhabanism, an indigenous folk religion with many shamanic features, still prevails in Ladakh. Lhaba is a male oracle, and Lhamo is a female oracle. During the actual fieldwork, it was realised that the field areas have Lhamo and not Lhaba. Lhaba/Lhamo is an integral part of spiritual and religious rituals in Ladakh. Lhaba/Lhamo may belong to families in which there have been several such receptacles of spiritual forces. Others are diagnosed as such without any hereditary background. Traditional shaman or traditional healers called Lhaba (male) or Lhamo (female) have a similar meaning which is ‘divine person’ in Ladakh. Schenk (1994) differentiates between the village Lha and the monastic Lha. Among these oracles, the socalled villages Lha (oracles) are also called khyim-lha or jim-lha, distinguished from monastic oracles (Sophie, 1989). While the monastic oracles serve the entire community, the village oracles practice healing sessions for individuals. The monastic oracles have more prestige than the village oracles. The ritual and social functions of village oracles consist of curing and divination. The Broq-pa believe implicitly in the influence of Gods and spirits on the material world. The Lhaba/Lhamo (oracles) also plays the role of exorcist expelling or controlling maligning spirits believed to be in patients suffering ill-health. They claim the seeing of spirits in a state of trance. Lhaba/Lhamo (oracles) acts as mediators between the spirit world and the material world. Attacks by different spirits are believed to be the common cause for several illnesses among the Broq-pa. Schenk (1994) mentions the use of different colourful costumes, drumming, chanting, reciting mantras and offering barley, rice, water, butter and oil lamp, khataks (auspicious scarf) and incense of juniper during Lha-phabs (shamanic) ceremonies. The oracles diagnose illnesses by performing divination on a da-ru (small drum) which is the usual Ladakhi colloquial expression. Lhaba/Lhamo predicts any kind of misfortune that may happen in future. So to resolve the situation, Lhaba/Lhamo also advises the community or person to perform specific rituals. Lhaba/Lhamo often predicts the auspicious time for starting any ceremony like marriage, birth, house construction, ploughing field, harvesting and threshing of crops. Before conducting any agricultural work, they first offer produce of crops to Lha (protector of the community) along with a ritual to appease the Lha (protector) and Lhu (God of soil and water).

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Methods of Treatment of Lhaba and Lhamo The Lhaba or Lhamo have their technique to diagnose the patient and the treatment, when they are in a trance. The Lhaba and Lhamo usually throw barley or rice seeds on the daa-ru (drum). In Hanu, the Lhamo puts few seeds of barley/rice, suck by creating suction and put back seeds on hand and tells the people what had happened and what should be done to cure illness or any misfortune. Once possessed, the Lhaba and Lhamo (oracles) perform their therapy. They suck out disease-causing substances from various parts of the patient’s body, placing them directly against ailing body part (Schenk, 1994), either through a pu-ri (pipe) or directly through the mouth and then spit them into a bowl or on the ground. Seeds of barley, barley flour, chang (local brewed), juniper incense and other herbs and religious instruments assist in the ritual during diagnosis. They also use a red hot knife and put it on their tongue and blow it on the patient’s affected areas. The patients feel relieved after the treatment. Lhaba/Lhamo not only cure humans but also use this same technique to cure domestic animals such as cow, dzo, dzomo, horse, etc. if animals swallow iron nails or other objects. Mainly, the Lhaba/Lhamo advices people about performing rituals and to appease them by making offerings to their Lha (protector). In Hanu, people seek the Lhamo’s advice in case of general illness. People often complain about the tug or zas-nyan (intrusion of disease-causing substance). Many patients come to remove tug or zas-nyan from Lhamo in Hanu Gongma. Buddhists and Muslims from neighbouring villages of Hanu Thang, Sanjak, Achinathang, Shakar-chiktan come to seek Lhamo’s therapy. Among the Broq-pa, the cause of illness or misfortunes is considered related to evil spirits/evil eyes. Some of the diseases and misfortune identified are mental disruptions, falling from a height, discomfort, not scoring good marks, feeling unusual body pains, having nightmares, etc. The meeting of local ladies considered gongskal (envious, hated person who has the power to intrude into other bodies) is also considered a misfortune. In these cases, natives seek advice, therapy and mental support from Lhaba/Lhamo.

Onpo (Astrologer) and Monk Onpo is an integral part of the society in Ladakh who have multiple roles. In the social context, the positions range from curing ailments, predicting auspicious dates to begin agricultural activities and giving amulets for different purposes like protection from the evil eye, spirit possession, safe journey, for bearing baby to childless parents, curing illness, etc. Among the Broq-pa, the role of Onpo is carried out by local Amchi who does the duty of Onpo on people’s demand. In Ladakh, the profession of astrology is on the verge of vanishing from every society. The demand is relatively high, but the younger generations are not interested in this profession.

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Table 12.5 Relationship between family type and performance of rituals during illness Types of family Ritual performance in case of illness

Total

Joint

Nuclear

Yes

125 (77.2)

54 (61.4)

179 (71.6)

No

37 (22.8)

34 (38.6)

71 (28.4)

162 (100.0)

88 (100.0)

250 (100.0)

Total Percentages are indicated in parentheses (P = 0.008)

Performance of Rituals to Cure Illnesses The Broq-pa are characterised by a firm belief and reverence of their tribe Lha (Protectors). They try to maintain the rites, offerings, sacrifices, rituals and beliefs in religion and restore health and mental peace (Table 12.5). Among the Broq-pa, rituals are performed in all families for peace and prosperity. However, in case of illnesses, the ritual performances are dependent on the family type, qualification, occupation and availability of monks in the village. The relationship between family type and ritual performance in case of illness is highly significant (P = 0.008). In joint families, where elderly members’ roles are supreme, the traditions and customs are still followed well. In contrast, nuclear families with younger members give less importance to rituals and customs. As the Broq-pa tribe is primarily Buddhist, the performance of rituals occurs more often. Many rituals are performed to appease their God or Lha for the well-being of family members, domestic cattle and prosperity of family wealth. The ritual performances in case of illnesses are observed in the last stages of the illness after availing treatment from other medical systems.

Discussion and Conclusion The authors wish to reaffirm the following points: Comparison of biomedical systems with local Amchi, reasons for acceptance of modern biomedical system and reasons for rejection of modern biomedical system. (i)

Comparison of Biomedical Systems with Local Amchi • The state government provides funds for the maintenance of the health centre. The medicine and other facilities are freely available in allopathic dispensary. In contrast, the local Amchis have no funds to prepare medicines. Therefore, they are unable to distribute medicines freely.

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• Biomedical systems are accessible all the time, but local Amchis are primarily cultivators. They have to look after many other domestic chores and are unable to prescribe medicines all the time. • The local Amchis are not under government service, nor do they receive any funds. (ii) Reasons for Acceptance of Modern Biomedical System • Quick relief and effectiveness of biomedicine. • Readily available and free of cost. • Health workers are always available in the health centre to serve people. In case the health worker is not available, they can go to their residence without any hesitation. (iii) Reasons for Rejection of Modern Biomedical System One by One • A prolonged cure or entire state of ill-health is not attained. • Ineffectiveness of the biomedicine in their ailment. • More faith and belief in traditional medical system. The people believe their body is more adapted to Amchi medicine and have more trust and mental satisfaction when working with the Lhaba/Lhamo and monk system of curing illness. • Many people believe in ritual performance in case of illness to seek health. • Many people found biomedicine unsatisfactory, especially those received from the health centre. • Few older adults cannot go to the health centre as they cannot walk due to severe pain in their knees and ankles and constantly suffering from backache. • As people are farmers, they are constantly engaged in domestic chores and working in the fields. Hence, they cannot go to the health centre and give precedence to their work rather than their health. • Few seek modern medical facilities as they felt the available facilities were not sufficient or satisfactorily addresses their state of illness. In conclusion, the respondents’ views regarding practices of traditional and modern health care were somewhat mixed. Older generations were more inclined towards traditional healing methods, while the younger generations were more inclined towards modern healing methods as they provided fast relief compared to traditional medicines. Though modern biomedical systems are readily available and provided fast relief to the sick, they continue to have strong beliefs and faith in their traditional medical system. But, Amchis are fast becoming scarce as they have suffered severe scarcity of funds and paucity of time to practise their age-old trade. Based on the above findings and discussions, it was observed that Amchi medicine and other traditional medical systems are as important as the modern biomedical system. Therefore it is imperative to improve and promote the quality of the services of both systems of medicine for restoring the better health of the Broq-pa people.

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Appendix: Case Studies Respondents from the Community Case Study 1 Dolma is an 81-year-old lady who lives with her partially blind husband. She has been suffering from back and knee pain for the last eight years, but her condition has aggravated over the previous month, and now she cannot lie down properly. She puts blankets on her lap and leans on the wall to sleep. She cannot walk upright, because of which she has begun to crawl. On being asked about the cause of her ailment, she believes that the cold climate and chuser (phlegm/watery fluid imbalance) are because of her advancing age. Since she cannot walk properly, therefore, she cannot go for any therapy. She has been trying many home remedies for her knee pain. One such treatment involves heat therapy. It consists of heating a smooth round stone and pressing on the affected body part and crushed leaves of shas-nya (medicinal herbs). The procedure lasts for 5–8 min. As a result of this therapy, she had a huge blister formed on her skin the next day. This blister was ruptured to release the watery fluid. This remedy relieves her from the pain for 3–4 days. Sometimes when the pain is severe, she applies heat therapy twice a day. Furthermore, elaborating on the nature of her backache, she says: Sket- pa ne thur bo chok gang-ma ashee med pa song. (Right down from the waist to legs, there is a severe continuous pain that is unbearable)

In addition to that, her breast is also infected these days. Sharing about the nature of her problem, she explains that first, she noticed some fluid coming out from her right breast that frequently wet her clothes. Initially, she did not take this seriously or seek any medication. Later, when she thought of consulting a doctor, she could not reach one due to physical immobility. She could not even go to the nearby medical centre, about 300 m away from her place. Her only caretaker, her husband, rears cattle at Broq (highland pasture) during the summers. These days her condition has deteriorated, and her right breast has gotten shrunken. She puts black wool on the infected breast to absorb the oozing fluid. Her condition is pathetic due to these ailments, and she is having a hard time at such an age. Case Study 2 Tsering Tsomo is an 84-year-old widow who lives in Dah area in a joint family. She is illiterate and cannot accomplish any domestic work as she is very old, and her body does not tolerate her doing any physical work. She is suffering from knee pain, gastritis and is unable to chew food properly. She is quick to add that in her village, the womenfolk share the majority of physical work, and she firmly believes that her knee pain is due to the excessive work that she indulged in during her youth. On being asked about the supernatural forces responsible for her illness, she says that though she does believe in supernatural forces and evil spirits making changes in their lives, she feels that her knee pain and gastric problem do not seem to have

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occurred due to any supernatural cause. She further adds that she thinks that her illness is caused due to old age, the excessive physical workload in the fields, and her gastric problem is due to the lack of digestion that occurs due to improper chewing of food. On being asked about the treatment, she says that she uses home remedies and Amchi medication. From the beginning of her illness, she procured Amchi medicines as she felt they were more suitable for her body. Upon being asked if she had obtained any medication from the village health centre, she said she had procured some medicines for her gastric problem. Case Study 3 Tsering Chorol is a 75-year-old housewife who lives in a joint family in Hanu village. She has been suffering from severe body aches for the last five years. She thinks that the cause of her illness is her Karma because she took every possible therapy to cure her condition but ultimately, any system could not cure it. Owing to her strong faith in Karma, she had performed many rituals to remedy her ailments. She had also consulted an Amchi to get herself cured. These days, she recites mantras and uses Amchi’s medication to get relief from the pain. On asking whether she feels that some supernatural forces may have been responsible for her body ache, she says that she thought that her ailment might be due to some supernatural cause. About the therapy, she says that she had performed storma (a ritual performed to eliminate the effect of the evil eye) and gyazi (ceremonies) at home to cure illness and ensure the welfare of her family. She says she had procured medicines from a local Amchi some three years ago. At that time, she felt relief, but since last winter, her condition has deteriorated. She procured medicines from the village health centre, which provided relief just about 2–3 days, but again the pain resumed. She says she has strong faith in Amchi and its medication. She feels that the local Amchi is better as compared to other medical systems. Its efficacy is dependent on the people’s belief in Amchi medicine. On being asked about the health status of the community, she says that earlier, few people had chronic diseases, but nowadays, every person is suffering from different illnesses. She commented in the native language as: nyan-la naks mangpo, zumo nyu-un, sman nyu-un, dak-sa zumo mang po, sman mang-po, naks medkan. (Earlier people had more difficulties, fewer illnesses and less medication. Now people have more luxury, more disease and more medicine)

Case Study 4 Tsewang Dolma is a 32-year-old housewife who lives in a joint family. She has four children and is illiterate. Her husband is a driver and also works on a farm. She was married at the age of 17 and had a miscarriage during the 8th month of her third pregnancy. She was suffering from a severe cough and felt that her heart was pumping hard during that time. She says that presently she does not have any significant ailments except that she often feels that her body has become quite heavy and sluggish. She feels it may be due to timo skyen (evil spirit) cause.

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Her baby girl also remains uncomfortable most of the time. She sometimes cries all night and does not even feed. Whenever something like this happens, she burns dukzas (mustard seeds prepared specially to cure evil spirits and evil eyes) and throws them outside the house. Sometimes, she also grabs a handful of ash or soil, takes three rounds over the baby’s head and throws them outside. While throwing the ash/soil, she says thou. On being asked about the effectiveness of these curing techniques, she says,pharak mang po cha ruk (It affects a lot). Besides this, she also procures medicines from the village health centre whenever she is not well. She also seeks treatment from an army camp at Biama. This spring, she went to Lhamo, who told her that she had timo skyen and would have to perform rituals to eliminate the wrath of timo skyen (evil spirit). She completed the rituals after 4–5 days and said she had been feeling relieved ever since. Presently, she is not taking any medication. She now wears an amulet from a Rinpoche at Leh and makes her daughter wear one. Case Study 5 Deachen Dolma is a 60-year-old woman married to her sister’s husband, and they all live together in a joint family. She is a mother of two sons and a daughter who are all married. She has been suffering from joint pains. She says that after giving birth to the third child, the pain in her joints started getting severe. She attributes hard physical work and her Karma as the cause of her illness. On being asked about the treatment, she says she had visited chutsan (hot springs) for bath therapy which is considered the best treatment for joint pains all over Ladakh. According to her, it is effective only for a short time and does not cure the ailment completely. She also had Amchi as well as doctor’s medicines, but her condition is still the same. These days she has an Amchi medicine early morning every day. If she forgets to take her medicine, her body aches for the whole day, and it becomes unbearable to walk around. She added that about seven years ago, she suffered from tuberculosis, for which she is still taking medicine every day. During those days, it was tough for her to walk uphill. It caused her tremendous fatigue and breathing difficulties. She further says that three of her family members—her husband, her sister and she—suffered from this illness. She ruefully confesses, “My life is wholly dependent on medicines, and I have to take more medicines than my meals”.

Medical Practitioners Case Study 6 Tashi Phunchok is a 45-year-old married man and is the head of the allopathic dispensary, Hanu village. He is from Mulbek village, 120 km towards Kashmir, on the national highway from Hanu. It falls in Kargil District. Tashi has done his Bachelor of Medicine and Bachelor of Surgery (MBBS) from Jammu Medical College. He is

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the head of the allopathic dispensary, Hanu village. For the last two years, he has been serving in the Hanu village. On being asked about the concept of health, he says that health is essential for a person to carry out his daily work and retain a calm state of mind. About the idea of illness, he added that illness was a state of mind in which one is not comfortable or feels uneasy while performing his daily work, including eating and sleeping. He says that the most common illnesses prevalent in this community are Chronic Obstruct Pulmonary Disease (COPD), chronic bronchitis, joint pains, eye problems, acid peptic ulcers, high blood pressure and skin diseases. He added that these people drink a lot of butter tea which is salty and, thus, makes them suffer from hypertension. On being asked about the stages of illnesses when patients visit the dispensary, he said that most elders are reluctant to come at the beginning of their disease as they prefer the Amchi system, but later on, they finally turn to the local dispensary. He further shared that during the treatment, he gives medicine for only two days and asks them to visit again after two days. This way, he makes the patients visit the dispensary every two days for their follow-up, but ironically, the patients here tend to miss their follow-ups. And then, they complain that the medicines are ineffective and, therefore, again starting following alternative medical systems. This way, neither of the systems works for them, as they keep changing the means of medication. On being asked about traditional medicine and its role in Hanu village, he said that the traditional Amchi system has deep roots in the culture of Ladakhi society. The system has been providing primary health care services for many years now. So, people have strong faith, socio-cultural and socio-religious relations with the Amchi system of medicine. It plays a significant role in the rural areas of Ladakh, besides providing an alternative system of medicine for the health seekers. Case Study 7 Kunzang Nyantak is a 38-year-old married man. He is from village Egu of Block Karu and is currently posted in Hanu village. His village is some 240 km away from Hanu. It has been almost a year since he has been serving in the Hanu medical centre. He completed his higher senior secondary school from Leh. He is a pharmacist in an allopathic dispensary in Hanu village. About the concept of illness, he said that if the immune system fails, illness is bound to occur. On being asked about the common illnesses prevalent in the village, he said diseases like respiratory infections, hypertension, acid peptic ulcers, conjunctivitis, irritation/redness in eyes, urinary tract infections, common fevers and cold, headaches, toothaches, etc. are commonly found in this region. He said that mostly the younger people approached the local medical facilities during the first stage of the illness. The older generation does not come for checkups till the last stage of the disease. Regarding the facilities available, he says that the medicines, vaccines and other services are free of cost for the public. He further adds that they organise health camps every year with the support of government hospitals and doctors. They also organise awareness camps to make pregnant women aware of the vaccines, health, prenatal care and make the school children aware of health and hygiene, anaemia,

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vaccine and other programmes. On being asked about his views on the traditional Amchi system, he said that the traditional system of medicine provides an important source of treatment for the population in rural and urban areas. He also adds that traditional medicines have no side effects. Case Study 8 Stanzin Dolker is a 34-year-old married woman. She has completed her higher secondary school from Leh and is now working as a nurse. She is a specialised Female Multipurpose Health worker (FMPHW) from the same village. She looks after the health of pregnant women and children. She says that the local pregnant women do not need to consult a doctor at the time of delivery, even though there are well-equipped hospitals at Khaltse and Leh for safer deliveries. She advises them to go for checkups a month before delivery, but they do not even bother to follow her advice. In emergencies, it is tough to find a vehicle to take the woman on time to the hospital in Khaltse as the local medical health centres are not well equipped to handle pregnant cases. The one which is well equipped is about 50 km away from their village. Sometimes, the people call her in the wee hours of the night. Last year, there was a 27-year-old pregnant lady who was in her 9th month of pregnancy. Stanzin informed the lady about her high blood pressure and had advised her to go to the Leh hospital for a safer delivery. However, the lady did not follow her advice. She was taken to Leh Sonam Norbu Memorial Hospital in the middle of the night due to epilepsy attacks and was operated. But unfortunately, both the mother and child died after two days. Stanzin says that this lady died due to high blood pressure. Despite being advised several times, she never went to the local health centre to check her blood pressure. Though Stanzin often visited her place to monitor her blood pressure, even that could not save the poor lady from an untimely end. She says that many other pregnant women do not go to hospitals for proper deliveries during childbirth or other significant checkups during the course of pregnancy. They still opt for the primitive home delivery method at their homes, with the help of midwives or elderly ladies. They have a firm belief that these midwives would save them in any case. Some said, diring tsuk pa nya-chi ama shak hospital la ma chha thugu dun-gyat jor rey chang ma song te rung na hushar be-yad las la (our mothers never went to the hospital for delivery and yet they are mothers of 7–8 children). She further reveals that in emergencies, the patients are referred to Khaltse, which is 50 km away from their village. During such situations, sometimes things get out of their control, and despite their best efforts, the doctors cannot help pregnant women. This is why she advises them in advance to consult doctors from the major hospital before a month or so, so that they may have a safe delivery. She and doctors and other village health workers often arrange awareness camps to make the patients aware of general vaccinations and medicines available for pregnant women and guide them about public health and hygiene. They also inspect food and health related issues under the village’s Integrated Child Development Program (ICDS).

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Case Study 9 Tsering Wangdus is a 42-year-old unmarried from Lingshed, about 200 km from his village. He has studied up to class five from the government primary school of Lingshed village. He was fortunate enough to be selected as a government Amchi. Currently, he has been working in the allopathic dispensary in Hanu Yokma, since June 2011. He learnt his Amchi practice from a renowned Amchi of Ladakh from Neymoo village. His brother, who himself is an Amchi, motivated him to practice the Amchi system. He took him to the Neymoo village to help him learn the Amchi system. First, he was made to understand the Bodhi script and then the Amchi practice, while in Neymoo. On being asked about the concept of health, he said, “Peaceful mind is healthy”. He further describes that it is the mind which creates ill-health. For a peaceful mind, meditation is necessary. On being asked about the concept of illness, he says, dod zeys nyad soks, sems ki nyad; lhung, thikspa, padkan, soks lus ki nyad (jealousy, hated, envy, stress, tension are the illness of mind and disorder of air, bile and phlegm are illness of body). Sharing the methods of his treatment and diagnosis, he says that the Amchis have their own treatment methods. The first step is to diagnose the very cause of the illness. This can be traced through history, pulse detection, urine and stool examination, tongue and eyes examination, etc. Adding further, he says that he does not give medicines on Saturdays because Saturdays are considered bad omens. In heat therapy, he consults the lotho (Tibetan Calendar) for the auspicious or appropriate day. He feels that the heat therapy should be conducted only on a good day. Describing the stages at which the patients visit him, he says that most come at the advanced stages of illness. He feels that the people have less belief in adopting the Amchi system. So, he gives medicine for 1–2 days and then calls them again after two days. He says some come back, while others do not. He strongly feels that patients should be given the Amchi medicine under a restricted diet. Sharing about the course that he adopts if the treatment fails, he says that he never keeps his patients in the dark and advises them about better practitioners and systems that may help them. In that case, he does not change the modes of treatment. On average, 6–7 patients visit him daily. Most come to seek medicines for joint pain, headaches, gastric problems, etc. About the supernatural cause of illness, he says that he does believe in the supernatural causes of illness. Once, he successfully treated a spirit possessed patient in his village. On being asked about his attitude towards the patients if they follow other medical systems simultaneously while procuring his medicine, he replies that he never interferes with their decisions. He believes that the trending claim on modern allopathic medicines as healing faster is propaganda popularised by the people. Instead, he believes that any cure depends on the suitability of a patient’s health. He confessed that at one time, even he had procured allopathic medicines for his eye treatment.

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Case Study 10 Yangdol is a thirty-five-year-old woman who lives in a nuclear family in Dah village. She has studied up to senior secondary level. Currently, she is working at the medical sub-centre at Dah. She is a specialised Female Multipurpose Health Worker (FMPHW). She is a local member of the village and looks after the health of the whole community. She is the only health worker in the medical sub-centre at Dah. Therefore, her absence proves quite disturbing and dangerous in case of an emergency. She is principally worried about the pregnant women as they do not visit better hospitals like the ones at Khaltse and Leh for delivery. In case of an emergency, it is tough to arrange a taxi and reach the hospital at Khaltse on time, about 50 km away. The local people often call her in the middle of the night, and she is always prepared to help them in any case. In Dah also, people come to her home instead of going to the medical sub-centre directly. She says that people are busy in fields and mountains during day time, so they seek medicines in the evening till 7–8 pm. She says many people suffer from joint pains, gastric problems, urinary tract infections (UTI) and hypertension. The health workers, most of the time, are engaged in training at Khaltse. She tries her level best to visit the patients who cannot visit her. In case of an emergency, she even arranges a taxi and takes patients to Khaltse Hospital.

Reasons for Acceptance or Rejection of Modern Medical System Case Study 11 Thinlas Samphel is a 70-year-old illiterate farmer living with his wife with no children in Hanu Village. He has been suffering from a kidney disorder for the last four years and recently developed severe knee pains. The causes of his illness may be due to the physical workload and his Karma. On being asked about the treatment of his kidney disorder, he says that he is illiterate and is not comfortable going outside his village. Besides, he could not afford the treatment. Previously, at a health camp organised by the Indian Army, the doctors advised him to get proper treatment from the Army General Hospital in Chandigarh. He says that he could not go due to scarcity of money. Besides, nobody in his family would take him to Chandigarh and care for him. The doctors tried to arrange for his treatment at the Army Hospital, Achinathang. The next day the army doctors sent dialysis equipment to the village health centre to change his old pipe and pouch. He was told about the same and asked to visit the health centre. He said that he would go to the health centre the next day, but later it was found out that apparently, he was busy with domestic work and did not listen to the doctor’s advice. The same thing happened in 2011 when a health camp in Hanu village was organised by doctors from Government Sonam Norbu Memorial Hospital in Leh. The doctors called him at Leh for proper treatment. He went to Leh, about 170 km away from his village, but came back without seeing the doctors.

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He only goes to the hospital in case of an emergency. He had to arrange for a car to reach Khaltse, where a better hospital is available than his village health centre. He was supposed to change his pipe and pouch every 25 days, but he was so careless that he did not even bother visiting the health centre to get them changed. According to the health care centre workers, he is a hopeless case, and even if they wish, they cannot help him.

The Case of Amchis Case Study 12 Tundup Tsephel is an 82-year-old married man who lives in a nuclear family in the Hanu Gongma. He is not practising the Amchi system, but he gives medicines to those seeking his medication. His uncle, Sonam Dorjey Sponpa, was an Amchi in his village, and it is from him that he learnt his practice. He says he studied up to class two but dropped out later to start the Amchi training. He recalls his uncle coming to his place and suggesting the practice of Amchi system. His parents agreed and sent him to his uncle’s place in the same village. He learnt the Amchi system of medicine for almost 12 years. Before practising the Amchi system, he also learnt the Buddhist Sanghe Smanla Chos (medicine book). When asked about the treatment, he said that the patients who have cough, cold, knee pains, headaches, backaches often visit him and procure medicines. However, he shares that he has difficulty remembering things since he is old and seldom practices the Amchi system. He then adds that these days people seek biomedicine. According to the local people, he is good at heart, but due to his unfavourable personal hygiene and addiction to smoking beedi, people often do not seek his medication. Throwing light on the same fact, he agrees that people have a better choice to seek medicines for ailments with the introduction of health centres. He seeks treatment from the health centre nowadays. Though he has many raw materials to prepare drugs, he finds it challenging to prepare them at this age. Local people believe that he was taken by ili phuru (invisible person) in middle age and lost for many days. One day, he eventually returned to the village, looking quite dull, tired with his index finger half cut. Explaining the cause of his woe, he told people how the ili phuru tortured him. Somehow eventually, he escaped from the ili phuru world. After listening to his plight, the villagers asked him to stay with them and get married. There was another case where some invisible men took a boy from the Hanu Gongma village, and he also returned with his index finger cut and was later found to be mentally retarded for life. People believe those who are srungma med khan (who do not have protector God/Lha) are usually taken by ili phuru and samn-mo (invisible people have the same village as we do).

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Case Study 13 Smanla Rigzin is a 56-year-old married man who lives with his family in Hanu Gongma. He learnt his Amchi practice from Amchi Sonam Dorjey of his village for almost ten years. He practices Amchi medicine and Onpo (astrology) on popular demand. Earlier in Hanu, people primarily used to seek him for the Amchi medicine, but over the years, he also learnt the performance of Onpo. He rightfully feels that the Amchi system is gradually losing its importance and recognition in the village. The pressure of the modernised medical system is affecting him and his earning and economic condition. In the absence of funds, he finds it challenging to prepare the medicines as well. The situation has compelled him to accept other jobs to increase his source of income. He is working as a kuli (labour) in Achinathang, about 30 km away from his village. So, he stays at the army camp and comes home at weekends. In Hanu Gongma, especially in Mohalla Pharol, people suffer from eye damage, joint pains, backaches and knee pains. Upon being asked why they were not seeking medicines from the health centre or Leh, they said that their illnesses were severe cases and suitable drugs were not available at the health centre. Some do not want to walk to get drugs from the health centre others have no money to go to Leh hospital for treatment. The Leh Sonam Norbu Memorial Hospital does not charge a fee for the treatment, but the patients are expected to buy medicines by themselves. Therefore, they usually wait for the local Amchi Smanla to treat them at their doorsteps. Case Study 14 Tsering Tundup (58 years) lives in a nuclear family in Hanu village. He learnt the Amchi practice from Tashi Bulu, a former great Amchi of the same town. He started his Amchi practice at the age of 15 years, while he was eager to become one because, at that time, there were no doctors, and only a few Amchis were practising in Hanu or Ladakh. During those days, Amchis commanded a lot of respect. He learnt the Amchi practice for almost eight years and started prescribing medicines while studying. The villagers had a strong faith in his treatment. Many people claim that he has cured many severe patients who could not be cured even by modern biomedicine systems. He feels that currently, the population has readily accepted the modern biomedicines as they are easily available and free of cost. But, some still seek local Amchi medicine. He ruefully recalls that it has been two years since the modern system of medicine was introduced in the village. Ever since its introduction, his role has dramatically diminished in the town. However, he still treats the few patients that come to him but advises them to avoid other systems while his treatment is going on. Most of the older people love to seek his medication as he was traditionally known as the medicine man of the community. Other than the Amchi practice, he also rears cattle and looks after the fields. So, he spends most of the time with the cattle

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and farming. The villagers also seek treatment from doctors and the governmentappointed Amchi from the allopathic dispensary in Hanu village. On being asked about his views regarding the allopathic system, he says that he is pretty happy; in fact, he supports the health care centre facilities for the community. The allopathic dispensary provides a choice of medication to the people. In addition, he was asked about his views of the Amchi system now available in the allopathic dispensary. He says he does not feel any pressure by the introductions of the Amchi system by the government; instead, he likes to share his knowledge and experience with the newly appointed Amchi in Hanu village. Case Study 15 Skarma Tamphel Gangchungpa is a 49-year-old married man. He has learned Amchi practice from his father, Amchi Tashi Bulu, a well-known, experienced and great Amchi of his time. He has also learnt Onpo from Onpo Rigzin Namgail for one year, empowered by Tokdan Rinpoche. These days, he is working as a potter at an army camp at Handang Broq. On popular demand, he also practices Amchi medicine. He is rarely available at the village since he remains at the camp most of the time, so villagers find it challenging to consult him. Otherwise, he is a reputed Amchi in the village. He would have continued his practice as a full-fledged Amchi, but the choice of a better livelihood brought him to the army camp.

References Bhasin, V. (1997). Medical pluralism and health services in Ladakh. Journal of Social Sciences, 1(1), 43–69. Cassel, J. (1976). The contribution of the social environment to host resistance. American Journal of Epidemiology, 104(2), 107–123. Kala, C. P. (2005). Health traditions of Buddhist community and role of Amchi’s in Trans Himalaya region of India. Current Science, 89(8), 1331–1338. Kleinman, A. (1978). Concepts and a model for comparison of medical systems as cultural systems. Social Science and Medicine, 12, 85–93. Kleinman, A. (1981). Patients and healers in the context of culture: An exploration of the borderland between anthropology, medicine, and psychiatry. University of California Press. Kressing, F. (2003). The increase of Shamans in contemporary Ladakh: Some preliminary observation. Asian Folklore Studies, 62(1), 1–23. Mitra, R. P. (2006). Treatment at a Tibetan dispensary: Some observation. In M. K. Bhasin & S. L. Malik (Eds.), The science of man in service of man (pp. 199–211). Department of Anthropology, University of Delhi. Peters, L. (1998). Tamang shamans: An ethnopsychiatric study of ecstasy and healing in Nepal, with an introduction by Jacques Maquet. Nirala Publications. Schenk, A. (1994). Schamanen auf dem Dach der Welt: Trance, Heilung und Initiation in Kleintibet. Akademische Druck und Verlaganstalt. Sophie, D. (1989). Embodying spirits: Village oracles and possession ritual in Ladakh, North India [Ph.D. dissertation, London School of Economics and Political Science]. Stephan, K. (2004). Tibetan medicine among the Buddhist Dards of Ladakh. Wiener Studien zur Tibetologie und Buddhismuskunde.

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Wilkinson, R. G. (1992). Income distribution and life expectancy. British Medical Journal, 304(6820), 165–168. World Health Organisation. (1986). Ottawa Charter for health promotion. WHO.

Chapter 13

Ethnomedicine in Question: The Case of Tharu Healers and Healing Practices Bamdev Subedi

Abstract Ethnomedicine refers to indigenous healers’ medicinal practices that rely on material and non-material components to prevent and treat illnesses. Indigenous healing works as an essential healthcare option for the indigenous population. Despite the advancement of biomedicine and expansion of healthcare services, indigenous people continue to consult indigenous healers for physical, psychosocial and emotional problems. However, there are concerns over the erosion of indigenous knowledge and a withered state of healing practices. Now, ethnomedicine is in question as there are suspicions or doubts over indigenous healing practices’ usefulness, relevance and continuity. Based on the field data collected from the healers and patients of the Tharu ethnic community in Nepal, this paper discusses the change and continuity in healing practices. This paper examines how deeply embedded the healing practices are in the cultural traditions, how such traditions contribute to the continuation of healing practices and how supportive the state policies are in preventing the erosion of indigenous knowledge and healing practices. Keywords Ethnomedicine · Healing practices · Indigenous knowledge · Cultural traditions · Tharu of Nepal

Introduction Ethnomedicine refers to indigenous healers’ medicinal or healing practices who rely on material and non-material components to prevent and treat illnesses. Material components include medicinal plants, animal parts and mineral substances, whereas non-material components include healing mantras, ritual, spiritual and shamanic healing methods. In simple terms, ethnomedicine is “the health-related beliefs, knowledge, and practices of a cultural group” (Ember & Ember, 2004). In this paper, ‘ethnomedicine’ has been used to refer to the indigenous traditional medicine and healthcare practices, which are not codified but widely practised among the ethnic B. Subedi (B) Medical Anthropologist and Social Activist, Kathmandu, Nepal e-mail: [email protected] © The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023 S. Reddy et al. (eds.), Ethnomedicine and Tribal Healing Practices in India, People, Cultures and Societies: Exploring and Documenting Diversities, https://doi.org/10.1007/978-981-19-4286-0_13

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communities traditionally. Indigenous traditional medicine is “the total of knowledge and practices, whether explicable or not, used in diagnosing, preventing or eliminating physical, mental and social diseases. This knowledge or practice may rely exclusively on experience and observation handed down orally or in writing from generation to generation. These practices are native to the country”. (WHO, 2019, p. 8). Ethnic communities in Nepal are also known as Adivasi Janajati (indigenous nationality), defined as “a tribe or community having its language and traditional rites and customs, distinct cultural identity, distinct social structure and written or unwritten history” (National Foundation for Upliftment of Aadibasi/Janjati Act, 2002). Fifty-nine indigenous nationalities notified by the Government of Nepal constitute more than one-third of the country’s total population. According to the 2011 census, the total population of Nepal is approximately 26.5 million, and Tharu, one of the indigenous nationalities (hereafter ethnic communities), comprises 6.6% of the total population (CBS, 2012).

Tharu and Context of Ethnomedicine Tharu people is the inhabitants of the southern region of Nepal. They are also found residing in Uttarakhand, Uttar Pradesh and Bihar of India and recognised as Schedule Tribe in those states (Guneratne, 2010; Krauskopff, 1995; Maiti, 2004). The original place of the Tharu is ‘Thar’ of Rajasthan, from where they had fled to Nepal and settled in the Tarai region (plain land) of Nepal. They were called Tharu because of their association with ‘Thar’ (Bista, 1969; Gurung, 1992; Rajaure, 1981a). Another position is that “they were the descendants of the Shakya, the clansmen of Lord Buddha, who was born in Nepal” (Manandhar, 1985). They speak the Tharu language, which is structurally close to Nepali (McDonaugh, 1989), and follow animistic traditions influenced by the Hindu religion. In the national censuses, they are followers of the Hindu religion (Dahal, 2014), with agriculture as their primary occupation supplemented by animal husbandry. Many of them work as labour in agricultural fields, construction sites and service sectors. Tharu people mostly live in and around the forest area and collect forest products, including wild vegetables, roots, fruits and medicinal plants. They also collect fish, crabs and snails from the river, rivulets, ponds and irrigation ditches, catch rats, hunt birds and wild animals. They possess the knowledge and skills about the local plants and herbs. Based on his close observation of the food practices, the use of varieties of domestic as well as wild vegetables, roots and fruits and meats of wild birds and animals, Rajaure (1981b, 67–68) states, “Tharu diet is more balanced than that of many rural Nepalese”. Indeed, they have a vibrant food culture. Nowadays, indigenous food practices and diets are changing with the influence of the market. The collection of forest products, including medicinal herbs, has been declining over the last few decades due to the encroachment of the forest area for agricultural land, deforestation and enforcement of forest acts, rules and regulations.

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They have experienced a change in their lives and livelihoods mainly because of the state intervention in health, education, agriculture, transport, communication, the expansion of markets, and exposure and interaction with outside communities. Many youths go to Malaysia and Gulf countries to work as unskilled or semi-skilled labourers and come back with modern electronic gadgets. Tharu ethnomedicine is not based on the written text, even though some healers possess handwritten symbols and manuscripts about medicinal plants and healing mantras, the protective spells. The healers are not institutionally trained but experienced in treating various ailments by practising. The knowledge is passed from aged and experienced healers to the younger ones through an oral tradition. Tharu has a rich body of oral traditions, including folklore, mythologies, dance, songs, arts, crafts, language, literature, rituals, festivals and ceremonies. Medicinal herbs, animal parts or products and mineral substances are essential healing strategies (Acharya & Acharya, 2009; Ghimire & Bastakoti, 2009; Paudyal & Ghimire, 2006). The healing rituals and healing mantras have an important role, mainly to deal with personalistic illnesses. The interaction between indigenous healers and patients or the healing session takes place in an informal setting. The healing practices are culturally, spiritually and religiously significant. Tharu ethnomedicine also serves as an alternative to the expensive official medicine to the community people. The ethnomedicinal practices of the Tharu comprise the vast knowledge of medicinal plants and a variety of specialised therapies such as bonesetting, traditional massage and midwifery. The popularity of ethnomedicinal practices is in question because policy measures do not encourage the young generation to learn and practice indigenous healing. Tharu has been increasingly utilising modern healthcare services, and indigenous healing is an important source of medical help. They make use of different forms of healing based on their strengths for various illness conditions. Scholars have recognised that biomedicine, as a form of healing, has become an option at best, rather than the substitute to indigenous healing practices (Attewell et al., 2012; Lock & Nguyen, 2010; Najunda et al., 2009). People often use indigenous medicine in combination with rather than in place of modern medicine (Tseng, 2009). The widespread and continued use of indigenous medicine itself reveals its importance. The people are pragmatic and pluralistic and use different treatment sources according to situation and need (Sujatha, 2014, p. 237). Besides, it is the rural, illiterate, poor ethnic communities and urban, educated, well-off and people from non-ethnic communities who resort to indigenous healing at times. A study conducted by Priya and Shweta (2010) shows that people take recourse to the folk healers not because of unavailable, inaccessible and unaffordable modern medicine but because of the ‘felt need’ for services other than that of the modern system. Notably, indigenous healing serves people’s differential healthcare needs, and people often turn to indigenous traditional medicine when modern medicine fails to provide them with a cure (Regmi, 2003, Singh & Agrawal 2009). Indigenous healing serves as a better option for ethnic communities because of its accessibility, affordability and acceptability (Joshi, 2004). The indigenous healers and their patients enjoy better relationships and share the same cultural values and

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worldviews. The healing methods are considered safe, efficacious and free from side effects. The continued use of indigenous healers also indicates the value of indigenous healing. The young generation is not motivated to learn and practice indigenous healing because there is neither economic incentive nor official recognition. Narratives on indigenous healing and knowledge systems explain that the ethnomedicinal practices are declining and disappearing—however, the paper contested by taking the case of Tharu healers and their healing practices. The paper examines how such practices are embedded in the cultural traditions, thereby backing the continuity of healing traditions. The paper discusses the therapeutic and cultural importance and policy measures to recognise and integrate indigenous healers and their healing practices.

Methods A field study conducted among the Tharu people of Dang District of Midwestern Nepal is from where the study will draw its reference (Subedi, 2019). Field data was collected by interviewing healers, patients and key informants. The healers (N = 18) were selected purposively for interview by making home visits. Exit interviews of the patients (N = 27) were conducted. Some of the healing sessions were observed seeking permission from both the healers and the patients. The study objectives were explained, consent sought and interviews conducted at their preferred time and venue. Besides, nine key informants such as local leaders, social workers, school teachers, private practitioners, health staff and female community health volunteers were also interviewed.

Types of Healers and Healing Practices There are three main types of healers among the Tharu people known as guruwa, baidawa and surenya (Adhikari, 2006; Dahit, 2008; Rajaure, 1981a, 1981b; Shafey, 1997). Most of these healers are aged and experienced (average age is 60, ranged from 32 to 74 years). The guruwas (or guraus), village priests or shamans, mainly recite healing mantras, perform shamanistic healing rituals and deal with supernatural, spiritual, emotional, social or psychosocial illnesses. They also do jhar-phuk (sweeping down and blowing out the evil spirits using a hand broom); pati-basne (swinging the earthen saucer with burning cotton wick); achheta herne (reading rice grain to diagnose the illness); bali dine (offering the blood of rooster to appease ancestral deities); buti baandne (making an amulet to wear to protect from evil spirits); and naadi chhamne (examine the pulse on the wrist manually). They recite different types of mantras while doing these healing rituals. They also involve in cultural, religious and ritualistic activities to prevent illness and misfortunes and worship deities as

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village priests. In many settings, guruwas also use medicinal herbs in their healing practice (Ghimire & Bastakoti, 2009; Paudyal & Ghimire, 2006). The healers who mainly use plants as medicine in their healing practices are known as baidawas. They are also known for treating specific illnesses such as jaundice, navel dislocation, joint pain, bonesetting, manipulative and massage therapies. Some of them are consulted for insect and snakebites, toothache and thorn prick, stomach problems and navel dislocation, nasal and eye problems and problems of the women and children. They do naadi chhamne (manual pulse reading), physical examination and rely on jadi-buti (literally roots and whole plants), which includes plant parts (such as rhizome, tuber, leaf, bark, stem, shoots, flower, fruit and seeds), animal products (fats/flesh) and minerals (particular stones, soil and water), which they collect and make them ready as medicine. In some cases, they suggest to their patients the medicinal herbs of common knowledge, give instructions on the preparation methods and recommend the doses to be taken. They also deal with veterinary problems. Some baidawas buy certain herbs from vendors and local manufacturers and sell them to the patients who need them. A baidawa cannot become a guruwa unless he (all guruwas and baidawas were men and surenyas were women) undergoes a formal ritual process called baanchirna. Every year, in the Dashain festival, the guruwas had to make minor cuts on their body parts (forehead, tongue, shoulder, chest, knee and feet) to offer the blood, which is called baan-chirna to become or to continue as guruwa. No such ritually binding traditions exist for baidawas. However, baidawa, as a benevolent spirit of a great traditional healer, is ritually offered and worshipped in every Dashain festival (Rajaure, 1982, p. 70). The distinction between guruwa and baidawa is that the inclination of guruwa is more on the use of mantras and ritualistic healing. In contrast, the inclination of baidawa is more on herbal healing. There are mainly five types of guruwas: ghar-guruwas and desh-bandhya guruwas are hereditary, whereas baidawa is not hereditary. Some guruwas also possess the knowledge of treating the kind of illnesses a biadawa can treat, and they are also called baidawa. Because of this overlapping, the distinction between guruwa and baidawa becomes indistinct or not very sharp. The surenyas (or sorinnya) are traditional midwives and follow massage and midwifery practices. They assist in childbirth and provide midwifery and massage services to mothers and newborn babies. Many of them know about the herbs, vegetables and spices having medicinal quality and the methods to prepare and apply as medicines in conditions of reproductive problems, abdominal pain, minor injuries and wounds and twist and joints dislocation. They usually called for postpartum care and massage for sore neck, back pain, stomach pain, joints pain and fatigue. They use mustard oil, cow ghee, homemade alcohol, turmeric and herbal paste as a massage oil—some used balm, Vicks and ointments, which people buy from local shops or medical stores. There are no other healers or medical practitioners to provide such a service. Nevertheless, there is high demand for traditional midwifery services from both Tharu and non-Tharu communities. These healers provide their services often free of cost because they believe in religious, moral values such as sewa nai dharma ho (to serve is our religion) which

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gives moral pressure to provide unselfish care without any greed for money. However, these healers are provided with a bowl of jand (home-brew beer or fermented liquor) or tea and snacks and petty cash as bheti (offering) and kind (as gift items, which includes fruits, green vegetables and foodstuff) for their services. Compensation is given to some guruwas through free labour for one or two days during the plantation or harvesting of crops. The desh-bandhya guruwas have Laal mohar (royal edicts), an authority to perform protective/preventive rituals. These rituals protect the village from evil spirits, disease, epidemics and wild animals; collect local revenues; and trap wild elephants for royal needs (Rajaure, 1982, p. 74). Guneratne (2001, 11) documents Raj gurau (king’s gurau), who used to have the highest authority among the guraus of Chitwan, a part of central Nepal. The baidawas are compensated with an amount, which is considered reasonable for their services and medicinal products. Surenyas are also provided with food items and a small amount of money for their services. For the birth assistance and post-delivery care and massage, footwear, clothes and an amount which is more or less equal to their daily wages is provided. The postpartum care and massage continue till the 11th day (naming ceremony) of the childbirth.

Types of Patients and Their Problems The patients who had come to visit guruwas had problems of the nightmare, evil spirit, soul loss, headache, heart palpitation, sudden vomiting and dizziness. Those who visited baidawas had problems of the swelled leg, thorn prick, stomach ache, wasting and physical weakness, nasal problem, stomach pain, joints pain, snakebite and sleeplessness. The patients visit the healer in most cases, but healers do a home visit in an emergency. The surenyas generally provide home services for birthing and post-delivery care and massage, but for occasional massage and advice, people come to visit them. The healers are preferred over the medical practitioners for indigenous illness, which is locally understood and explained. Besides that, the local healers’ services cost much less than modern medical practitioners living in the cities. Patients have visited such healers to save travel costs and have a strong faith in the healing practices. Further, the healer happens to be someone who can understand the socio-economic and familial context of the patient. They choose the healers based on the kind and condition of their illness. Indigenous healers are believed to provide better care than medical practitioners for the illness caused by supernatural forces. The guruwas are for personalistic illnesses, while baidawas or herbal healers are for naturalistic illnesses. Some of the patients visited faraway bonesetters by skipping nearby hospitals because of the healer’s reputation and affordable cost. Surenyas’ services are considered the best for midwifery, birth assistance, post-delivery care and massage. The services of these healers are sought by both Tharu and non-Tharu, rich and poor, women and men, educated and uneducated.

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Erosion of Ethnomedicinal Practices More than half of the key informants and a few healers and patients, particularly those educated and young, agreed that indigenous healing practices are on the decline. They said that indigenous healers are less consulted than in the previous times. More people use modern medicine than ever before because now there are medical clinics in the village and transport facilities to the urban hospital. They pointed to establishing hospitals, health posts, medical colleges, private pharmacies and medical clinics to increase modern medicine use. A healer said that “educated persons like you prefer to go to the hospital instead of visiting healers like me”. The main reason for the decline in the use of indigenous healers is the lack of highly experienced healers and the slow effect of herbal medicine, doubt over the drugs given by healers (or the possibility of adulteration), no official recognition to the healers as traditional medicine practitioners. Besides, some of the ritualistic practices of the guruwas were explained as superstitious, unscientific and harmful. A few patients said that they do not believe in the healing practices of guruwas but visit them. For instance, a patient said that he did not believe in shamanic healing but attended a shamanic healing session a few weeks later. Similarly, a schoolteacher whose child had the problem of sukenas, wasting child, justified her visit by saying, “I do not believe much in Guruwa’s healing. Nevertheless, the herbal medicine they gave may work sometimes, or they may suggest something important. I give priority to official medicine. Even in this case, I had been to the city hospital. The medicine brought from there seemed not working, and my friend suggested to visit him (the guruwa), and I am here”. A few young and educated patients also questioned the logic of healing rituals and the efficacy of such practices. A few guruwas also accepted that now people visit hospitals more than ever before and consult them less frequently. It is an indication of the shrinking popularity of ethnomedicinal practices. However, many participants believe that ethnomedicinal practices are still as popular as before because when illness befalls, community people cannot help visiting local indigenous healers. The practices of the guruwas may have declined, but they are consulted frequently. They believe that the illnesses caused by lagu-bhagu (evil spirits) need to deal with the way guruwas do. Except for a few young who expressed doubt over the potency of medicinal herbs dispensed by baidawas, they all have strong faith in jadi-buti (medicinal herbs and plants). One of the participants showed the importance of jadi-buti compared herbal medicine with compost manure and biomedicine with chemical fertilisers. The compost manure keeps the quality of soil intact, whereas chemical fertiliser gives quick results but damages the soil quality. He means that biomedical injection and drugs work as chemical fertilisers in the human body, showing quick results but damaging side effects. Nichter (2005, 213) has already documented a similar perception in South India. However, it is notable that the dependency on chemical fertilisers and biomedicine has increased. Several studies have already pointed to the declining state of indigenous healing practices, mainly because of the lack of official recognition of ethnomedicinal knowledge

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and practices (Acharya & Acharya, 2009; Aryal et al., 2016; Bajracharya, 2006; Ghimire & Bastakoti, 2009; Koirala & Khaniya, 2009). The healers lack official legitimacy and often are discouraged and demoralised to continue their practice. There is no encouragement and incentive to motivate the young generation. The healers who are practising are also struggling with the moral value and market value of their services. On the one hand, they cannot ask for money for their healing services because this is morally wrong, and on the other hand, the compensation given is meagre. They find it hard to adjust under the present-day monetary necessity. Now, they have to invest more time and resources and face difficulties in collecting herbs from the forest and many herbs, including the locally processed or manufactured ones, have to pay a high price. The healers known as specialists of fractures, bonesettings, snakebite healing, jaundice and stomach problems started to see their services in terms of market value. Even some of the experienced masseurs and midwives indicate an influence of dominant cultures’ money, market and consumerism. Indigenous cultures and value systems are also changing. Konadu (2007) takes culture as “the most precious and endangered resource” in African Society, which is true to the South Asian context. The essential cultural elements of ethnomedicine eroded due to an influence of the dominant worldview. It becomes a challenge with vanishing volunteerism in ethnomedicine and the commercialisation of healing services. The market and commercial influence can be observed even in the indigenous healing practices. Some healers have started charging for their services, selling Ayurveda medicine and using modern technologies.

Importance and Strengths of Ethnomedicine Many studies have highlighted the importance of ethnomedicine and healing practices (Kleinman & Sung, 1979; Leslie, 1976; Nichter, 1980). Several medicinal plants, which the ethnic communities have been using, have shown medicinal effects under laboratory conditions (Iwu & Wootton, 2002; Konadu, 2007; Ramawat, 2009). These plants are the source of medicine and fibre, fat, carbohydrates, protein, vitamins and minerals. Ethnomedicine is the repository of herbal knowledge and also the mother of all scholarly traditional and biomedicine. It benefits humanity at large (Katewa, 2009, p. 34). Many modern drugs derived from plants are in use among indigenous communities. Shrestha et al., (2014, 1212) affirm that the plants used by indigenous healers have solid pharmacological evidence. They are likely to be more effective in treating different conditions and having enormous possibilities to contribute to the health of the communities. The Tharu ethnic community, like all other ethnic communities of Nepal, depends on indigenous practices to address ill health. The dependency on indigenous healing is not only because of limited access to official healthcare facilities or because they believe in the supernatural causation of illnesses but because ethnomedicine works. The strength behind indigenous healing practices is the knowledge of jadi-buti, the medicinal plants. People choose to consult healers because they can treat them

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successfully using medicinal plants with curative value. Moreover, local healers’ services are accessible and affordable, and the healers can understand the sociocultural context in which people live and experience illness. The healers can provide culturally meaningful treatment because their practices are culturally close and emotionally appealing to the people (Subedi, 1992, p. 323). The ethnomedicinal practices are criticised on the grounds of science and rationality. Many ethnomedicinal practices are criticised for unscientific, irrational or superstition based (Subedi & Joshi, 2018). However, it is not the superstitions or ignorance on which ethnomedicine is based (Subedi, 1992). The challenge is to seek science, which is inherent in ethnomedicine and the medicinal knowledge that indigenous people have developed over time. There is a need for scientific research to examine the pharmacological potency of the medicinal plants to explore their therapeutic potential (Gaire & Subedi, 2011).

Change and Continuity of Healing Practices Indigenous cultures have deep connections with their environments evolving over thousands of years (Anderson et al., 2016, p. 1). Tharu healers know many plants available in the local forests and have an intimate relationship with and respect for nature (Manandhar, 1985; Paudyal & Ghimire, 2006). They worship nature, the forest, the river and the plants. Gurung (1992) notes the banaspati pooja (worship of banaspati, the Goddess of the forest), which is performed under the Saal tree (Shorea Robusta) by both the father of bride and groom together with accompanying villagers before the day of the wedding. Such instances abound among Tharu and many other ethnic communities. Many communities worship bhume (the earth God), bayu (the wind God), nadi (the river God), birds (crow), naag (the snake God), tulasi (holy basil) bar-pipal (banyan-sacred fig), sun and the like. Culture of other communities who migrated into their place influenced Tharu culture, with the volume of other forms of healing increasing significantly. Biomedicine commands in terms of official provision, market support and medical education. Ayurveda has a more significant presence among the official traditional medicines. Though limited in their presence, Homeopathy, Yoga and naturopathy, Unani, Sowa-Rigpa, traditional Chinese medicine and acupuncture also coexist in the diversity of medical traditions. Tharu also uses these systems based on their accessibility and availability.

Healing as Customary Practice Despite all the disincentives to practice, the healers must serve their clientele. The community expects a traditional role of healing from their healers. For example, a guruwa, after his father’s death, had to take the responsibility to serve his father’s

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clientele. He left the idea of going abroad for a job and started devoting himself to the clients’ service. This decision enforces and sustains healing practices as customary practices and sustains them as family traditions. It is possible to find local healers practising for generations like Cameron (2008) identified and interviewed a traditional vaidya of the twenty-third generation. There are some rituals only performed with the help of one’s guruwas. So, even if someone in the family cannot see the value of ritual/spiritual healing, no one can make an overt objection. Some of the practices, such as lausari (a ritual performed twice a year for the children’s health at the family level), gurrai (a ritual performed for community health at the village level), are associated with the cultural and religious traditions, and disrespect to these traditions is not socially acceptable. Moreover, the guruwas is the respected elder community member with rich knowledge of healing and dealing with a range of family and community problems. They help perform rites and rituals, which are inseparable parts of Tharu life, signalling that indigenous healing practices interweave with the cultural and religious beliefs of the communities. Hence, the healing roles of guruwas may change, but some of their healing practices may continue as long as these cultural-religious traditions hold strengths. The shamanic or ritualistic healing mode is criticised from the logic of science and considered even harmful in many instances, but this is not the only healing strategy. Moreover, from the patient’s perspective, the etiological explanation of guruwas and their healing strategy can be equally scientific. Further, several studies have shown the importance of shamanic/faith healing in emotional, spiritual and psychosocial health (Castillo, 2001; Dalal, 2011; Quack, 2012). The popularity of herbal healing has not diminished because the general perception is that herbal drugs are safe, effective and have fewer side effects. This perception, to some extent, supports herbal healing practices. As Kunwar et al. (2006, p. 1) state, “the importance of plants as medicine has not diminished in any way in recent times”. Some herbal healers’ popularity and reputation for their knowledge of specific illnesses such as jaundice, gastritis, joints pain and the like will help continue such practices. Some of the guruwas and baidawas have been practising for generations, hereditarily. However, with the market influence, the baidawa may use manufactured herbal drugs along with (or instead of) their herbal preparations because some plants are not readily available. They have to spend extra time searching, collecting and processing the medicinal herbs to make them ready to use. Moreover, the tightening of forest rules has discouraged many healers from going into the forest and collecting medicinal plants. Sometimes, they have to bribe Banpale (the forest guards) because of the fear of a legal trap. So, the manufactured products seem to become an easy solution for both the healers and the patients. The patients feel comfortable using them as they are in the form of tablets or syrups. It is morally justified for the healers to earn an amount by selling the medicine because the companies are considered responsible for the price of the medicine they sell. Some of the herbal healers have sent their son and daughter to the Ayurveda College for paramedical courses, with an effort to continue their practices adjusting with the demand of state rules and regulations.

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The importance of assisting in birth and post-delivery care and massage is not diminishing yet. The role of the surenyas as the birth assistant is changed as the government is encouraging institutional deliveries. However, there is no substitute for their role to provide post-delivery care and massage. Besides, a large number of low-income families still depend on a traditional birth attendant for home birthing. For instance, the role of surenya can be essential and supportive to the continuity of midwifery practices. Surenya’s task is to name a child in the cultural event of the naming ceremony. Rituals such as ghatwa karaina (a purifying ritual after childbirth) allow surenya to introduce the water source to the mother. Some of the ethnomedicinal practices are reinforced by the cultural and religious values of the ethnic population. Thus, Tharu ethnomedicine holds strength because their healing practices form a part of everyday life, answering the question of relevance and continuity. People have realised the importance of natural medicines and herbal practices. The ethnobotanical and ethnopharmaceutical studies have also shown the importance of ethnomedicinal plants for bioprospecting and drug discoveries. The revitalisation of local health traditions in India as a policy agenda also points to the recognition of the importance of herbal knowledge of indigenous people. The protection of locally available medicinal herbs and promoting ethnomedicinal practices is crucial for strengthening indigenous knowledge systems.

Lack of Policy Interventions The world is looking back to nature. Many people are now looking for more natural and less harmful products, and the demand for traditional and complementary medicine, most of which are plant-based resources, is increasing. In this context, indigenous knowledge of plant resources can play a crucial role. The promotion of tribal health practices contributes to providing affordable and sustainable primary health care to indigenous populations and developing herb-based drugs and products for broader use. Policy documents highlight the importance of medicinal herbs but hesitate to recognise the healers who have accumulated the knowledge of those medicinal plants and have been serving the communities for generations. Following the recommendation of the 1978 Alma Ata declaration, many nations made efforts to recognise traditional medicine and integrate traditional medicine practitioners into their national health system. However, no such laudable efforts were made in bringing indigenous healers into the fold of the national health system. In Nepal, the need of linking indigenous healers with the public health system is expressed (NESAC, 1998), but no such policy is formulated to recognise and integrate them. Government health policies and programmes emphasise the production, utilisation and management of medicinal plant resources as an opportunity for herbal trade (MoHP, 2014; MoHP, GoN, 2015) but often miss recognising the role of healers, indigenous knowledge and healing practices. The national health policy presents healers as relevant only in the past when people had to rely on them because the official healthcare system was not expanded (MoHP, 2014, 2017). Aryal et al.,

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(2016, 22) study show that they continue their indigenous practices as a family tradition and culture. The healers are involved in occasional training and interaction programmes and support implementation in national health programmes. However, there are no such visible efforts to link them with the public health systems. Even if anything happens, they are ‘peripheral and lukewarm’ (NESAC, 1998, p. 60). The policy documents recognise the vast existence of indigenous healers and healing practices, including those of Gurau in the Tarai and Amchi in the mountain (MoHP, GoN, 2015, p. 19). However, there are no programmatic actions aimed at the assessment, validation, accreditation and integration. On obtaining the licence the Article 22 (3) of The Public Health Service Act, 2018 states, “in the case of the traditional treatment service, service shall be provided after obtaining approval according to the standards prescribed by the local level” government. Based on the clause of this article, the Department of Ayurveda and Alternative Medicine (DOAA) has drafted a “Listing Criteria for Traditional Healers, 2020” (DOAA, 2020), allowing indigenous healers to get registered with the local government. The indigenous healers included must be practising traditional healing as their primary profession for the last 15 years and meet the set criteria. The rules and regulations are favourable for those who complete short courses (for example, 15-month course for Pre-Diploma in Ayurveda or Auxiliary Ayurvedic Health Worker) to get registered than the indigenous healers. The latter has been practising for many years. Article 5.1.1B of The Ayurveda Medical Council (First Amendment) Act, 1999, considered only those of 50 years of age and above and had been practising traditional Ayurveda since the last three generations eligible to get registered to carry on the Ayurveda profession. Such provision of the act is critic as ‘ridiculous and humiliating’ (Bajracharya, 2006). Though many indigenous healers were/are practising without getting registered, they have no (or have lost) official legitimacy with such legal provision. Such a prohibitive act needs amendment and policy formulated to accommodate the indigenous healers in the national healthcare delivery system. The one size fits all policy, and Ayurvedisation of indigenous healing may conflict with indigenous people’s cultural and customary rights. Appropriate policy and programmes for due recognition of indigenous healers and healing practices are needed. The accreditation of the indigenous healers is necessary to link them with and make them play a meaningful role in the national health system. The indigenous healers have been serving community people with traditional knowledge and expertise. Their services are handy and help save time and resources for the people. The community people can benefit if the indigenous healer’s knowledge is enhanced and the quality of their services ensured. Indigenous healing can reduce public expenditure on health by providing appropriate care at the doorsteps, showing the need for capacity building for indigenous healers. Enhanced knowledge and skills of indigenous healers help to vitalise the indigenous healing practices and serve people with quality indigenous traditional medicine services. There is a need to recognise and integrate indigenous practices into the public health system for the common benefit. Recognition and integration also help promote safe and efficacious indigenous practices and contribute to enhancing indigenous knowledge.

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Ethnomedicinal practices carry a long history of development and are deeply rooted in cultural and religious traditions. The weakening of ethnomedicinal knowledge can harm community health. A strong ethnomedicine can bring positive health outcomes among the indigenous population. Indigenous healers have contributed to primary health care by providing affordable and culturally meaningful health care to the community. For many, who are poor, who do not have access to official health facilities, the indigenous healers are the only source of help. Besides, they are the only hope for biomedically untreatable conditions. However, there is a threat of losing such a crucial indigenous knowledge base. The protection of ethnomedicinal knowledge and promotion of healing practices is culturally essential and politically empowering. The state intervention with specific policy direction for the recognition and integration of healers and healing practices of ethnic communities is indispensable for preventing ethnomedicinal knowledge from further erosion.

Conclusion Ethnomedicinal healing practices are embedded deeply with the cultural traditions of the ethnic communities. The continuity of the indigenous healing practices, to a large extent, depends on the continuity of their cultural traditions. Hence, the decline in the healing practices can be viewed in the decline of the cultural value system, influenced by the dominant cultures. Thus, the efforts which aim to safeguard the indigenous health knowledge must not ignore the cultural traditions. By emphasising only on herbal knowledge of indigenous communities, we miss the essence. The focus only on the medicinal herbs and not the cultural context is similar to seeing the only tree but not the forest. Without considering the cultural context of healing practices, the effort of protecting indigenous knowledge may be half-hearted. The promotion and strengthening of indigenous knowledge and healing practices empower the indigenous communities and further contribute to biodiversity conservation. The traditional cultural value system can be supportive of the conservation and sustainable use of medicinal plants. Policy measures are necessary for the recognition of ethnomedicinal knowledge with due respect to the indigenous cultural traditions.

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Rasuwa District. Journal of Ethnopharmacology, 155(2), 1204–1213. https://doi.org/10.1016/j. jep.2014.07.002 Singh, N., & Aggarwal, B. (2009). Health communication among scheduled tribes of chhatisgarh: An anthropological analysis. The Eastern Anthropologist, 62(4), 491–498. Subedi, J. (1992). Primary health care and medical pluralism exemplified in Nepal: A proposal for maximizing health care benefit. Sociological Focus, Special Issue: Health and Health Care in Developing Countries, 25(4), 321–328. Subedi, B. (2019). Medical pluralism among the Tharus of Nepal: Legitimacy, Hierarchy and state policy. Dhaulagiri Journal of Sociology and Anthropology, 13, 58–66. https://doi.org/10.3126/ dsaj.v13i0.26197 Subedi, B., & Joshi, L. R. (2018). (Un) popular traditional medicine: Community perceptions, changing practices, and state policy in Nepal. Esocial Science and Humanities, 1(2), 157–167. Sujatha, V. (2014). Sociology of health and medicine: A new perspective. Oxford University Press. Tseng, W. S. (2009). Indigenous, folk healing practices. In M. G. Gelder, N. C., Andreasen, J. J. López-Ibor Jr. & J. R. Geddes (Eds.), New oxford text book of psychiatry (Vol. 1–II, pp. 1418– 1422). Open University Press. The ayurveda medical council (First Amendment) Act 1999, no. Act number 21 (1999). http://www. lawcommission.gov.np/en/documents/2015/08/ayurveda-medical-council-act-2045-1988.pdf The Public Health Service Act. (2018). no. Act Number 11, Parliament. https://www.lawcommis sion.gov.np/en/wp-content/uploads/2019/07/The-Public-Health-Service-Act-2075-2018.pdf WHO. (2019). WHO global report on traditional and complementary medicine 2019. World Health Organization. https://apps.who.int/iris/handle/10665/312342

Chapter 14

Ethics, Morality and Healing: A Bhil Perspective Minakshi Dewan

Abstract One sees medical pluralism in tribal communities’ health-seeking patterns. For instance, Bhil, a tribe in Rajasthan, often recourses to traditional healers like herbalists, shamans and dais (midwives) and biomedical practitioners. Though not bound by any written rules/regulations, these practitioners are guided by particular moral/ethical perceptions that govern their behaviour. This paper looks at various dimensions of ‘ethics’ and ‘morality as understood by one of the most deprived sections in the country. It investigates how Bhils characterise different healers as dharmi/adharmi based on the adherence/non-adherence of ethics and moral code. It sheds some light on the factors (other than just economic) essential for Bhils in choosing between different healthcare providers. The public health ramifications of these aspects are also touched upon. Keywords Bhils · Ethics · Morality · Traditional healers · Health-seeking behaviour

Introduction The Indian health culture is highly pluralistic. One finds the coexistence of the allopathic system and traditional systems like Siddha, Unani and the local health traditions (Dewan, 2017). The local health traditions include home remedies and dietary practices for health along with practitioners like herbalists, bonesetters, massagers, dais and poison healers. Each culture and tradition of medicine is directed by specific code of conducting medical practice (Fabrega, 1990). Classical Indian writings also devote special attention to these aspects, including the practitioner’s behaviour, emphasising the physical, moral, intellectual and social background characteristics needed for medical practice (Desai, 1988; Fabrega, 1990). Unlike the practitioners of codified traditions, oral traditions are seldom bound by any written rules or regulations. However, these traditional healers are guided by certain moral or M. Dewan (B) Gurgaon, India e-mail: [email protected] © The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023 S. Reddy et al. (eds.), Ethnomedicine and Tribal Healing Practices in India, People, Cultures and Societies: Exploring and Documenting Diversities, https://doi.org/10.1007/978-981-19-4286-0_14

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ethical precepts that govern their behaviour (Kakar, 1986; Nichter, 1983; Fabrega, 1990; Joshi, 2004). For instance, a commercial self-beneficial approach to healing is consistently criticised, while characteristics like kindness, empathy, patience and the high moral character are considered desirable (Levey, 1967, Kakar, 1986, Priya, 2012). Most of the studies (Kakar, 1986; Nichter, 1983; Joshi, 2004; Cohen, 2006, Sujatha, 2009) mention various dimensions of ‘ethics’ and ‘morality’ while describing different healing traditions, but scant literature on the detailed analysis of these aspects per se. This chapter will thus present various aspects of ethics or morality as understood and practised by different healers in a tribal community. The chapter will also look at how multiple healers, including allopathic practitioners, are characterised (both by the community members and the healers) as ‘dharmi’ and ‘adharmi’ based on the adherence/non-adherence of ethical norms (as understood by the community) by the healers. These aspects also shed some light on the factors other than economics that play an essential role in choosing between different health providers. It is especially pertinent to look at these aspects in the present context when the older notions of seva (service) are getting eschewed in the current curricula of biomedicine and the formal Ayurvedic and Unani colleges of today (Hardiman & Mukharji, 2012).

Context The village discussed here is Ghodan Kalan of Udaipur District, Rajasthan. It is scattered with hilly terrain covering a total area of 456 ha (Census, 1991). Denuded hillocks surround it with patches dotted with trees and wild shrubs. A pakka road built in 2006 connects the village to the outer region. The village is twenty kilometres from the Udaipur District headquarters, with four scattered hamlets and a population of 979 persons (Census, 2001). Ghodan Kalan is dominated by the Bhil tribe, one of the largest tribes of Rajasthan (Census, 2001). Besides the Bhils, only two families from the Kalal caste (caste of liquor distillers) own small utility shops and serve as petty moneylenders in the village. The village suffers from economic challenges caused by small landholdings, irregular rains, no permanent source of irrigation and poor soil yield. The primary sources of income are construction work and agriculture, with very few people employed in government jobs or the organised private sector (Dewan, 2017). The education and health status of the tribal communities in the district also remains poor. The non-governmental organisations (NGOs) working in the area recorded poor maternal and child health status among the tribal communities (Mandir, 2013).

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Material and Methods This chapter is based on one-year-long fieldwork undertaken as part of the author’s doctoral research. The research was conducted among the Bhils of village Ghodan Kalan of District Udaipur, the author’s Mphil fieldwork site. The author’s Mphil research looked at the role of ‘traditional healers’ among the Bhils, while the doctoral research focused on the health culture, concentrating on the pain-afflicted persons with long-term physical pain (lasting more than a month) and the healers they visit. The author collected the narratives of the 14 chronic pain patients and their family members. The help of health workers such as accredited social health assistant (ASHA), auxiliary nurse midwife (ANM) and dais in locating the causes of chronic pain was also sought. The purpose of the enquiry was explained as a ‘survey’ on lambi bimari (long-term illness). After locating the cases, repeated/frequent visits were made to inquire about health and well-being. The author observed the patienthealer interaction and the healing practices or rituals of the different healers or shrines by accompanying the patients to healing sites like dargahs, temples, local shrines and hospitals. Along with this, the author conducted interviews with 14 traditional healers like bhopas (shamans) and Jaankaars (herbalists), including the caregivers at the shrine, to understand their approach towards chronic pain (Dewan, 2017). The details of all the participants are kept confidential, and pseudonyms were used to conceal the identity of both pain patients and the healers.

Health Seeking The health-seeking in Ghodan Kalan is highly pluralistic. Both biomedicine and traditional healing systems coexist without replacing one with the other. Two forms of understanding the disease causation common in the village are sharir hi bimari or augan (illness caused by natural forces like cold or rain, etc.) and dosh of lafda (illness caused by supernatural and divine forces). For sharir ki bimari or augun, people usually visit doctors, herbalists or jhada specialists. The community members generally visit herbalists or jhada specialists for boils, snakebites, diarrhoea, naval dislocation and chest congestions in children. On the other hand, the community members resort to allopathic physicians for more complex and persistent fevers caused by malaria and typhoid. While the private practitioners (commonly known as private daktars) are preferred for day-to-day problems, public hospitals (sarkari) are used for significant illnesses and the ones that require examinations and tests. For supernatural causation, the community members use exorcists of diviner’s services and visit Sufi shrines (piru or dargah) (Dewan, 2017).

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Traditional Healers and Healing Systems in Ghodan Kalan The traditional healers in the village of Ghodan Kalan can be grouped into four main categories based on the kind of therapy that they administer. These traditional healers generally practice healing along with their primary source of livelihood.

Jaankaars—Herbalists and Bite Healers Jaankaar is a generic term used for ‘the knowledgeable one’. Both ‘herbalists’ and ‘bite healers’ are commonly referred to as jaankaars, who know the use and dispensation of herbs (jungli davai). These jaankaars deal with illnesses caused by natural forces (sharir ki bimari or augan). They administer jungli davai for various illnesses like nikala (a generic name used for prolonged fevers including typhoid, caused by the blocking of sweat glands), snakebites, diarrhoea (duste) and headaches (matho dukhna). Diseases like the white-discharge problem among men and women (safed pani), stone formation (pathri), retention of placenta (aval nahin padna), infertility (baanj) have a cure in jungli davai. Some of them are also trained in mechanical manipulations like massage (matarna) for setting bones and navel dislocation (dunti khisakna—navel pulse having moved out of place due to a jolt or a missed step). Some of them also administer daam (daam is administered with a burnt cloth or a warm iron piece on particular nerves for treating congestions, i.e. jadav/asthma and is based on counter-irritation therapy). The jaankaars also combine the use of herbs with Jhada (sweeping). It is done by blowing on the inflicted part by brushing it with margosa (neem) while simultaneously reciting mantras. They administer jhada for headaches (matho dukhna), bites, dunti/gola (navel dislocation) and nikala. These healers are also well versed with the humoral properties of food items and the healthcare needs of the community members in the village. Some of the gifted jaankaars are even summoned by the community members from the other caste groups.

Jhada Specialists These specialists do not administer any herbs but have specialised skills in administering Jhada to humans and cattle. These healers administer Jhada for a variety of problems like snake and scorpion bites, boils, nikala, swelling in the body caused by injury and poison spread in the body of the cattle caused due to consuming poisonous beans or plants.

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Dai Dai is a traditional birth attendant who assists a woman during childbirth. It is a gender-specific role, generally practised by older women forty five and above. Some of them are well versed in administering herbs for a variety of problems like retention of placenta, diarrhoea and boils among children. However, few of them also have the expertise in handling complicated deliveries. With time, some of them have also taken up new roles like motivating women for antenatal and postnatal checkups, immunisation and assisting women in institutional deliveries. They generally cater to the women from their community, both within the village and the surrounding villages.

Bhopa This category of healers deals with dosh/lafda (supernatural forces) problems. It is a gender-specific role, and women are refrained from practising it. They can be divided into two more categories: Mutthi Akha: These bhopas have expertise in diagnosing (Jaanch karna), preventing and treating the problems related to black magic, sorcery, witchcraft (dakni), ancestral spirits (purvej) as well as evil spirits (veers). They look at a handful of corns (mutthi dekhna) to diagnose the problem. These corns are first circled around the patient’s head twenty-one times and then brought to the bhopa for diagnosis. The bhopa first lights a dhoop (incense) and then looks at these corns (while simultaneously reciting inaudible mantras) to reach a diagnosis. These supernatural forces (sent by human agency) bring pain and suffering (dukh) in the form of illness, misfortune and even death. These mutthi akha bhopas have command over these elements like no one else. They are generally consulted at some point during an illness episode or other miseries. Many ‘crafty’ bhopas are popular even among the other caste groups; some even travel to distant villages to conduct propitiation rituals. Bhavdari Bhopa: According to the prevalent ideology, the Gods choose these men to manifest the Gods’ wish to serve the people. This is revealed via trance, at which time the God (devi/devta) speaks through the entranced bhopa (bhav aana). It is not the bhopa who heals, but the God. The services of a bhopa are usually sought to get divination (bhav karana) for all sorts of problems (dukh/dard) like health problems, thefts, loss of cattle, infertility and even business questions.

Aspects of Dharmi and Adharmi for Other Healers ‘Dharm’ refers to the expected sacred duties/ethical norms/prescribed conduct. For instance, serving people as healers and necessary service and devotion to a deity is

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considered ‘Dharam ka Kaam’. The healers have specific characteristics and practices commonly perceived as adding to or detracting from their moral standing, like following niyam/following the righteous path (dharam niti per chalna). With these, purity, truthfulness and selflessness are needed from the care seekers, although different healers have different expectations. Based on the adherence to the expected code of conduct, these healers are often termed dharmi or adharmi. Dharmi is the one who practices his duties and follows the niyam, and adharmi refers to the one not abiding by the expected norms. There are very different parameters that govern these healers. They are mostly governed by the ethos within the community, the rules laid by the community members. Various aspects of dharmi and adharmi will be elaborated below:

Truth Truthfulness/honesty is regarded as the most important virtue for a healer. It goes a long way in building faith in a particular healer. The healer is expected to make the proper diagnosis as well as recommend the right treatment. These aspects primarily pertain to the ethical imperatives of practitioner-patient interactions. It is the dharam of a bhopa, to tell the truth. If a person lies and cheats people, then he/she does not follow the path of dharam niti. It is not correct if he/she says one thing to a person and something else to another (change versions). If he/she tells people whatever he sees in the mutthi, then he/she is an honest man. If he sees one thing and conveys another, then he/she is not a dharmi bhopa. If he/she is not giving a clear picture, he/she is at fault, explained one of the bhavdari bhopas (Dewan, 2013). I always follow dharam; I do not tell a lie, and I do not betray people. If I do not follow dharam niti, then God will not ‘play’ on me (annadata mujpe khelege nahin), explained a bhavdari bhopa (Dewan, 2013). I do not lie. If I do not see lafda/dukh in a mutthi, I inform people. The God above keeps an eye on everyone, said a mutthi akha bhopa (Dewan, 2013). A dharmi bhopa should be a learned and truthful man. Someone could tell things wrong and could also tell a lie. Some of them just work for money and fool people. Some mutthi akha bhopas go away (paisa len paran jai) with the money, and the person’s condition also does not improve (Dewan, 2013).

The above quotes reveal that ‘truth’ is considered a fundamental element of dharam. A dharmi healer is expected to help the sick uncover the ‘right’ agents behind the illness and make the correct diagnosis, administer the right or the most efficacious regimen and not exploit the sick person. For instance, mutthi akha bhopas are expected not to use their supernatural powers to cause illness. Fabrega (1990) also mentions this as a crucial component of ethics. Among Bhils, there is a strong belief that supernatural agencies can treat or cause illness. The healers are supposed to use their power beneficially on behalf of the sick person. Cheating people by telling a lie and making a wrong diagnosis is considered an adharmi trait. It is also

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believed to bring inevitable consequences for the healers. There is a general belief that the healing power gets obviated, or God punishes if he/she lies or cheats people or detracts from this virtuous path. Some narratives also elaborated how the healer suffered the same illness as the patient because he duped his patient/patients.

Following Niyam Each healing tradition has a set of rules (niyam) governing the training and practice that the healers have to abide by. There are different sets of rules for different categories of healers that will be elaborated below: Food-related Niyam: Some healers have to observe food restrictions on certain days, while others have to renounce non-vegetarian food completely. The quotes below will illustrate this further: My sect forbids me from eating meat and consuming alcohol. I cannot even accept ceremonial food (nukta) because my sect forbids me. I am a strict vegetarian and observe fast on Mondays and poornima (full moon night). I do not entertain people who come to visit me after consuming alcohol, said a herbalist belonging to dasnami sect (Dewan, 2013). I abstain from consuming meat and alcohol on Saturdays because it is seva ka din of Bheruji (a male deity), explains a bhavdari bhopa. I cannot enter the temple otherwise because Bheruji does not accept animal sacrifice and is a dharmi devta, it will be sinful for me to consume non-vegetarian food, explains a bhavdari bhopa (Dewan, 2013).

The above text reveals food restrictions for some categories. For instance, it is the dharam of bhavdari bhopas to abstain from non-vegetarian food and liquor on seva (divination) days and observe fasting during Navratri days. However, bhavdari bhopas are revered if they completely renounce non-vegetarian food and liquor. It enhances their moral standing. The healers belonging to the Bhagat tradition have to completely renounce non-vegetarian food and liquor (as explained in one of the quotes). Their periodic/complete renunciation perhaps marks them out as the ones who have transcended one of the fundamental primary pre-occupations of their fellow beings. On the contrary, mutthi akha bhopas are not expected to abstain from eating non-vegetarian food or liquor. It is acceptable for them to consume and accept meat and alcohol as part of the offerings made to them (in-kind) post the ritual appeasement. They deal with malevolent spirits and ghosts referred to as adharmi cheez (non-virtuous forces) sent through black magic. Hence, it is considered acceptable to consume meat and alcohol for their appeasement. This reflects an inherent understanding that the one who engages with adharmi cheez can also engage in acts that are ‘otherwise’ considered adharmi. It is also believed that mutthi akha bhopas gain their healing power by frequenting shamshans (cremation grounds), usually the forbidden places and the homes of supernatural powers. Other Niyam/s: Bhavdari bhopas have to perform the ritual worship of family deities (seva) on the prescribed days and undergo regular fasting periods. Kakar

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(1986) also mentions that a bhagat (shaman) has to follow prescribed conduct (dharma) and the rules (niyam). At the same time, healers of herbalists and dai tradition have to follow niyam in dispensing and disposing of herbs. Healers of dai tradition also have to follow the rules of disposing of the placenta (aval) in a prescribed way. ‘Secrecy’ is another crucial dimension of the prescribed conduct that these healers have to follow. Knowledge of herbs is a closely guarded secret, and it is not revealed to others. This aspect was also mentioned by Joshi (2004). I take an early morning shower on Saturdays, and then only I enter the temple. I also have to observe fasting during Navratri and refrain from eating green vegetables during Gavri festival, explained a bhopa (Dewan, 2013). I have been practising healing for the last 30 years or so, but I don’t share my practice with anyone; the herbs are rendered ineffective if we do so, explained a herbalist (Dewan, 2013). We never show the plant to others; otherwise, its therapeutic value diminishes, remarks a bite healer (Dewan, 2013). I do not collect the herbs in advance; I get them from the forest when the need arises. The herbs lose their potency if we collect them beforehand. I have to keep track of herbs in and around the area, explained a herbalist (Dewan, 2013).

Non-denial of treatment to any patient is another critical dimension that governs these healing traditions. These healers have to readily make themselves available to the community members at all hours. It is considered the dharam of a healer to attend to people from all communities at all hours. I get people from all age groups and caste groups (Mahajan- the business community, Brahmins, Dangi- OBC and tribal communities). I do not deny treatment to anyone because it is dharam ka kaam (Dewan, 2013). If people are in pain, then we have to help them. We have to attend to them at all hours even if I have to leave my work and look after them; this is dharam. If I refuse them, then the paap will fall on me (Dewan, 2013).

Not Accepting/Demanding Money/Fees Accepting/demanding money/fees or payment modality in exchange for services has also been another critical criterion governing these healers. Although different healers have different expectations, the customary recompense of a bhavdari bhopa is in the form of a coconut, bidi (rolled tobacco) or incense sticks, but that too is voluntary. They are viewed as chosen ones by the God/deity, and their foremost duty is to serve people in pain and suffering (dukh). They cannot deny services to anyone as healing is considered dharam ka kaam. These healers also believe that their priestly healing will be obviated or punished/cursed by the deities on demand of fees/money. These norms are meant to ensure the least exploitation of the patient who is in a vulnerable position of being ill or in any other misery.

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I do not charge anything for my services; this is what dharam is all about. People come and offer incense and coconut here. Even if people come to me late at night, I do not charge anything, which is dharam niti. I just accept tea and that too if people offer. Charging money is incredibly wrong; it is not the right path (voh sahi rasta nahin hain), explained one of the bhavdari bhopas (Dewan, 2013). We get bhav because of God’s grace, so we have to follow dharam. My dharam does not allow me to charge or accept anything for my services. I just accept a cup of tea and nothing else. My job is related to God, who is the ultimate saviour. I follow dharam, as the deities get very angry if we do not follow dharam. These deities can also cause doshan to the bhopas if they ignore their dharam. Some bhopas can also lose their mind/become insane because of the curse of the deity, explained another bhavdari bhopa (Dewan, 2013).

Both the quotes reveal that the bhavdari bhopas have to follow a righteous path and not accept or demand anything in return for their services. However, it is important to note that the ultimate onus of cure is placed on the supreme beings and healers neither take the credit for the healing nor do they accept anything in return. Likewise, healers like the Jaankaars and the jhada specialists also do not charge anything (cash or kind) for their services. Dai’s can accept gifts voluntarily given to them in cash/kind for their services. Demanding money is again considered immoral, but it is considered acceptable for mutthi akha bhopas to make/demand money or cash. Joshi (2004) also mentions that different healers have to abide by different payment norms. I charge money for doing a totka since I have to work for the whole night (poori raat khoti hoona pade). However, I only charge money after the work gets accomplished. I have to show my face to God. I follow the path of dharma, says a mutthi akha bhopa. I charge for my services since this is tedious, and I have to invest time and energy (khoti hoona pade). However, I only charge after finishing the rituals because I also have to keep my dharam (dharam rakhno pade). Bhopas take money first and only then perform rituals, says a mutthi akha bhopa (Dewan, 2013). Some dharmi bhopas will do their job well and will even charge fifteen/twenty rupees less. Mutthi akha bhopas also used to charge money in the past but they followed dharam. Now they demand money, there is a lot of Jhooth maar but the God only supports the dharmi ones, explained a bhavdari bhopa (Dewan, 2013).

This explanation points out to an implicit understanding that the one who deals with evil (bad) can engage in acts otherwise viewed as immoral. This criterion of paying mutthi akha in cash is often justified by saying that dealing with evil is risky and cumbersome (vo jhokhim ka kaam hai). Bhopa is responsible for getting rid of all the dangerous evil forces and be reimbursed for the same. People somewhere also believe that these healers will meticulously perform the propitiation rituals if paid in cash for their work. Not paying in cash might also mean annoying the bhopa who has the power to send evil forces to cause harm. Mutthi akha bhopas also have to follow niyam in not demanding/accepting fees before accomplishing the ritual. Mutthi akha bhopas are adharmi, if they engage in demanding/extracting exorbitant sums of money before accomplishing the rituals and conduct wrong diagnoses to make money or perform black magic with evil intentions (lafda kare dukh bhejne ke liye). Other studies mention payment modality as an essential aspect of ethics related

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to healing. For instance, Sujatha (2012) mentions that in some healing traditions, demanding payment for treatment or collecting money in advance of curing a patient is considered unethical. Likewise, Nichter (1983) noted that the healers of vaidya tradition have to perform the rituals like Dhanvantri puja to mitigate the negative karma that the healer receives by accepting payment from the clients. This reveals that accepting money is considered an immoral act that attracts negative karma. Cohen (2006) also mentions that native American healers never charge fixed or unreasonably high sums from the patients; it is believed to be a sign of contemptible professional ethics.

For Allopathic Practitioners The same criterion of dharmi and adharmi may not ultimately transcribe to biomedical practitioners. However, they too are judged for their ethics and morality. I visit this private doctor in Dhar, his medicines are effective, and he sometimes charges 10–20 rupees less. He is not greedy; he follows his dharam. Some of them have become greedy. This is kaliyug, and people are more interested in money, said a Jhada specialist (Dewan, 2013). I developed severe pain in my stomach. Then my family members took me to the bada sarkari hospital in Udaipur. The doctor suggested an operation, and I got petrified. I was not sure if I would be able to manage heavy work again post-surgery. Since I do not have a Below Poverty Line (BPL) card, this operation would have involved a heavy out-of-pocket expenditure of some 30,000 rupees. These Sarkari doctors also prescribe expensive medications that have to be brought from outside; doctors these days have become greedy. I am the only earning member in my family; I cannot afford it, explained Munna Lal (Dewan, 2013).

The above quotes reveal an appreciation for biomedicine practitioners for their medicines and success in providing relief, but the community members equally assess their morality/ethics in practice. Overcharging and extracting money by prescribing excessive medicines are viewed as immoral practices. Both public and private practitioners are equally deprecated for their commercialisation of medical care. However, the criticism is more vigorous in the government personnel’s case due to the unethical commercialisation process. The community members also view this increasing commercialisation as the immorality of the present times. Priya (2012) also found the commercialisation of health care perceived as “immorality of the times” by a group of Dalit construction workers of the Tonk District in Rajasthan.

Vishwas Patients are appreciative of the therapeutic successes of the healers. However, their adharmi practices can often make people lose their trust (vishwas) in a healer, and trust plays a crucial role in choosing between different providers.

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We visit this temple because we have trust in this bhopa. He keeps niyam and follows the path of dharam niti, explained Munna Lal (a devotee) (Dewan, 2013). We trust this jaankar (vishwas hai), which is why we go to him; we have been using his services for many years. If we feel better with his/her davai, then we start trusting him. If his diagnosis is not proper, we stop going to him again and consider him a liar/fraud (woh jhutla hai). It is just like when we visit a doctor, and his treatment works, then we visit that doctor again, explained Jamna Bai (Dewan, 2013). I do not visit mutthi akha bhopas anymore because they charge lots of money, and the problem remains. These bhopas are not trustworthy; they give you the wrong diagnosis in order to extract money. I have instead started visiting a dargah in Kapasan, said Magan (a chronic pain patient) (Dewan, 2013). We visit this private doctor (biomedical practitioner) because we have trust (vishwas) in his medicines. He has been practising here for the last 15 years or so, explained Champa bai (Dewan, 2013).

The above quotes reveal that adherence to ethical codes like following niyam and following the path of truth can go a long way in building respect and honour. On the other hand, adharmi practices/traits like money mindedness, cheating people for money can often make people lose their trust (vishwas) in a healer/practitioner. For instance, mutthi akha bhopas are often distrusted for their adharmi traits. Since people are generally fearful of questioning the motivation and skills of these healers, they often display their discontentment by either criticising at their back or by discontinuing using their services. Similarly, the private practitioners have to win the vishwas of their rural clients by establishing a reputation of giving good medicines at affordable costs.

Discussion ‘Ethics’ and ‘morality’ of the healers are essential considerations for the Bhils in characterising and choosing between different healers; dharmi healers are preferred over the adharmi ones. As seen above, the content of ‘ethics’ might differ across different healing traditions. However, the following of niyam and accepting/demanding money/fees are important criteria that characterise the healers as dharmi or adharmi. The healers are deprecated for their adharmi practices/traits like money mindedness, untruthfulness and cheating. The same criteria may not ultimately transcribe allopathic practitioners, but they are also judged for their ‘ethical’ practices. They, too, are condemned by the community members for their unethical practices like overcharging and extracting money by prescribing excessive medicines. Priya (2012) also found the commercialisation of health care perceived as “immorality of the times” by a group of Dalit construction workers of the Tonk District in Rajasthan. Suppose money/fees is one such important criterion. In that case, a system with norms of pre-payment cannot garner the ‘trust’ of these communities, and ‘user fees’ can only further affect the ‘trust’ in public health facilities. Especially so when vishwas

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in a healer/system of medicine plays a crucial role in choosing between different healthcare providers. It is also pertinent to revisit the aspects like seva that the healers still value and practice in this small village. These include selfless service, dedication and nondenial of treatment, among others. These are otherwise undervalued and fast declining from the curriculum and practice of biomedicine and other medical traditions. The physicians produced by medical colleges (both biomedical and Unani Tibb) of today often forgo rural service and prioritise financial rewards and personal gains over older notions of seva is a testimony of this deterioration (Hardiman & Mukharji, 2012). It is crucial to see if this criterion of ‘ethics’ as understood by one of the most deprived sections can guide public health system and health services development policy. Priya (2012) points out that people’s perspective often gets ignored in operationalising policy initiatives like National Rural Health Mission (NRHM). She found that the local health tradition is given little attention under NRHM, while they are the most commensurate with Dalit workers’ perception of healthcare quality. It is thus vital to take cognisance of people’s perspectives and ‘effectively’ integrate or instead link LHTs in the policy initiatives like NRHM.

References Cohen, K. (2006). Honoring the medicine: The essential guide to native American healing. Ballantine Books. Desai, P. (1988). Medical ethics in India. The Journal of Medicine and Philosophy, 13, 231–255. Dewan, M. (2013). Chronic pain, healing and health care providers: Among Bhils in Ghodan Kalan Village of Udaipur District. Unpublished PhD thesis. New Delhi: Centre of Social Medicine and Community Health, Jawaharlal Nehru University. Dewan, M. (2017). Chronic pain and health seeking among the Bhils of Udaipur District. In B. Das & H. Siddalingappa (Eds.), Policies and practices: Assessing Indian tribal health system. Notion Press. Fabrega, H. (1990). An ethno-medical perspective on medical ethics. The Journal of Medicine and Philosophy, 15, 593–625. Government of India. (1991). Primary census abstract: Rajasthan. Registrar General and Census Commission. Government of India. (2001). Primary census abstract: Rajasthan. Registrar General and Census Commission. Hardiman, D., & Mukharji, P. B. (Eds.). (2012). Medical marginality in South Asia: Situating subaltern therapeutics. Routledge. Joshi, P. C. (2004). The world of tribal healers. In A. K. Kala & P. C. Joshi (Eds.), Tribal health and medicines. Concept Publishing Company. Kakar, S. (1986). Shamans mystics and doctors: A psychological inquiry into india and its healing traditions. Oxford University Press. Levey, M. (1967). Medical ethics of medieval islam with special reference to Al Ruhawi’s practical ethics of the physician. Transcultural American Philosophy Society, 57, 3–96. Mandir, S. (2013). Finding our own voice. Retrieved June 18, 2013, from http://www.sevamandir. org/wp-content/uploads/2011/03/Project-X.pdf Nichter, M. (1983). Paying for what ails you: Sociocultural issues influencing the ways and means of therapy payment in South India. Social Science and Medicine, 17(14), 957965.

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Priya, R. (2012). AYUSH and public health: Democratic pluralism and the quality of health services. In V. Sujatha & L. Abraham (Eds.), Medical pluralism in contemporary India. Orient Blackswan. Sujatha, V. (2009). The patient as a knower: Principle and practice in siddha medicine. Economic and Political Weekly, XLIV, 16, 76–83.

Part III

Revitalization and Integration of Tribal Medicine/Local Health Traditions and Intellectual Property Rights

Chapter 15

Systematic Documentation and Drug Development from Local Health Traditions (LHTs) and Ethnomedical Practices (EMPs): Challenges and Way Forward N. Srikanth and Sumeet Goel Abstract India is one among the countries that enjoy great antiquity of health practices imbibed into their daily lifestyle and culture backed by a strong base of its documented and/or in practice, traditional knowledge (TK). These traditional healthcare knowledge include systematically documented literature like treatise of Ayurveda, Siddha, etc., and also as supplementary health information in various non-medical works of literature, history books, journals, etc., while certain health traditions in vogue which are being conveyed from ancestors as Oral Health Traditions (OHTs.), ethnomedical practices (EMPs), remain largely undocumented or as personal diaries. Methodical documentation and scientific validation are essential for mainstreaming of LHTs prevailing across different ethnic communities and tribes in India. Various research institutes/Organisations are putting efforts to document and validate them, though the efforts are in silos. One such effort by Central Council for Research in Ayurvedic Sciences (CCRAS) is through two approaches, firstly Proactive approach, wherein the expert team approaches the community under various public health programmes like Tribal Health Care Research Program (THCRP) and Medico-Ethno Botanical Survey (MEBS) for identification of folk healers, direct interaction and documentation and secondly by Reactive approach, wherein a mechanism is made to invite folklore claims and its information directly by the practising community/individual and they are validated and taken forward for research after an MoU with the folk healer so to duly recognise and preserve his interest and benefits. After documentation, the claims are validated and depending upon their translation value and research potential through a structured, systemic approach; they are taken for Research and Development (R&D). In recent times, some promising TK has been taken forward by CCRAS, successfully for drug development (through quality, safety and toxicity studies) and thereafter for rigorous clinical study, like AYUSH D in Diabetes, C1 oil in wound healing and AYUSH A in N. Srikanth (B) · S. Goel Central Council for Research in Ayurvedic Sciences, Ministry of Ayush, Govt. of India, New Delhi 110058, India e-mail: [email protected] © The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023 S. Reddy et al. (eds.), Ethnomedicine and Tribal Healing Practices in India, People, Cultures and Societies: Exploring and Documenting Diversities, https://doi.org/10.1007/978-981-19-4286-0_15

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the management of Bronchial Asthma, etc. National networking for documentation of LHTs in a coordinated manner involving multiple agencies is essential for developing a centralised data bank. This would certainly facilitate for ready retrieval of information and besides avoiding duplication of work. Regulatory compliance of Drug and Cosmetic Act is imperative in drug development for translation of research into clinical practice. Keywords Ayurveda · AYUSH · CCRAS · Folk healers · LHT validation

Introduction The quest to attain and preserve the best possible health has always been one of the priorities since the dawn of mankind. This has led to a number of healthcare systems emerged and flourished across the globe. Civilizations/communities have developed practices to mitigate the disease and to promote better health, devising their own indigenous techniques and procedures through experiences and inter-cultural exchanges, and these are mostly based on their natural surroundings and locally available flora and fauna. Though in the Indian context, many of these practices have some common thought processes or fundamentals (Gupta et al., 2014). Local health traditions (LHTs), also known as folklore medicine, indigenous or traditional knowledge/wisdom (Fien, 2010), refer to the undocumented knowledge possessed by individuals or communities and are in vogue for generations in a particular area or community. It includes (but is not limited to) birth attendants (dais), bonesetters, herbal healers, poison specialists, Marma chikitsa experts (understanding and management through vital points in the body like acupressure) and faith healers. In addition, the knowledge on locally available medicinal plants possessed by household members and wisdom on lifestyle and diet imbibed in the culture of a particular community are also LHTs. Similarly, the term ethnomedicine or ethnoMedical Practices (EMPs) means the traditional healthcare methods based on indigenous cultural beliefs and practices based on a long history of experience and usage (Bhuyan, 2015). The mainstream formal system of health is still way behind in achieving health for all especially in developing countries; therefore, it looks tough to achieve optimum healthcare delivery alone by the healthcare systems working in silos, despite concerted national and international efforts. Even in resource-rich countries, holistic health is still a matter of pursuance, and the present formal healthcare system may not address it completely. Recognizing such difficulties, “the 67th World Health Assembly resolution on traditional medicine has been instrumental in developing the updated WHO Traditional Medicine Strategy (2014–23) with objectives to harness its contribution and promote effective use” (Rudra et al., 2017, p. 2; WHO, 2013). As per the national health policy 2002, under the Clause 1.4 (Ministry of Health & Family Welfare, 2002), the Indian Systems of Medicine have great potential to cater to the healthcare needs of a more significant section of the society owing to its

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accessibility, low cost, affordability and acceptance among a considerable proportion of the public. Ethnography is a crucial methodological lens in health policy and systems research for adequate documentation of LHTs and EMPs (Ahlin et al., 2016; Kielman, 2012; Pfeiffer & Nichter, 2008). The concept of ethnography or ethnobotany is even present in the classical treatises of Ayurveda; Charaka Samhita has emphasised having direct interaction with the persons who are well-informed with the proper use and identification of herbs for procuring ideal herbs for their medicine (Pandey & Chaturvedi, 2005). Sushruta Samhita also mentions that the physician should always seek information from the shepherds, cow herd and other foresters who lives in the particular forest area and are well-versed in identifying the right herb, so he could procure authentic herbs. Dalhana, the commentator of Sushruta, has also emphasised identifying plants from the tribal people (Jadavji Trikramji, 1997).

Need for Effective Documentation India’s vast traditional knowledge (TK), folklores and LHTs are gradually vanishing due to rapid socio-economic and cultural changes, lack of career opportunities in this field for younger generations, and continuous migration of local inhabitants to the urban areas. Therefore, documentation of TK is essential for the communities and future generations and scientific consideration and translation of this knowledge for the benefit of the public; further, the indigenous knowledge and rights of the tribes/communities also need to be secured. Adequate documentation is needed to conserve, protect and sustainably utilise our country’s rich traditional knowledge wealth. Effective regulatory mechanisms for fair benefit sharing while preserving the biodiversity and rights of the knowledge holder communities need to be evolved following a Sui generis system (Ekpere, 2002). Furthermore, the TK collected through documentation may be further validated and extensively studied for their scientific merits to translate them for the benefit of the common people at the grassroots (Arya et al., 2018). India is rich in traditional medicinal knowledge, and LHTs are still flourishing in various rural parts of India, though urbanisation and changed lifestyle resulted in a slow erosion of such knowledge rays. Strengthening of indigenous Materia medica: Updating the Indigenous system of medicine’s Materia Medica is a challenging task; it depends profoundly on the methodology adopted for collection of TK, local health traditions, folklores and their analysis and validation. Systemic documentation and validation of LHTs and EMPs could open great avenues towards new drug discoveries, identification of substitutes for already existing herbal medicines and unravelling the proper identification of herbs mentioned in classics Ayush books, etc. Documentation and study of the diverse Indian flora through ethnomedico-botanical survey studies can act as a bridge between codified Ayush systems and the vast TK in form of LHTs and Folklore (Shubhashree et al., 2017). Enriching Ayurveda, Siddha and Unani (ASU)

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drug pharmacopoeia through systematic absorption of folklore medicine through proper documentation and validation will certainly make avenues for the protection of ethnomedical heritage. Thus, India with a huge repository of such knowledge must collect and scientifically document this information to enrich its existing Pharmacopoeia. Documentation is reckoned necessary to check erosion of the traditional wisdom of folklores and EMPs, to prevent commercial exploitation of knowledge without due recognition to the healer and its community, to conserve the biodiversity by prevention of exploitation and non-sustainable use of the medicinal plants, to ensure health security to people in rural areas through mainstreaming of these LHTs and to realise greater public health potential through systematic documentation and validation of practices.

Challenges in Documentation of LHTs A number of individuals, government organisations and non-government organisations (NGOs) have made efforts in recording this knowledge. Enormous data has been collected, compiled and published in various journals and books. Yet, most of the researchers/scholars involved in documentation work lacks the clarity of objectives of documentation, the ethnobotanical/ethnomedical aspect of documentation. It is observed that the majority of such works only documents LHTs as some claims on medicinal plants, thus limiting the scope of such documentation and the knowledge holders/practitioners to mere informants from whom this data is collected, which could have little value left if to be taken further for validation and research studies. Such documents are mere a collection of plants and claimed remedies, which limits the scope of LHTs. These claims need to be documented as community-based health knowledge and not merely as botanic properties or nosology of some disease. There are framed methodologies for proper documentation of such knowledge, collection of herbs and their identification, what procedure they followed to diagnose the patient, how they prepared the medicine, when did they collect it, what lifestyle, the diet they prescribed along with it, etc. These are essential elements to make the documentation work comprehensive and worth taking forward for further studies. Thus, it is argued that documentation with data only on medicinal plants (in terms of botanical names, medical usage and their application) is only a part of it and should not be taken in silos without understanding the holistic view of the approach taken by the traditional healer in particular diseases management (Mishra & Nambiar 2018). This was a major concern in the documentation of LHTs as ethnobotanical works. CCRAS is documenting and studying such practices as it is in the setting the healers prescribe them so as to understand it in its true form and documents it comprehensively. They are doing the documentation work through its 18 research institutes spread across different parts of India (Central Council for Research in Ayurveda & Siddha, 1986, 1987, 1999, 2009).

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While planning the integration of LHTs within the primary health care, it will be important to preserve their person-centric holistic approach, which might wane off by just using them as claims for some disease to extract a new chemical entity from it to develop a new pharmaceutical drug, which will not yield its true potential, rather they may be integrated into Ayush systems while preserving their approach and holistic nature and should be brought in the mainstream as such after due scientific scrutiny (Dalal, 2014). This challenge may be addressed through inclusion of LHTs into codified traditional medical system of India, by incorporating them into ASU pharmacopoeia. India has a rich heritage of LHTs/folklore practices, a lot of anthropological literature, books, personal diaries, etc., are also there on it; still, there is a dearth of precise policy and regulatory level engagement with these non-codified TK systems and LHTs for healthcare systems. There is a need for more focus at the regulatory level to promote and support extensive documentation, research, and engagement with LHTs practitioners and such communities/tribes for proper assessment so that the benefits/knowledge of these tribal medicine/LHTs could be preserved and could be recognised. Such LHTs could be crude, and getting to the right person who knows it completely and genuinely is a challenging task for the scholars engaged in documentation; they might end up getting false claims. Still, a start on a larger scale needs to be made. A sense of trust needs to be inculcated among the tribal communities/folk healers for their support in an effective documentation of the folklore, so it can be conserved, by developing stringent rules for the beneficence of the folk healers and the community having the knowledge so they can be the real owner and beneficiary of the knowledge.

Systematic Documentation and Validation Studies by CCRAS Robust systematic documentation, scientific validation and its translation in public health are the crucial tasks for mainstreaming LHTs and TK prevalent across the world in different communities/ethnic groups; it will play a pivotal role in preserving the rich heritage of the traditional healthcare knowledge of the country. Several organisations/institutes are engaged in the documentation of LHTs through different approaches and methods in silos, which are lacking in one way or another. In this sequence, CCRAS has also developed a robust format for systematic documentation of LHTs/folklores. It includes documenting through direct interaction with the healer by visiting the place where they practice, documenting botanical/chemical/other biological sources of the medicine, their identification, method of preparation and use. They also capture photographs, videography of the whole procedure, etc. Additionally, for preliminary confirmation of the novelty of the LHTs, a study of already published literature/studies is also done. It helps understand the folklore claim, whether it is unique to the given community, documented earlier also and if so,

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similarities and differences in the documentation of the two and if any research study has been undertaken for this claim, etc. (Srikanth et al., 2017a). The major aspect of such documentation is a team comprising of an Ayurvedic doctor, who can appreciate and better understand the procedure and disease conditions where a particular claim is being used by the healer, he can observe the patients to whom treatment is given, can understand the approach, which are generally in accordance with Ayurveda fundamentals (as majority of the traditional systems of medicines including LHTs follows a common holistic approach) and a Botanist, who can identify the exact plant species, prepare a herbarium of the plant and preserve it for further validation. The documentation and validation work adopted by CCRAS is done with the following objectives “(i) Screening LHTs and folk claims collected under its different programmes (ii) Validation of the LHTs and folk claims, through a structured validation format (iii) Identification of the LHTs and folk claims pertaining to new indication of the plant already mentioned in Ayurveda literature and also therapeutic indication of a (plant) part mentioned other than in Classics for further scientific validation (iv) Publication of the LHTs and folk claims, which are not novel/found in classics” (CCRAS, 2018, p. 53). To realise this, CCRAS has been engaged in documenting and validating ethnomedicinal claims through Tribal Health Care Research Program (THCRP), Medico-Ethno Botanical Survey (MEBS) across 14 states (including 5 states) of the country (Central Council for Research in Ayurvedic Sciences, 2018). CCRAS has been documenting these health traditions principally in two ways: (a) the Proactive approach through the THCRP and MEBS, and (b) by appraising and taking forward the leads/information voluntarily provided by individuals through a Reactive approach (Detailed information generation tool for collection of claims has been published by the Council) (Srikanth et al., 2017b). These leads and knowledge are examined through a meticulous consultative process for their scientific merit to ascertain suitability for drug development through systematic studies. The plant, animal, marine mineral, or metal resources, formulations, practices associated with LHTs are collected, identified and preserved during surveys under the THRCP/MEBS or as provided by individuals/claimants. Subsequently, the information collected in the folk claims is examined for novelty and inimitability by confirming that they are not mentioned in codified texts by verifying select Ayurvedic literature which are listed under the first schedule of Drugs and Cosmetics (D&C) Act—1940 and Books on Ayurveda Materia Medica (Nighantu) Plant databases, Pharmacopoeia/Formularies of Siddha, Unani and Homoeopathy Systems of Medicine through by rigorous search, etc. Then these claims are categorised into different stages of validation. The unique claims which fall under Grade ‘A’ are put before different committees to ascertain their suitability to be undertaken for further scientific research and drug development based on scientific merit as per provisions of CCRAS—Research Policy and Drugs and Cosmetics Act 1940. Certain leads like C1 oil for wound healing, AYUSH D for diabetes mellitus and AYUSH A for bronchial asthma, etc., from the

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validated folklore claims are further taken for drug development through systematic quality assurance, safety/toxicity studies and clinical studies (Khanduri et al., 2018). CCRAS has set up an IPR and Business Development Cell to facilitate transfer of Technology, Commercialization and Benefit sharing of the products/medicines developed through such folklore and LHTs. The council has made clear provision of benefits sharing of such drugs which are developed and commercialised. Due care is taken for proper benefits and recognition of the healer who has provided the information. This ensures protection of the rights of the healer.

Protection of the Biodiversity While Documentation of LHTs and EMPs Prof. M. S. Swaminathan in 1992 (Swaminathan, 2019) has said that if we fail to conserve by sustainable use of our biodiversity (the wealth of flora and fauna and micro-organism), we may not be able to sustain the national food security system and may face adversaries of climate change. This notion equally stands true in terms of conservation of medicinal biodiversity. The growing herbal medicine market and an upsurge of LHTs documentation and developing new herbal medicines in pharmaceutical industries is causing a constant threat to the conservation of biodiversity; hence, a need is there to address challenges and way forward for the protection and conservation of the biodiversity, protection of Intellectual Property Rights (IPRs) of traditional knowledge, fair benefit sharing and the right of the folk healers/communities, etc. The Twelfth Five Year Plan document (2012–16) has emphasised bioprospecting and protection against biopiracy and has bolstered the need for proper documentation of traditional healthcare knowledge based on our rich biological diversity. Numerous measures have been taken in this regard, including the formation of National Medicinal Plants Board (presently under Ministry of AYUSH) and State Biodiversity Boards (both in 2000) in India, also various institutional setups at the international level like Medicinal Plants Conservation Network (of NGOs, state forest departments, academic institutes, etc.) in 1993, Convention on Biological Diversity in 1992 and the World Intellectual Property Organization (WIPO) in 2000, etc. Their primary focus is on addressing various challenges towards protecting traditional medical knowledge and the conservation and sustainable use of biodiversity. (Unnikrishnan & Suneetha, 2012) Sustained use of biodiversity and its conservation while mainstreaming the LHTs has been advocated at many international discussion forums and documents, including the WHO resolution at World Health Assembly in 2003. The National Medicinal Plants Board (NMPB) under Ministry of AYUSH works (in coordination with a network of State Medicinal Plant Boards under respective states) to coordinate activities relating to conservation, marketing, developing linkages between farmers and industries, policy work for the development of the medicinal plants’ sector which includes preservation of biodiversity, protecting the rights

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of the farmers and communities engaged in cultivation. The new initiative by NMPB, i.e. “e-Charak”, is an online platform for medicinal plants which provides an interface for the exchange of information among stakeholders like industries, farmers, etc., working in medicinal plants. The e-Charak platform was jointly developed by the NMPB Ministry of AYUSH, Government of India and Centre for Development of Advanced Computing (C-DAC) Pune. It will provide a platform for the farmers to sell their medicines directly to the industry and also will promote production and cultivation of medicinal plants, thus conserving them. However, efforts need to be made to bring and sensitise the farmers towards this initiative. Further, NMPB also supports Joint Forest Management Committees (JFMC) Panchayats, Van Panchayats, etc., for the setting of a local cluster for managing raw herbs through their proper storage, drying, warehousing and promoting marketing infrastructure. JFMC work for sustainable forest management with the help of community participation. It is a mutual management mechanism that involves local communities/tribes living in the forest and forest department to improve their livelihood and decreasing their dependency on the forest, thus leading to conservation and protection of forest areas in a sustainable way. Apart from this, research and training on various aspects of medicinal plants are also a part of this initiative which will help in long-term conservation of biodiversity and thus EMPs (National Medicinal Plants Board, 2019). Further, a sustainable forest plan needs to be prepared for extraction of the plant products; i.e. how many leaves/flowers of particular area to be extracted so that the regeneration is not affected.

Way Forward National Networking for Documentation of LHTs and EMPs (NNDL) National networking for centralised documentation of LHTs and EMPs needs to be set up in India. Several organisations like CCRAS, Council of Scientific & Industrial Research (CSIR), National Innovation Foundation (NIF), Division of Ethnomedicine & Ethnopharmacology (Jawaharlal Nehru Tropical Botanic Garden and Research Institute—JNTBGRI) and Foundation for Revitalization of Local Health Traditions (FRLHT) and National Institute of Traditional Medicine (NITM– ICMR) Belagavi are working in silos for documentation, study and validation of LHTs. National coordinating network for documentation of LHTs and EMPs and harmonisation of the data is needed for its uniform documentation. Different organisations/institutions are adopting diverse approaches for documentation, and further study of these leads to bringing them into clinical use. A common approach majority of such institutions are adopting is reductionist; i.e. their efforts are more focused on isolation, fragmentation, etc., of the plant materials to extract some new chemical entities, which is proving to be a futile exercise and is not propagating

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the holistic view of the LHTs neither preserving it. Besides this, such disorganised efforts by many stakeholders in silos are leading to depletion of the resources and also duplication of work. Thus, it is imperative to set up a centrally coordinated mechanism for adequate documentation and scientific validation of LHTs through translational research by an interdisciplinary team while preserving their holistic approach and taking care of the rights of the folk healer/community and the biodiversity. This may preferably be a Govt. Research organisations/institutes (to avoid conflict of interest) like North Eastern Institute of Ayurveda & Folk Medicine Research (NEIAFMR) or NMPB as a central nodal point for coordination of national networking of LHTs and EMPs. Further, an effective mechanism of stringent documentation and holistic approach for the development of drug from the leads of LHTs through ASU drug regulatory mechanism need to be developed and centralised coordination and networking for information management on LHTs for preparation of national database like Traditional Knowledge Digital Library (TKDL). Suggested team for documentation work: Through national networking among various research organisations, universities and other stakeholders, a comprehensive team comprising of an Ayurveda expert (for effective recording of the claim in its true sense), an anthropologist (to understand their culture, lifestyle, social values associated with the folk healer), a botanist (for proper identification of the herbs used by the healer, preparation of herbarium and specimen collection) and a linguistic person (who understands the culture and language of the community from where the data is to be collected). This will ensure proper data collection. This will also help in better understanding of socio-cultural background, ethics, medical practices, plant identification/collection/storage methods adopted by traditional/folk healers. Data collection tool: A uniform documentation protocol may further be developed taking leads from already existing documentation formats as used by various organisations, which may be in two parts one short format for preliminary data collection and after primary screening a detailed format for complete data collection may be prepared. This will further ensure uniform data collection across documentation work and then a uniform centralised database may be created which can serve as a centralised pool of information, further a coordinated research work for documentation, validation and drug development may be taken up with engagement of PhD scholars from different disciplines like Ayurveda, botany, pharmacology, as a part of this national networking. Building trust among the folk healers: The most important task is to develop a sense of trust among the healers and the communities, the team for documentation needs to be in continuous contact with the folk healers to develop that trust and to collect proper information. Stringent rules for beneficence and non-maleficence of the community need to be ensured. Proper ethical guidelines in this regard may be framed. While documentation of LHTs proper informed consent in the language, the healer can understand should be taken before initiating the process of documentation, thereafter during the validation phase and drug development phase (if it is done), and the healer should be made a part of all the drug development process. The healers and the community should also be trained simultaneously for sustainable use of the

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medicinal plants and effective techniques for their cultivation. The “Herbs for All and Health for All” objective of Division of Ethnomedicine & Ethnopharmacology (Jawaharlal Nehru Tropical Botanic Garden and Research Institute—JNTBGRI)(About— JNTBGRI, 2018) is a novel concept which can be adapted for sustainable use of herbs and promoting herbal gardens and medicinal plant cultivation in PHCs for promotion of its use as primary care. Protection of novel claims: Sometimes the documentation works of LHTs, ethnobotany, ethnomedicine, etc., have been published, without checking for their uniqueness and as such it renders those claims open for exploitation and without proper validation and patent the rights of the healer may be jeopardised, and hence, all these documentation work need to be validated for uniqueness and novel claims should be preserved and protected before bringing them to the marker after proper drug development and patent, to protect the rights of the healers and its community. Further, a mechanism needs to be developed for identification of right beneficiary of the claim; either it is an individual or the community as a whole. Inclusion in ASU pharmacopoeia: Further, those which are novel claims, the medicinal plants of which are not mentioned in scheduled books of Drug & Cosmetic (D&C) Rule, which falls in CCRAS validation grade A (categories 1 and 2), it becomes difficult to develop drug and take licence for them, because of this the science may vanish, it is the need of the hour to introduce these claims in ASU Pharmacopoeia suitably after taking necessary steps for ensuring its quality, safety and efficacy. This also calls for certain amendments in the D&C act in schedule 158 (b) to make necessary provisions to validate and licence these medicinal plants under ASU pharmacopoeia. To formalise the national network, the Ministry of AYUSH, Government of India may conduct high-level inter-ministerial consultation involving, Ministry of Environment, Forest and Climate Change, Ministry of Tribal Affairs, Ministry of Law and Justice, Ministry of Health & Family Welfare, etc., and other stakeholders such as Botanical Survey of India, Zoological Survey of India, Department of Science and Technology, Department of Biotechnology, Indian Council of Medical Research, Council of Scientific & Industrial Research, National Biodiversity boards, Academic Institutions, Universities and other representatives from NGOs working with similar mandates and objectives. Further, a national steering committee may be set up to oversee and monitor the activities of national network. A Scientific Committee/Scientific Board may be set up to offer technical advises from time to time, also national guidelines need to be framed and published for coordination documentation and scientific validation and studies of LHTs, folklore medicine and EMPs with core components focusing on ethical consideration, social aspects, scientific and technical issues, IPR protection, benefit sharing, biodiversity and ecological aspects, a short-term training course for qualified Ayush professional/Ethnobotanists and Social workers/anthropologist to be engaged in interaction with healers, collection, documentation, validation and studies of LHTs, folklore medicines and EMPs may also be visualised.

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Conclusion Recent policy developments like national health policy 2017 have envisaged the promotion of traditional healthcare systems, including LHTs, in strengthening primary health care; however, to realise it and tap the potential of traditional medicine and LHTs, a lot has to be done. It is even crucial for developing nations like India, which have well-codified, regulated AYUSH systems, and is rich in LHTs and achieving health for all is a daunting task for the mainstream healthcare system alone (Mishra et al., 2018). It is high time for more extensive work for documentation and revitalization of the LHTs and Folklore from different parts of the country and works towards bringing them to the mainstream by integrating them with AYUSH and then to the public health initiatives of the government. This will answer the important question of public acceptance as also studied in Meghalaya State of India (Albert & Porter, 2015), such indigenous LHTs are popular among public especially in rural dwelling where the need of integration and pluralism is very important for providing better primary healthcare services. Further, the documentation and study of LHTs as done by CCRAS will ensure protection of this knowledge and will help in opening new dimension of healthcare services in India. Validation of local health traditions is vital to revitalise, promote and harness local health traditions, for this systematic documentation of LHTs need to be done through a centrally coordinated system following a uniform documentation strategy. The procedure adopted by CCRAS and other such organisations like FRLHT, NIF and JNTBGRI, Kerala may play a pivotal role in systematic documentation of folk claims and LHTs further systematic approach for validation and study of these herbs under various LHTs claims need to be studied for absorption of these medicine in ASU pharmacopoeia as extra pharmacopoeia drugs, thus enriching the documented traditional system of medicine in India. This will help in providing legislative stature to the LHTs and will help in bringing them to the mainstream for use among masses.

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Central Council for Research in Ayurvedic Sciences. (2018). Ayurveda—A Focus on Research and Development. Fifty Years of Transforming Research and Development in Ayurveda (1969–2018). Central Council for Research in Ayurvedic Sciences Ministry of Ayush, Government of India. Central Council for Research in Ayurveda & Siddha* . (1986). Ayurveda the Science of Life: A Profile and Focus on Research and Development. Central Council for Research in Ayurveda & Siddha, Union Ministry of Health and Family Welfare, Government of India. (* Now: Central Council for Research in Ayurvedic Sciences). Central Council for Research in Ayurveda & Siddha* . (1987). Study of Health Statistics under Mobile Clinical Research Program. Central Council for Research in Ayurveda & Siddha, Department of AYUSH, Ministry of Health and Family Welfare, Government of India. (* Now: Central Council for Research in Ayurvedic Sciences). Central Council for Research in Ayurveda & Siddha* . (1999). An Appraisal of Tribal-Folk Medicines. Central Council for Research in Ayurveda & Siddha, Department of AYUSH, Ministry of Health and Family Welfare, Government of India. (* Now: Central Council for Research in Ayurvedic Sciences). Central Council for Research in Ayurveda & Siddha* . (2009). Management of Chikungunya through Ayurveda and Siddha: A Technical Report. Central Council for Research in Ayurveda & Siddha, Department of AYUSH, Ministry of Health and Family Welfare, Government of India. Dalal, A. K. (2014). Salience of indigenous healing practices for health care programmes in India. In R. C. Tripathi & Y. Sinha (Eds.), Psychology, Development and Social Policy in India (pp. 193– 209). Springer India. https://doi.org/10.1007/978-81-322-1003-0_10 Ekpere, J. A. (2002). “Sui Generis” Systems: The Case of the “OAU Model Law on the Protection of the Rights of Local Communities, Farmers and Breeders and for the Regulation of Access to Biological Resources”. Paper presented at the International Seminar on Systems for the Protection of Traditional Knowledge, New Delhi, April 3–5. Fien, J. (2010). Indigenous knowledge & sustainability. Teaching and learning for a sustainable future. http://www.unesco.org/education/tlsf/mods/theme_c/mod11.html. Accessed August 23, 2019. Gupta, P., Sharma, V. K., & Sharma, S. (2014). Healing Traditions of the North Western Himalayas (Springer Briefs in Environmental Science). Springer. Jadavji Trikramji, A. (1997). Bhumipravibhag Vigyaniya Adhyaya, Verse 10. In Sushruta Samhita of Sushruta with the Nibandhasamgraha Commentary of Dalhan (6th ed., p. 159). Chaukhamba Orientalia. JNTBGRI. (2018). About—Jawaharlal Nehru Tropical Botanic Garden and Research Institute. Jntbgri.res.in. http://jntbgri.res.in/index.php/research/ethnomedicine-andethno-pharmacol ogy/about-ethno. Accessed August 23, 2019. Khanduri, S., Sharma Bhagwan, S., Sumeet, G., Rao, B. C. S., Maheshwar, T., Arjun, S., Chinmay, R., Gaidhani Sudesh, N., & Srikanth, N. (2018). Drug development select diseases: A short appraisal of CCRAS and R and D initiatives. Journal of Drug Research in Ayurvedic Sciences, 3(2), 128–132. Kielman, K. (2012). The ethnographic lens. In L. Gilson (Ed.), Health Policy and System Research: A Methodology Reader (pp. 235–352). Alliance for Health Policy and Systems Research, World Health Organization. Ministry of Health and Family Welfare. (2002). National Policy on Indian Systems of Medicine & Homoeopathy. New Delhi. http://ayush.gov.in/sites/default/files/7870046089-Ayush%20%20n% 20policy%20ISM%20and%20H%20Homeopathy0.pdf Mishra, A., & Nambiar, D. (2018). On the unraveling of ‘revitalization of local health traditions’ in India: An ethnographic inquiry. International Journal for Equity in Health, 17(175), 1–12. https://doi.org/10.1186/s12939-018-0890-1 Mishra, A., Nambiar, D., & Madhavan, H. (2018). The making of ‘local health traditions’ in India. Economic & Political Weekly, 53(30), 41–49. National Medicinal Plants Board. (2019). Nmpb.Nic.in. https://www.nmpb.nic.in/. Accessed August 26, 2019.

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Pandey, K., & Chaturvedi, G. (2005). Dirghanjivitiya Adhyaya, Verse 121. In Caraka Samhita of Agnivesh Revised by Caraka and Dridabala with Elaborated Vidyotini Hindi Commentary, Part 1 (p. 47). Chaukhamba Bharati Academy. Pfeiffer, J., & Nichter, M. (2008). What can critical medical anthropology contribute to global health? A health systems perspective. Medical Anthropology Quarterly. https://doi.org/10.1111/ j.1548-1387.2008.00041.x. Rudra, S., Kalra, A., Kumar, A., & Joe, W. (2017). Utilization of alternative systems of medicine as health care services in India: Evidence on AYUSH care from NSS 2014. PLoS ONE, 12(5), e0176916. https://doi.org/10.1371/journal.pone.0176916 Shubhashree, M. N., Rao, V. R., Mathapati, S., Naik, R., & Bhat, S. (2017). Role of ethnomedicobotanical survey in advancement of ayurveda. Journal of Drug Research in Ayurvedic Sciences, 2(4), 301–305. Srikanth, N., Maheswar, T., & Singh, S. (2017a). Methodical documentation of local health traditions and folklore claims: Scope, relevance and suggested format. Journal of Drug Research in Ayurvedic Sciences, 2(2), 149–155. Srikanth, N., Maheswar, T., Sunita, Tripathi, A. K., Rath, C., Khanduri, S., Sharma, M. M., Sahi, V. K., Singh, S., Mangal, A. K., & Gaidhani, S. N. (2017b). Generation of basic information on claims pertaining to local health traditions, oral health traditions, and ethnomedical practices for validation: An elective pro forma for documentation by individuals. Journal of Drug Research in Ayurvedic Sciences, 2(4), 306–311. Swaminathan, M. S. (2019). Research foundation (2019) Overview of the Programme [Online]. Available at: https://www.mssrf.org/content/overview-programme. Accessed August 20, 2019. Unnikrishnan, P. M., & Suneetha, M. S. (2012). Biodiversity, Traditional Knowledge and Community Health: Strengthening Linkages. Xpress Pte Ltd. World Health Organization. (2013). WHO Traditional Medicine Strategy: 2014–2023. WHO

Chapter 16

Climate Change and Protection of Traditional Ethnomedical Knowledge in India: A Critical Socio-Legal Reappraisal David Pradhan and Alok Kumar Patra Abstract The communitarian ethnomedicinal traditional knowledge systems comprise an essential component of indigenous culture, faith and identity. While indigenous ethnomedicinal traditional knowledge systems promise to revolutionise modern medicine, the bioresources of these medicinal systems are increasingly at threat due to climate change and inadequate legal protection of indigenous communities’ traditional knowledge. Based on secondary sources, this paper attempts to critically analyse the existing legal mechanisms to ensure more significant and more equitable protection of traditional knowledge of indigenous communities in India. It also attempts to reform the revelatory foundation and existing conceptual and normative framework to locate international and supranational principles and national legal procedures with the local praxis. This sociological jurisprudential analysis argues for transforming the present predominantly commercial approach of the Intellectual Property Laws to a more communitarian cultural rights-based and envisioning greater protection to tangible bioresources and intangible indigenous ethnomedical traditional knowledge and also for preservation against climate change-related environmental and socio-cultural disruption. Keywords Climate change · Biodiversity · Intellectual property laws · Traditional knowledge · Indigenous ethnomedicine

D. Pradhan (B) School of International Studies, Jawaharlal Nehru University, New Delhi, India e-mail: [email protected] A. K. Patra Assistant Professor, Kalinga Institute of Industrial Technology, Bhubaneswar, Orissa, India © The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023 S. Reddy et al. (eds.), Ethnomedicine and Tribal Healing Practices in India, People, Cultures and Societies: Exploring and Documenting Diversities, https://doi.org/10.1007/978-981-19-4286-0_16

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Introduction There is increasing scientific consensus on the correlation between anthropogenic global warming-induced climate change, caused primarily by emissions from developed countries, and its deleterious impact on human health and environmental ecosystems. Critical engagements linking economy, environment and society have brought to the fore the exclusionary nature of the climate change discourse about intra-state, inter-generational and socio-economic equity (Walker & Bulkeley, 2006, p. 657). India’s indecisive and uncoordinated climate change policies reflect that its comprehension of the issue is limited primarily to its anxieties about the equity of interstate emissions and its economic development. The lack of a domestic discourse on climate justice reveals the extraordinary asymmetry of economic and socio-political power embedded in Indian society and demonstrates an equitable law related to climate change (Harvey, 1996, p. 401). A focus on the inadequacies of the contemporary International and Indian legal regimes to address protection of traditional knowledge, especially related to ethnomedicinal resources of indigenous communities, confronting predicted global climatic change is the desideratum. This chapter analyses the prevailing Indian legal regime on the protection of bioresources and traditional knowledge of ethnomedicinal practises, especially among the indigenous communities (Scheduled Tribes), contextualises it to climate change and critically examines how existing inadequacies in law and policy can be addressed to build ecological and biocultural resilience of communities against climate change-induced health hazards. As referred to in this chapter, indigenous ethnomedicine does not include and is distinct from the codified Indian Medical Systems, regulated by the Ministry of AYUSH of the Government of India.

Indigenous Culture, Ethnomedicine and Climate Change There is a clear and unassailable scientific certainty about anthropogenic climate change and its adverse implications on global environmental ecosystems and the health of humans associated with such ecosystems (Field et al., 2012). While there have been international efforts to address the issue of global warming, which causes climate change, the recalcitrance of the developed world, which contributes the bulk of the greenhouse gases, makes it rather unlikely that there will be an expeditious resolution (Smith et al., 2014). Climatic factors such as changes in temperatures, extreme weather events like storms and cyclones, alterations in range, seasonality and quantum of precipitation can significantly increase the vulnerability of human populations to disease through exposure to pathogens and vectors. In contrast, changes in rainfall-sensitive agricultural production can induce changes in traditional diets, causing malnutrition or obesity-related diseases (Lloyd et al., 2011). It has been estimated that unless mitigated, by 2030, climate change could increase the number of extremely poor by another one hundred million people (Hallegatte et al.,

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2016). Climate change-induced health hazards are expected to disproportionately increase the vulnerability of socio-culturally or geographically segregated indigenous communities given their ubiquitous lack of access to modern medicine and the risk to the bioresources that are constitutive of their indigenous ethnomedicinal systems. The costs associated with effectively and universally provisioning modern health care to mitigate the health impacts associated with climate change are predicted to be prohibitive and economically impracticable (Pandey, 2010). However, the links between climate variability, ecological change and human health are seldom so linear but usually convoluted and indirect, being influenced by social, economic and geographic human factors. Poverty, social marginalisation, geographic isolation, religious and cultural taboos, practices and government intervention and policies can either ameliorate or exacerbate the effects of changing weather patterns or altered environmental conditions on health in human societies (Liu et al., 2015). The World Health Organization defines health as “a state of complete physical, mental and social well-being, not merely the absence of disease or infirmity” (Constitution of the WHO, 1946). The inclusion of social well-being as a component of health by the WHO attests to the importance of culture in medicinal practises, especially in ‘ethnomedicine’, which is defined as “beliefs and practises relating to disease which is the product of indigenous cultural development” (Foster, 1986 cited in Rajasekharan, S. and Latha, P.G. (2008)). At the same time, the general perception is that India’s cost and inadequate penetration of the modern medical, institutional system force people to resort to traditional medicine. Some scholars have proven with empirical studies-based evidence that there are multiple variables for the preference for traditional medicine prevailing over modern medicine, such as access to plural medical systems, cultural beliefs and influences, anecdotal references and lived experiences of comparatively assessed efficacy of the folk remedies (Sujatha & Abraham, 2012, pp. 28–29). The indigenous people usually perceive traditional knowledge as an essential component of their religion–cultural identity (Noble, 2009). Spiritual powers are often ascribed to the associated endemic pharmaco-botanical resources, and indigenous ethnomedicinal traditional knowledge is usually closely guarded as sacred or divine wisdom of supernatural origin, to be imparted only to worthy initiates rather than a publication for pecuniary gain (Kipuri, 2009). The indigenous ethnomedicinal traditional knowledge forms the basis of their process of ‘knowing’ the world in a matrix that creates sense and is real, rational and scientific to them in their perception (Berkes, 2009). The difference in the concepts, values, institutions and norms in indigenous societies extends to notions of the proprietorial nature of indigenous traditional knowledge (Carpenter et al., 2009). Generally, it is not personally owned in the legal sense of individual intellectual property by the holder but can be described more aptly as a “shared property in commons” being held in trust by the holder for the community (Amankwah, 2007; Helfer & Austin, 2011), regulated by customary norms for appropriate use, and inextricably attached with rituals and symbolism (Thom & Bain, 2004). The ascription of symbolic personification or religio-cultural significance to the environment by the indigenous is a crucial difference in their perception of environment, nature and biodiversity from others,

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including scientists (Infield, 2001). The organic and symbiotic link between indigenous communities and conservation of biodiversity, habitats, nature and environment has created indigenous cultural practices defined by religious notions of sacred and taboo, and consequential reserves of local biodiversity preservation from the bioresources for ethnomedicine are sourced (Laird, 2019). Indigenous ethnomedicinal traditional knowledge is often based on endemic resources and ritualised symbolism, the meaning of which may be lost upon those from outside the community with different social or legal contexts (Hardison & Bannister, 2011). Globalisation has now integrated economies and the problems, predominant among which are climate change-induced destruction of biodiversity due to the socio-economic changes in societies across the world (Wood et al., 2000). Indigenous ethnomedicinal traditional knowledge is an invaluable resource for research and development of modern medicine, but one, which is itself under increasing threat of ‘imminent destruction’ (Motte-Florac & Ramos-Elorduy, 2002, p. 210) due to deforestation, biodiversity erosion, invasive species and climate change. The cost of loss of even marginal loss of biodiversity resources in terms of pharmacological development has been estimated to be billions of dollars (Farnsworth & Soejarto, 1985). There is an urgent need to preserve and conserve the bioresources constituting the pharmaco-botanical base of traditional knowledge of ethnomedicine for its potential as the unexplored cornucopia of phytopharmacological compounds for modern medical research. Access to indigenous ethnomedicinal traditional knowledge, ethnobotanical studies for identifying plants with medicinally bioactive compounds and the pharmacological synthesis of these compounds within the laboratory can be anticipated. However, industrial production of identified phytopharmacological bioactive compounds can have the effect of rendering the source bioresources dispensable, reducing motivation for the protection of biodiversity and indirectly threatening indigenous culture. The role that indigenous culture and practices play in the preservation of biodiversity is well documented (Berkes, 2009; Ghai, 1994), and extensive studies have established that indigenous traditional knowledge can help in a non-intrusive and ecologically sustainable adaptation to climate change and preservation of biodiversity (Clements et al., 2011). Scholars note that indigenous norms and values play a crucial role in protecting endemic ecosystems by the local community. Such norms and values motivated the community to ensure food security, exercise local economic and cultural autonomy and religious considerations or preserve the ancestral lands’ lifestyle (Langton & Rhea, 2005; Laird, 2019, p. 352). In contrast, industrial societies have no emotive connection with a tangible ecosystem and are less inclined to feel the need to use an ecosystem sustainably or to protect a particular commercial or non-commercial resource (Milton, 1996). The relationship between biodiversity and human society is even more pronounced in the case of indigenous communities leading to the academic acknowledgement of a non-hierarchical human biocultural diversity (Posey, 1999, p. 3). The different communities and cultures perceive nature, biodiversity, health, well-being and medicinal systems based on their own biocultural contextual experiences, which represent (equally valid) world views of human societal understanding and interaction with

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the environment, which offers a diverse range of future possibilities for the growth of human societies (Milton, 1996; Posey, 1999). These cultural diversities in human societies can, in turn, envelop different practises for biodiversity conservation, which can help ensure survival, even if some methods fail (McNeely, 2000). The fact remains that in most industrialised societies, the indigenous communities are marginalised, and indigeneity itself conjures images of backwardness and savagery due to cultural stereotyping resulting in a dismissive lack of sensitivity towards deeply cherished indigenous beliefs (Posey, 1999, p. 3). India has a rich culture of indigenous ethnomedicinal traditional knowledge (Arora, 2006), and there have been cases of attempts at biopiracy of the traditional knowledge of indigenous communities (Bhutani & Kothari, 2002, p. 92). It is, therefore, hardly surprising that indigenous communities are often reluctant to share their traditional knowledge due to fears of misappropriation, misuse or disrespect to sacred aspects of their culture embodied therein (Yu, 2003). The limited success of legal measures for biodiversity conservation and concerns about the rapid depletion of the bioresources of indigenous ethnomedicinal traditional knowledge have endangered its recognition as an essential biological, ecological, economic, social and cultural resource for communities, crucial for the survival of future generations (Cunningham, 2001; Maffi, 2001). Moreover, laws can be structurally elitist, condescendingly patronising and participatory exclusive and have a democratic deficit, consequently failing to address integral issues such as geographical isolation, power asymmetries, economic inequalities and social disparities inherent in societies, which severely attenuate the indigenous communities access to legal remedies even in case of biopiracy (Hill et al., 2012). Therefore, social adaptation and exploration of existing and accepted ethnomedical systems constitute the most viable measure undertaken by developing countries in the interim, especially for the indigenous communities who have a rich traditional knowledge of ethnobotanical pharmacology associated with their environment. To ensure the inclusive development, preservation of indigenous communities’ culture and its associated bioresources, there is a necessity to legislate and promulgate laws for the design and implementation of culturally sensitive policies for the protection of the tangible biodiversity and the intangible traditional knowledge of indigenous ethnomedicinal systems, from the vagaries of climate change.

The Indian Legal Framework for the Protection of Traditional Knowledge India is a state of sub-continental proportions inhabited by different civilisations since antiquity. It is also one of the twelve mega-diverse regions of the world with a rich biodiversity of flora and fauna. Many indigenous communities have been living in autonomous self-sufficiency in these biodiverse forested regions in complete harmony with nature. While India does not recognise any community de jure as ‘indigenous’, the Scheduled Tribes, defined in Article 366 (25) of the Constitution

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of India, fall within the ambit of ‘indigenous’ as envisaged by the International Work Group for Indigenous Affairs. They possess the Ministry of Tribal Affairs specified community traits of distinctive culture, geographical isolation, shyness of contact with non-tribals and primitive backwardness. The tribals of India are de facto acknowledged to be the ‘indigenous people’. The intimate relation between the tribals and the forests they live in is exemplified by the non-codified but remarkably sophisticated living traditions of indigenous ethnomedicinal practices, based on endemic bioresources for fairly effective treatment of a variety of ailments. This rich repository of practical biocultural knowledge, preserved inter-generationally primarily through oral traditions and/or socio-ecological and religio-cultural norms, values and practices, among others, constitutes the indigenous ethnomedicinal traditional knowledge of the tribal communities of India (Warren, 1992). Traditional knowledge is a concept easy to conceptualise but difficult to define statutorily. There is no strict legal definition of the term. Article 8 (j) of the Convention of Biological Diversity, 1992 (CBD) provides the basic International normative legal framework for the protection of “…knowledge of…indigenous and local communities …”. It refers to indigenous traditional knowledge but does not define it. Article 12(1) of the Nagoya Protocol on access and benefit sharing to the Convention on Biodiversity, 2010 (Nagoya Protocol) explicates the role of indigenous traditional knowledge and local customary laws in its supranational recommendations for incorporation in procedural mechanisms while designing domestic laws, policy frameworks, compliance mechanisms and procedures, but does not explicitly demarcate or define the term or its content. However, it suggests consultative documentation of the core values and norms of the indigenous communities in the form of Community Protocols for regulation of disclosure of indigenous traditional knowledge, equitable access to the profits from the utilisation of resources and their sustainable management. Article 12 (2) of the Nagoya Protocol mandates non-derogatory obligations on the state to inform third party end-users of indigenous traditional knowledge about, and ensure compliance with, International ethical standards by the third parties when dealing with the intellectual holders of the indigenous traditional knowledge. Article 12 (4) further suggests that the domestic laws establish prohibitions on any restrictions or violations of customary uses or exchanges of the indigenous traditional knowledge holders. The recommendations of the CBD and the Nagoya Protocol notwithstanding, India has no specific legal framework for the complete protection of indigenous traditional knowledge. Instead, a mosaic of provisions from different laws is patched together to provide a modicum of protection to indigenous traditional knowledge and the bioresources it is based on. The legal protection of indigenous traditional knowledge, especially for non-codified and unorganised indigenous ethnomedical biocultural practices dependent on local bioresources, is somewhat haphazard. While there is recognition for, and a systematic attempt at preservation, thorough documentation of the ethnobotanical materia medica of the codified Indian Systems of Medicines (ISM) like Ayurveda, Naturopathy, Unani, Siddha and Homoeopathy through Institutional mechanisms like the Ministry of AYUSH funded, and Council for Scientific and Industrial Research (CSIR) administered, Traditional Knowledge Digital

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Library (TKDL). A similar system for recognition, documentation and preservation of the non-codified indigenous ethnomedical indigenous traditional knowledge and the protection of the biocultural resources is still lacking in India. Once the indigenous ethnomedicinal traditional knowledge is severed from the indigenous social practises and customary laws of the indigenous community and regarded solely through the lens of Intellectual Property Law, it risks commodification and poses a threat of loss of associated ritual and customary symbolism as hallowed spiritual, cultural heritage associated with the identity of the indigenous community (Riley, 2005). Intellectual Property Laws have provisions against appropriation and unfair use, but hurdles such as lack of access to information, expertise and legal representation make protecting indigenous communities’ rights from unfair exploitation of their traditional knowledge difficult (McManis & Terán, 2001; Overwalle, 2005). India follows the legal doctrine of dualism, and an international treaty entered into by India cannot become the law of the land unless the Parliament passes a statute under Article 253 of the Constitution of India (West Bengal v Kesoram Industries.1 ), which authorises only the Parliament of India to enact laws for the implementation of International Laws and Treaties alluded to in Article 51 (c), which directs the state to endeavour to foster respect for international law and treaty obligations (Jolly George Varghese v Bank of Cochin2 ). However, Article 73 vests the executive branch of the Government of India to make policies matters on subjects falling within the legislative competence of the Parliament of India. Despite being a signatory to, and ratifying, many International Conventions on Climate Change, including the Paris Agreement, 2015, India has not enacted any statute, and the Indian policy framework for mitigating and addressing climate change is a loose aggregation of discrete laws. The federal structure of India and the demarcation of legislative competence of the Federal Parliament and the provincial legislatures on subjects and in list three of the seventh schedule of the Constitution of India, which affect climate change, further complicate the situation of allocation of authority and apportionment of responsibility. This has created an ambiguous situation about implementing climate changerelated policy in India (Jörgensen et al., 2015). The impact on future generations due to the failure of the Indian Government to frame and implement climate change laws has been challenged in the sub-judice case Ridhima Pandey v Union of India (2017). The indigenous communities most vulnerable to climate change must be stakeholders in climate change-related policymaking and legal implementation since their indigenous traditional knowledge can play a crucial role in adaptive management and the restoration of the environment (Parrotta & Agnoletti, 2007). The legal protection of indigenous, therefore, ought to be a priority for India. Although India has a rich, diverse and specialised corpus of non-codified ethnomedicinal and home remedy traditions preserved in the indigenous communities inter-generationally through oral transmission and training of practitioners

1 2

(2004) 266 Income Taxes Reporter 0721. (1980) All India Reporter 470.

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(Sulochana et al. 2003, p. 58), contemporary protection of indigenous ethnomedicinal traditional knowledge in India is being effectuated through the national Intellectual Property Law Regime rather than a dedicated sui generis legal system devised by taking into account the unique characteristics of indigenous traditional knowledge. Similarly, the protection of the biocultural resources is being administered generically through provisions of the Biological Diversity Act, 2002, which has incorporated the access and benefit-sharing provisions of the CBD for compliance with the Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS Agreement). The Patent Act, 1970 (with substantial changes brought about by the 2002 and subsequent amendments), is presently the primary legal instrument for protecting indigenous traditional knowledge in India in the absence of specialised law. Section 3 (p) of the Patent Act prohibits grant of patent and excludes from the definition of the invention any claim for patent, which is in effect is traditional knowledge or an aggregation of the known properties of traditionally known components. Section 10 (4) (d) (ii) seeks to control biopiracy by making it mandatory to disclose the source and geographical location of the biological material along with a sample of it to be deposited as per the Budapest Treaty, 1977. A patent granted in violation of Section 3 (p) and can be revoked under Section 64 (e) and (j) if it is established as prior knowledge and if in violation of Section 10 (4) (d). It can be revoked under Section 64 subsections (j), (p) and (q) for false representation, without disclosure of complete specifications including source or geographical origin of the bioresources or the patent was granted in respect of any knowledge, oral or otherwise available within a local or indigenous community of India or elsewhere. The Patent Act, 1970, thus seeks to protect indigenous traditional knowledge of India and other states from being exploited for commercialisation in India. The other statute relevant to protecting indigenous traditional knowledge in India is the Biological Diversity Act 2002, enacted to meet obligations under the CBD. The bioresources, the foundational materia medica for the indigenous ethnomedicinal systems, are protected under this law. At the national level, Section 27 of the Biological Diversity Act provides for creating ‘Biodiversity Funds’. Section 32 mandates such Biodiversity Funds at the provincial level, and Section 34 mandates allocation of funds to the local authorities for supporting conservation. It establishes the National Biodiversity Authority under Section 8 and State Biodiversity Boards under Section 22. Section 21 acknowledges local communities as the right holders to equitable benefit sharing, and Section 36 (5) calls for the creation of specialised sui generis legal mechanisms to protect their indigenous traditional knowledge. It recognises the importance of sustainable use and documentation of biocultural resources in section 41 and under section 36 to identify, monitor and document non-codified ethnobotanic pharmacological traditional knowledge. Section 21 (2) (a) of the Biological Diversity Act assigns the authority to the National Biodiversity Authority to allocate itself as a joint owner of the Intellectual Property Rights (and the benefits accruing from there) in case the specific owners of the indigenous traditional knowledge cannot be positively identified.

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Alternate Model for Protecting Indigenous Ethnomedical Traditional Knowledge The use of Intellectual Property Law, especially Law of Patents, is tactically helpful in preventing misappropriation of indigenous traditional knowledge by unauthorised parties from the holders without acknowledgement, obtaining their prior and informed consent or sharing benefit (Sahai & Barpujari, 2007). There are, however, certain inherent conceptual incongruities and decisive practical loopholes in the present legal mechanism for the protection of the non-codified indigenous traditional knowledge and its appurtenant biocultural resources in India. These conceptual incongruities originate from a perception of knowledge as a resource for material commodification. The entire legal framework of Intellectual Property Laws on indigenous traditional knowledge preservation in India pivots on the commercialisation and disclosures of knowledge and its resource-based, which carries certain risks. The case of the Intellectual Property Law mediated the unplanned commercialisation of Trichopus zeylanicus travancoricus, which led to a thriving black market in the product (Unnikrishnan, 2000). This resulted in criminalising the collection of the fruit by the local Kani tribe, destroying a viable market and culture (Bijoy, 2007). It affords an apposite case study of the dangers of ill-conceived legal development projects causing more harm than good. The indigenous traditional knowledge of the ethnobotanic medicinal properties of the bark of the Pacific Yew led to the development of an effective anticancer drug (Moerman, 1998). This prompted debarking of the yew trees, which resulted in the once common plant becoming critically endangered (Laird & Wynberg, 2008; Wynberg et al., 2009). Intellectual Property Law is based on the concept of ‘ownership’ of property and Patent Rights, especially ‘owned’ by juristic persons rather than communities collectively. By their very nature, Patent Rights are based on the protection of monopoly in exchange for public disclosure of all the specifications. In contrast, indigenous traditional knowledge has a normative cultural value that may not be amenable to disclosure or may lose its ritual significance or spiritual value upon disclosure outside the community. Patents are monopoly rights with limited validity in time. After the rights expiry, the knowledge is openly disseminated in the public domain for utilisation by any interested person without any recourse available to the patent holder. On the other hand, indigenous traditional knowledge is a communitarian knowledge resource held in perpetuity by the possessors in trust for the inter-generational transmission of the knowledge and the related religio-cultural aspects associated with it. The patent law necessitates that the subject of patent possesses the characteristics of non-obvious inventive novelty and commercial/ industrial utility, in the landmark patent law case of Lallubhai Chakubhai Jariwala vs Chimnlal Chunilal & Co.3 The Bombay High Court had highlighted that: …the two features necessary to the validity of a patent are novelty and utility, but the real test is the novelty of the invention. Novelty is essential, for otherwise, there would be no benefit 3

(1935) 37 Bombay Law Reporter 665.

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given to the public, and consequently, no consideration moving from the patentee [while interpreting the factor related to public knowledge and public use…The next question is whether a prior public user has anticipated the plaintiff’s invention. Has it been publicly used by the plaintiff and/or by others before the date of the application? For instance, if the invention is into practice before and at the date of the grant, then a grant cannot be given based on a new invention or manufacture. Similarly, this applies equally whether the patentee practised the invention by himself or by others...

This novelty may not be readily demonstrable in incrementally gained indigenous traditional knowledge. The deficiencies of the patent law to adequately protect indigenous traditional knowledge have prompted some scholars to suggest the use of Copyright Law for documentation and protection of traditional knowledge. Others have suggested that indigenous traditional knowledge should be considered a part of humankind’s common intangible heritage and open to access. While the dangers of designating indigenous traditional knowledge as a common human heritage are apparent in the inequitable denial of ownership to the indigenous community, with their disenfranchisement from control over their heritage, once it is taken over in the name of all humanity (Coombe, 2009), the risks associated with Copyright Law necessitate explication. Copyright, like patent, is a temporary monopoly granted to an author for his published work, and after the expiry of which the written work is deemed to be in the public domain. The fact versus expression dichotomy of Copyright Law means that even during copyright protection, only the specific written expression is protected and not the ideas that underlie or derive from it. This implies that once fixed by documentation, it becomes accessible to the public for all purposes except further publication. This strips the indigenous traditional knowledge of its spiritual, cultural and normative context (Bannister, 2004). Even if government agencies do the documentation, fair use exceptions associated with copyright and accessibility through Right to Information Law may further allow access to government records opening the indigenous traditional knowledge for exploitation without any consequent benefit payable to the indigenous community. Indigenous ethnomedicinal traditional knowledge is an important spiritual aspect of the way of life of the indigenous communities, and disrespect towards it or its misuse can have psychosocial impacts on members of the community, which may be difficult to mitigate (Berkes, 2012). There is a need for a sui generis law for the adequate protection of indigenous traditional knowledge. Sui generis law within the Intellectual Property Law implies a statutory legal mechanism intended to protect those specialised Intellectual Property Rights inadequately covered by the classical quadrant of patent, copyright, trademark and trade secret regimes (Romero, 2005). The Indian Biological Diversity Act, 2002, is an example of a sui generis legal regime in India. However, while it addresses the protection of diversity through socially inclusive mechanisms like institutionalisation and regulation of commercialisation of biological diversity, and benefit sharing with indigenous communities, it does not include any reference to traditional knowledge, nor does it address the rights of the traditional holders of indigenous traditional knowledge. Any legislative action towards designing a statute for the protection of indigenous traditional knowledge, especially those related to ethnomedicinal and

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ethnobotanical resources, must incorporate a participatory mechanism that ensures the conservation of the bioresources and the preservation of spiritual and biocultural aspects of the indigenous society. This can only be achieved if the statutes are formed under the doctrine of Rights of the Indigenous Communities, including their right to religious faith and culture instead of mere economic vantage of intellectual property. The access to indigenous knowledge resources could be regulated through legal valve provisions based on democratic community-based prior informed consent as was established in Orissa Mining Corporation Ltd. v Ministry of Environment and Forests.4

Conclusion Protection of indigenous traditional knowledge is necessary to prevent its extinction and open the secreted wealth of information for the benefit of humanity. It can be more effectively done through a sui generis legal framework based on the paradigm of protection of biocultural rights of the indigenous community rather than the economically focused Intellectually Property Laws at present. Participatory and framing of sensitive and flexible legal protocols for the preservation of indigenous ethnomedical traditional knowledge with conscious regard to the spiritual and ritualistic aspects can be achieved to mitigate the power disparities and create equitable and socioculturally acceptable legal frameworks with appropriate stewardship obligations and protection of indigenous rights in consonance with national and international legal norms based on respect for the holders and prior informed consent.

References Amankwah, H. A. (2007). Traditional values and modern challenges in property law. Journal of South Pacific Law, 11(1), 18–38. Arora, V. (2006). The forest of symbols embodied in the Tholung sacred landscape of North Sikkim, India. Conservation and Society, 4(1): 55-83. Bannister, K. (2004). Indigenous knowledge and traditional plant resources of the Secwepemc first nation. In M. Riley (Ed.), Indigenous intellectual property rights: Legal obstacles and innovative solutions (pp. 279–308). Alta Mira Press. Bhutani, S., & Kothari, A. (2002). The biodiversity rights of developing nations: a perspective from India. Golden Gate University Law Review, 32, 587. Berkes, F. (2009). Indigenous ways of knowing and the study of environmental change. Journal of the Royal Society of New Zealand, 39(4), 151–156. Berkes, F. (2012). Sacred ecology. Routledge. Bijoy, C. R. (2007). Access and benefit sharing from the indigenous peoples’ perspective: The TBGRI-Kani model. Law, Environment and Development, 3(1), 1–18. Carpenter, K. A., Katyal, S. K., & Riley, A. R. (2009). In defense of property. Yale Law Journal, 118, 1022–1125. 4

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Clements, R. J., Haggar, H. A., & Torres, J. (2011). Technologies for climate change adaptation— Agriculture sector. UNEP Risø Centre, Roskilde. Coombe, R. J. (2009). The expanding purview of cultural properties and their politics. Annual Review of Law and Social Science, 5(1), 393–412. Cunningham, A. B. (2001). Applied ethnobotany: People, wild plant uses and conservation. Earthscan Publications Ltd. Farnsworth, N. R., & Soejarto, D. D. (1985). Potential consequence of plant extinction in the United States on the current and future availability of prescription drugs. Economic Botany, 39(3), 231–240. Field, C. B., Barros, V., Stocker, T. F., & Dahe, Q. (Eds.). (2012). Managing the ris ks of extreme events and disasters to advance climate change adaptation, a special report of working groups I and II of the intergovernmental panel on climate change. Cambridge University Press. Ghai, D. P. (1994). Development and environment: Sustaining people and nature. Blackwell Publishers. Hallegatte, S., Bangalore, M., & Vogt-Schilb, A. (2016). Assessing socioeconomic resilience to floods in 90 countries. The World Bank. https://doi.org/10.1596/1813-9450-7663. Hardison, P. D., & Bannister, K. (2011). Ethics in ethnobiology: History, international law and policy, and contemporary issues. In E. N. Anderson, D. Pearsall, E. Hunn, & N. Turner (Eds.), Ethnobiology (pp. 27–49). Wiley. Harvey, D. (1996). Justice, nature, and the geography of difference. Blackwell Publishers. Helfer, L. R., & Austin, G. W. (2011). Human rights and intellectual property: Mapping the global interface. Cambridge University Press. Hill, R., Grant, C., George, M., Robinson, C. J., Jackson, S., & Abel, N. (2012). Typology of indigenous engagement in Australian environmental management: Implications for knowledge integration and social-ecological system sustainability. Ecology and Society, 17(1), 123–134. Infield, M. (2001). Cultural values: A forgotten strategy for building community support for protected areas in Africa. Conservation Biology, 15(3), 800–802. Jörgensen, K., Mishra, A., & Sarangi, G. K. (2015). Multi-level climate governance in India: The role of the states in climate action planning and renewable energies. Journal of Integrative Environmental Sciences, 12(4), 267–283. Kipuri, N. (2009). Culture. In UNDSP state of the world’s indigenous peoples. Secretariat of the permanent forum on indigenous issues (pp. 52–81). United Nations Publication. Laird, S. A., Laird, S., & Burningham, M. (2019). The botanical medicine industry. In The commercial use of biodiversity (pp. 78–116) London: Routledge. Laird, S., & Wynberg, R. (2008). Access and benefit-sharing in practice: Trends in partnerships across sectors. Secretariat of the Convention on Biological Diversity. Langton, M., & Rhea, Z. M. (2005). Traditional indigenous biodiversity-related knowledge. Australian Academic & Research Libraries, 36(2), 45–69. Liu, J., Mooney, H., Hull, V., Davis, S. J., & Gaskell, J. (2015). Systems integration for global sustainability. Science, 27(47), 62–67. Lloyd, S. J., Kovats, R. S., & Chalabi, Z. (2011). Climate change, crop yields, and undernutrition: Development of a model to quantify the impact of climate scenarios on child undernutrition. Environmental Health Perspectives, 119(12), 1817–1823. Maffi, L. (2001). Introduction: On the interdependence of biological and cultural diversity. In L. Maffi, & J. A. McNeely (Eds.), On biocultural diversity. Linking language, knowledge, and the environment. Smithsonian Institution Press. McManis, C., & Terán, Y. (2001). Trends and scenarios in the legal protection of traditional knowledge. In T. Wong & G. Dutfield (Eds.), Intellectual property and human development: Current trends and future scenarios (pp. 139–166). Cambridge University Press. McNeely, J. A. (2000). Cultural factors in conserving biodiversity. In A. Wilkes, H. Tillman, M. Salas, T. Grinter, & Y. Shaoting (Eds.), Links between cultures and biodiversity. Proceedings of the Cultures and Biodiversity Congress (pp. 128–142). Yunnan Science and Technology Press.

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Milton, K. (1996). Environmentalism and cultural theory. Exploring the role of anthropology in environmental discourse. Routledge. Moerman, D. E. (1998). Native American ethnobotany. Timber Press. Motte-Florac, E., and Ramos-Elorduy, J. (2002). Is the traditional knowledge of insects important? In Stepp, J. R., Wyndham, F. S., and Zarger, R. K. (eds.), Ethnobiology and Biocultural Diversity. Proceedings of the Seventh International Congress of Ethnobiology, The International Society of Ethnobiology, (pp. 207–224). Athens, GA. Noble, B. (2009). Owning as belonging/owning as property: The crisis of power and respect in first nations heritage transactions with Canada. In C. Bell & V. Napoleon (Eds.), First nations cultural heritage and law: Case studies, voices, and perspectives (pp. 465–488). UBC Press. Pandey, K. (2010). Costs of adapting to climate change for human health in developing countries. Development and Climate Change Discussion Paper No. 11. World Bank, Washington, DC. Parrotta, J. A., & Agnoletti, M. (2007). Traditional forest knowledge: Challenges and opportunities. Forest Ecology and Management, 249(1), 1–4. Posey, D. A. (1999). Cultural and spiritual values of biodiversity. A complementary contribution to the global biodiversity assessment. In D. A. Posey (Ed.), Cultural and spiritual values of biodiversity (pp. 1–19). UNEP and Intermediate Technology Publications. Rajasekharan, S., & Latha, P. G. (2008). Ethnomedicine and Lead Based Product Development: A Case Study at the National Workshop on Grower-Industry Linkage for Promotion of Medicinal and Aromatic Plants Cultivation, 12-13 Feb 2008, Kerala Agricultural University pp 73–77. Riley, A. R. (2005). “Straight Stealing”: Towards an indigenous system of cultural property protection. Washington Law Review, 80(1), 69–165. Romero, T. L. (2005). Sui generis systems for the protection of traditional knowledge. International Law: Revista Colombiana de Derecho Internacional, 3(6). Sahai, S., I. Barpujari. (2007). Are geographical indications better suited to protect indigenous knowledge?. A developing country perspective, Gene Campaign, New Delhi. Smith, K. R., Woodward, A., Campbell-Lendrum, D., Chadee, D. D., & Honda, Y. (2014). Human health: Impacts, adaptation, and co-benefits. In C. B. Field, V. R. Barros, D. J. Dokken, K. J. Mach, & M. D. Mastrandrea (Eds.), Climate Change 2014: Impacts, Adaptation, and Vulnerability; Part A: Global and Sectoral Aspects. Contribution of Working Group II to the Fifth Assessment Report of the Intergovernmental Panel on Climate Change (p. 09–754). Cambridge University Press. Sujatha, V., & Abraham, L. (2012) Medical pluralism in contemporary India. Orient Blackswan. Sulochana, A. K., Raveendran, D., Krishnamma, A. P., & Oommen, O. V. (2015). Ethnomedicinal plants used for snake envenomation by folk traditional practitioners from Kallar forest region of South Western Ghats, Kerala, India. Journal of intercultural ethnopharmacology, 4(1), 47. Ten Kate, K., & Laird, S. A. (2019). The commercial use of biodiversity: access to genetic resources and benefit-sharing. London: Routledge. Thom, B., & Bain, D. (2004). Aboriginal intangible property in Canada: An ethnographic review. Industry Canada. Unnikrishnan, P. (2000). From Rio to reality: A case study of bio-prospecting local health knowledge in Kani Tribal Community of Kerala, India (Unpublished master’s thesis). The Netherlands: University of Amsterdam, Amsterdam. Van Overwalle, G. (2005). Protecting and sharing biodiversity and traditional knowledge: Holder and user tools. Ecological Economics, 53(4), 585–607. Walker, G. P., & Bulkeley, H. (2006). Geographies of environmental justice. Geoforum, 37(5), 655–659. Warren, DM (1992) Indigenous Knowledge, biodiversity, conservation and development, Keynote Address. International Conference on Conservation of Biodiversity in Africa: Local Initiatives and Institutional Roles. 30 August - 03 September 1992, National Museums of Kenya, Nairobi cited (pp. 81-89) in James, V. U. (Ed.). (1996). Sustainable development in third world countries: applied and theoretical perspectives. Westport, CT : Greenwood Publishing Group.

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Wood, A., Stedman-Edwards, P., & Mang, J. (2000). The root causes of biodiversity loss. Earthscan Publications Ltd. Wynberg, R., Schroeder, D., & Chennells, R. (2009). Indigenous peoples, consent and benefit sharing: Lessons from the San-Hoodia case. Springer. Yu, P. K. (2003). Traditional knowledge, intellectual property, and Indigenous culture: An introduction. Cardozo Journal of International and Comparative Law, 11(2):239–245.

Chapter 17

Intellectual Property Rights in Indigenous Medicinal Knowledge: A Case of ‘Saikot Cancer Medicine’ in Manipur Nemthianngai Guite Abstract The issue of biodiversity conservation and intellectual property protection that arose due to the globalisation process has far-reaching consequences on the local health traditions of the indigenous people, particularly in developing countries. The unrestricted transfer of indigenous knowledge to commercial interests and the consequent destruction of biodiversity directly affect the indigenous medicinal knowledge of the indigenous people. Many reports, studies, articles and books have discussed and deliberated upon the issues related to indigenous people of the developed countries, especially on their rights over their knowledge and resources. Drawing inferences from the literature on spheres of indigenous knowledge and conflict over indigenous knowledge, the paper will discuss the case of ‘Saikot Cancer Medicine’ of Manipur, which happened in 2008. The accounts narrated from experiential reality were of hopes for many terminally ill patients. Moreover, many concerns on the management and proprietary rights of ‘Saikot Cancer Medicine’ as traditional knowledge were also raised and debated. A content analysis of the media reports is done in this paper. Keywords Indigenous knowledge · Biodiversity · Conservation · Intellectual property rights · Saikot cancer medicine

Introduction Indigenous medicine plays a crucial role in health care and serves the health needs of many people in developing countries. Access to ‘modern’ healthcare services and medicine may be limited in developing countries, especially in remote areas where indigenous people reside. Their indigenous medicine and the substances existing within their reach become the only affordable treatment available for them. It is important to recognise here that indigenous medicine is treated as part of indigenous N. Guite (B) Centre of Social Medicine and Community Health, Jawaharlal Nehru University, New Delhi, India e-mail: [email protected] © The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023 S. Reddy et al. (eds.), Ethnomedicine and Tribal Healing Practices in India, People, Cultures and Societies: Exploring and Documenting Diversities, https://doi.org/10.1007/978-981-19-4286-0_17

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knowledge. That is why the whole issue of ownership and rights over knowledge arose under the new laws and policies implemented in the 1990s. The existing intellectual property paradigm understands the medical knowledge of the indigenous communities as knowledge, which is gathered and perfected through trial and error. It further understands that the actual ownership of such knowledge cannot be established. Therefore, it considers that such knowledge is, for legal reasons, kept in the public domain and hence exploitable by all who can lay hands on it. Consequently, such intellectual property paradigm will affect the accessibility and utilisation of indigenous medicine for healthcare needs. On the other hand, it is considered that the medicinal knowledge of each indigenous group is a part of their more extensive healthcare system, and the knowledge rests within that particular community. Therefore, the medical knowledge of the indigenous communities cannot be evaluated as knowledge in the public domain. On the other hand, if the indigenous communities are given a legal entity status like a company or a cooperative, they can only benefit from Intellectual Property Rights (IPR) in the present framework.

Spheres of Indigenous Knowledge The Commission on IPRs (2002) viewed that communities’ indigenous knowledge is passed on from generation to generation, which is part of their cultural identities. The knowledge is generated and refined every time they are passed on. It has played a vital role in the food security and health of millions of people in the developing world, providing affordable treatment to poor people. In addition, the source of many modern medicines is based on the knowledge of the healing properties of plants known to the indigenous communities. Therefore, indigenous and local knowledge generally refer to the matured long-standing traditions and practices of specific regional, indigenous, or local communities. It also encompasses the wisdom, knowledge and teachings of these communities. In many cases, indigenous knowledge has been orally passed for generations from person to person. Indigenous knowledge is expressed through stories, legends, folklore, rituals, songs and even laws. The spheres of indigenous knowledge (Fig. 17.1) are often expressed through different means, be it oral or codified, and some knowledge is disclosed. At the same time, some remained undisclosed, sometimes misappropriated by outsiders when disclosed. A community can be distinguished from another community based on its indigenous knowledge. For some communities, it takes on a personal and spiritual meaning. Indigenous knowledge can also reflect a community’s interests, their innovative capacity leading to wealth creation. Some communities depend on their indigenous knowledge for survival. According to Anaya (2004), recognising the value of indigenous knowledge regarding biodiversity conservation and management is becoming an evolving subject among scientists, managers and policymakers of national and international law, including the essential role of the indigenous peoples and local communities.

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Indigenous knowledge

Oral Or Codified

Stories Legends Folklore Rituals Songs Laws

Misappropriation

Disclosed Or Undisclosed

Innovative capacity and wealth creation Wisdom Knowledge Teachings

Personal and Spiritual Meanings

Individual or community

dependent on Indigenous knowledge for survival Fig. 17.1 Spheres of indigenous knowledge

Scott (1998) also argued that scientist always doubts the value of indigenous knowledge unless proved to be scientific. There is a strong tendency to label indigenous knowledge with superstition, irrationalism and tribalism. The emphasis on preserving indigenous knowledge tends to have intellectual and economic benefits to corporate giants and pharma companies by providing drug discovery and raw materials for biotechnology and agriculture innovation. The principle of fundamental rights to indigenous knowledge as claimed by the indigenous peoples as a necessity for their cultural survival is increasingly being recognised in international law. These rights include many non-material and material values bundled into ‘indigenous resource rights’ (Posey, 1996). The benefits gained from using their knowledge and traditions outside indigenous communities should be given as they are entitled to control the process and benefit.

Conflict Over Indigenous Knowledge Indigenous knowledge and the discourse surrounding it takes place on several levels. According to Barsh (1999), the first level is where the World Trade Organization

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(WTO) agreements view ownership of indigenous knowledge and biological diversity as private ownership, which can be traded. Another level is where the environmentalists view it from the ecosystem preservation in mind. The inevitable conflict and discussion over indigenous knowledge exist because the indigenous people’s territories have most of the world’s biodiversity. Therefore, the issues of sovereignty, identity, colonialism and exploitation cannot be ignored against a backdrop of a globalising market economy. Article 2 of the CBD, 1992 defines biodiversity as “the variability among living organisms from all sources including, among other things, terrestrial, marine and other aquatic ecosystems and the ecological complexes of which they are part; this includes diversity within species, between species and of ecosystems”. The global south, i.e. developing countries occupied mainly by the indigenous populations, are rich in biodiversity with numerous genetic medicinal plants having potential applications, which are perceived to be unexplored and not owned by any individual. Therefore, the knowledge of the local communities can be used to tap beneficial compounds and scientific properties present in medicinal plants, and agricultural resources can be tapped from the local communities. According to Bratspies (2007), the researcher can utilise the community’s knowledge (public domain) under the WTO protocol. The researcher can discover the scientific properties of the biological resources from the communities’ knowledge and apply for a patent as their discoveries. Furthermore, if the patent is issued, it will make the patent holder wealthy at the cost of the indigenous community. This will enable them to exploit and exclude the indigenous people from freely accessing their proprietary natural resources. Patenting acts as a toll on trade and commerce of the biological resources, leaving the community that developed the know-how to own nothing and receive nothing. Article 26 of the International Covenant on Civil and Political Rights (ICCPR) was referred by Barsh (1999) to understand how indigenous knowledge can be linked to landscapes. It provides that “persons belonging to ethnic, religious or linguistic minorities … shall not be denied the right, in community, with other members of their group, to enjoy their own culture…”. Within the sphere of protection, the Covenant added that a broader vision is to include all aspects of a group’s history, works, traditions, practices and knowledge. However, the existing legal system recognised only the tangible product by indigenous culture and did not consider how that product was produced and used by indigenous people (Fig. 17.2). As a result, the existing international trade regimes can have a significant flaw in refusing indigenous communities to claim and enforce communal Intellectual Property Rights forcing indigenous resources into property definitions external to the cultures themselves (Blakeney, 1998, 1999). In this process, the real wealth of indigenous people—their indigenous knowledge about biodiversity, their folklore, designs and traditions—are not protected under the WTO and have been the subject of severe criticism from worldview.

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Environmentalist

Trade Advocates Biodiversity Conservation

WTO

BioResources – Unexplored and Unowned

International Covenant on Civil and Political Rights (ICCPR)

International Trade Regimes

Communities Right to enjoy culture

Wealth accumulation of patent holder

Culture includes history, works, traditions, practices and knowledge within the sphere of protection

Loss of the right to community ownership of bioresources

Community ownership on bioresources and its knowledge

?

Refusal to permit indigenous communities to claim/enforce communal IPR

Conflict

Fig. 17.2 Conflict over indigenous knowledge

A Case of Saikot Cancer Medicine in Manipur The negative consequence of international trade regimes can be further elaborated with the case of ‘Saikot Cancer Medicine’. The accounts narrated by Chawlien Hmar, 82, who discovered the cancer medicine in Saikot village of Churachandpur district, Manipur, in 2008, believed that it raised hopes for many terminally ill patients. However, many concerns were raised on cancer medicine’s management and proprietary rights derived from the traditional knowledge on bioresources. A content analysis of the media reports on ‘Saikot Cancer Medicine’ highlighted an issue of claim of knowledge ownership, a lack of informed judgement and a stoic silence from the state administration. However, it awakens the consciousness among a handful of individuals, researchers, intellectuals and interest groups. They have begun to raise, discuss and investigate patenting indigenous knowledge under the WTO.

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The Cancer Healer In 2004, 82-year-old Chawlien Hmar, a resident of Saikot village of Churachandpur, was diagnosed with cancer in the large tumour growing behind his right side ear by the Radiology Department in Regional Institute of Medical Sciences (RIMS) Imphal, Manipur. Unable to meet medical expenses, he endured the pain for three years. However, he claimed that God instructed him in his dream to drink the Ranlung Damdawi (meaning animal’s worm medicine in Hmar dialect) plant extract. He drank it as he had complete faith in the words of God. The aching on his ear stopped instantly, and the swelling on his ear took some time to recede, and it was gone entirely in just two months (The Sangai Express, 2008a, April 28). The discovered plant, traditionally known as Zanlung Damdei, is found in Saikot village and its vicinity. The miracle cancer-curing plant and its extract have become popular to the extent that small vendors and shops on the roadside have the green plants and its extracts. The extracts are filled in plastic bottles with plant saplings and displayed for sale. Chawlien claimed that only after God ordered him did he give medicine to those who sought it. People lined up to receive the prayer and the green cancer medicine from Pa-Chawlien. The healing power of Chawlien’s claimed to have cured ailments ranging from Cancer, Asthma, Piles and even HIV/AIDS (The Sangai Express, 2008h, June 11).

The Saikot Phenomena The organic components of the plant are immaterial for people to ascertain. However, what matters is Chawlien’s green leaf medicine, which works on them and cures them. The daily requirement of the magic leaves is around 20 sacks. They were brought in bulk to Chawlien’s place for the preparation of the medicine. The manual preparation process is to clean the leaves, separate the twigs and chop them into bits for pounding. The leave juice is extracted after pounding and filtered to make it ready for consumption. There is no price fixed for the mug full (200 ml) of medicine. It is provided to everyone who comes to Chawlien Cancer Medical Research Agency (CCMRA). The spirit of voluntarism was high among the people who helped in CCMRA with only the intention of curing the sick. They have to handle 5000 to 10,000 people every day thronging CCMRA, some standing in the queue from 4 am (The Sangai Express, 2008i, June 14).

People’s Account of Being Treated The media reported exciting accounts of people being treated by the ‘green cancer medicine’. For instance, a patient who is an inter-state bus driver from Bishnupur

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district narrated that he went for the second time as the medicine works not only to control his blood pressure but also to reduce his waist size. Another patient is a 40-year woman with breast cancer and swelling in her left arm. In 2006, she confirmed having breast cancer after a medical examination and laboratory testing at Imphal. She claimed that her condition had improved considerably after taking the potion made from Zanlung Damdei. The Medical Officer in charge of Saikot PHC also noticed that her condition has improved while comparing the medical check-up reports prior to and after the consumption of the cancer medicine. As a result, she continues to take the potion (The Sangai Express, 2008i, June 14).

Saikot Undergoes Miracle Change The government department has to interfere due to a high number of visitors. The PHED built temporary toilets for sanitation purposes. There were reports of the sale of the medicine in another part of the states at an exorbitant price. Around 150–170 volunteers in and around the village were engaged in controlling the crowd. Visiting days were announced through the media in order to control the crowd. Health officials from Manipur health services, a scientist from Central Agriculture University, and members of the Manipur unit of the Indian Medical Association visited the sites to collect the samples to be tested. A team of scientists from the Institute of Bioresource and Sustainable Development (IBSD) were also sent to understand the prospect and assess the rich state resources. The team made the following observations. First, the open-air laboratory needs to be more hygienic while preparing the potion, as it can cause infection after consumption. Secondly, the life-saving plant harvesting trend can also lead to extinction if no replanting takes place. Thirdly, there is the possibility of significant side effects from adulteration by undesirable toxic plants (The Sangai Express, 2008g, June 23).

Cautionary Notes from Officials Given the popularity, cautionary notes were suggested. The head of the radiotherapy department in the Regional Cancer Centre, RIMS (Imphal), suggested that all necessary measures to prevent disastrous consequences need to be taken. Through intensive research, it has to be done to identify the active agent, determine the appropriate dose, and know the immediate and long-term side effects, including antidotes. The Director, Institute of Bioresources Development, Imphal, also expressed the need to register the shrub in the National Bureau of Plant Genetic Resources, New Delhi, for its protection given the massive demand from various parts of the country. AYUSH doctors were entrusted with investigating the herb extraction processes (The Sangai Express, 2008k, June 17 and 18). A team of scientists from IBSD also expressed their concern over Intellectual Property Rights issues. Unrightful owners could misuse the

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plant unless the state registers it. Therefore, it was suggested that the state research and development institute take measures for its sustainable growth and protection from exploitation. An analysis of the chemicals and the medicinal value of the Zanlung Damdei plant was suggested by the IBSD scientist through various processes taking more than 45 days to confirm its medicinal properties. In case if the usefulness in curing cancer is proved, the IBSD will propose to the central and state governments the need for its extensive cultivation and give credit to Chawlein Hmar for the discovery (Nanda Sukham, 2008, June 24, Sinlung News).

Identity of ‘Damdei Plant’, the Saikot Cancer Medicine Dr P. Kumar, along with his team, found the variety of the plant to be Croton Caudatus Geiseler.1 Furthermore, the same investigation process has been registered at the Manipur University herbarium with coll number 004101. For further affirmation, the recent findings of the plant variety were sent to the Botanical Survey of India (BSI) at Shillong, who made an official confirmation of the anticancerous plant as Croton Caudatus Geiseler. It is listed under ACC No. 96367 of the BSI, Shillong. The plant has three active components of Crotoflorine, a phenolic substance, Crostsparimine, a new base mop and Sparsiflorine, an alkaloid substance. Croton caudatus Geiseler found at Saikot has its peculiar ingredients of Datriacontanom beta amyrine and beta sitosterol at its barks and stems, which are used to treat ailments related to calcareous (cancer), as per the reports from the Central Drug Research Institute, Lucknow. According to Prof. Singh, there is a precise instance of many highly medicinal plants proven because of cancer medicine. He believed that proper steps have to be taken by the concerned departments of the state government for the proper protection and conservation of such plants before it is widely exploited (The Imphal Free Press, 2008b, June 11).

Intellectual Property Rights (IPR) Issues As the demand for medicine increases and seeing the people’s response from farflung areas approaching the healer and his discovery of a potion for curing cancer, the state government also decided to intervene and see what could be done. The 1

Five varieties of C. caudatus identified by legendary plant explorer and plant geographer Sir J. D. Hooker, in Flora of British India, Vol. 4 and H. J. Esser in Flora of Thailand also described C. caudatus. He also mentioned the plant to have five varieties, viz., C. caudatus var hispid; C. caudatus var ruminate; C. caudatus var globosa; C. caudatus var tomentosa, and C. caudatus var malaccana. The presence or content of the biologically active molecule(s) which is/are responsible for the cure of cancer or other ailments will differ with varieties. So, the true identity of ‘Damdei’ should be established by gathering every bit of morphological details, and, nevertheless, its identification using a DNA marker is highly required.

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state government has now decided to consider getting a patent for the potion and identifying the toxic compounds present in the plant after realising the potential of the cancer cure plant. The Commissioner for State Science and Technology, during a press conference, maintained that an advisory committee comprising of state scientists and lecturers of various colleges in the state, who jointly surveyed the plant species, submitted an official finding to him. The findings consisted of details on the consequences of taking the potion if the state government fails to form specific policies and strategies to deal with the subject in time. The scientists and experts were very much concerned over the failure of the state government to take up timely measures for taking a patent despite making a botanical identification 50 days back and acknowledging the potential of the potion. They also expressed concern over the emerging of two claimants over the proprietary rights of the plant, which could be a hindrance in taking a patent for the potion officially.2 (The Imphal Free Press, 2008c, June 21). Therefore, a meeting was held in this regard on what should be the role of the state. The outcome of the meeting of the high officials of the state called for immediate containment of the prevailing distribution system of the cancer cure potion. The observation and proposals made by the experts were that it is a chaotic issue for the state due to the rush of the general public to collect the potion. They also proposed that intervention by the state health department with good mass awareness campaigns to warn the people of the health hazards of consuming the unbranded potion is required. The conservation of the Damdei plant was suggested as it could become extinct due to overexploitation. The mass hysteria needs to be checked as there is no official proof of cancer being cured by this potion so far in the state, and glorification of the potion by some vested interests could be only to fool the public. There is the need to initiate steps for proper laboratory analysis to determine the primary toxic substances present in the plant and the potion. The high officials suggested taking up appropriate measures for immediate intervention into the distribution and unwanted exploration of the plant till the actual value of the plant is scientifically identified. They also further suggested taking a patent for the plant as the state could earn unexpected resources if the Damdei plant was indeed found to have great medicinal value (The Imphal Free Press, 2008d, June 22). Hearing the decision of the State High Officials from the media and seeing their reaction, the indigenous people of Saikot, who are the Hmar tribe.3 (the healer himself belong to the Hmar tribe) responded by taking out a press release to make people 2

Cousin of Chawlien, Mr Darminglien, a schoolteacher, says his late father, Mr Hneira, who died in 1997, first practised the medicine for years. He used the said plant to treat animals for various ailments. Given the effective result in animal treatment, it experimented with Mr Chawlien’s cancer treatment as a last resort. 3 Hmar tribe belongs to the Chin-Kuki-Mizo group of tribes and is recognised as Scheduled Tribes under the 6th schedule of the Constitution of India. They mainly reside in the Southern area of Manipur, especially in the districts of Churachandpur and its neighbouring region. Apart from Manipur, they are located in some parts of Mizoram, Assam, Meghalaya and Tripura. They are primarily Baptist and follow Christianity. They are the cultivators as they make their livelihood from farming. They are medium in stature and believes in their hands and are known for their

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understand the actual scenario. They said that the ‘Ranlung Damdawi’ (literally cattle worm medicine), now referred to as ‘Chawlien Damdawi’ medicinal properties, is not a discovery but has been known to the indigenous Hmar people for decades, if not centuries. While it may be true that this plant has been used for treating humans for the first time by Chawlien Hmar, it has been traditionally used by the Hmars to treat cattle and hence the name Ranlung Damdawi. They also mentioned that, like this plant, the Hmar Community also uses other medicinal plants for treating the ailments of both animals and human beings. The opinion of the experts and so-called intellectuals and leaders of the state was not acceptable. They attacked, saying it is exhilarating that traditional indigenous medicines are recognised and accepted for their curative qualities. However, putting ‘Ranlung Damdawi’ under the Western Intellectual Property Rights system will be wrong and damaging. In short, it means that efforts to patent this plant or the medicinal property by the state or by any other body or bodies, be it corporate or individuals, are against the indigenous system and specifically against Hmar’s traditional values and practices. The medicine is to date distributed free of cost to all who need it in Saikot, Churachandpur. The Hmar Students Association (HAS) expressed their anguished and wants as other indigenous people over the world that all life forms and life-creating processes that are sacred should not become the subject of proprietary ownership. They believe that IPR, as defined in the TRIPS Agreement, are monopoly rights given to an individual or legal persons who can prove that the inventions or innovations they made are novel, involve an innovative step and are capable of industrial application. They also observed that indigenous knowledge and medicinal systems are counter to privatising and appropriating those collectively owned and used. It is of primacy that indigenous medicines and systems are well protected against biopiracy, appropriation and patenting and that the existing state and other institutions must support such move. However, they feel that it is indeed unwarranted on the part of the state that it is jumping into the exploitative and Western intellectual property system without fully understanding the implications of patenting ‘Ranlung Damdawi’. They feel that this attempt reflects the state government lack of understanding of the values and system of traditional medicines and resources. The positioning by the institutions and the government to appropriate community knowledge and resources is highly condemned by the HSA. They also believe that the attempts by the medical and health professionals to undermine the Ranglung Damdawi on the ground of hygiene and lack of sufficient research show their prejudice, failure to understand and give due and equitable recognition to the healing powers of traditional cures (The Imphal Free Press, 2008e, June 23).

bravery. Nevertheless, with changing times, pretty educated Hmars work in various fields and make handicrafts.

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Conclusion The case of ‘Siakot Cancer Medicine’ is an appropriate example to explain the real and present situation of indigenous medicinal knowledge. Instead of protecting and promoting the indigenous medicinal plants and their rights over the knowledge, the state created fear for the indigenous people. It criticised the ground of hygiene and the lack of sufficient scientific research. The state also suggested taking precautionary measures as it may contain harmful bacteria, which can have harmful side effects to the people who consume. One of the main reasons for opposing was also due to the religious sanction attached to it. According to the healer, God told him to make a potion from the damdei plant to cure cancer in his dream. Reports say that people are cured, which may be due to their belief in the potion and the healer’s God. Therefore, it can be regarded as totally an indigenous healing system based on religious beliefs and faith instead of a holistic approach to health. However, the unique relationship of the spiritual world with the elements of such practices can be perceived as the harmony of individuals, families and communities with the universe surrounding them. Community-based projects led by indigenous people, focusing on cultivation, conservation, promotion and protection of knowledge of medicinal plants and practices, have generally yielded positive results. There can be an integration of sustainable livelihood programmes in medicinal plants cultivation and marketing with healthcare needs. The profit motive of the pharmaceutical company is investing in research on developing potentially profitable products has to be dealt with cautiously. There has been a blatant disregard for improving the health condition of indigenous peoples and their cultural heritage. The case of ‘Saikot cancer medicine’ (damdei plant) is a clear and valid example of how the state as an enforcing agency is ready to take away the credit and benefit, neglecting the rights of the healer and the indigenous community. There are many pressing issues, which can be derived from the case of ‘Saikot Cancer Medicine’. Many issues have come up as more knowledge on biological resources becomes easily accessible due to technological advancement facilitating an easy route to biopiracy. Some of the immediate issues identified are the practical public health concerns and legality, IPR issues and scientific validation process involved, benefit sharing and business opportunities. The success stories and accounts of ‘Saikot Cancer Medicine’ are expected to produce a healthy dialogue among policymakers, scientists, and community people on traditional knowledge systems. ‘Saikot medicine’ indicates the things to come shortly for many other traditional healers. The government may collaborate with other institutions/organisations with the expertise and experience in such matters or establish state-level centres to facilitate such a process. The onus to ensure that indigenous medicinal knowledge holder(s) rights are protected and promoted is on the intellectuals, academicians, researchers, administrators and public health organisations.

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References Anaya, S. J. (2004). Indigenous peoples in international law (2nd ed.). Oxford University Press. Barsh, R. L. (1999). How do you patent a landscape? The perils of dichotomising cultural and intellectual property. International Journal of Cultural Property, 8(1), 14–47. https://doi.org/10. 1017/S0940739199770608 Blakeney, M. (1998). Communal intellectual property rights of indigenous peoples in cultural expressions. Journal of World Intellectual Property, 8(1), 985–986. https://doi.org/10.1111/j. 1747-1796.1998.tb00045.x Blakeney, M. (1999). Intellectual property rights in the genetic resources of international agricultural research institutes—some recent problems. Bioscience Law Review, I, 3–11. Bratspies, R. M. (2007). Symposium on lands, liberties, and legacies: Indigenous peoples and international law. American Indian Law Review, 31(2), 315–340. http://www.jstor.org/stable/200 70790 Posey, D. A. (1996). Traditional resource rights: International instruments for protection and compensation for indigenous peoples and local communities. IUCN and World Conservation Union (WCU). Scott, J. C. (1998). Seeing like a state: How certain schemes to improve the human condition have failed. Yale University Press. Sinlung. (2008). Saikot undergoes ‘miracle’ change. Lamka, Manipur: Sinlung News. Retrieved from www.sinlung.com Staff Reporter. (2008a). Plant extracts help reduce cancerous growth. Lamka, Manipur: The Sangai Express. Retrieved from www.thesangaiexpress.com Staff Reporter. (2008b). Scientific name of probable anti-cancer plant identified. Manipur: The Imphal Free Press. Retrieved from www.ifp.co.in Staff Reporter. (2008c). State Government considering getting patent for Damdei medicine. Manipur: The Imphal Free Press. Retrieved from www.ifp.co.in Staff Reporter. (2008d). Experts suggest proper exploration and use of Damdei at the meeting. Manipur: The Imphal Free Press. Retrieved from www.ifp.co.in Staff Reporter. (2008e). HSA rues people’s lack of understanding of Damdawi. Manipur: The Imphal Free Press. Retrieved from www.ifp.co.in Staff Reporter. (2008g). Saikot undergoes ‘miracle’ change. Lamka, Manipur: The Sangai Express. Retrieved from www.thesangaiexpress.com Staff Reporter. (2008h). Miracle plant from Saikot: First to identify claim staked. Imphal, Manipur: The Sangai Express. Retrieved from www.thesangaiexpress.com Staff Reporter (2008i). Saikot stays awake as miracle plant seekers swarm. Lamka, Manipur: The Sangai Express. Retrieved from www.thesangaiexpress.com Staff Reporter. (2008k). Ayush Doctors to conduct a test on Saikot plant. Imphal, Manipur: The Sangai Express. Retrieved from www.thesangaiexpress.com

Chapter 18

Strengthening Capacity of Tribal Communities to Revitalise Tribal Medicine Through Research, Education and Outreach B. N. Prakash, G. Hariramamurthi, N. S. Sarin, and P. M. Unnikrishnan Abstract More than 200 biomedicines have originated from traditional or ethnomedicine. However, the translation from traditional medicine to biomedicine involves high investments and a long duration for evidence generation. This route is arduous and unnecessary for medical cultures such as India, which has supported the coevolution of pluralistic health cultures, such as folk medicine, AYUSH and allopathy. However, codified traditions such as Ayurveda, Siddha, Unani, SowaRigpa have evolved from these oral traditions. The Scheduled Tribe population reportedly uses over 2000 medicinal plant species. The ethnomedicinal knowledge, though documented in codified systems of medicine, is not accepted by conventional biomedicine due to lack of ‘evidence’. India has to develop trans-disciplinary research methods based on non-conventional and whole system approaches to validate ethnomedicinal practices. Approaches like participatory and rapid assessment, endogenous development, reverse pharmacology have been tried, but we need to look for a significant paradigm shift to integrate various health systems with biomedicine. TDU-FRLHT is making efforts to strengthen the capacities of tribal communities to revitalise tribal medicine through research, documentation, education and outreach. It is also essential to look at currently available options of access and benefits-sharing mechanisms that are fair and equitable to overcome the danger of biopiracy. Keywords Pluralistic health culture · Evidence · Revitalise · Tribal medicine B. N. Prakash (B) · G. Hariramamurthi · P. M. Unnikrishnan University of Trans-Disciplinary Health Sciences and Technology (TDU), Bangalore, Karnataka, India e-mail: [email protected] G. Hariramamurthi e-mail: [email protected] P. M. Unnikrishnan e-mail: [email protected] N. S. Sarin The Institute of Public Health, The University of Trans-Disciplinary Health Sciences and Technology (TDU), Bangalore, Karnataka, India e-mail: [email protected] © The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023 S. Reddy et al. (eds.), Ethnomedicine and Tribal Healing Practices in India, People, Cultures and Societies: Exploring and Documenting Diversities, https://doi.org/10.1007/978-981-19-4286-0_18

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Traditional and Complementary Medicine Traditional and Complementary Medicine (T&CM) is an important and often underestimated part of health care. T&CM is found in almost every country in the world, and the demand for its services is increasing (WHO, 2013). The demand for herbal products continues to increase in regions that have less biodiversity and traditional knowledge. More and more pharmaceutical products are increasingly derived from natural products. The growing numbers of patents are being obtained on traditional knowledge-based research leads that use biological resources known to and used by indigenous and local communities. India is witnessing several innovative community-based experiences on traditional knowledge and access and benefit-sharing models. International and national policies recommend supporting, recognising, integrating and utilising traditional community healthcare practices in national health systems. Policy documents are increasingly developing concerning regulation, safety, efficacy, research, clinical trials and rational use related to traditional medicine. The level of utilisation of herbal or traditional medicine in a significant number of countries is reported by either high or medium as shown in a WHO Global Atlas of Traditional, Complementary and Alternative Medicine (Bodeker et al., 2005) (Fig. 18.1).

Fig. 18.1 Utilisation of herbal/traditional medicine in the globe

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Indian health traditions consist of two distinct but symbiotic and mutually sustaining streams, namely the codified and non-codified streams. The codified stream consists of Ayurveda, Siddha, Unani and Sowa-Rigpa (as practised in the Himalayan region). The codified stream of Indian Systems of Medicine is based on the medical manuscripts, some as old as four thousand years, which have documented theoretical foundations and knowledge of this stream. This stream represents sophisticated pharmacological, clinical and pharmaceutical knowledge that has partially drawn upon tribal or folk knowledge but also developed independently through the genius and research of medical scientists. With the codified stream of Ayurveda, Yoga, Unani, Siddha, Sowa-Rigpa and Homeopathy currently having 712,132 registered practitioners (AYUSH, 2022), it covers all aspects and branches of medicine and surgery as well as specialised fields, such as gynaecology and obstetrics, dentistry and ophthalmology. The efficacy of remedies from the codified Indian Systems of Medicine for maternity care, cardiac conditions, diabetes, difficult skin diseases, gynaecological diseases, orthopaedics, mental health, ophthalmology, geriatrics and gastro-intestinal tract disorders is fairly well acknowledged in clinical circles. The codified stream of medical knowledge with its enormous potential for improving healthcare quality, both in India and the world, can contribute to the frontiers of clinical medicine in diagnostics, regenerative medicine and metabolic and non-infectious diseases. While the practitioners of codified healing traditions are available in a significant number, they are mostly located in urban and semi-urban towns. The non-codified stream of healing knowledge and skills is mostly transmitted orally through family elders and teacher-disciple learning and is also available in equally significant numbers. They are reportedly numbering one million village based, traditional AYUSH community health workers (MHFW, 2011). Traditional Community Healthcare Providers (TCHPs) are mostly distributed across almost in all villages and especially significantly present in tribal areas. These knowledge carriers of non-codified health traditions are ethnic community and ecosystem specific and empirically proven. Hence, these are referred to as local health traditions. Most of them belong to socially challenged communities belonging to Scheduled Tribes or Scheduled Castes or backward communities, among the more than 4,635 ethnic communities (Chandramouli, 2011). Around 700 ethnic communities belong to Scheduled Tribes in India (Indian Tribal Heritage, 2017). Scheduled Tribe communities comprise 14% of India’s population (Chandramouli, 2011). The Traditional Community Healthcare Providers manage a range of simple to complex health conditions. Several millions of knowledgeable women, including grandmothers or mothers, practise these local health traditions at the household level, in the form of home remedies or nutritional recipes, especially for adolescent girls, pregnant women and lactating mothers. The most common among these TCHPs are the herbal healers who manage common ailments, such as cold, cough, fever, joint pains, jaundice, etc. There are also a few thousand Traditional Birth Attendants called ‘dais’, who manage normal deliveries. They used to be available across most of the villages earlier. However, they are discouraged from serving the needy pregnant women in rural or tribal households since the public health policy has begun promoting institutional deliveries.

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Other streams of TCHPs are called traditional bonesetters who are skilled in handling simple bone fractures or dislocations, or Visha Vaidyas, who manage poisonous bites, including snake, scorpion or dog bites. They are available in hundreds and distributed across several clusters of tribal or rural villages. There are also fewer specialised TCHPs who manage diverse health conditions relating to eye, skin, dental or mental care. The Traditional Community Healthcare Providers use as many as 6560 species (TDU, 2018) of trees, climbers, herbs, shrubs, grasses, lichens, fungi; about 308 species of animals and about 70 different metals and minerals. More than 95% of the medicinal plant species are located in forest dwellings where tribal communities reside. These tribal communities know and use them for their health care for their health security and also gather them in the form of non-timber forest produces and sell them to traders for their livelihood. Even though we have the following policies that call for local health practices revitalisation, they are not yet a part of mainstream healthcare outreach strategy. • • • •

National Policy on Indian Systems of Medicine, India, 2002, National Rural Health Mission Statement, India, 2005, Five Year Plan Documents, India, 2007 & 2012, and National Health Policy, 2017.

Due to continuing lack of policy support and shrinking social legitimacy, the Traditional Community Healthcare Practices are undergoing rapid erosion. Traditional Community Healthcare Practices are prevalent and used much in tribal areas of India, which have difficulties accessing both public and private healthcare services. Therefore, there is an urgent need to revitalise tribal health practices. It is especially very important to strengthen the capacity of tribal communities to revitalise tribal health culture through research, education and outreach since a large number of tribal villages are situated in remote and less accessible areas of our country. Despite being not accorded significant credence on account of its non-codified nature in India, the fact remains that globally these practices are an integral constituent of the broader arena of traditional medicine (TM). The World Health Organization (WHO) defined TM as. the total of the knowledge, skill, and practices based on the theories, beliefs, and experiences, indigenous to different cultures, whether explicable or not, used in the maintenance of health as well as in the prevention, diagnosis, improvement or treatment of physical and mental illness (WHO, 2013).

WHO supports the mainstreaming of TM and Complementary and Alternative Medicine (CAM) (WHO, 2002) by: (i)

Facilitating integration of TM/CAM into national healthcare systems by member states via their national policies. (ii) Producing guidelines, standards and methodologies for research into TM/CAM therapies, products and use of the same. (iii) Supporting clinical research on safety and efficacy of TM/CAM (iv) Promotion of evidence-based use of TM/CAM.

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(v) Facilitating information exchange on TM/CAM. In the practice of tribal health traditions, several of the plants have global significance. Phyllanthus amarus is one such example. This plant is used for the management of non-obstructive jaundice. Interestingly, this practice was validated by an American Nobel Laureate, Prof. Baruch S Blumberg, a few years ago. The tribal health traditions are generally not documented or codified (except in a few states such as Manipur, Tamil Nadu and trans-Himalayan areas of Himachal Pradesh, Ladakh, Arunachal Pradesh or Sikkim). Another species of global importance is Artemisia annua to manage malaria, which is currently the choice drug. This species and its associated traditional knowledge originate in China and tribal communities living in Northeastern India. The 2015 Nobel Prize in Physiology or Medicine was awarded to Professor Tu Youyou from China for her critical contributions to the discovery of artemisinin. Artemisinin is reportedly saving millions of lives, representing one of the great contributions from traditional medicine to global health. Following is one of the few community-based interventions that have been undertaken by the University of Trans-Disciplinary Health Sciences and Technology, in the last decade and a half (2002–2017), through several non-governmental and community-based organisations to strengthen the tribal health culture in India.

Participatory Action Research, Education and Outreach Interventions for Prevention of Malaria India reportedly contributes to over one fifth (22.6%) of clinical episodes of Plasmodium falciparum and 42% of episodes of Plasmodium vivax globally (Guerra et al., 2010; Hay et al., 2010), and around 200,000 persons die annually due to malaria (Dhingra et al., 2010). “As in almost all tropical endemic countries, malaria in India affects people living in tribal, remote, rural areas, where most often affordable modern drugs are not available and poor health care infrastructure cannot assure prompt and appropriate treatment” (Nagendrappa et al., 2016). Thus, a majority of the tribal population still relies on traditional herbal medicines for the management of malaria. The community-based intervention described above was undertaken to study the potential of traditional community healthcare practices in the above tribal areas to prevent malaria. In India, the socio-economic burden due to malaria alone is estimated to be around $1.94 billion (Gupta & Chowdhury, 2014). To tackle the challenges of malaria, a national strategy for malaria elimination has been developed in the National Framework for Malaria Elimination in India 2016–2030 (NVBDCP, 2016). Affordable and accessible local interventions through tribal knowledge correlated by Ayurveda can significantly help address malaria prevention effectively. Most of the available antimalarial drugs target the pathogenic, asexual blood-stage parasites. Only a few drugs like, chloroquine, primaquine, mefloquine, sulphadoxine

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target hepatic parasites and act as chemoprophylaxis. The significant challenges with these drugs are the evolution and spread of drug resistance to all important classes of antimalarials. Artemisinin combination therapies (ACTs)—the first-line of treatment for malaria—is also failing fast in the Southeast Asia region, resulting in a real threat to malaria treatment and elimination efforts worldwide (Fairhurst & Dondorp, 2016). Other limitations include the complexity and cost of purchasing, delivering prophylactic drugs to the whole population, sustainability of the programme and impairment of the natural immunity (Greenwood, 2010). Importantly, effective drugs that are safe for children and pregnant women are not readily available (Fernando et al., 2011). Furthermore, many of the antimalarial drugs are expensive and inaccessible to the needy population. This results in the resurgence of infection and increased malariarelated deaths in malaria-endemic areas (Reyburn, 2010). These challenges warrant that an alternative system/drugs need to be evaluated.

Traditional Community Healthcare Practices Over 1200 plant species have been reported to be used worldwide to treat malaria (Willcox & Bodeker, 2004). In India, the tribal communities know and use Traditional Community Healthcare Practices to prevent and treat malaria. The codified systems of Ayurvedic medicine also have textual references for the uses of local flora in the management of malaria, referred to as vishamajwara. In order to explore the potential of tribal medicine for the prevention of malaria, community-based interventions for documentation, assessment and promotion of Traditional Community Healthcare Practices for prevention of malaria were taken up in a few selected tribal villages of Chhattisgarh and Odisha. These efforts were financially supported by the ETC, Netherlands, and the Department of Science and Technology, Government of India. An ethnobotanical study conducted by the TDU research team in Jashpur District of Chhattisgarh during March 2010 and December 2010, through semi-structured interviews of seven tribal healers, revealed 12 species, namely Acoruscalamus L., Alternantheraphiloxeroides (Mar.) Griseb. Andrographispaniculata (Burm.F.) Wallich ex Nees. Azadirachtaindica A. Juss., Holarrhenaantidysenterica (Roth.) A.Dc., Momordicacharantia L., Nyctanthesarbor-tristis L., Ocimum sanctum L., Piper nigrum L., Pongamiapinnata (L.) Pierre, SidaacutaBurm. F., VitexnegundoL. are used in the prevention of malaria (Prakash et al., 2013). It was also observed that these Tribal Community Healthcare Providers better understand malaria “as a disease and identified malaria based on clinical signs and symptoms that included fever, sweating, chills, headache, joint pain, and bitter taste in the mouth” (Goswami, 2017). The objective of the above field study in Jashpur, Chhattisgarh, was to evaluate tribal knowledge and medicinal plant-based intervention for the prevention of malaria in tribal villages in selected malaria-endemic villages of Chhattisgarh through a

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community-based approach. The study was implemented in selected villages of the Jashpur District of Chhattisgarh, the central part of India. Three villages, namely Revere, Kharidard and Bhanria, were selected in Bagicha block, Jashpur District of Chhattisgarh. In this study, new strategies were employed to control malaria through traditional health knowledge, which has existed within the communities for many decades and through a community participatory approach. A quasi-experimental (field) study was conducted to demonstrate the efficacy of traditional herbal malaria preventive remedies. The local traditional healers used the remedies for the prevention of malaria. The study was conducted on healthy subjects (volunteers) who resides in the malaria-endemic area of Jashpur District (Bagicha block). They were recruited to the study group who received the traditional herbal remedy twice a week for three months, whereas 215 volunteers recruited to the control group did not receive any malaria preventive remedy. Thick and thin blood smears and rapid diagnostic tests (RDT) were used to monitor malaria cases. At the end of the study, the incidence of malaria in the study group was seven (2.52%) compared to forty-three (20%) in the control group. The difference in the incidence of malaria is highly significant. Thus, the study showed the traditional herbal remedy is an efficacious prophylactic remedy for the prevention of malaria that can be used as alternative prophylaxis in malaria-endemic tribal areas of Jashpur, Chhattisgarh (Unpublished data).

Ethnobotanical Study in Odisha Ethnobotanical research carried out by a team of researchers from Trans-Disciplinary University (TDU) in Odisha revealed 16 plant species used for malaria prevention by traditional healers (Nagendrappa et al., 2013). Further, research carried out at TDU shows promising malaria prophylactic effect for herbal formulation (coded as TPMP74) based on Tribal Community Healthcare Practices and prepared as per the Ayurveda texts. TPMP74 is a simple, herbal formulation having five medicinal plants mentioned in Ayurveda, which are locally available in malaria-endemic areas and are easily accessible and affordable to the population of malaria-endemic areas. TPMP74 was standardised at TDU laboratory through organoleptic, physicochemical, phytochemical, microbial analyses, heavy metal, pesticide residue and HPTLC analysis.

Pre-clinical Study Standardised TPMP74 was pre-clinically tested for malaria prophylactic activity using a pre-erythrocytic stage model of Plasmodium yoelii in collaboration with INSERM Laboratory, Paris, France. Pre-clinical studies have shown an inhibition of the Plasmodium yoelii hepatic stages in vitro (50% inhibitory concentration [IC50 ] 0.74 mg mL), having a Therapeutic Index [TI] of 9.54 (Nagendrappa et al., 2015). In the in vivo study, mice were treated with an aqueous extract (2000 mg kg day)

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and peak parasitaemia values were 81.4% lower in the experimental group compared to control, suggesting the prophylactic activity at the hepatic stage of Plasmodium (Nagendrappa et al., 2015).

Field Study TPMP74 Further, TPMP74 was tested in a community setting (prospective comparative study) among healthy volunteers in the Koraput District of Odisha. This study was conducted in collaboration with the National Institute of Malaria Research (NIMR), Bangalore, and a local NGO (THREAD) in Odisha. The prospective comparative field study conducted in Odisha showed a 64% reduction in malaria incidences in the experimental group with the intervention of TPMP74 (malaria incidence rate = 12.3%) compared to the control group (malaria incidence rate = 26.6%) in malaria-endemic season (Nagendrappa et al., 2016). These studies show of proof-of-concept and strengthen traditional medicine to use effectively in communities for local health problems.

Conclusion From the above community-based interventions, it is evident and possible to strengthen the capacity of the tribal communities to revitalise tribal medicine through research, education and outreach. They know the medicinal uses of locally available plants to manage their health conditions. It is a sustainable strategy to empower them to care for their health needs with their traditional knowledge and skills. However, they require support and hand-holding for research, education and outreach.

References AYUSH. (2022). AYUSH practitioners in India. Ministry of AYUSH GOI. https://dashboard.ayush. gov.in/ (as on 24th Jan 2022) Bodeker, G., Ong, C. K., Grundy, C., Burford, G., & Shein, K. (2005). WHO global atlas of traditional, complementary and alternative medicine, 1 (1). WHO Centre for Health Development, Japan. Chandramouli, C. (2011). Census of India. Census of India. http://www.un.org/en/development/ desa/population/events/pdf/expert/23/Presentations/EGM-S2-Chandramouli%20presentation. pdf Dhingra, N., Jha, P., Sharma, V. P., et al. (2010). Adult and child malaria mortality in India: A nationally representative mortality survey. The Lancet, 376(9754), 1768–1774. Fairhurst, R. M., & Arjen, M. D. (2016). Artemisinin-resistant plasmodium, falciparum malaria. Microbiology Spectrum, 4(3).

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Fernando, S. D., Rodrigo, C., & Rajapakse, S. (2011). Chemoprophylaxis in Malaria: Drugs, evidence of efficacy and costs. Asian Pacific Journal of Tropical Medicine, 4(4), 330–336. Goswami, K. (2017). Assessment of Anti-Malaria Program Using Herbal Medicine. In B. Das & H. Siddalingappa (Eds.), Policies and practices: Assessing tribal health system (pp. 145–159). Notion Press. Greenwood, B. (2010). Anti-malaria drugs and the prevention of malaria in the population of malaria endemic areas. Malaria Journal, 9(Suppl 3), S2. Guerra, C. A., Howes, R. E., Patil, A. P., et al. (2010). The international limits and population at risk of plasmodium vivax transmission in 2009. Plus Neglected Tropical Diseases, 4(8), e774. Gupta, I., & Chowdhury, S. (2014). Economic burden of Malaria in India: The need for effective spending WHO. South-East Asia Journal of Public Health, 3(1), 95–102. Hay, S. I., Gething, P. W., & Snow, R. W. (2010). India’s invisible malaria burden. The Lancet, 376(9754), 1716–1717. India Tribal Heritage. (2017). How Many ‘Scheduled Tribes’ Are There in India? And What Distinguishes them from other communities? (‘Tribal’ or Otherwise)—Information Provided by the National Commission for Scheduled Tribes. Tribal Cultural Heritage in India Foundation. http:// www.indiatribalheritage.org/?p=22095 Ministry of Health and Family Welfare. (2011). Report of the Steering Committee on AYUSH for 12th Five Year Plan (2012–17) https://www.google.com/search?q=Report+of+the+Steering+ Committee+on+AYUSH+for+12th+Five+Year+Plan+%282012%E2%80%9317%29.+&ie=utf8&oe=utf-8&client=firefox-b Nagendrappa Prakash, B., Naik, M. P., & Payyappallimana, U. (2013). Ethnobotanical survey of Malaria prophylactic remedies in Odisha, India. Journal of Ethnopharmacology, 146(3), 768–772. Nagendrappa, P. B., Annamalai, P., Naik, M., Mahajan, V., Mathur, A., Susanta, G., Gay, F., & Venkatasubramanian, P. (2016). A prospective comparative field study to evaluate the efficacy of a traditional plant-based malaria prophylaxis. Journal of Intercultural Ethnopharmacology, 6(1), 36–41. Nagendrappa, P. B., Franetich, J.-F., Gay, F., et al. (2015). Antiplasmodial activity of traditional polyherbal remedy from Odisha, India: Their potential for prophylactic use. Asina Pacific Journal of Tropical Biomedicine, 5(12), 982–986. NVBDCP. (2016). National Framework for Malaria Elimination in India 2016–2030. Prakash, B. N., Muruli, P. K., Joseph, T., Haridasan, K., & Padma, V. (2013). Traditional phytotherapy for prevention of Malaria in Jashpur District, Chhattisgarh. International Journal of Indigenous Medicinal Plants, 46(3), 1294–1300. Reyburn, H. (2010). NewWHO Guidelines for the Treatment of Malaria. BMJ, 340(May 28,1), C2637-c2637. TDU. (2018). Master database on medicinal plants. The University of Trans-Disciplinary Health Sciences and Technology, India. WHO. (2002). WHO traditional medicine strategy: 2002–2005. World Health Organisation. http:// apps.who.int/medicinedocs/en/d/Js2297e/10.2.html WHO. (2013). WHO Traditional Medicine Strategy: 2014–2023. World Health Organisation. http:// www/who.int/medicines/publications/traditional/trm_strategy14_23/en Willcox, M. L., & Bodeker, G. (2004). Traditional herbal medicine for Malaria. BMJ, 329(7475), 1156–1159.

Chapter 19

Empowering Traditional Healers Using Modern Quality Management Tools Debjani Roy

Abstract There are an estimated one million Traditional Community Healthcare Providers (TCHP) in India, and while they exist in practice, there was no formal recognition to them. In order to preserve this traditional knowledge, a pilot project was carried out by Indira Gandhi National Open University (IGNOU) with support from the Quality Council of India (QCI) and the Foundation for Revitalisation of Local Health Traditions (FRLHT). The objective was to create a uniform and standardised framework, perhaps for the first time in the world, for Voluntary Certification of the TCHPs, who manage various streams of health services based on their traditional knowledge, experience and expertise. The framework for certification was designed following the International Standard for Personnel Certification ISO 17024. In 2016, QCI revived the Voluntary Certification Scheme for the Traditional Community Healthcare Providers (VCSTCHP) for six streams of ailments, namely jaundice, common ailments, traditional bonesetting, traditional birth attendant, poisonous bites and arthritis. The paper describes the journey of developing the voluntary certification scheme for the TCHPs based on international best practices and the challenges for the process of certification. Keywords Indira Gandhi National Open University (IGNOU) · Quality Council of India (QCI) · Foundation for Revitalisation of Local Health Traditions (FRLHT) · Voluntary Certification · Traditional Community Healthcare Providers (TCHP)

Introduction Technological development and online platforms have helped reduce distances, thereby placing modern society in an advantageous position for gaining knowledge. This shift in learning and knowledge gathering has also resulted in heightened awareness about the values of the traditional knowledge system, especially in healthcare, agriculture and the arts, thereby accepting and acknowledging the importance of D. Roy (B) New Delhi, Delhi, India e-mail: [email protected] © The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023 S. Reddy et al. (eds.), Ethnomedicine and Tribal Healing Practices in India, People, Cultures and Societies: Exploring and Documenting Diversities, https://doi.org/10.1007/978-981-19-4286-0_19

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preserving and promoting traditional knowledge. The knowledge and skill acquired by the practitioners of this system are mainly handed down as family tradition either orally or through observation while assisting knowledgeable elders. Many such practitioners may neither have attended school nor have any formal education. The folk healers or Traditional Community Healthcare Providers (TCHP) (as defined in India’s National Health Policy) is a community of traditional knowledge bearers for health care, providing yeomen service mainly to rural people living in remote, inaccessible and complex terrains. This knowledge requires validation, and if documented judiciously, it would be an asset for all times to come. The paradigm shift in the learning process has also resulted in the emphasis on knowledge and skill-based competence rather than academic degrees across all sectors. The competence acquired is regardless of the method by which it is gained, and is evaluated through the demonstration of their competence, especially when health and safety issues are involved. Along with competence, the quality of their services in the current context for TCHPs is an equally important aspect. Quality encompasses several components—voluntary standards, certification and accreditation.

Modern Quality Management Tool and International Standards The International Standards are set under the aegis of the International Organisation for Standardization (ISO), a voluntary, non-treaty federation of a specialised system for worldwide standardisation. It was founded in 1946–47 in Geneva. ISO has the mandate to develop standards to promote and facilitate international trade and cooperation on economic, scientific, technical and intellectual aspects in goods and services. The technical committee develops the International Standards for specific fields of technical activity. The technical committee has representatives from the national bodies across the globe who are members of ISO. Besides the national bodies, other government, non-governmental and international organisations also interact with ISO for the development of Standards (ISO/IEC, 1995). In 2012, ISO released the Standard for Personnel Certification—ISO/IEC 17024 to provide a globally accepted benchmark for organisations operating personnel certification. The certification assures the person’s competence certified by the Third-Party Certification Body for Persons—known as Personnel Certification Body (PrCB). The PrCBs attain their recognition by way of accreditation by the accreditation body. For India, it is the National Accreditation Body for Certification Bodies (NABCB). The PrCBs ensure that the candidates aspiring to get certified meet the stipulated competence standards during their knowledge and skill assessment. Unlike academic degrees, the ISO 17024 certification is not a one-time certification but has a validity

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period. If the certified person wishes to continue their certified status, they need to get recertified by reassessment. Thus, personnel certification schemes developed following ISO 17024 criteria, and requirements compensate for the variations in the quality of education and training. The Standard and the scheme require the persons seeking certification to demonstrate their knowledge and skill during assessment as defined by the competence criteria. Since the certification is as per International Standard, it facilitates recognition, worldwide acceptance and global exchange of certified personnel.

Status of TCHPs in India and Pilot Project Though the exact number of TCHPs in India is still not available, it is believed that their number is almost the same as those of AYUSH practitioners—around 7.5 lakhs (AYUSH, 2015). While they exist in practice, there is no formal recognition for them. Recognising the need to preserve this valuable traditional knowledge and tradition, creating a uniform framework arose. The Centre for Traditional Knowledge Systems at the Indira Gandhi National Open University (IGNOU) conceived the concept of certification the TCHPs in 6 districts of 6 states of India. IGNOU steered this as a pilot project—perhaps the first-ever in the world. A voluntary scheme of personnel certification for TCHPs was implemented as a pilot project in 2010–2012. The pilot project was mentored and funded by the then Department of AYUSH, Government of India. Quality Council of India (QCI) provided the expertise in designing and operating a competent third-party evaluation and certification system. The Foundation for Revitalisation of Local Health Traditions (FRLHT), Bangalore, collaborated as the domain expert. After a series of stakeholders meeting and following the broad principles of ISO 17024, the Minimum Standard of Competency for the personnel certification of the TCHPs and the criteria for the accreditation of the Personnel Certification Body (PrCB) was prepared. A methodology for the dissemination of information to the TCHPs about the process of voluntary certification was established. Dozens of applications from TCHPs duly endorsed by the Gram Panchayats/Village Councils were received, and screening of the applications was done based on the stipulated criteria for their evaluation and certification as agreed during consultations with senior and experienced TCHPs drawn from various regions of the country. Though the TCHPs provide healthcare services for various ailments, it was decided to conduct a rapid baseline village survey to identify the most common ailments found across the country for which the TCHPs provide their service. The data analysis of the rapid baseline village survey showed jaundice, common ailment, arthritis, poisonous bites, traditional birth attendant and traditional bonesetting were the most common ailments attended by the TCHPs found across the country. The Minimum Standard of Competence was developed for the above mentioned six streams. In order to have the pilot project spread across the nation, the East Siang

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District of Arunachal Pradesh and West Khasi Hills of Meghalaya were selected from the northeastern region, Mayurbhanj District of Odisha for the eastern region, Korba District of Chattisgarh for the central region, Dang District of Gujarat and Udaipur District of Rajasthan for the western region and Shimoga District of Karnataka and Vellore District of Tamil Nadu from the southern region. Due to paucity of time and other constraints, certifications could not be taken up in the two northeastern states. For the rest of the six states, a total of 517 TCHPs was certified for their competency for managing specific streams of ailment—62 from Korba District in Chhattisgarh, 91 from the Dang District in Gujarat, 111 from Shimoga District of Karnataka, 21 from Mayurbhanj District in Odisha, 98 from Udaipur District in Rajasthan and 134 from the Vellore District of Tamil Nadu out of 1234 applications received for certification (Roy, 2012). Since it was a pilot project, the validity of the certificate was for three years. Another important component of the TCHP certification scheme was developing the criteria for the accreditation of the training institution. Contrary to the notion that training happens before certification, for the TCHP certification, fact is that the TCHPs are the prior knowledge holders, would subject themselves voluntarily to assessing their competence as per the norms of the international best practices for certification. The scheme requires them to prove their competence first, and then if they fall short in demonstrating their competence, they can opt for skill upgradation training by accredited training providers. The same legal entity cannot do the certification and training to ensure there is no conflict of interest.

National Scheme for Certification of TCHP The National Scheme for the Voluntary Certification of the TCHPs was launched jointly by QCI, the apex quality body under the Ministry of Commerce & Industry, with FRLHT, one of the original partners of the pilot project, in March 2017 at Thiruvananthapuram, Kerala. The positive feedback received from the pilot project in 2016 and considering society’s needs for the far-flung unreached rural population of the country, were some of the reasons behind the scheme’s launch. With the scheme’s launch, there arose the need for generating mass awareness amongst the TCHPs and stakeholders in general. With this objective, the mass awareness campaign— Lok Swasthya Parampara Abhiyan—was flagged off from Kanyakumari in Tamil Nadu also in March 2017. The name Voluntary Certification Scheme for Traditional Community Healthcare Providers (VCSTCHP) was given after much deliberation taking a cue from the National Health Policy 2017. This National Scheme, a first in the world, provides competence standards presently for six streams of ailments namely, arthritis, common ailments, jaundice, poisonous bites, traditional birth attendants and traditional bonesetting. The scheme sets out evaluation and certification process following the worldwide concept of competence which involves defining knowledge and skills for a

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particular job and evaluating them through appropriate means like an oral interview, demonstration and onsite observations.

Progress Made Since the Launch of the Scheme in March 2017 A. Government of India support On Republic Day, 26 January 2018, the Government of India, for the first time in recognition of the services being provided by the TCHPs, conferred the prestigious Padma Awards to three TCHPs from Kerala, Karnataka and Tibet. It was a well-deserved recognition for the TCHP community, who are the first point of contact for the rural and tribal areas for any primary healthcare issue. This recognition by the Government of India made other state governments think about utilising the services of the TCHPs for primary healthcare. Even before the conferring of the Padma Awards to the TCHPs in 2018, the Government of India, through a cabinet decision, had decided to establish the North Eastern Institute of Folk Medicine (NEIFM) in Pasighat, Arunachal Pradesh, in 2008. The Government of Sikkim announced the establishment of the Folk Healing Centre in 2018. The Chhattisgarh Government decided to recertify the certified TCHPs under the pilot project implemented by the Centre of Traditional Knowledge Systems, IGNOU realising the importance of the services rendered by the certified TCHPs of the Korba District of Chhattisgarh by sanctioning financial assistance for their recertification. The Governments of Karnataka, Kerala, Meghalaya and Nagaland have also come forward to support the scheme. Although there are efforts by various governments, these are still sporadic and concrete, cohesive measures need to be taken to mainstream the TCHPs by recognising their knowledge, skill and services for the primary healthcare sector. On 10 May 2018, a meeting was held in Niti Aayog, attended by the representatives of the Ministry of AYUSH. The meeting decided that “QCI may explore the funding from the states interested in implementing the certification scheme under purview. Such states, if needed, should project their requirement of funding in the State Annual Action Plan under the “Flexi-pool component of AYUSH Mission”. It was also decided that “considering the value of the certified community healthcare providers or traditional healers, for easy accessibility at the community level for providing healthcare services in identified streams/domains, it is the prerogative of the state governments to determine the rights and privileges of healthcare practice of TCHPs since health is a state subject to provide healthcare services to the people”. It may be added that there is a provision for the states to maintain a register of local vaids and hakims under the Biodiversity Act. This scheme would help identify genuine TCHPs. Thus, the National Biodiversity Authority and the State Biodiversity Boards are also vital stakeholders for the scheme.

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The Government of Meghalaya has decided to set up Khasi Traditional Wellness Centres and Spas across the state where they would use certified TCHPs. Similarly the Government of Tripura has also supported the certified TCHPs of the state. B. Provisional approval for Personnel Certification Bodies (PrCB) for three years by QCI After the completion of three years of provisional approval by QCI or even within the three years of provisional approval, the Third-Party Personnel Certification Bodies can move for accreditation to the National Accreditation Body for Certification Bodies (NABCB), a constituent Board of QCI as per ISO 17024 and Scheme criteria. The scheme had the following provisionally approved PrCBs by QCI: PrCB-001 Etica Clinpharm Pvt. Ltd., Raipur, Chhattisgarh from 01 October 2018. PrCB-002 North East Christian University, Dimapur, Nagaland from 18 Oct, 2018. PrCB-003 The University of Trans-Disciplinary Health Sciences and Technology, Bangalore, Karnataka from 02 July 2019. PrCB-004 Chhattisgarh Certification Society (CGCERT), Raipur, Chhattisgarh from 26 July. 2019. Out of the above four provisionally approved PrCBs, the North Eastern Christian University, Dimapur, Nagaland, applied to NABCB. The organisation was assessed and accredited on 11 June 2020 for three years. C. Certifications (i) TCHP applications for certification The TCHPs application format was developed after a series of in-depth deliberations to ensure that the applicants understand the rigours of the certification process. Secondly, only genuine TCHPs come forward for the process. As a result, the application form is a 5-page document comprising of the application form, the code of conduct, the free prior informed consent and self-declaration. Each document must be signed by the applicant and endorsed by Gram Panchayat/Village Council/Local Municipal Bodies/State Biodiversity Management Committees (Annexure 1—Application form).

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Application Form for Voluntary Certification Scheme for Traditional Community Healthcare Providers (VCSTCHPs) for Applicant TCHP Full Name: Sex:

Male / Female

Date of Birth:

Contact Address: Taluka:

, District:Pin code:

Telephone Number:

Mobile Number:

Particulars of family elder / Guru who trained the applicant Full Name:

Relationship:

Contact Address: Taluka:

, District:Pin code:

Telephone Number:

Mobile Number:

Your years of experience or practice as TCHP:

years

List the streams of practice: Which stream(s) would you like to be assessed for certification? Common Ailments Jaundice Poisonous Bites Traditional Birth Attendant Traditional Bone Setting Arthritis Have you registered with any PrCB before? Was your application rejected before?

Yes

Yes

No No

If already certified or applied assessment under the same scheme, state your application number? Declaration: I hereby declare that to the best of my knowledge and ability I provide traditional/folk treatment for primary healthcare conditions with herbal remedies and as trained by my family elder / Guru mentioned above and that I Do Not provide any treatment to my patients with help of medicines of Allopathy or Homoeopathy. I hereby declare that all information provided by me above are truthful and to the best of my knowledge. I have enclosed self-attested 3 passport size photographs Name of TCHP

or Thumb impression of applicant TCHP

Signature of applicant TCHP Date

(dd/mm/yyyy)

Place

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The following forms are also to be signed by the applicant TCHP and submitted along with the application for endorsement:

SELF DECLARATION I …............................................... (Name of the TCHP), confirm that I provide traditional healthcare to my community in the stream of in accordance to knowledge and skills acquired from my family/Guru. I understand that if I am found to be claiming to provide my services of any formal system of medicine or misrepresenting my certification, at a later date, my certification maybe suspended and / or withdrawn. I also confirm that I am in good health and of sound mind to be able to impart healthcare services and will bring it to your notice when there is a change in my health which will adversely affect my functioning as a traditional community healthcare provider (TCHP). I understand that if I am found not fit health-wise to discharge my duties as a TCHP at a later date, my certification can be suspended and / or withdrawn. I will ensure a safe and responsible environment in my workplace and provide quality care to all those who seek it from me. I confirm that I have read and/ or understood the document forming part of this declaration.

Name of TCHP Signature of applicant TCHP

Date

or Thumb impression of applicant TCHP

(dd/mm/yyyy) Place

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CODE OF CONDUCT The Scheme for Voluntary Certification of Traditional Community Healthcare Providers (VCSTCHP) recognizes the importance of the role played by the TCHP in primary healthcare (http://www.qcin.org/Traditional-Community-Healthcare Providers.php). Consequently, it is the responsibility of the TCHP to ensure a responsible, safe and protected environment towards those who seek care. In order to uphold the highest work standards for TCHPs, I accept the following foundational principles: 1. I shall avoid discriminating against or refuse to provide care to anyone who seeks it from me, based on race, gender, sexual orientation, religious, or national origin. 2. I shall expand my knowledge and skills in the stream of healthcare services through peermeetings, educational activity and study. 3.

I shall maintain an ethical and moral practice in the stream of healthcare service certified for and shall not misrepresent my certification.

4.

I shall follow a healthy lifestyle.

5.

I shall establish and maintain safe work environment and working relationship with all healthcare seekers.

6.

I shall cultivate an attitude of humanity in my work and support community health initiatives.

7. I shall only handle cases in my stream of healthcare service and refer any emergencies to the nearest health facility. 8. In all Traditional healthcare related matters, I shall maintain best practices and procedures and strive to continuously enhance knowledge and skills. 9. I view my knowledge, services and work associations as being transparent and for the benefit of the people in my community. 10. I shall respect the integrity and protect the welfare of all persons who seek healthcare from me, and recognize that it is our obligation to safeguard any information about them obtained in the course of service provision. 11. I shall not carry out any advertisements, including any announcement, public statement or promotional material made by me, or for me, for informing the public about our activities. 12.

I shall not make public statements, advertisements, etc. which are false, fraudulent, misleading or deceptive.

13. I shall display my certificate (both sides) visibly at my work place.

Name of TCHP Signature of applicant TCHP

or Thumb impression of applicant TCHP

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Date

(dd/mm/yyyy) Place

FREE PRIOR INFORMED CONSENT Part 1: Information Sheet This assessment of your knowledge and skill-based competency is being carried out under the Quality Council of India (QCI) - Foundation for Revitalization of Local Health Traditions (FRLHT) Voluntary Certification Scheme for Traditional Community Health Providers (VCSTCHP) (http://www.qcin.org/Traditional-Community-Healthcare-Providers.php). The assessment would be carried out by means of oral evaluation, case presentation, practical demonstration and field verification. Information with regard to your practice and the medicines, procedures and techniques that you employ for the same may be disclosed during the course of your assessment. As per the commitments and obligations under national laws, the information disclosed shall be treated as confidential. The information collected is only for the purpose of assessing knowledge and certification. Your participation in this assessment is voluntary and you have every right to withdraw from the assessment without assigning any reason whatsoever. On successful completion of the assessment of your knowledge and skill, you will be certified for the specific stream of healthcare service for which you were assessed. The Certificate would have the validity for a period of 5 years. If you feel you were benefitted by the certificate you may apply for recertification and would have to undertake the process of assessment of your knowledge and skills. The Certificate would not allow you for the claim of any sort of registration as a medical practitioner or inclusion in the mainstream medical system. Part 2: Voluntary consent of applicant TCHP I (Applicant TCHP name) have read/ been informed of the above and given opportunity to clarify any queries to my satisfaction. I consent to share information as required for my assessment.

Name TCHP

of

Signature of applicant TCHP TCHP

Date

or Thumb impression of applicant

(dd/mm/yyyy) Place

_

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Endorsement by Village Panchayath Gram Sabha / GramaPanchayat / Local Government (Please confirm (a) Identity, (b) Residential Address, (c) Number of years practicing, (d) Streams of Practice and (e) Usefulness of the TCHP in your village community) We hereby state that Shri/Smt.

son

/ daughter / husband / wife of Shri / Smt. practicing as a TCHP in

is Village,

the

Post,

Taluka,

District,

State

since

years. W e also state that s/he is providing traditional community healthcare for the following streams of practice as mentioned below (please specify); We

endorse

that

the

services

of

Shri

/

Smt.

as a TCHP has been very beneficial to our village community.

Name of TCHP Signature or Thumb impression and Seal

Date

(dd/mm/yyyy) Place

_

(This document to be obtained from the Grama Sabha / GramaPanchayat / Local Government President or Secretary of the place of residence of the TCHP)

To date, 743 TCHPs have been certified under the VCSTCHP. They are from Andhra Pradesh, Assam, Chhattisgarh, Haryana, Karnataka, Kerala, Madhya Pradesh, Maharashtra, Nagaland, Punjab, Rajasthan, Tripura,

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Uttar Pradesh (https://qcin.org/voluntary-certification-scheme-for-traditional-com munity-healthcare-providers-tchp). The first-ever formal TCHP certification was started in March 2019 in the state of Tripura. (ii) TCHP evaluation process The Voluntary Certification Scheme for Traditional Community Healthcare Providers (VCSTCHP) has laid the criteria for evaluating the competence of the TCHPs seeking certification. The evaluation team comprises one team leader—generally an Ayurveda physician and two senior TCHP evaluators for the domain to be evaluated. The entire evaluation team is to be empanelled with either the provisionally approved PrCB by QCI or PrCB accredited by NABCB, depending upon the status of the PrCB. The evaluation team is accompanied by the certification head and support staff of the PrCB conducting the evaluation. The process and marking system for the evaluation has also been clearly defined in the scheme document. There is an oral evaluation on Day-1 of the evaluation and on Day-2, a demonstration. The candidates are informed about the last evaluation stage depending upon the marks scored on Days-1 and 2. This last stage is an essential exercise since the entire evaluation team visits the candidate’s practice station to inspect the micro-details of the practical aspects of their services for healthcare. Marking for the last evaluation stage is based on record-keeping, medicine preparation, hygiene and dispensing, area of their home herbal garden and medicinal plants cultivated. The last exercise is the interaction with the patients (Annexure 2—Evaluation criteria).

Evaluation Durations and Marks Evaluation Method Knowledge Evaluation through oral multiple choice questions 30 mins for a total of 50 marks A Case Presentation 30 mins for a total of 50 marks Viva Voce on case study presentation 30 mins for a total of 50 marks Practical Demonstration on identification of medicinal plants, preparation of formulations, storage of raw drugs and quality of preparations 30 mins for a total of 50 marks Field verification at TCHPs work environment 60 mins for a total of 100 marks

Weightage 10% 10% 10% 30% 40%

D. Impact of Certification on the livelihood of TCHPs For any new process, its impact assessment forms an important component. A few case study was done for the TCHPs certified and senior TCHPs who were the evaluators for the certification process in the Dang District of Gujarat during the pilot project. It was encouraging to interact with the TCHPs and determine how their lives have been impacted after their certification.

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(i) Sri Sukarbhai Bhangubhai Pawar of village Jamlapada of Dang District was certified for managing jaundice and common ailments (Plate 1). Prior to his certification, although he had the knowledge and skills to provide healthcare services, nobody knew him. He worked mostly as a daily labourer in the farms and would earn Rs. 30/- per day for his healthcare service, which was his secondary occupation. After he was certified, people in his village and other neighbouring villages got to know him for his skills. He no longer works as a daily labourer today as he is exclusively a healthcare provider. His monthly income has risen to Rs. 25000–30,000/-. With his increased earning, he has bought a plot of land to set up the facility for his services and named it Charak Vanoushodhi Evam Kudarati Pratham Upchar Kendra. Besides setting up Kendra, the certificate has allowed him to access raw materials easily as the forest officials know him as a genuine, certified TCHP. With the increase in his income, his family (Plate 2), especially the son and daughter, have also started assisting him. His daughter has established a registered Self Help Group in the name of Disha and has a small outlet next to the National Highway.

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(ii)

Pandit Motirambhai Choudhary of village Sonunia of Dang District was also certified for jaundice and common ailment during the pilot project (Plate 3). He said that being a tribal, he could collect raw materials for his medicines but could not enter the forest areas. With the certification, he now faces no problems entering the forest to collect raw materials to prepare his medicines. His earnings have increased after his certification, and he can help his family every month by earning Rs. 15,000– 20,000/-. With the increase in income, he has developed a home herbal garden on his land and is not dependent on the forest for collecting raw materials. He has earned respect among his community and the surrounding villages by which he can motivate the community to undertake medicinal plant cultivation on their respective plots of land.

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(iii) Sri Soniabhai Kasiram of Nilosi village of Valsad District was an evaluator for jaundice during the pilot project (Plate 4). He believes that his participation as an evaluator helped him to understand the certification process. He learnt the healing tradition from his father, Kashiram Raoji, and knew all the six streams taken up for certification under the pilot project. It is a family tradition for them, and all his four children—three sons and one daughter—are continuing the tradition. He has cultivated medicinal plants on his one-acre land and has engaged daily wagers for his cultivation work for whom he pays Rs 200/- per day and one-time meal. He spends approximately Rs.5000/- to Rs.7000/- per year to pay his daily wagers.

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He runs 4 centres in the name of Parampara Raoji Kendra at Dharampur, Vapi, Nilosi and Valsad. He caters to approximately 400 patients in each Kendra for arthritis, back pain, sugar, blood pressure, a common ailment and stones every month. He is referred to by allopathic doctors of Valsad District for paralysis cases and gets 10–15 referred patients for paralysis. He also provides free treatment for the needy and has an ambulance service. He has an earnings of between Rs. 1,00,000/- to Rs.1,50,000/- per month.

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(iv) Sri Manubhai Pilubhai Chavadari of village Wangan of Navsari District evaluated common ailments during the pilot project (Plate 5). He is 65 years old and provides his service for cases pertaining to paralysis, sugar, blood pressure, jaundice, a common ailment, poisonous bites and bonesetting. He has two sons. The elder son, Ishwar (Plate 6), has studied up to class V. Although Manubhai was well known for his services, since the pilot project, his name spread widely, and the number of patients rose. He was unable to handle his work alone. His son Ishwar, working in Mumbai in a steel polishing factory, left his job and joined his father.

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Both the father and son have set up four centres at Rumla, Dharampur, Kangwai and Manpurwada. They attend to 300–400 patients in a month for all four centres and earn Rs. 20000–25000/- per month to support by the family. The allopathic doctors of the region are aware of the services provided by Sri Manubhai Pilubhai Chavadari and his son Ishwar. As a result, they sometimes send their patients to the father and son duo, mainly for paralysis patients. While we were at their centre, a patient was brought on a two-wheeler from Nashik, a 3 hours ride. The patient (Plate 7—older adult seated on the two-wheeler) had paralysis. This was his third visit. He had to be carried on his first visit, but now he walked with support and could sit on the two-wheeler, although the right side, which is still affected, had to be tied to the vehicle for balance.

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It was a touching experience to see the positive impact created by the TCHP certification process in the lives of disadvantaged people. The certification has given much-awaited recognition. They now are recognised by their immediate beneficiaries, and the concerned government officials know them as genuine persons with the knowledge and skills for their tradition. Their family members are motivated to keep the tradition alive as their family heritage. The communities in close association with them have been encouraged to establish medicinal plant gardens on their land. Overall, there has been a remarkable upliftment for the sustainability of their practice as TCHPs and livelihood.

Conclusion Before the birth of the National Scheme for TCHP certification, the TCHP community was at a crossroad due to certain persistent challenges such as formal recognition (Unnikrishnan et al., 2019). The Central Government chose to honour three traditional healers on Republic Day in 2018 with the ongoing TCHP certifications. The central and state governments are being requested to adopt the scheme and induct the certified TCHPs into the primary healthcare delivery system of the nation. The National AYUSH/Health Mission is responsible for providing healthcare services that ideally need to integrate various systems under the mission available to provide healthcare to the common man. With the certification scheme being available, it would now be possible to integrate the TCHPs into the healthcare system. The Government of Meghalaya has taken the first step in integrating the certified TCHPs and senior TCHPs evaluators in their Traditional Khasi Wellness Centre and Spa, thereby making them a part of the Health and Wellness programme under the Central Government’s Ayushman Bharat Scheme. Similarly the Government of Tripura has also recognised the services of the certified THPs of the state recently in 2022. The policymakers should recognise traditional healers certified under the

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QCI scheme in the healthcare delivery system and incentivise them to go for such certification by various means, including subsidising their cost of certification under the National AYUSH /Health Mission or other schemes. Acknowledgements The author acknowledges the guidance of Prof Darshan Shankar and Sri Anil Jauhri. The numerous insightful discussions with Sri Hariramamurthy, Dr Anil Saraf, Dr Thirunarayanan and Mr S. Krishnamurthy while framing the scheme and the financial support from the then Department of AYUSH, Government of India, for funding the pilot project. The experience gathered from the pilot project led to the birth of the National Scheme for Voluntary Certification of the TCHPs.

References AYUSH. (2015). ‘Medical Manpower AYUSH’. Available at http://ayush.gov.in/sites/default/files/ MedicalManpower Table 2015 1995. ISO/IEC 10741–1. (1995). Available at https://webstore.iec.ch/preview/info_isoiec107411%7Bed1.0%7Den.pdf. (Accessed on 26 September 2021). ISO/IEC 17024. (2012). Conformity assessment—General requirements for bodies operating certification of persons. Roy, D. (2012). The IGNOU method for certification of traditional folk practitioners and practices. In Proceedings of the International Workshop on Integrating Traditional South Asian Medicine into Modern Health Care Systems (pp. 67). Jawaharlal Nehru University. Unnikrishnan, H., Sarin and Roy, D. (2019). Accreditation, certification and self-regulation. In A. Mishra (Ed.), Local health traditions plurality and marginality in South Asia (pp. 54–75). Hyderabad Orient Black Swan. QCI. (2018). Traditional Knowledge/Informal learning sectors: Possible role of Universities/IITs. Available at https://qcin.org/PDF/THP/Universities%20in%20Informal%20sector_ Ver%201.1_%2020%20052018.pdf. (Accessed on 26 September 2021).

Chapter 20

Local Health Traditions and Preservation of National Heritage: Emphasis on Intellectual Property Rights Protection, Benefit Sharing and Mainstreaming Sumeet Goel and N. Srikanth Abstract Traditional knowledge on health sciences in India is broadly comprised of systematically documented and dedicated compendia of Ayurveda, Siddha, Unani and Sowa-Rigpa. Besides this, there are health traditions in vogue, transmitted orally from generation to generation as local health traditions (LHTs) and ethnomedical practices (EMPs), which largely remain undocumented. During different periods, policies and strategies of the government opened avenues for integration of AYUSH and conventional medicine at research and clinical practice. However, non-codified traditional systems of medicine, practised as LHTs and EMPs, need to be brought into the mainstream through various implementation models, thereby formalising the LHTs within the health system. The significance of traditional medicine is seen in improving ecologically sensitive life patterns and interventions conducive to local natural conditions. In a resource-strained ecosystem, usage of available resources within their vicinity and their choice of health care becomes relevant. The use of TM impacts people’s health, and there is an increasingly commercial and scientific interest in traditional medicine systems, which has led to the need for their protection. However, the local folk healers and the communities do not have the means to safeguard their traditional knowledge. Strategy to protect the rights of the folk healers and the communities needs to be addressed. Therefore, effective models for intellectual property protection and proper benefit sharing need to be developed. An national networking system may be evolved for centralised documentation of these LHTs, ensuring ex situ protection of the IPR rights for the traditional healers or community. It becomes imperative to evolve a pragmatic model for the preservation of traditional medicine within the community and mainstream the practices through appropriate scientific validation and protection of their Intellectual Property Rights. This needs to be developed within the ambit of the biodiversity act, Drug and Cosmetic act and other social, ethical and community issues in force. Strong linkages and networking S. Goel (B) · N. Srikanth Ministry of Ayush, Central Council for Research in Ayurvedic Sciences, Government of India, New Delhi 110058, India e-mail: [email protected] © The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023 S. Reddy et al. (eds.), Ethnomedicine and Tribal Healing Practices in India, People, Cultures and Societies: Exploring and Documenting Diversities, https://doi.org/10.1007/978-981-19-4286-0_20

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across the scientists, regulatory authorities, authorities related to national biodiversity and patent offices for a strategy for the cause of protection of Indigenous heritage of LHTs. Keywords Local health traditions · National heritage · Intellectual property rights protection · Benefit-sharing · Mainstreaming

Introduction Local health traditions (LHTs) are the practices and experiences of general people and practitioners. It is transmitted through generations in the community orally or sometimes in personal diaries etc. LHTs, in context to India, is a crude, limited medical/health knowledge category that is fundamentally relatable and yet different from and acquiescent to India’s codified and officially recognised AYUSH systems. India is a big nation bequeathed wide diversity in ecoclimatic and geographical conditions besides several races, religions, traditions, dialects, culinary habits, languages and cultural beliefs with a significant economic variation. There are as many as 400 ethnic groups in India, rich in various traditional health practices interwoven in their cultural beliefs and daily regimen (An Appraisal of Tribal-Folk Medicines, 1999). Erstwhile neglected, traditional healthcare systems are appropriately recognised in the National Policy on Indian Systems of Medicine and Homoeopathy (2002); this recognition marks the coinage of the term ‘local health traditions’. This document has defined the term ‘local health traditions’ i.e. the undocumented Knowledge (or folklore health practices) possessed by birth attendants (dais), bonesetters, herbal healers, poison healers and other local community healers. After that, in 2005, policy on National Rural Health Mission (NRHM) was made, which proposed mainstreaming AYUSH systems and encouraging LHTs to strengthen primary health care. The Ministry of AYUSH also supports research work related to the documentation and scientific validation of LHTs under the Central Sectoral Scheme through the revitalisation of local health traditions scheme (Ministry of AYUSH, 2019). National Health Policy, 2017, has also accentuated access to assured AYUSH services, mainstreaming and integration of AYUSH services and has advocated for adequate documentation, validation and support of LHTs (Mishra & Nambiar, 2018). In this chapter, various approaches being adopted worldwide are discussed, and an attempt is made to understand and address the challenges and a way forward for the protection, preservation and mainstreaming of LHTs in India.

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Protection of the Traditional Medicinal Knowledge and Intellectual Property Rights of Customary Knowledge Holder/Traditional Healer India’s vast and diverse LHTs can address various healthcare challenges faced by the present world and hence possess a great perspective of being commercialised, benefiting the local communities at large. Intellectual property protection’s primary purpose is to protect the contributions made by holders of traditional healthcare knowledge and to check any third parties from getting undue advantages from its commercialisation by exploiting them. It will also help protect India’s TK from being patented outside the country, as in the case of a patent granted on turmeric for its wound healing properties in the USA and likewise a patent on Neem as a fungicide in the European Patent Office in May 2000. Both were later revoked after intervention from India, but this work is exhaustive and cumbersome, involving a lot of time and money; thus, a globally accepted answer to such biopiracy is required. The Traditional Knowledge Digital Library (TKDL), developed by CSIR and the Ministry of AYUSH (then Department of AYUSH), has addressed this problem to a remarkable extent (Traditional Knowledge Digital Library, 2019). Furthermore, as the tribal culture is rapidly changing in India, we will be losing valuable data related to folk practices if not documented and preserved for posterity. For this due recognition and protection need to be given to LHTs to preserve it and protect the rights of the customary knowledge holders. Also, many LHTs are exposed to exploitation by Herbal Pharma industries, which can directly exploit these herbs rather than engaging in patenting the chemicals, as can be sold in the name of ancient traditional medicines jeopardising the rights and appropriate benefit to the TK holder. Hence, rules need to be there that if such herbal companies exploit traditional knowledge they should repatriate the benefit to the customary holder of the knowledge. To understand it, we need to know the policy in force in these aspects. Policy Provisions on IPR protection: India follows the Convention on Biological Diversity (CBD) held on 29 December 1993 to protect and sustain the use of biodiversity and fair benefit sharing. As per Article 8 (j) of CBD, we must respect the knowledge and practices of indigenous and local communities relevant to sustained use and safeguard of biodiversity. It further binds contracting the parties to support the more large-scale use of such TK and ensure and support the equitable sharing (Article 15(6), (7), 16, 19(1) and (2)) of the gains arising from the commercial use of this knowledge. The CBD recognises every state’s freedom over its natural resources and asserts that the sustainable use and protection of biological diversity is “a common concern of humankind” (CBD preamble, Article 3). Thus, it empowers the country to conserve and sustain its biodiversity (Convention on Biological Diversity 1992). Whereas the Trade-Related Aspects of Intellectual Property Rights (TRIPS) agreement provisions minimum standards of protection for IPR, including the patents like innovations in biotechnology utilising biological and genetic resources, as these

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inventions are not relatable to the traditional knowledge associated with the genetic resources (Gupta A. 2004). The Biodiversity Bill, 2000, Section 36 (iv) of India provisions for the protection of LHTs of indigenous people related to biodiversity by measures such as registration of such expertise and development of a sui generis system, for ensuring fair sharing of benefits resulting from the use of the biological resources. Sections 19 and 21 conditions, prior permission of the National Biodiversity Authority (NBA) before their access. While approving, the NBA will impose terms and conditions that secure equitable sharing of benefits. As per Section 6, prior approval of the NBA is mandatory for obtaining IPR on research based on biological resources of India or data obtained from it to ensure fair benefit sharing. Section 18 (iv) specifies that NBA can take necessary steps to oppose the grant of IPRs in other countries on India’s biological resource and the obtained data/knowledge. (World Trade Organization, 14 July 2000). In the light of the above policies and provisions and keeping the National Health Policy of India 2017 in view, various modalities may be adopted to protect knowledge, innovations and practices. For instance, the documentation of LHTs, effective benefitsharing models, and development of a sui generis system and mainstreaming of LHTs in India through the systematic amalgamation of these into the AYUSH system of medicine. Documentation of Traditional Knowledge: Systemic centralised documentation of associated LHTs and EMPs could help in checking biopiracy. This documented database can be made available to patent examiners worldwide and the researchers after some provisions of registration and self-declaration. Prior art in the case of innovations based on such knowledge/data is easily obtainable by them, as in the case of TKDL. It will also facilitate connecting to the indigenous communities and genuine holders of the traditional knowledge and enable proper benefit sharing with them after commercialising such knowledge. It would help control the patents based on TK by bringing them into the public domain (Chouhan & Kumar, 2012). For this, a searchable systematic database on traditional healing knowledge/folklore practices can be developed, which will serve as single-point access to healing traditions in the country, and further, they may be gradually be included in the codified TK of India by their absorption in ASU pharmacopoeia. In India, documentation is being done by various stakeholders like CCRAS, Tropical Botanic Garden and Research Institute (TBGRI), Foundation for Revitalisation of Local Health Traditions (FRLHT) and Indian Council for Medical Research (ICMR), etc. Likewise, village-wise Community Biodiversity Registers (CBRs) are prepared to document several states’ knowledge, innovations and practices. Similarly, some organisations/institutions are systematically making the innovations compiled in their databases go public to prevent future patents based on the innovations, like the Farm Rights Information System (FRIS) maintained by the Swaminathan Foundation. ‘Honey Bee database’ established by SRISTI is another example found a decade ago in India; it is a facility for recording innovations by scientists/researchers themselves. It comprises documentation, experimentation and dissemination of indigenous/traditional knowledge. The interface has about 10,000

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innovations, with names and addresses of the innovators (individuals or communities). Different other healers’ associations are to be associated in the task of networking of documentation of LHTs. Like Lok Swasthya Parampara Samvardhan Samiti (LSPSS), Rashtriya Guni mission—a trust working on traditional medicine and other such agencies to be associated during Documentation for coordinated uniform Documentation of LHTs and EMPs across the country. However, these documentation works will only ensure protection under CBD, but sadly under TRIPS, it does not. Hence apart from documentation, other modalities are equally vital for the protection and preservation of TK.

Developing an Effective Model for Benefit Sharing Effective models for benefit sharing and law enforcement are vital for protecting the rights of TK holders. For instance, the South African Khomani San tribe uses the Hoodia plant (or Xhoba) to suppress hunger. In 1963 the SA Council for Scientific and Industrial Research (SA-CSIR) isolated P57, its proactive compound, and gave its licence to Phytopharm (a British pharmaceutical company). Later the lawyer of San Tribe contacted the SA-CSIR, which acknowledged its 1998 biopolicy that the owners of TK will benefit from the commercialisation of research findings based on their knowledge. Years later, in February 2003, the SA-CSIR and the Khomani San tribe entered into a Memorandum of Understanding and thus became beneficiary of millions of Rands shared each year between the San tribes of Southern Africa after its commercialisation in 2007 (International Intellectual Property Institute, 2007). If a proper law was there at that time, the tribe might not have to face such a condition, and many other tribes might not even know or try to fight back and get their due rights and benefits, thus losing their rights to the knowledge they have owned for centuries. Hence there is a need to develop models for benefit sharing and its enforcement under the law. Ideas may be taken from various models used worldwide. Certain prominent examples include the model adopted by Merck and Co. and Costa Rica’s National Biodiversity Institute (INBio) in 1991. The biodiversity conservation policy of Costa Rica prioritises sustainable use of biological diversity, thus promoting its conservation. Richerzhagen and Holm-Mueller (2005), has provided an insight to the benefit-sharing model of Costa Rica. They concluded that “by the establishment of an intermediate organisation as INBio, providing technical and scientific support and assisting in the conservation of biodiversity, countries can substantially boost their likelihoods to benefits from biodiversity prospecting”. This may also help to understand the importance of conservation and sustainable use of natural resources. Although a robust benefit-sharing model was not present in this study, the INBio’s Merck deal and its bioprospecting contracts failed to create sufficient income for the Institute to be economically viable. Hence, an essential takeaway of this case is that the schemes that are only based on royalties from the medicine’s patent are

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less likely to succeed even if countries have vigorous domestic legal enforcement in place (Edward, 2015). In India, the benefit-sharing models in the case study of herbal drug developed from arogyapaacha plant (trichopus zeylanicus) used by the Kani tribe of Thiruvananthapuram district Kerala may be explored. TBGRI developed a drug, taking the lead from this claim known as ‘Jeevani’. Three process patents on the making of herbal medicine from folklore medicine, arogyapaacha, were filed in India. In this regard, TBGRI supported the creation of the Kani Samudaya Kshema Trust aimed towards the welfare of the Kani tribe and also conservation through sustainable use of biological resources. TBGRI also extended monetary benefits to the trust through a fixed percentage of the royalties received from commercialising arogyapaacha-related technology (Pushpangadan, 1988). Similar innovative models need to be worked out. Several aspects require deliberations before developing the Indian benefit-sharing model. As in the case study on the Kani tribe, questions need to be answered like, who is qualified to get patent protection, the traditional healers/ knowledge holder community or the researchers or both. If commercialised, what should be the ratio of benefit sharing between traditional healers if he is an individual or a community and with the industry who is commercialising it. Who will regulate it and how to regulate sustainable cultivation of the medicinal plant, as it may have a sudden increase in demand (Gupta, 2004). A proper regulatory mechanism for protecting the collective rights is required in case the knowledge is owned in a community or more than one community besides a mechanism of individual rights. UNCTAD study on the existing models of transaction in India (Mukhopadhyay, 2002a) reported that the scope of benefit-sharing wanes with more public access to knowledge, as done by some organisations. Further disseminating novel claims of coded formulations exposes the knowledge and make it vulnerable to exploitation by third-party/industries, which will imperil benefit sharing. The study opines that monitoring and regulating access to such traditional knowledge is better to ensure fair benefit sharing and recognition of genuine knowledge holders. It is needed to create a sui generis arrangement with provisions to monitor and regulate such access.

Developing Sui Generis System for Protection of TK Evolving a robust mechanism for protecting LHTs and folklore healthcare practices is imperative for the countries with rich biodiversity, and LHTs, like India. As per Indian submission to WTO, a sui generis system apart from the existing IPR system needs to be devised to preserve and safeguard Indian TK. For this purpose, the parameters, components and modalities of a sui generis system require ponderance. Mukhopadhyay (2002) has given an extensive and explicit explanation of some crucial aspects essential for planning the sui generis system for India. He opined that IPR or free exchange or a reasonable aggregation of both might be a workable preposition for TK management in commercialisation to achieve greater benefit sharing.

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This system must consider the respective knowledge holder community their sociocultural and ethical resiliency, protection of biodiversity while serving the interest of the nation in the best possible and sustainable way. Thus, it emphasised preserving the respect of the Local community and their culture and protecting biodiversity while taking care of the TK provider’s interest and the nation both and considering it to be the base of any policy. Certain countries have made specific legislation that seeks to preserve the rights of TK holders, like in Brazil (Pereira et al., 2019). The Organisation of African Unity (OAU) (Regional Laws on Traditional Knowledge and Access to Genetic Resources Biocultural Heritage, 2019) etc. Policy and provisions can only be effective if proper law enforcement is there. Just strengthening the local communities only in the absence of proper law enforcement may be disastrous. For instance, as in the case of Cameroon in West Africa, which failed to exploit its medicinal knowledge sustainably, this caused the classic case of Prunus Africana (Hook. f.), which is used to treat benign prostatic cancer. The overexploitation of the plant took place by overextraction of the bark of the plant. There was no provision of Intellectual Property Rights in existing forestry laws or other regulations related to harvesting and biological diversity. As a result, overexploitation happened, and the TK holder community did not benefit (Laird & Lisinge, 1998). In this case, there was rampant exploitation of trees for their bark due to increasing commercial competition, and there was no management system in place at the regulatory level. This study suggests that mere issuance of permits without strong regulations does not guarantee the sustainable use of biological diversity since there is no harvesting control regulation or conservation of biodiversity-related enforcement in place (Sunderland & Tako, 1999). After that, several international, non-government organisations (NGOs) and governments came forward to promote sustainable control of biological resources in the wild, their proper cultivation and monitoring for fair trade. Villagers were strengthened and encouraged to come forward to safeguard the Prunus trees against illegal poachers and to check that only a legally sustained harvest of its bark is done. (Ndam, 2004). Later Cameroon became a Party to the CBD. Learning from these events, the Cameroon government affirmed a new Forestry Law No. 94/01 of 20 January 1994, which governs Forestry, Wildlife and Fisheries. As an outcome of this law, the major company involved in Prunus business in Cameroon and the villagers of Mapanja in 1997 signed the Agreement for Sustainable Management and Production of Prunus Africana at Mapanja Village”. It was signed to ensure sustainable use of biodiversity and limit exploitation while generating appropriate benefits sharing for local communities by commercialising Prunus bark. This agreement provided proper benefits for the village like better payment per tonne of collected bark etc.; it also provisioned training of villagers in sustainable harvesting methods under this agreement. Thus it paves the way for better conservation of the species and improving its population by concerted efforts for its cultivation. As a result, Cameroon witnessed a drastic drop in illegal activities and overexploitation of Prunus bark and provided better economic benefits to the community (Hall et al., 2000). It stands as an important cautionary tale for the importance of a comprehensive regulatory and ethical

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framework to be in place for protection against the exploitation of commercially viable species (Bodeker et al., 2014). In IPR, we talk about pharmacological, chemical derivatives of these herbs, which are a small part of vast TM. As per TRIPS, if it is not patented, it is not earned, whereas as per CBD, if it is in practice by a community, they are the owner. Measures need to be taken to bridge this gap and make a comprehensive law covering the provision. Under IPR provisions, the inclusion of various aspects for the protection of TM may also be explored like trademarks, Geographical Indicators (GI) etc.

Distinctive Signs (Geographical Indications, Certification Marks) India has a diverse and distinctive cultural heritage of which LHTs is an integral part, interwoven as a part of daily life in many communities. These can be protected through a distinctive sign, such as a GI like Parmesan cheese only in Italy. Similarly Ashwagandha grown in Nagaur region of Rajasthan state of India may be given a GI tag of ‘Nagauri Ashwagandha’, which have special qualities as per Ayurveda. For this Documentation of LHTs to be taken based on geographical location, state level and central level through a National Network for Documentation of LHTs (NNDL), the North Eastern Institute of Ayurveda and Folk Medicine Research (NEIAFMR) at Passighat Arunachal Pradesh can be designated as NNDL. Moreover, the WIPO-UNEP study about Nigeria (Gupta, 2004), where the laboratory of Bioresources Development and Conservation Programme (BCDP) provided certification and attached a label to the product for providing quality assurance, likewise, the certification mark can be made for an assertion on the genuineness and quality. This may improve its market acceptance and hence could generate better benefits for the innovators and the community/TK holder. Furthermore, this certification mark may also ensure that only the product from sustained harvesting gets it, and no product made of illegally procured raw material may get this mark. However, this part may need due deliberation on the regulatory aspect. Such provisions can help in the long term protect biological biodiversity and strengthen these communities by providing more benefits from the knowledge they pass to the world by improving their market acceptability.

Suggested Approach for Protection of TK • The TK needs to be preserved in the form it is practised. These traditional practices are very similar to Ayurveda in terms of their holistic approach. Hence, going for a phytopharmaceutical way for new chemical entity though it can be done simultaneously, cannot fully justify the TK. Neither it will always give the same

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result as giving the treatment holistically. Since AYUSH is now established, it can play a pivotal role. These LHTs and EMPs may be systematically absorbed in ASU pharmacopoeia, thus preserving their holistic form in use and also the knowledge. Further, the formulations thus made and commercialised from these folk claims must have adequate benefit sharing with the folk healer and his community (if it is a knowledge of community). The formulation must always acknowledge its source, like any classical formulation marketed, always carry the reference of the text on which it is based like Charak Samhita, Bhaishajya ratnavali, etc. Likewise, any formulation made from the folk claims must carry their community name. This will ensure proper acknowledgement of the community. Protection and sustainable use of bioresources need to be addressed with utmost care as a medicinal plant is fast vanishing. Thus an interface could be created wherein the industries could fund, and the community-level commercial cultivation of medicinal plants may be done for its supply as per their annual need without jeopardising the rights and benefits of the cultivating communities. Furthermore, a pre-defined part of the earnings from the commercialised finished product made of TK can be allocated to conserve the plant. As suggested by Priya and Shweta (2010), the Ayush healthcare providers posted at PHCs can be sensitised towards the locally practised LHTs. The folk healers can also be invited to the PHCs under the supervision of the Ayush physician, and the provision of small gardens for plantation of the medicinal plants of these LHTs in the PHCs and health and wellness centres with due recognition of the folk healers can be made. It will substantially impact its conservation by sensitising the general public in the vicinity and making it available to the public in a cost-effective way for their primary health care needed. The Convention on Biological Diversity (2019), Article 2, defined ‘sustainable’ as the methods of use of biological diversity in such a way and at a rate that should maintain its long term biological diversity to ensure it is available substantially for our future generations also. This definition needs to be incorporated in the policy for the protection of Biological biodiversity and TK, including TM. Training on sustainable cultivation of medicinal plants in the communities will be conducive. Further, to empower the villagers/community in sustained cultivation and to bring the product to market, linking their cultivation with microfinance self-help groups could be explored. This will make them the direct beneficiary of the TK they possessed. The community people/villagers may be encouraged and trained towards better cultivation techniques to increase total bioresources and document them with liaison to AYUSH institutions in the vicinity to keep the LHT alive. The trade of raw medicinal plants needs to be checked through strict regulatory mechanisms. Farmers and local communities engaged in the cultivation of medicinal plants may be sensitised to NMPBs ‘e-Charaka’ initiative to bridge the gap between the industries and the farmers. More significant consultative meet(s) to be organised under NNDL to discuss various issues involved in implementing the task, viz., preparation of standard

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format, methodology for documentation of LHTs, protection of biodiversity and benefit sharing, etc. The government may set up a nodal agency under NNDL to store the database of documented LHTs. Further, communities or the local leaders may be educated to preserve their TK in documented form, even if they do not wish to disclose it to anyone. If they wish to disclose it at a certain point, they need to be taught through sensitisation programmes to whom to disclose. The documentation work also needs to ensure that the novel claims should not be published prematurely as earlier done many times as ethnobotanical claims, etc. They can be first validated and protected through patents to provide appropriate benefits to the community. An effective mechanism needs to be developed to extend the benefit sharing and all necessary support to the healers. Healers/ local communities are to be duly recognised for their contribution. Unique/novel LHTs must be protected from biopiracy through defensive protection in the case of LHTs. A validated claim should be programmed basically to extend livelihood security to healers/local communities and not as mere industry-oriented/ commercial benefit. Healing traditions can be identified through systematic study of tribal communities/ anthropological studies. The studies undertaken by the universities and the data generated through different PhD. /MPhil works can be considered while implementing the task, and research scholars should be encouraged to take up further studies in LHTs. Sustainable sources of medicinal plants need to be ensured before the planning of commercialisation of LHTs; otherwise, it may lead to destruction or overexploitation of medicinal plant resources.

Mainstreaming of Local Health Traditions There is a great diversity in the LHTs being practised in India, and still, most LHTs exhibit striking similarities in fundamental approaches. These are based on generations of experiential knowledge being passed orally or as personal diaries through generations. Unlike Ayurveda and other AYUSH systems, which are systematically codified through documentation, however, there are striking similarities among both, and a substantial number of LHTs are crude form and locally adopted forms of Ayurveda system. To harness its true potential in addressing the primary healthcare needs and protecting them, mainstreaming LHTs is one of the vital modalities. Certain efforts have been made to mainstream LHTs in India. As discussed vide-supra, the Indian Public Health Standards (IPHS) has also advocated the setting up a herbal garden in sub-centre and PHCs (AYUSH in India., 2014). Furthermore, few states have some promising initiatives. For instance, innovative activities like ‘Ayurved Gram’ and ‘Dadi Maa Ka Batua’ in Chattishgarh; the inclusion of home remedies in the AYUSH drug kit by J&K Programme Implementation Plans; the ‘Gyan Ki

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Potli’, which includes AYUSH medicines and cost-effective home remedies based on LHTs in Madhya Pradesh.

Suggested Approaches for Mainstreaming of LHTs in India Various modalities may be worked upon for effective mainstreaming of the LHTs and folk healers. • Systematic documentation and scientific validation are crucial for mainstreaming EMPs and folklore claims and other LHTs prevalent across different ethnic groups and communities. (Srikanth et al., 2017) Inclusion and mainstreaming of the LHTs are very important for the preservation and propagation of this traditional wisdom. India is rich in traditional medicinal knowledge. LHTs are still flourishing in various rural parts of India, though urbanisation and changed lifestyle resulted in the slow erosion of such knowledge rays. With a vast repository of such knowledge, India must collect and scientifically document this information to enrich its existing pharmacopoeia (Darshan Shankar & Unnikrishnan, 2004). Enriching ASU drug pharmacopoeia through systematic absorption of traditional medicine through proper documentation and validation will certainly make avenues for the protection of ethnomedical heritage. • As suggested by Priya and Shweta (2010), with documentation, legitimising LHTs can be linked up to ensure the located AYUSH doctor in that area is made aware of the LHTs and bring them into use/practice for integration in national healthcare delivery system. This will pave the way to integrate the folk healers into the mainstream and help assuage the burden from the healthcare sector. However, genuine folk healers need to be identified, and specific certification may be done as advocated by the University of Trans-Disciplinary Health Sciences and Technology. It can be done through the Accreditation and Certification of Prior Learning programme (ACPL) (Traditional Community Healthcare Providers, 2019) or Voluntary Certification Scheme for Traditional Community Healthcare Providers (VCSTCHPs) developed by Quality Council of India and FRLHT, Bengaluru. Such linkages of LHTs with the AYUSH services would be mutually beneficial, will help in the development of the system as well. • The study on the, “Status and Role of AYUSH and Local Health Traditions under the National Rural Health Mission: A Health Systems Study across 18 States” elaborated that the documentation should be followed by validation, based on the locally prevalent systematised traditional medicine. The validation has to be done by the AYUSH doctors at the district level and then promoted for use by the community and put to use at the health centres. This would revitalise the LHT and contribute to strengthening the knowledge base of AYUSH and promote its non-commercial practice using local herbs. Each state may generate Standard Guidelines for Treatment to all healthcare providers (including the doctors of allopathy and AYUSH, ANMs and ASHAs), stating the role of LHTs in primary

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care and the points of cross-referral as done in Srilanka. This certainly is one of the most viable ways for bringing the LHTs along with AYUSH into the mainstream. Through its preventive and primary level care, this would also decrease the need for secondary and tertiary care, thereby creating the possibility of sustainable and comprehensive healthcare services. A similar suggestion was made way back in 1974, in the Srivastava Committee’s Report on Medical Education and Manpower Support (Government of India, 1974: 26). It recommended that indigenous healers could be integrated into the community as ‘local para-professionals’ who can contribute in providing “simple specified medicines for common day-to-day illnesses”. The same thought process is also reflected in the Alma Ata Declaration (September 1978) that traditional medical practitioners and birth attendants are found in most societies. They are often part of the local community, culture and traditions, and have a respectful social status, especially in rural settings. With amicable support from the formal health system and regulatory bodies, these folk healers can become key allies in providing pre-primary to primary care, which will help improve the health of the community as a whole. It is, therefore, worthwhile exploring the possibilities of engaging them in primary health care and training them accordingly. • Another approach can be to fund the education of heirs of the folk healers in Ayurveda through BAMS course to understand the basics concepts of Ayurveda and medical science. Through this, they can also better appreciate the traditional knowledge they have acquired through their family or community and can better serve the society in their locality by the effective amalgamation of their knowledge with Ayurveda bringing it into the mainstream. He may further contribute to the validation and research work for drug development and inclusion in ASU pharmacopoeia. Though it will take time, this may help bridge the gaps between local health traditions and codified traditional medicine in India. This will also help solve the challenges of introducing AYUSH in certain areas where LHTs are pretty popular. Like in the case of Meghalaya (Albert & Porter, 2015), in Sikkim, Arunachal, Manipur and all the other North Eastern States (Reddy, AIFIGNCA Report, 2019), they may also be sensitised and taught the importance of protecting such knowledge through current regulatory laws. They may also contribute to proper documentation of their TK and be made vigilant towards any misuse of their TK without due recognition, as done by TKDL through defensive protection. However, protecting their TK from outside agencies is a long battle to be fought, and stringent rules need to be devised. Still, bringing the heirs of the TK holder community into the mainstream will undoubtedly help pave a way towards strengthening the defensive protection of their TK. Simultaneously, they can work towards appropriate commercialisation through positive protection by helping their community preserve their knowledge and use it for appropriate benefits to the community. They may be trained during their studies in conservative cultivation and sustainable use of their bioresources, preparation of medicines, improving their shelf life, research work and publication, and also by bringing their knowledge into codified AYUSH systems of medicine.

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• Genuine and locally trusted folk healers in the villages can be identified and trained in holistic health practices. They can provide the first level services, and it will also ensure its preservation. Some efforts have been made in this regard; however, it still needs to be driven on a larger scale as LHTs, and genuine folk healers are vanishing fast with urbanisation and poor livelihood prospects in its continuation by the younger generation. They may be made the fourth level of health care or a pre-primary level who can work in assistance of the Panchayat and convergence with local healthcare setup (PHCs, sub-centres) with priority to AYUSH health setup. They can play a substantial role in meeting the basic health needs and act as a strong link between the health agencies and local people. This will be a significant step towards ensuring universal health coverage even in developing countries like India • Developing linkages with the folk healers by using their services, promoting interactions of Ayurveda scholars with folk healers, by inviting the folk healers as guest lecturers in Ayurveda College, interaction with local community healers through field studies to document the claims would help the AYUSH doctors to develop better convergence with the folk healers and help in improving their integration into mainstream health service by improving confidence and trust among each other. The newly developed North Eastern Institute of Ayurveda and Folk Medicine Research (NEIAFMR) (erstwhile North Eastern Institute of Folk Medicine) can act as a think tank and nodal point for evolving policies and mechanisms for adequate documentation and mainstreaming of folk medicine into mainstream AYUSH systems and at the same time, preserving the rights and benefits of the knowledge holder community. • An inclusive approach having a successful integrative healthcare model integrating local health traditions with another Indian system of medicine should be done judiciously without losing their core fundamentals and preserving the rights of the folk healers. Hence, it must always be the central objective while devising a roadmap for the protection of LHTs.

Conclusion To sum up, the vast and diverse traditional knowledge which is an integral part of the lifestyle and custom of many Indian communities need to be duly acknowledged and protected from getting extinct. Simultaneously, measures need to be taken for effective mainstreaming of LHTs, which will help address the primary level healthcare needs. Further, national laws in coherence with international laws for the protection of IPR of the customary knowledge holder of the TK and from undue exploitation of the bioresources need to be framed and effectively enforced. NNDL may play a crucial role in bringing all stakeholders engaged in LHT documentation and working on various benefits sharing models on one stage to evolve a comprehensive and practical benefit sharing and documentation method. Under the Ministry of AYUSH, the North Eastern Institute of Ayurveda and Folk Medicine Research (NEIAFMR)

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at Passighat Arunachal Pradesh can be designated as NNDL. Holistic approach in which the LHTs are practices will be better appreciated and can serve the healthcare need, by their amalgamation in Ayurveda, being similar in the methodology and approach to Ayurveda. Hence, systemic inclusion of LHTs in the pharmacopoeia of Indian Traditional Medicine (ASU pharmacopoeia) will ensure the TK’s protection and help in appropriate commercialisation and benefit sharing, though a proper and transparent regulation of the same need to be framed.

Fig. 20.1 Outline of a suggested approach for the protection of Traditional Knowledge (TK) in context to Local Health Traditions (LHTs)

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Solid linkages and networking across the scientists, regulatory authorities, authorities’ related to national biodiversity and patent offices for future strategy are needed for the cause of protection of indigenous heritage of LHTs (Fig. 1). Effective modalities for developing the Sui generis system for the Indian scenario need to be framed and enforced on an urgent basis to safeguard and preserve India’s vast and diverse traditional medical heritage. The TK holders and communities do not know the policies about IPR protection or safeguarding their monetary rights and are susceptible to exploitation by third parties. In congruence with natural justice, the traditional healers are given a more significant say in all matters regarding the documentation, study, extraction and commercialisation of their TK and bioresources. A policy that does not hinder the progress of knowledge preserves biodiversity. It is done by its sustainable use and proper intellectual property protection with a robust, transparent mechanism. This will ensure fair benefit sharing, encouraging and developing entrepreneurs, supporting them through certification marks, GI tags, and under One District One Product initiatives. Their recognition and mainstreaming in AYUSH and as the fourth tier of health care will, in proper form, do justice to the vast TK wealth of India.

References AYUSH Report. An Appraisal of Tribal-Folk Medicines. (1999). Central Council for Research in Ayurveda & Siddha, Department of AYUSH, Ministry of Health and Family Welfare, Government of India, New Delhi. Arima Mishra and Devaki Nambiar. (2018). On the unravelling of ’revitalisation of local health traditions in India: An ethnographic inquiry. International Journal Equity Health, 17, 175. https:// doi.org/10.1186/s12939-018-0890-1 AYUSH in India. (2014). Planning & Evaluation Cell, Ministry of Ayurveda, Yoga & Naturopathy, Unani, Siddha and Homoeopathy (AYUSH). Government of India. Bodeker, G., van‘t Klooster, C., & Weisbord, E. (2014). Prunus Africana (Hook.F.) Kalkman: The overexploitation of a medicinal plant species and its legal context. The Journal Of Alternative And Complementary Medicine, 20(11). Mary Ann Liebert Inc: 810–822. Chouhan, V. K. (2012). Protection of traditional knowledge in india by patent: Legal aspect. IOSR Journal of Humanities and Social Science, 3(1). IOSR Journals: 35–42. Convention on Biological Diversity (CBD). (1992) Rio de Janeiro 5:31. https://www.cbd.int.doc. legal.cbd-en 2019 Text of the Convention. Article 2: Use of terms. Online document at: www. cbd.int/convention/articles/default.shtml?a=cbd-02 Darshan Shankar, P. M., & Unnikrishnan. (2004). Challenging the indian medicinal heritage. In Foundation Books (pp. 42–53). Edward, H. (2015). Amid controversy and irony, Costa Rica’s INBio surrenders biodiversity collections and lands to the State. TWN Info Service on Biodiversity and Traditional Knowledge. Third World Network. Government of India. (1974). “Srivastava Committee Report—Health Services and Medical Education: A Program for Immediate Action,” New Delhi: Ministry of Health and Family Planning http://www.nhp.gov.in/sites/default/files/pdf/Srivastava_Committee_Report.pdf. Gupta, A. (2004). WIPO-UNEP study on the role of intellectual property rights in the sharing of benefits arising from the use of biological resources and associated traditional knowledge. World

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Intellectual Property Organization (WIPO) and the United Nations Environment Programme (UNEP), (pp. 104). Hall, J. B., O’Brien, E. M., & Sinclair, F. L. (2000). Prunus Africana: A monograph. School of Agricultural and Forest Sciences Publication Number 18, University of Wales, Bangor (pp. 104). International Intellectual Property Institute. (2007). “Is a sui generis system necessary? BenefitSharing agreements”. Archives/International Intellectual Property Institute. https://iipi.org/200 4/01 Laird, S. A., & Lisinge, E. (1998). Benefit-sharing case studies: Ancistrocladus korupensis and Prunus Africana. In Conference of Parties to the Convention on Biological Diversity. 4th meeting Bratislava, Slovakia 4–15 May (pp. 49). UNEP/CBD/COP/4/Inf.10 Ministry of AYUSH. (2019). LHT. Central Sector Scheme. http://ayush.gov.in/schemes/central-sec tor-scheme/lht. Mukhopadhyay, K. (2002) Indian medicinal knowledge: possibilities of benefit-sharing in the context of the present trade and the IPR regime. In Cuts centre for international trade, economics & environment. Briefing Paper February 2002a. “Traditional medicinal knowledge of India: An overview on commercialisation and benefit sharing”, Mimeo, UNCTAD, New Delhi Narayanam, S., Maheswar, T., Sunita, Tripathi Ashish, K., Chinmay, R., Shruti, K., Sharma Madan, M., Sahi Vinod, K., Sobaran, S., Mangal Anupam, K., & Gaidhani Sudesh, N. (2017). Generation of basic information on claims pertaining to local health traditions, oral health traditions, and ethnomedical practices for validation: An elective pro forma for documentation by individuals. Journal of Drug Research in Ayurvedic Sciences, 2(4), 306–311. National Health Policy. (2017). Ministry of Health and Family Welfare, Govt. of India. NHP; 2017. Available from: https://www.nhp.gov.in//NHPfiles/national_health_policy_2017.pdf National Policy on Indian Systems of Medicine & Homoeopathy. (2002). Ministry of Health and Family Welfare, Government of India, New Delhi. Ndam, N. (2004). Prunus Africana: A traditional medicine finds international fame. In C. Lopez & P. Shanley (Eds.), Riches of the forests: For health, life and spirit in Africa (pp. 33–36). Pereira, F., Da Cunha Cintra Azarite, F., & Leite, G. A. (2019). “Brazil: Provisional Measure No. 869/18 Creates The Brazilian Data Protection Authority And Amends Several Articles Of The Brazilian General Data Protection Law”. Mondac. http://www.mondaq.com/brazil/x/818496 Priya, R., & Shweta, A. S. (2010). Status and role of AYUSH and local health traditions under the national rural health mission: A health systems study across 18 States. National Health Systems Resource Centre. Pushpangadan, P., Rajasekhjran, S., Ratheesh Kumar, P. K., Velayudhan Nair, V., Lakshmi, N., & Sarad Amma, L. (1988) Arogyapacha (Trichopus Zeylanicus). The Ginseng of Kani Tribes of Agasthyar Hills (Kerala) for evergreen health and vitality. Ancient Sciences of Life, 7, 13–16. Regional Laws on Traditional Knowledge and Access to Genetic Resources Biocultural Heritage. (2019). Biocultural.Iied.Org. (Accessed 25 August). https://biocultural.iied.org/regional-laws-tra ditional-knowledge-and-access-genetic-resources Richerzhagen, C., & Holm-Mueller, K. (2005). Ecological Economics, 53, 445–460. Sandra Albert and John Porter. (2015). Is ‘mainstreaming AYUSH’ the right policy for Meghalaya, northeast India. BMC Complementary and Alternative Medicine, 15, 288. Sunderland, T. C. H., & Tako, C. T. (1999). The exploitation of Prunus Africana on the island of Bioko, Equatorial Guinea. A Report for the People and Plants Initiative, WWF Germany and the IUCN/SSC Medicinal Plant Specialist Group. Traditional Community Healthcare Providers. (2019). In Activities of: Centre for local health traditions and policy. Available at http://tdu.edu.in/home/clhtp/. (Assessed on 15 Aug 19) Traditional Knowledge Digital Library. (2019). Tkdl.res.in. http://www.tkdl.res.in/tkdl/langdefault/ common/Home.asp?GL=Eng.

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WHO. “Alma Ata Declaration”. (1978, September). In Presented at the International Conference on Primary Health Care at World Health Organization, Geneva, (pp. 6–12). http://www.who.int/ publications/almaata_declaration_en.pdf World Trade Organisation. (2000, July 14). Protection of biodiversity and traditional knowledge— The Indian experience, Submission of India, Committee on Trade and Environment and Council for Trade-Related Aspects of Intellectual Property Rights, WT/CTE/W/156, IP/C/W/198. https:// www.twn.my/title/cteindia.htm

Chapter 21

An Expanded Health Systems Perspective on Tribal Health Knowledge and Practices: Contemporary Relevance and Challenges Ritu Priya Abstract The health knowledge of indigenous/tribal peoples, developed globally over centuries through their intimate relationship with nature, is a highly understudied component of the present health system by health systems research or health policy research. While in practice, it is a living and dynamic stream in almost all parts of the world, the disciplines of public health and health systems research have tended to ignore it as a valuable resource. Ethnobotany and anthropology, as well as pharmacology and the pharmaceutical industry, have studied it and drawn upon it for both academic knowledge development and product development, for academic and commercial purposes. This paper will examine the contemporary relevance of indigenous health knowledge in India and argue its importance from a health systems perspective. Drawing from national and international debates and approaches adopted by various countries, it will examine the challenges to its continuing use and the various options available to protect and promote it. Keywords Health systems perspective · Tribal health knowledge · Health policy · Health practices · Challenges

R. Priya (B) Centre of Social Medicine and Community Health, Jawaharlal Nehru University, New Delhi, India e-mail: [email protected] © The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023 S. Reddy et al. (eds.), Ethnomedicine and Tribal Healing Practices in India, People, Cultures and Societies: Exploring and Documenting Diversities, https://doi.org/10.1007/978-981-19-4286-0_21

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The Context of Healthcare Policy for Adivasis/Tribal1 Populations in India The over 104 million Scheduled Tribe population in India constitutes only about 8.6% of the country’s population. However, their distinct social and cultural life, shaped by the natural ecosystems of which they have been a part for a long time, gives them a unique place in the development map of the country. The Constituent Assembly that drafted the Indian Constitution in 1946–49 had intensely debated the unique situation of tribals. The diverse views on how the independent Indian state should address these communities’ issues; various approaches advocated their continued isolation from mainstream society, their assimilation, or integration while retaining their distinctiveness. It finally resolved to give them the freedom to continue to live their traditional life pattern, even while they were to be supported in developing according to their wishes and genius. However, by the last decades of the twentieth century, the health status of the tribal population was worse off than the other social categories for which the state had disaggregated data. For instance, in 2008, the infant mortality rate (IMR) was 74 for the ST as against 62 for all other groups together, and data of 2015–16 shows that life expectancy at birth was 63.9 years for ST as against 67 years for others (Govt. of India, 2018). Can this be interpreted to argue that they are ignorant and backward people who need to be educated and civilised into the mainstream way of life and medical care? Does it mean that the way of life of the tribal communities is ‘unhealthy’ and their medicines or health knowledge is of little value? Going by the dominant health systems thinking that is focused on top-down provisioning of health services of ‘modern medicine’, what has more recently come to be known as ‘conventional medicine’, this seems to be the conclusion. Nevertheless, if we take a bottom-up view of the issue, i.e. from the perspective of the tribal and other communities, and if we are looking for solutions to the ecological and social crisis the world finds itself in today. Then it can be argued that ‘tribal health systems’ have relevance for the tribal communities and the rest of us seeking ways of building sustainable futures in the twenty-first century. This paper, therefore, argues that the contemporary relevance of tribal medicine is not only as a nature-based pharmacopoeia or clinical medical knowledge but as part of a way of thinking about health and health care in health systems development (HSD). Furthermore, this can help us build a more equitable and empowering health system for the tribal communities and a more sustainable one for the world. We use the term ‘tribal health knowledge’ for all the various ways human health is understood, safeguarded and maintained

1

While ‘indigenous populations’ is currently an internationally used term, in India, ‘tribal’ came to be used by colonial governance in the nineteenth century to denote the communities with certain characteristics that put them outside the mainstream and with social structure and life patterns considered ‘primitive’ and non-complex. This continued in postcolonial India in the category of Scheduled Tribes. However, some communities in this category, especially in the Central Indian belt, have contested such a term and prefer ‘adivasi’, translated as ‘the original inhabitants’.

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by tribal communities and use ‘tribal medicine’ to denote its component related to treatment.

The Contemporary Dominant Health Systems Perspective Public health and health systems research (HSR) itself is not an adequate dominant perspective as it is practised today. It is often contended that public health is broader and more ‘holistic’ than clinical medicine because it addresses the population and its subgroups rather than the individual. On the other hand, ‘holistic medicine’ has also been used and has become increasingly popular. However, it is limited to individualcentred clinical practice that goes beyond the physical and takes the psychosocial and spiritual dimensions of the person or patient into account and addresses them at the individual level. As we define it, public health is distinct from medicine because it is about society and the population health. Therefore its diagnosis, prevention and ‘treatment’ are at a population level, with community diagnosis and systemic solutions. The ‘ecological’ approach in public health views causality of ill-health as multiple factors and processes, linking to the macro, meso and micro-level determinants. It follows that the solutions for public health problems have to address these multi-level factors and processes through a combination of interventions designed to act concertedly across these levels of social organisation (Susser & Susser, 1996, McLaren & Howe, 2005). Therefore, it will mean approaching health care in a much wider frame than the hospital and doctor-centred dominant approach, thereby centring people’s health in their life context and health care from home and community level, in addition to the primary, secondary and tertiary level institutions (Priya, 2018, 2011). All these levels of care, especially the home and community, are culturally attuned and should address the specific features of diverse ecosystems. This includes, in practice, even in the twenty-first century, the use of knowledge and technologies other than the dominant, conventional modern biomedicine (Bodeker & Kronenberg, 2002; Priya, 2013). The strengths and limitations of the dominant biomedicine and the other knowledge have been acknowledged in writings since the 1970s. Therefore, today they are seen as all of them have features that can complement each other in preventing and treating ill-health (Illich, 1977; NIH 2021). These are relevant in contemporary times, on the one hand for healthcare access and context specificity as well for the assertion of the identity of the marginalised such as the tribal populations, and on the other for the generation of approaches for sustainable solutions to health problems (Priya & Kurian, 2018). Health systems research (HSR), however, in its current dominant framing, does not consider any other than the dominant biomedicine (Gilson, 2012). As a component of public health, HSR attempts to consider the social, political, economic and cultural dimensions of determinants of health and health care. However, over the last few decades, it has been narrowed to “health service systems research” with the system being restricted to modern medical services. It leaves the social determinants of health outside its purview, thereby addressing other development sectors

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and not as part of the ‘health system’. The dominant stream of public health and health systems development is, at least since the 1990s, focused on health services delivering biomedical technologies and since 2000, in attempting ‘Universal Health Coverage’ with such services (HLEG, 2011). This reductionism in HSR has been due to the discourse of health becoming more and more medicalised. It has been captured mainly by the medical-industrial complex and social scientists, mainly in economics and management science. It has, thus, essentially become ‘implementation research’ for medical services. The “six building blocks of health systems” enunciated by the WHO (as depicted in Fig. 21.1) demonstrate the top-down reductionism in this perspective—where the people or the system’s users are absent! The desired outcomes and goals are spelt out, but there is no recognised role in the envisaged health care for the communities to be served. At best, they are to be ‘educated’ in the biomedical requirements necessary to use medical services properly. Subsequently, this glaring absence has been acknowledged and given a token inclusion. The contemporary dominant HSR stream restricts even its economic analysis to ‘inequities’ of access to conventional health care and the ‘cost-effectiveness’ of its technologies. It does not examine the linkages and impacts on health and healthcare systems of more prominent societal factors and processes. However, other streams engage in HSR with a broader perspective. The broader analysis in HSR generally comes from those engaging in analysis of the political economy of health and health care (Qadeer, 2019, Priya, 2018). Both the above-discussed streams, the dominant and the political economy streams, rarely use a cultural lens. They consider ‘modern’ biomedical knowledge as the only legitimate form of health-related knowledge (or concede that there are other knowledge systems but that the ‘modern’ is the highest form of knowledge). SYSTEM BUILDING BLOCKS

OVERALL GOALS/OUTCOMES

SERVICE DELIVERY HEALTH WORKFORCE ACCESS

INFORMATION

COVERAGE

MEDICAL PRODUCTS, VACCINES &TECHNOLOGIES

IMPROVED HEALTH (LEVEL AND EQUITY) RESPONSIVENESS SOCIAL AND FINANCIAL RISK PROTECTION

QUALITY

FINANCING

SAFETY

IMPROVED EFFICIENCY

LEADERSHIP/GOVERNANCE THE SIX BUILDING BLOCKS OF A HEALTH SYSTEM: AIMS AND DESIRABLE ATTRIBUTES

Fig. 21.1 WHO health system framework. Source Everybody’s business: strengthening health systems to improve health outcomes: WHO’s framework for action. WHO, 2007, Geneva

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Because the ‘health system’ delivers conventional medical services based on it, the issue becomes primarily one of ‘universalising its access’. There is no question of studying medical pluralism, bringing in the role of politics of knowledge or community agency in looking after its health, that would then require an understanding of other health knowledge systems, with the understanding that they have valid, though different, epistemologies. The study of people’s health-seeking behaviours, including tribal communities, identifies why they do not always come for conventional medical services. What, according to them, are the gaps in these services and what may be helpful knowledge and practice in other forms of health care. Thereby the dominant HSR, which claims to be very comprehensive and holistic, does not end up being either because it gives little space to the political economy of health and health care and none to their politics of knowledge. At the same time, the ongoing work of several other streams globally and nationally, from those on Traditional, Complementary and Alternative Medicine (TCAM) to those on Rights of Indigenous/Adivasi Peoples, has generated enough evidence and pressure for the beginnings of its consideration by mainstream HSD, globally and in India (WHO, 2013; Anderson et al., 2016; NHSRC, 2009; Priya & Shweta, 2010, Unnikrishnan, 2010). While acknowledging mainstream institutions such as the WHO and national governments, they develop as a parallel stream to the dominant HSR. These developments in the mainstream approach to tribal health systems can be evidenced by two recent Government of India committee reports and the international World Intellectual Property Organisation’s (WIPO’s) debates on protecting the rights of traditional knowledge holders.

National and International Development of Formal Institutional Responses to Tribal Health Knowledge in the Twenty-First Century The report of the High-Level Committee on Socio-Economic and Health Status of Tribal Communities in India set up by the Ministry of Tribal Affairs (GoI, 2014) finds little mention of tribal medicine or health knowledge. It highlights the negative health indicators of tribals as a dismal group in the country. It also gives data to show a lack of access to public health services and yet does not credit any access to health care through their use of tribal medicine. The report shows that malnutrition is rampant among the Adivasis, but it does not mention that their food diversity was traditionally the highest and had a minuscule carbon footprint. There is enough documented evidence that the most diverse, naturally produced, collected and cultivated food exists in the traditional tribal food system (Jain & Tiwari, 2012). While presenting data on health indicators, those positive for the tribal population compared to other sections are presented but not discussed. For instance, the markedly better sex ratios in favour of females (990 females/1000 males while all-India is 927/1000), or the

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significantly higher rates of exclusive breastfeeding for infants 0–5 months (61% among the tribal population as against 43% of the non-tribal population) (GoI, 2014). It is argued by those who question the validity of tribal knowledge that, at one point in time, the tribal food systems and tribal medicine may have been relevant. However, today they are not since the more advanced knowledge of biomedicine is available, the perspective that seems to have been taken by the 2014 report. It takes the argument forward to conclude that the ‘modernisation’ of tribal communities can be their only saviour. While recommending their modernisation, the report completely misses the link between the adverse effects of ‘modern development’ on the tribal communities and their health, except in terms of alcohol and tobacco consumption, high levels of hypertension and stress, which it terms as the diseases of modernity. They reduce the social determinants of health of the tribals to nutrition, water supply, sanitation and dirty fuel, just as considered significant for other populations in low-income countries. On the other hand, a holistic ‘social determinants of health’ perspective on public health issues recognises that the basis of their poor health status is their historical and continuing exploitation and deprivation of access to the natural resources on which their life was dependent (Edison & Devi, 2019). Rather than the lack of effective medicine or illiteracy, lack of water supply and toilets alone. The report does not draw any links between their health condition and the next chapter of the report itself, which details the “land alienation, displacement and enforced migration” of tribal communities. The political ecology of tribals helps us understand that the natural resources are under their control and the loss of control due to their historically experienced exploitation. It is of significant relevance when we consider the political economy of the tribals way of life. The tribals health indicators are considered significant only from the dominant, ‘modern development’ perspective that has proved unsustainable for the world. It recommends the spread of the dominant knowledge system among the tribal communities while merely mentioning the presence of traditional health practices and not even recognising its distinctiveness for tribal communities as against other forms of traditional health systems in the country. It recognises the need to study the tribal ‘practices’ to find out those that are negative and those beneficial based on ‘modern’ parameters and thereby continues the delegitimisation of their health knowledge. However, it emphasises that tribal people’s health conditions must get more attention and be involved in decision making about their health services. This set the stage for the setting up of an expert committee on tribal health.

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The Report of the Expert Committee on Tribal Health, 2018: An Excellent Product of Contemporary Health Systems Thinking The Ministry of Health and Family Welfare and the Ministry of Tribal Affairs (Govt. of India, 2018) jointly set up the Expert Committee on Tribal Health Report. It is an excellent example of the contemporary dominant HSR approach, attempting to create some space for tribal medicine in the formal public system. It has produced a thorough analysis of all existing data on tribal health from a public health perspective—related to their demographic, epidemiological and health services availability situation. It recognises the diversity across the 705 tribes of India, between the central Indian and North Eastern states. The specificity of the particularly vulnerable tribal groups (PVTGs) and the need for flexible planning in the face of the fact that there are highly varied proportions of tribals across districts, of the total 640 districts as enumerated in 2013. While there are 90 tribal-dominated districts with more than 50% tribal population and 79 with 20–50%, they constitute 45% of the tribal population of India. Another 55% of India’s tribals live in more mixed populations where they form a small proportion, including 134 districts with 5–20% and 282 with 1–5% tribal population. Only 55 had 0–1%, and another 50 had no tribal population notified at all. Besides the diversity of spread of the tribal population in different parts of the country, their migration brings about changing population patterns. The report also recognised how this would affect the health-seeking behaviours of different tribal groups. It goes into the history of the government of India’s approach to tribal communities and development interventions, anchored by the Constituent Assembly debates and the Panchsheel Principles for Tribal Development adopted by the Nehru-led government in 1958. These set out an enabling framework for the tribal communities to develop “according to their genius”, “sharing the benefits of development yet retaining the best elements of their tradition, cultural life and ethos” (p. 1). It also recognised the need to respect the tribal community’s traditional rights to their land and forest. While accepting the relevance of the Panchsheel even in the present times, the poor health status of tribals is taken as adequate proof that they lack literacy and health care. Further, it promotes the policy approach of ensuring access to conventional (modern biomedicine) health care. Since tribal communities often live in “interior and difficult territories”, ensuring primary level care is prioritised. The report then sets about the task of designing a health service system that can ensure this. What role does it find for ‘tribal medicine’ within that? While consciously aspiring to be ‘culturally sensitive’, the expert committee honestly acknowledges its limitations—that it has only 3 out of 13 members from a tribal background themselves and that there is no consideration of the body of anthropological literature on tribal medicine. Guided by the Panchsheel principles and the fact that tribal community members tend to distrust the modern health system, the committee acknowledged the relevance of tribal health practices and the critical

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role of the tribal healers. Recognising the significance of ‘autonomy’ in the tribal identity assertion and the need for empowerment of the tribal community, “participation in the planning of services has been emphasised as a vital plank of their health services governance design, from the village level right up to the national, through a well-worked out institutional structure” (Govt. of India, 2018, p.163–176). Given the system’s constraints, it is argued that much of what is provided to other populations through doctors, nurses and trained paramedics can be given by community-level volunteers and paid providers of services from the village itself, to be called the Arogya Mitras. They are to be created as the additional workforce that will also bring health literacy to the communities. It also has a whole chapter on how to integrate tribal medicine with conventional modern medical services. This includes steps to document and validate tribal medicine practices and then promote their use, if beneficial, and advocate against them if they are found detrimental to their health. The modern professionals and paramedical personnel are also oriented to the value of positive tribal practices to create a respectful relationship and generate mutual trust (ibid p. 141). Objective 2 of the Report reads as follows: Integrate Traditional healers in Primary healthcare: Despite the advent of modern medicine, traditional healers continue to play an essential role in the lives of tribal communities. It is imperative to work with these tribal healers for two reasons. Firstly, they inspire faith amongst the community and are often the first reference and care for many tribal families. Secondly, these healers are the repository of centuries-old traditional wisdom and are often well versed with local flora and fauna. This knowledge needs to be respected, documented, validated and used to benefit the tribal community and others.

(a) The first step in integrating these traditional medical practitioners is recognising their traditional position and skill and differentiating them from untrained modern medicine practitioners, commonly referred to as quacks. These two types of informal practitioners are often mixed up and referred to by similar names, leading to an erosion of the traditional medicine practitioners’ credibility in the non-tribal population’s eyes. This perpetuates a cycle of misunderstanding, lack of trust and mutual respect, putting the tribal practitioners on the defensive. There is a need to enlist all traditional healers in a community properly. (p. 143) Thus the recent government documents discussed above show that a space has been created in the governance framework for tribal health with a bottom-up decision making and governance structure, from the village to the national levels. It provides for a separate governance structure in the tribal-dominated districts with a Village Health Sanitation and Nutrition Committee (VHSNC) in each tribal hamlet, a Tribal Health Assembly in each of the 809 tribal blocks, a District-level Tribal Health Officer with a District Tribal Health Advisory Council and a State-Tribal Health Directorate, going right up to the national level with a National Tribal Health Directorate and a Tribal Health Council (Govt. of India, 2018, p.171). Given that 55% of tribals live in non-tribal dominant districts, how would their distinct health needs be understood and catered to remains unaddressed. However, this structure provides an excellent beginning of a participatory structure, which may even provide a model for all communities and not just the tribal.

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However, given the prevailing hegemony of conventional modern medicine and government identification with it, proactive steps will have to be taken to ‘relegitimise’ and promote tribal health knowledge. The Lancet-Lowitja Global Collaboration on Indigenous and Tribal People’s Health (Anderson et al., 2016) insists that, "We recommend that the development of indigenous data systems be done in close collaboration with indigenous peoples, to ensure that indigenous values, health concepts and priorities are reflected in them”. However, the 2018 Report generates a top-down plan that does not consider it. This approach includes the development of priorities for data creation, interpretation and reporting, and of measures that draw on indigenous notions of well-being and health. The political and cultural understanding of health systems inherent in the tribal approach to health (Kirmayer & Brass, 2016) is missing in the report’s recommendations. It adopts the colonial way of cultural sensitivity, i.e. uses cultural concepts to introduce own knowledge system and bring about acceptance of behaviour that one considers desirable, confident in the supremacy of modern ‘scientific’ knowledge. Thus, this report is a significant work of bringing together available data on tribal health status data and developing a healthcare system that is sensitive to the tribal aspiration for autonomy, an excellent participatory healthcare governance model for tribal populations. However, in ensuring participation of the tribal communities, it deals only with governance structures, ignoring the issue of unequal power in the politics of knowledge between the conventional modern medicine, the AYUSH systems and tribal medicine/health knowledge. At the same time, space is created in the governance framework for a bottom-up approach. The politics of knowledge that will operate, buttressed by the power of the medical system and the political economy of the medical-industrial complex and the formal ‘mainstream’ traditional medical systems, seems to have been left unaddressed. Thereby, very few are likely to use the space provided in favour of strengthening tribal medicine.

The WIPO IGC Debate Under the Access and Benefit-Sharing (ABS) arrangements suggested by the Convention on Biological Diversity (UN, 1992), benefit-sharing acknowledges the rights of the traditional communities. The communities reside in specified geographical areas and are users of specific local plants. The plants (genetic resources) have to be used for innovation research that generates new products to share the benefits. In the case of medicinal plants and herbs, this means that the pharmaceutical industry gets ‘access’ to the tribal plant resources to develop new products and will give some ‘benefit’, a percentage of its profits, back from where it got the original plants and their knowledge. The Nagoya Protocol (CBD 2010) further sets out details of the possible arrangements for monetary and non-monetary benefit sharing: By promoting the use of genetic resources and associated traditional knowledge, and by strengthening the opportunities for fair and equitable sharing of benefits from their use, the

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Protocol will create incentives to conserve biological diversity, sustainably use its components, and further enhance the contribution of biological diversity to sustainable development and human well-being. (CBD 2010, p. 1) Recalling the relevance of Article 8(j) of the Convention as it relates to traditional knowledge associated with genetic resources and the fair and equitable sharing of benefits arising from the utilisation of such knowledge. Noting the interrelationship between genetic resources and traditional knowledge, their intimate nature for indigenous and local communities, the importance of the traditional knowledge for the conservation of biological diversity and the sustainable use of its components, and the sustainable livelihoods of these communities. (ibid p. 3)

The World Intellectual Property Rights Organisation (WIPO) acknowledged the rights of traditional knowledge holders and rights over genetic resources of the communities in their traditional areas. In a process aimed at developing some international mechanism to protect traditional knowledge, it has set up the WIPO InterGovernmental Committee on Intellectual Property and Genetic Resources, Traditional Knowledge and Folklore/Traditional Cultural Expressions (IGC) (WIPO, 2021). The WIPO IGC has evolved the draft of a legal instrument on protecting the rights of traditional rights holders. The draft has been under discussion for over fifteen years. The reason being the inability to reach a consensus among countries with competing interests. Between those repositories of traditional knowledge holders and related herbal biodiversity on the one hand and those with the primary interest of the pharmaceutical industry on the other. Among the several issues under discussion at the IGC are two keys to tribal health knowledge. Protecting the rights of traditional holders will require that the modern researchers and industries using traditional knowledge to create new products must disclose the source of knowledge. This is being resisted by countries that uphold the pharmaceutical industry’s interests (Javed et al., 2019). Suppose mandatory public acknowledgement of the source of knowledge becomes part of the legal requirement in any patent application. It will convey the message that respecting traditional knowledge and knowledge holders is essential. This is what the WIPO IGC-GR/TK/TCE has been negotiating for the past fifteen years and facing strong opposition from the ‘developed’ countries and their pharmaceutical industry. The debates at the WIPO IGC-GR/TK/TCE posed a related challenge for the users of modern science. When they use traditional knowledge for innovation in products or procedures, they would be required to ensure it “to be in keeping with the cultural principles of the traditional knowledge holders”. How would they reconceptualise the innovation and incorporation in modern science and technology if they implemented it? This clause puts the onus on modern knowledge systems to rethink and rework them for sustainable development. Besides sharing in the profits, it demands an epistemological rethink. It requires a genuine dialogue between the different knowledge systems and dialogue requires interaction with mutual respect.

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A Holistic Health Systems Approach It is to address such issues of the politics of knowledge and the unequal power equations that play a regressive role in the implementation of bottom-up governance processes that some of us have been proposing that we forge a discourse of public health and health systems research more holistically. In this approach, the ‘health system’ incorporates (i) the social determinants of health status (along with the biological), (ii) the politics of knowledge that determines the content of health care and (iii) the political economy and management of health care. In order to emphasise the more wholesome approach of this perspective, we have christened it the “holistic health systems approach” (HHSA) (Priya & Kurian, 2018). We have already discussed the reductionist versus holistic approach to social determinants of health, indicating the significance of interlinked historical and political ecology dimensions at the macro level, in addition to the institutional dimensions at the meso-level and community /individual level factors at the micro-level. The importance of ‘politics of knowledge’ lies in addressing the issue of ‘which’ knowledge and ‘whose’ knowledge is considered legitimate by the scientific establishment of health, including relationship on the various forms of knowledge with the social and power hierarchy available in a society. This includes considering lay people’s knowledge as against expert knowledge and the various ‘traditions’ of expert knowledge (often grouped as ‘traditional’ and ‘modern’). The values and principles of validation of knowledge are often very different when viewed from the dominant expert perspective and from that of communities with varied traditions of knowledge and practice that have led to the widely practised medical pluralism, documented in almost all countries of the world (Bodeker & Kronenberg, 2002). Adopting the HHSA with this understanding of the politics of knowledge, we propose that all forms of health knowledge be considered diverse traditions of knowledge and not divided into binaries of ‘modern’ and ‘traditional’. There has already been much debate on using the terms traditional and modern (Gale, 2014; Sujatha & Abraham, 2012). The argument is that when both are in practice in the present times and both are dynamically adapting to changing needs and conditions, why should the older forms be characterised as ‘traditional’? With two centuries of practice, the ‘modern’ has become ‘conventional’, and it was built on the shoulders of the earlier knowledge systems that are now being called traditional/alternative/complementary. Practitioners of other systems of medicine and folk practice are documented to be constantly innovating and adding new components to their practice (Sujatha, 2011, Bode, 2012). Thus, we need to understand tribal medicine/health knowledge and its various forms as distinct traditions of knowledge, not merely as ‘traditional knowledge’. Since the dominant knowledge system gets the advantage of state support at any point in time, thereby greater spread of services and inclusion in educational systems occurs. These then shape the popular perceptions to a great extent. Therefore, the legitimate knowledge considered by those in power gets promoted by the scientific establishment of health sciences and technology. Thereby, it further gets developed

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and achieves higher standards of ‘effectiveness’. Policies and programmes are all shaped by this dominant, privileged knowledge. Mass media messages and commercial advertising also add significantly to this shift from other traditions of knowledge and practice to the biomedical perspective. This changes mass perceptions of what health is all about and what health care is all about, and that is what we have witnessed in the last several decades, if not the last two centuries, leading to the medicalisation of health and the hegemony of conventional medicine in health care (Busfield, 2017). On the other hand, the resulting hegemonic experience of conventional biomedicine is also a critique of its reductionism. It has led to greater openness at the frontiers of the scientific establishment to ‘systems biology’ (Kirschner, 2005), to broader socio-psychological linkages of health (Gale, 2014; Marmot & Wilkinson, 1999) and a systemic application of holism and complexity (Pieterse, 1998). So there is today a growing exploration of “Traditional, Complementary and Alternative Medicine” to create an ‘Integrative Medicine’ (NIH, 2021). However, this still largely remains an ‘undemocratic pluralism’ (Priya, 2012) since it maintains the dominance of conventional biomedicine. The other knowledge traditions are to be secondary—as either complementary or alternative into which they are to be integrated. Various older traditions of health knowledge reassert themselves across the globe. People turn to them in their search for ways to overcome the limitations of conventional medicine. However, HSR pretends to be like an ostrich that does not want to see the reality before its eyes. On the other hand, the evolution and utilisation of tribal health knowledge (and other older knowledge traditions) have been so intertwined and embedded in the social and cultural dimensions of the communities. Therefore, the practitioners need not develop a direct relationship with the social sciences, public health and HSR as the disciplines considered critical for modern health systems planning and policy formulation. Practitioners and proponents of tribal medicine generally do not relate to the HSR and health services development debates. This non-interaction between HSR and tribal medicine or other knowledge traditions needs to be broken and bridges built. Eventually, health systems are about putting policy into practice, and therefore, how can we shift to a more democratic pluralism in the present discourse? Medical/ health pluralism needs to be considered a legitimate component of healthcare systems, and a new paradigm for HSR will then be necessary. This is what is being attempted by advancing the HHSA.

Relevance of Tribal Medicine in a Systemic Frame From the HHSA perspective, there is the relevance of tribal health knowledge for the tribal populations, and there is relevance for health systems development in general. The social histories of tribals from various parts of India and Southeast Asia show that they did not want to become a part of the mainstream socially hierarchised and unequal world. That also followed a more commercialised and nature-exploiting livelihood and life pattern than they did (Scott, 2009; Sharma, 1994; Xaxa, 2005).

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The exploiters pushed them to the margins. They usurped the tribal lands where tribal communities had ‘ruled’ for centuries so that they moved up the hills and into the thick of forests, with a low level of interaction with the mainstream. This allowed them to live their way of life and develop their knowledge systems according to their ecological, social and cultural context. Community identity was associated with the natural location they lived in, and there was high social cohesion. Therefore, their way of life was intertwined with nature’s multiple dimensions, with much uncertainty and endurance of high levels of physical hardship and ill-health as a natural part of it. They also developed a body of knowledge about ways of maintaining health, preventing disease and treating ill-health using plants, minerals and animal products.

Relevance for the Tribal Communities For the tribal populations today, it is an issue of access to the natural materials they use as food and medicine. Their rights to the forest were curtailed by colonial legal provisions (The Indian Forest Act, 1927), and further because of declining availability by the depletion of forests and displacement of tribal communities for developmental activities such as big dams and mining. Minor forest produce is still a source of seasonal livelihood for many tribal groups as collectors of raw materials, which is a large and currently enlarging trading sector in non-timber forest products. The Forest Rights Act 2006, which allows the tribal communities access to forest resources, including medicinal plants, is vital in this regard, as is the local community’s role under the biodiversity protection legislation provisions.

Relevance as Base Knowledge for the Development of Modern Pharmacology and Pharmaceuticals Studying tribal medicine from the point of view of exploitation of this knowledge and practices by the modern researchers and industry is relevant. The disciplines of pharmacology and the pharmaceutical industry picked up this knowledge as if it were free for all over the colonial period and until the 2000 when the UN Convention on Biological Diversity (in force from 1993) recognised the sovereign right of nationstates over their genetic resources. International legal instruments for fair access and benefit sharing of economic gains due to the use of biodiversity then followed in the 2000s, such as the Nagoya protocol, 2010. Whether it was in the public domain as published work or held as a closed family or community secret, modern science converted it into modern pharmaceutical knowledge without an acknowledgement or credit to the source and thereby committed what is beginning to be recognised internationally as ‘biopiracy’ (Priya & Kurian, 2018).

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Till the 1950s, the growth of pharmacology in the modern conventional medical system was of a photo or plant-based model. It provided the majority of models for producing medicine in modern pharmacology and the modern pharmaceutical industry. It is only over the years between the 1920s and 1950s that bacteria, microbiological, or just pure chemicals came in and chemical molecules, which are now being tried. Since the 1950s, R&D with large molecules produced not for medicines but across all industries for chemical products, petrochemicals etc., have been examined to look at their medical effectiveness, or molecules synthesised based on a medical conceptual hypothesis. What makes the pharma industry’s present research and development so expensive is that it tests hundreds of molecules whose medical value is unknown to identify medicinal effects of value in only a very few. So the pharma industry and the pharmacologists and researchers today is ‘bioprospecting’ using traditional knowledge. The already known medicinal value of a plant is used for identifying and extracting new molecules. This shortens the duration and costs of drug R&D production by providing a more targeted search for molecules.

Relevance as Base Knowledge for the Development of Codified Traditional Knowledge In the overall Indian health system, the politics of knowledge is not only about conventional modern versus traditional tribal knowledge. In the African and Latin American settings, tribal/ indigenous medicine is synonymous with traditional medicine, while in Asia, it is not. In the Asian context (whether in the middle-Eastern countries, south /Asia, Southeast Asia or Eastern Asian countries), there are the codified textual systems of knowledge and the orally transmitted ‘folk medicine’, including tribal medicine. In India, there are the classical texts and classical codified systems of Ayurveda, Yoga, Unani, Siddha, Sowa-Rigpa. While these have been officially recognised in the country and a separate ministry (the Ministry of AYUSH) formed to address their issues, tribal medicine and other local health traditions have not received that attention (Ministry of AYUSH, 2021). Thus, there is a hierarchy with conventional modern medicine as the dominant leader, the codified traditional systems and homoeopathy as the marginal but recognised streams of knowledge and practice, and the tribal medicine/local health traditions at the bottom of the hierarchy. The link between the codified and folk/tribal medicinal knowledge has historically been an organic one, but social status and political patronage decide the hierarchy. Charak’s well-known quote in one of the classical base texts of Ayurveda (Charak Samhita, Sutrasthana 1/20–22) acknowledges that the forest dwellers have more knowledge about the plants their medicinal values and know many more plants than the Vaidya does. However, it then avers that the Vaidya has codified knowledge and is, therefore, superior in expertise terms. Within the codified traditional systems, too, there is the understanding that if they want innovation and additions into their system, one way is that they go to the folk practitioners or the tribal groups to learn

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about more plants or their medicinal uses from them. Documentation by MOEF and FRLHT shows that about six thousand plants are used in folk practice, while in the Ayurveda text, only 1600 plants are in use. Therefore, a large gap of knowledge exists between folk practice and classical texts (ENVIS-FRLHT, 2021). Therefore, tribal medicine has value for advancing the codified traditional knowledge systems themselves and yet tends to be denigrated by them, reflecting the social and political status of the classical codified knowledge holders and the tribal communities.

Ethical Principles for Health Systems Development: The Democratic Structure of Knowledge Generation In the modern science system, knowledge generation starts at the top, from laboratory and clinic experts. In tribal systems, knowledge generation starts from the bottom, from the users experiential learning, self-care on themselves, in families and the communities. The ‘experts’ of tribal medicine, the folk healers, go deeper into health issues for prevention and therapy, learn from elders, and/or, in their understanding, gain special knowledge through divine dispensation. Thereby they gain recognition from their communities as knowledgeable persons. They are often engaged in other occupations and practice their specialised knowledge as community service free of charge, with gifts given by grateful ‘patients’ when they experience benefit. They may also form their peer community of healers and hold secret some elements of knowledge within this specialised group. Such non-commercialised service is still evident in the practice of tribal medicine (Mishra, 2019).

Relationship with Nature and the Ethics of Collection of Medicinal Plants for Sustainable Development Given that the world is now aspiring and looking for ways to structure equitable, affordable, just and sustainable systems (SDG, UN, 2016), some learnings have to be applied to developing futuristic health systems across the globe. The pharmaceutical products and the moral and ethical grounding of health systems such as tribal medicine need to be first understood and then adapted for the larger HSD. Intellectual Property Rights (IPR) regimes are becoming stronger and a major legitimiser of knowledge and how to protect innovation in knowledge. WIPO IGC is witness to some of the most sensitive negotiations at the international level while debating the draft international law to protect traditional knowledge, some of which have been discussed above. However, inserting tribal health knowledge into the IPR regime counters the very principles of tribal knowledge and practice. There is the tribals’ collective conception of knowledge generation. For instance, the whole idea

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of IPR today, as applied for the pharmaceutical industries, is an innovation encouragement for knowledge generation. IPR regimes are based on the individual (person or organisation) ownership of knowledge and, therefore, entitlement to adequate commercial and professional returns. However, it is completely counter to the principles of collective knowledge holding and generation of knowledge in the traditional tribal format. Adopting a notion of a ‘knowledge commons’ rather than of ownership of ideas and intellectual property could remove many of the ills of the present medical system and the inequities it generates. Similarly, traditional knowledge is situated temporally and spatially, Kaal sthan sapeksh (appropriate to the particular time and location). On the contrary, there is the universality of modern science and its pharmaceutical products that can be used anywhere and among human beings across the world. The tribal perspective questions this clearly, with the localised health measures by time-place and individualisation of health measures. Ethical rules on collecting and conserving natural resources and asking forgiveness and praying to nature before taking anything from it, followed in tribal medicine, are entirely missing in modern science and technology. They are not just consumers but also preserve and conserve natural resources. This is what sustainable development has to be able to do. Therefore all of society may learn from the tribal knowledge systems, their ontology, epistemology and practice (Priya & Kurian, 2018). One would argue that, following the tribal approach, the principles of any knowledge system can be universally applied, but its specificity would be spatially and temporally located. Therefore, the relevance of tribal medicine in its setting and its principles for all settings worldwide (Arora, 2019).

Integrating Tribal Medicine into Contemporary Health Systems Development All the above issues can inform the dominant health systems framework to make its implementation more holistic in principle and implementation. This is possible only if the politics of knowledge is acknowledged and addressed. Of the six building blocks in the WHO health systems framework (as in Fig. 21.1), we illustrate the measures that can be adapted to integrate tribal medicine into the development of health services: 1. Service delivery—Home remedies and community-level tribal healers should be considered the first tier of health care. Other community-level healthcare providers such as the ASHAs, ANMs, AWWs can be facilitated to use local herbal preventives and therapies. Under the NRHM, for example, revitalising local health traditions (LHTs) was one of the strategies suggested, and herbal gardens were recommended to be grown in sub-centre and primary health centre compounds. If SCs and PHCs start to do so, the co-located AYUSH professionals and others can also prescribe their use. In fact, in tribal areas, these

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herbal gardens should link the public health services to the local tribal healers and their knowledge. Health workforce—The tribal healers may be envisaged as traditional community healthcare providers and integrated into the local health and wellness centres. Besides contributing to patient care, they could also support the cultivation of local medicinal herbs and plants and orient conventional healthcare providers (doctors, nurses, paramedics, multipurpose workers) to their knowledge, principles and practice. Health management information—Data on utilisation of home remedies and community-level health care should be collected as part of ‘treatment-seeking behaviour’. Since the 1970s, when public health data started being officially collected and published, it has been invisibilised, pushed under the carpet of knowledge. The National Sample Survey, for example, every decade collects data on health-seeking behaviour. Until the 71st round, it has not included treatment sought by other than the formal doctors as treatment, classifying it all as ‘untreated’ illness (NSSO 2015). [In this 71st round, AYUSH treatment seeking has become part of the data that has been generated, but not the use of LHT.] With no data in the public system, the actual practice becomes ‘invisible’ to administrators and policymakers and goes out of any policy discussion. Data generation related to public policy and planning must consider all the health-seeking practices of the people, not only those relating to formal systems. Medicines, vaccines, technologies—Tribal and other herbal medicines, preventive technologies (Priya, 2013), tribal foods, etc., need to be considered as options when designing management protocols for any health problem. The issues of availability, access and quality of all these then become health system issues. IPR and ABS issues for protecting the rights of traditional knowledge holders need to be publicly discussed, and national law for the protection of traditional knowledge is necessary, even for international negotiation (Javed et al., 2019). Evolving a ‘knowledge commons’ for shared knowledge and innovation rather than knowledge as individual property is another attempt that needs to be taken forward for a just and open use of all knowledge and research (Priya & Kurian, 2018). Financing—Starting protocols with home-based and community-based care can decrease the institutional care costs by at least 20% (Priya, 2011). Additionally, it also decreases costs for the patient in terms of travel, loss of wages, etc.; generally, this translates into cheaper medicines. Thereby, budgetary support for the tribal healers to grow medicinal gardens or scholarships to promote LHTs, their participation in health training in District Health Knowledge Resource Centres should be viewed as adding value to health care, both economically and in terms of health and well-being. Leadership/Governance—Institutionalising support for local health traditions by decentralised documentation, validation and voluntary certification of traditional tribal/community healthcare providers; participation of tribal communities in community monitoring and planning of healthcare services; involving traditional tribal and other community healers in primary healthcare services, preparing

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people’s biodiversity registers and using them for protection and promotion of local tribal knowledge, will make these activities more meaningful for these vulnerable but primary knowledge holders. 7. Besides the above six building blocks, there is growing recognition of the need to interlink human, animal and plant health for sustainable health care. One Health and Planetary Health are evolving public health concepts. Tribal medicine and its healers relate closely to animal health and veterinary care services, food systems and social distress of any kind, including disasters. The roles of the tribal healers in each of these sectors should be explored and utilised for local contextualisation, community participation, and decentralised planning and implementation (Jain & Tiwari, 2012; Mutatkar, 2021).

Creating an Integral System for Tribal Health Knowledge There is a growing development of inter-disciplinary and trans-disciplinary research trying to break the silos of disciplinary boundaries and knowledge hierarchies. Systems biology, systems thinking and complexity theory are rapidly developing approaches that hold promise. There is an increasing awareness to develop futuristic ‘just’ science and research, which attempts to incorporate the perspectives and concepts of various relevant actors in a problem space, especially with a focus on propoor/marginalised section perspectives. This would facilitate changes in the dominant knowledge system and thereby in the cognitive, normative, social and material dimensions of societal discourse and lives of the marginalised (Marshall et al., 2018). Integrative knowledge generation by bringing various knowledge traditions to converse and draw from each other can lead to new concepts emerging. This has already been attempted fruitfully in several centres (Lohokare, 2013). After almost a century of the pharmaceutical industry’s practice of extracting molecules from herbal medicinal knowledge, it is now being realised that this is not as effective or safe as the use of ‘whole plants’ and their formulations that form part of the principles of traditional or tribal medicine. Frontiers of modern medicine include a more holistic research stream and deal with ‘whole plants’ and traditional multiple herbal formulations (Wagner & Ulrich-Merzenich, 2009). Thus there is a movement towards consideration of the principles of traditional health knowledge by mainstream knowledge. Systems biology and ‘omics’ research is bringing modern medical and older traditions of health knowledge closer. The term ‘omic’ indicates the interlinkages of the study in genomics, proteomics, microbiome studies, etc. It is different from the classical study model of individual genes, proteins and gut flora (Kirschner, 2005). For instance, today’s microbiome has become an essential entity in understanding the central role of bacterial flora in the intestine for normal functioning of the human body, which is similar to the principle of Ayurveda where the colon and its activity is considered central to the health of the body. The microbiome could become an explanatory format for the Ayurvedic principle and a modern validation of traditional

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knowledge. Even researchers of the microbiome could learn from the concepts of Ayurveda to decipher its systemic linkages. Similarly, one can visualise components of tribal medicine being similarly validated ineffective outcomes and in their epistemological principles and providing insights and methods that could enrich and facilitate research in ecological approaches to health and health care. The big challenge before us is how we, as health systems researchers, planners and policymakers, can respect other traditions of knowledge, including tribal knowledge? The primary healthcare approach (PHCA) is one on which we can build further to bring this kind of thinking into health systems (WHO & UNICEF, 1978). PHCA is the one that has consistently been reiterated over the past forty years and is still recognised as essential (WHO & UNICEF, 2018). This approach in health systems was one, which did acknowledge the role of traditional healers. However, it did not acknowledge the knowledge system they brought with them. Together with the current understanding of sustainable development and the SDGs (UN, 2015) and the Convention on Biological Diversity (UN, 1992; CBD, undated), there is an international commitment and framework that supports the need to promote tribal medicine. The dialogue between diverse traditions of knowledge and practice can, thus, make the futuristic knowledge systems more holistic, and that is where one would see the real systemic relevance of a body of knowledge and practice such as tribal medicine. Nationally, there is a need to link implementation of the Forest Rights Act, the National Biodiversity Act and use provisions of the Report of the Expert Group on Tribal Health (GoI, 2018). However, to design the healthcare systems with a bottom-up perspective, this effort has to be informed by anthropological studies on tribal medicine, tribal health knowledge and practices, and the tribal way of life and their ontology and epistemologies. Innovations in both governance and institutional arrangements are required. This will give centrality to self-determination by the tribal communities and for inter-disciplinary health systems research and trans-disciplinary research for expanding the epistemological and experiential basis of knowledge and its use for planning and implementation.

Conclusion This paper argues that tribal medicine should be viewed from a knowledge service perspective and not merely a commercial product innovation perspective. Besides providing ecological solutions to health problems, especially for the tribal people who still need it, tribal medicine can play a more significant role. The global ecological and social crises pose a challenge to the development paradigm of the twentieth century that demands a response from health systems. This paper argues that tribal medicine can contribute to developing a health system that can meet these severe challenges. The significance of the politics of knowledge has to be recognised and addressed in health systems design to facilitate the process. Colonial rule and its

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continuing legacy have prevented us from recognising that the local health traditions provide benefits experienced by the user communities. This does not imply that we romanticise ‘tribal medicine’ as an esoteric form. However, we need to examine tribal medicine’s diverse knowledge, ontology and epistemology as ‘subaltern systems’. Doing so can yield solutions if only they are allowed to flourish in their own way and contribute to societal pathways for the future. Anthropologists have rightly raised questions of how the tribal healers developed their body of knowledge without the kind of tools pharmacology now has of chemical analysis, spectrometry, etc. We need to understand the tribal healers’ methods of enquiry and experimentation, of how they innovate and adapt even in the present. This could provide new insights into understanding the ecosystem—human health relationship and how to evolve more sustainable perspectives on researching and dealing with health issues.

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Chapter 22

Revival of Local Health Traditions from Healers Perspectives: Urgency of Recognition and State Support Sunita Reddy

Abstract Herbal healing practices among the tribes is natural and an essential part of daily life as it goes with the ecosystem and life closer to the forests. This noncodified knowledge acquired through oral tradition and long apprenticeship with the elderly healers, passed on generation after generation, is a lifeline for society’s rural and marginalized sections. The knowledge of flora, fauna and its application to the local healing communities serve a dual purpose: the communities cannot access and afford modern health care, and they depend on these healers for their primary level healthcare needs. Secondly, the traditional and folk wisdom keeps the knowledge of biodiversity alive by conserving and preserving it for future generations. This paper is based on an empirical study on the local health traditions of a total of sixty healers in Manipur, Arunachal Pradesh and Sikkim in 2019. They shared various challenges they faced as well as their recommendations for supporting and revival of the traditional healing practices. Further, the officials of biodiversity boards, AYUSH, and the North Eastern Institute of Ayurveda and Folk Medicine Research (NEIAFMR) were interviewed. Recognition of the importance of local health traditions (LHTs) and herbal healing by WHO, AYUSH, and the steps to document the practices of healers is ongoing. However, such efforts are yet to see the benefits at the larger level of adding to the traditional knowledge base, and reviving, supporting and sustaining for the benefit of local communities. This paper concludes by advocating for proactive measures to recognize the herbal healers through certification, provide incentives and support systems to practice their healing services to the benefit of marginalized communities and also through the revival of NEIAFMR. Keywords Revival · Local health traditions · Recognition · State support · Biodiversity

S. Reddy (B) Centre of Social Medicine and Community Health, School of Social Sciences, Jawaharlal Nehru University (JNU), New Delhi, India e-mail: [email protected] © The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023 S. Reddy et al. (eds.), Ethnomedicine and Tribal Healing Practices in India, People, Cultures and Societies: Exploring and Documenting Diversities, https://doi.org/10.1007/978-981-19-4286-0_22

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Importance of Traditional Medicine According to the World Health Organization (WHO), around 65–80% of healthcare practice worldwide involves the use of traditional medicine (TM), also called Complementary and Alternative Medicine (CAM) (Pan et al., 2014), making it an indispensable system of medicine. Further, at least 25% of all modern medicines are derived directly or indirectly from medicinal plants (Perinchery, 2020). TM has the potential to empower communities by enhancing access to affordable primary health care based on local ecosystem-specific resources and indigenous knowledge and thus can lead to bottom-up planning and health care (WHO, 2018). It has been a long time since WHO recognized the importance of traditional medicine (Davey, 2013; WHO, 1978, 2001, 2002, 2013, 2019; WHO & UNICEF, 1978). However, in India, at the national level, there is still a lot that has to be achieved. This edited volume is a step in that direction. This paper is based on empirical and qualitative research1 in three North Eastern states: Sikkim, Arunachal Pradesh and Manipur highlighting a few cases of local healers’ contribution to the primary level of care for their communities. Workshops in the state universities, healers workshop, in-depth interviews and observations were the methods used for the study. Verbal and written consent was taken from the healers and other key informants for interviewing and sharing their names and photographs. Researchers2 who knew the local language were hired for the study. Total sixty healers across three states were interviewed; however, only few healers have been covered in this paper. Their popularity and legitimacy in the community due to their effective care using herbal medicines and traditional wisdom, which is affordable, accessible, acceptable and available, make them indispensable for the community. This paper critically looks at the process of recognition, certification of healers and the making and unmaking of the North Eastern Institute of Folk Medicine (NEIFM) in Pasighat, Arunachal Pradesh, which has been recently renamed as the North Eastern Institute of Ayurveda and Folk Medicine Research (NEIAFMR). It also addresses the fears and anxiety of healers and their plea to support their practices. The paper gives policy recommendations and strategic planning for the revival and recognition of local health traditions for the benefit of the local communities.

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The author is grateful to Indira Gandhi National Centre of Arts for supporting this study, a collaborative project with Anthropos India Foundation and Dr. Sachidanand Joshi, Dr. Molly Kaushal and Dr Ramesh Gaur for their valuable inputs. 2 Thankful to Dr Tshering Lepcha, Dr Asem Tomba, Dr Alok Kumar, Mr Tabhang Tai, Ms. Umpi Dabi for assisting in the Field and Ms Shefali Bharati for photographs.

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Ethnic Groups and Diversity of Medicinal Plants There are one million practitioners of local health traditions (LHTs), apart from the several millions more who practice at the household level, in India. A whopping 6200 plant species constitute the resource base of LHTs, out of which almost 200 species are now threatened due to commercialization (Harirammurthi, 2012). Each region—the Western Ghats, Eastern Ghats, the North Eastern region, Himalayas and the forests—have an abundance of medicinal herbs and plants. The custodians of this knowledge, mostly indigenous populations divided into around 4635 ethnic groups, have empirical knowledge of their specific ecosystems. They preserve, conserve and make use of herbal medicines and are self-reliant in providing primary health care to millions. The Botanical Survey of India reports 8000 species of medicinal plants as early as 1678, in a twelve-volume treatise on the medicinal plants of the Malabar region (Perinchery, 2020). If we do not recognize, integrate and mainstream them, we are losing this vast knowledge base. Most important is the knowledge of medicinal plants for the health and well-being of the marginal communities across the country. The Central Council for Research in Ayurveda Sciences (CCRAS) conducted a Medico-Ethno Botanical Survey of 400 forest areas all over India, and more than 120,000 plant specimens have been collected besides 5000 crude drug samples and documentation of 2500 folk claims (CCRAS, 2021) The information is published in the form of twelve monographs and one book, titled An Appraisal of Tribal Folk Medicine, preserving durational medicinal heritage (Ramesh Babu, Dir. Gen. CCRAS, AYUSH). Given the recent attention on universal and improved healthcare access for all, a renewed interest to strengthen the potential of traditional medicine and health practitioners is underway, though the full potential has not been realized yet. The steps taken by the Ministry of Ayurveda, Yoga, Naturopathy, Unani, Siddha, Sowa-Rigpa and Homoeopathy (AYUSH) ethnobotanists is documentation, which is successfully being done. But, in order to sustain these healing practices at the community level, there is a need to certify, recognize, facilitate and support the healers. Without this, we will lose the immense valuable knowledge base of the ageing healers’ population and the younger generation will not show interest in pursuing this field, given the lack of any support system available to them, and with procuring herbal medicines becoming precarious and challenging. Thousands of species of trees, climbers, herbs, shrubs, grasses, lichen fungi and species of animals, different metals and minerals, are used in treating various ailments and diseases. They are used for bone-setting, poison healing, treating skin allergies, gastric problems, supplementing food, nutrition, and for obstetric, gynaecological, paediatric, acupressure and common and chronic ailments. Some of them have a global value; for example, Phyllanthus amarus is used for the management of the stomach, genitourinary system, liver, kidney and spleen (Patel et al., 2011). Most of the literature on plant-based medicinal knowledge is through the studies of ethnobotanists. A large number of ethnobotanical and anthropological studies on ethnomedicine have focused on one or the other tribe, describing the plant medicines being used for various diseases and their scientific names. Many studies also bring

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out rich medicinal knowledge the healers possess and practice (Junsongduang et al., 2020; Shankar, 2007; Shankar et al., 2012). A study conducted by Das and Tag (2006) among the Khamti tribe-dominated area of the Chongkam and Namsal circle of Lohit district of Arunachal Pradesh found forty-five medicinal plants, out of which five were for malaria and fever, four for bone fracture, three for anaemia, two each for rabies, snakebite and reproductive health. They even had medicine for treating cancer. They also had plant medicine for tuberculosis, diabetes, jaundice, and for various other ailments. The healers chanted mantras along with the application or use of these plant medicines. It is mostly the older generation who are into this practice and, further, they also have small backyard gardens to cultivate a few plants used for common ailments. Many studies have also shown concern of anthropogenic action like timber operations, other developmental activities and large-scale collection of medicinal plants, which are leading to depletion of precious ecosystems (Lakshman, 2016; Lone et al., 2014; Shankar & Rawat, 2013). The Central Council for Research in Ayurvedic Sciences (CCRAS) in the Ministry of AYUSH, New Delhi, carried out a study (2017) that reported the use of medicinal plants to treat malaria, fever, bone fracture, anaemia, snakebite, cancer, tuberculosis, diabetes and jaundice. Nyishi tribes residing in Itanagar, Naharlagun, Chessa, Nirjuli and Doimukh of Papumpare district in Arunachal Pradesh use them. Another tribe holding traditional knowledge and wisdom is the Mishing community, which largely resides in Assam and Arunachal Pradesh. In Arunachal, they stay on the foothills of the East Siang district. Likewise, there are numerous healers in Manipur and Sikkim. More than a million traditional healers as human resources for health are accessible in the inhospitable terrains of the North East region, Eastern Ghats, Western Ghats, in the states of Odisha, Madhya Pradesh, Rajasthan, and Kerala, and the union territory of Andaman and Nicobar Islands (Bode & Hariramamurthi, 2014).

Sustainable and Equitable Health Care TM helps in sustaining available biological resources and sufficient access to good quality health care for all members of society. Sustainability and equity are closely connected, especially in rural communities of developing countries, as health care is primarily delivered by local healers or community health workers, or the members of the household, using biological resources. Cultural cognition of local health practices is also crucial for those seeking health services; there is social legitimacy for these healers in their respective communities and their services are easily accessible and cost-effective, especially when there is an acute shortage of health personnel in the country. Only 9 lakh doctors, including AYUSH doctors, and 8 lakh nurses and midwives were active in the health workforce in 2019 (Periodic Labour Force Survey 2018–19), although the Medical Council of India and Indian Nursing Council report 11.6 lakh doctors and 23 lakh nurses and midwives in 2018. However, as per the WHO recommended threshold of 44.5 skilled health workers per 10,000 persons required for achieving universal health coverage and sustainable development goals,

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India is only a little over one-fourth of this number (Karan, 2021). Due to this lack of human resources in health care in the rural and tribal belts of the country and the availability of modern medical care, the community largely depends on traditional medicine. Local health practitioners thus have a clear public health role, as health caregivers, councillors, health educators and also as priests, ritual specialists and diviners in their respective communities (Payyappallimana, 2013).

Introduction to the North East: Diversity in Flora, Fauna, and Tribal Populations Out of thirty-six biodiversity hotspots in the world, India has four: Eastern Himalayas, Western Himalayas, Western Ghats and Andaman and the Nicobar Islands (Sarkar, 2021). The biodiversity in the North East region (NER) is a genetic treasure of various flora and fauna, which comes under the Indo-Burma biodiversity hotspot, and 60% of this area is under forest cover (Bagli, 2021). Many medicinal plants are found in NER, with 200 plant species in Arunachal, 526 from Nagaland, 194 species in Tripura and 834 found in Meghalaya (Bagli, 2021). Sikkim Himalaya alone houses over 6000 species of flowering plants, 700 medicinal plants forming a wide gene pool as mentioned by the Mountain Institute, scholars from Sikkim University and officers from the Sikkim Biodiversity Board. There are pluralist folk healers in Sikkim based on their ethnic identities; dhami, jhakri, phendongba, bombo in Nepali; pwe, nejum in Bhutia; bonthing in Lepcha; bajwa in Rai; baidang, phdagma in Limboo; jogi, baidya (folk healers) and sodhini (massagers). The prayer flags across the length and breadth of the states showcase the widespread belief in God for the people’s health and well-being. Another bigger state in the North East region, Arunachal Pradesh, is home to 26 major tribes, 100 subtribes and 30 languages, with the major tribes being Galo, Mishing, Adi, Apatani and Nyishi. For the communities, rivers and mountains are sacred. People’s lives revolve around festivities; they worship deities, believe in gods and spirits and thus depend on dondai and bo for every major decision in their lives. Rituals are performed for the health and well-being of individuals and families. Communities propitiate gods and spirits for good fortunes and good health. Manipur too has rich traditions of folk healers and have also codified forms of the maiba and maibi traditions apart from the local health traditions. Before colonial rule, in the palace of Manipur, there were two schools of traditional healing practices, and these still exist: Maiba Loishang, or the school of traditional healing for males, and Maibi Loishang, or the school of a traditional healing centre for females. Most of the cross-fertilization and exchanges of healing practices happened in these two traditional schools in Manipur during the rule of the kings. Many medicinal plants are found in the vicinity of the village itself, as a Maibi herbalist shared. For treating the ailments of skin disease, like boils, remedies are found in the ‘eirak khunlak’ (inside the lane in the village), ‘enakha luka’ (by the sides

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of the house), ‘umang-then long’ (the space at the front of the house) or ‘eng-khol’ (the home garden) and in most of the household-grown papaya, which neighbours grow and happily share. The healers in Manipur shared that there are a lot of medicinal plants to cure many diseases and illnesses, including cures for cancer and HIV/AIDS. The government should give full attention to developing aiba-maibi laiyeng pathap in Manipur since many patients suffering from bone fractures, jaundice, joint pains, sprain twisted, tonsillitis, sinus, boils, etc., are used to visiting local maiba and maibi to avail their healthcare healing practices.

Oral Traditions, Practices and Challenges of Herbal Healers The following section gives some examples of healers in these three states: Arunachal Pradesh, Sikkim and Manipur, the challenges they face and their recommendations to revive traditional medicine. One of the very well-known herbal healers is Yanung Jamoh Lego, who lives in Pasighat, Arunachal Pradesh. Patients from the local communities and across the states visit her for health issues, both for minor and major ailments. She treats even chronic diseases by using natural and herbal products. Every official from Pasighat, Itanagar, knows about her work. She has her own Facebook page and uploads testimonials of patients to share her work. Compared to the cost of allopathy, her treatment is very nominal. She sees her work as a service to humanity (Fig. 22.1). She faces challenges in the collection of herbal medicines, which needs a lot of investment in time and energy. Not everyone can identify, pluck and store herbal medicine, so she has to accompany two or three collectors to difficult terrain. There are also restrictions on the collections of herbal plants. She feels herbal gardens should be encouraged. Currently, they are limited and cannot be cultivated, especially those which are grown as trees in the forests at different levels of altitude. The process of drying and storage takes time and the tools to prepare medicines are crude and raw. She recommends that the state can help in giving appropriate tools and machines to the traditional healers along with financial help in the collection of herbal plants and growing medicinal gardens. The claims by the healers can only be verified and cross-checked by community-based prospective ethnographic studies, which can be conducted by the local universities with the help of other universities, researchers from AYUSH and NEIAFMR staff. Oinam Ningthem Singh and his wife from Imphal West, Manipur, opened a Traditional Healing Centre (THC) in Langol, which is located in Lamphel, Imphal West district. The THC was registered in the All Manipur Maiba-Maibi Phurup as an association in 2007. O. N. Singh learned healing from his father, who was a famous Maiba in reflexology, locally known as ari-matang suba maiba or puk-suba maina, meaning a male local healer). He shared:

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Fig. 22.1 Treating a patient by the herbal healer Yanung Jamoh Lego from Pasighat (photo courtesy Shefali Bharati)

Since my youth, I have been very interested in learning the art of reflexology healing. The traditional knowledge I acquired was transferred from my father while preparing the medicines together. My father and grandfather collected the indigenous herbal medicines from the forests and fields. Most of the reflexology treatments are done by my wife, the herbalist and reflexologist Maibi (female local healer) as I am seventy-one--years old. I help her in the preparation of the medicines and collecting medicines from the nearby forests. We treat all kinds of diseases and illnesses such as sinus, tonsillitis, blood pressure, stroke, paralysis, indigestion, weight loss, cough and fever, boils, cancer, bone fracture, sprain twists, fresh accident injuries, bigger head of the child. Agang Yang Chingba (sudden contraction of a child’s body due to higher fever), backbone pain of L4 and L5, breast cancer, diarrhoea, and dysentery are also treated. We also treat women for gynaecological problems and infertility and we children for various ailments. We help couples in the gender selection of the unborn baby. In two cases, we helped the couple who had a series of girl children. We instructed and gave herbal medicine and the couple bore two sons after that (Fig. 22.2).

The Maibi said her ‘Idhou’ taught her ‘Mihungi Kanglol’ (pulse reading) and ‘Mari-matang shuba’ (reflexology) to treat backbone pain, sprain and paralysis. She said she could easily detect what was wrong with the patients by looking at their eyelids and reading their pulse to determine whether they had high blood pressure or not. The Maibi also said she used indigenous medicinal plants for healing different kinds of ailments. O. N. Singh said, with a sad note in his voice, that they have not received any monetary funds or assistance to build their healing centre or any equipment like wheelchairs for the patients. The healers are disappointed as many people come and document their practices, but the government is not supporting them. They built their own centre, out of their interest and passion to heal people. Earlier, they used to do it

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Oinam Ningthem Singh and his wife in front of their Traditional Healing Centre (Photo Courtesy -Sunita Reddy)

at home in a smaller place. Now they have built this place, though with all temporary material, and even then they had to spend two lakh rupees. However, they still fear eviction as the land does not belong to them. O. N. Singh continued, “We do not take fees when people seek our traditional knowledge for healing the ailments. Our father and forefathers gave the knowledge without any charge and the continuity of the knowledge is important by serving the people for minor ailments. People also come with major ailments like piles and cancer, however. If I feel they need special care or surgery, I advise them to consult AYUSH or a biomedical doctor. If traditional knowledge is developed like modern-day biomedicine, most people would definitely come to seek this healthcare treatment”. Padma Shri awardee Laishram Nabakishore Singh, from West Imphal, Manipur, was bestowed with the award for his humanitarian service for providing patients kidney stone case treatment by medicinal herbs, which is locally known as ung leibada mana-mashing gee laiyeng pathap. As we entered his humble clinic, we could see glass puppets with small stones arranged in order, with a collection of kidney stones that he had extracted using herbal medicine. The patients bring it back to him and he collects, stores and displays them. Truly, these are like decorative medals for his achievements. He was upset that his foreign patients could not send him the stone after expelling it. So far, more than 30–40 lakh patients have been successfully treated for kidney stones. He learned from his father and his son now is continuing this legacy. The healer said, There are a number of medicinal plants available in Manipur as well as in other parts of the country to prevent the formation of stone as well as to dissolve and remove them from the human body. I prepare seven types of indigenous medicine and they are given in two ways for the treatment of kidney stones. Three types of prepared medicine are given before lunch

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Fig. 22.3 Laishram Nabakishore Singh in front of his prized possession of expelled kidney stones in his healing room (photo courtesy – Sunita Reddy)

and four types of medicines after dinner, together with seven types of medicines. I advise the patients to drink a lot of water. After these medicines are given, the stones are passed out after one or two days or within a week. The total course of the medicine is for seven weeks. The stone is passed out or its size is reduced like salt or sugar, or the stone is completely dissolved by the action of the medicines. However, after seven weeks, if the stone is not expelled, I advise the patients to consult other doctors. I can’t treat the patient the size of the stone is more than 20 mm (Fig. 22.3).

In Meetei society, there are days in which it is forbidden to harvest these medicinal plants. It is forbidden to pluck ongmangkha, a local medicinal plant used for healing cough and fever, on Sunday. The idea was not related to religion but there are few medicinal plants that are on the verge of extinction, so our forefathers wisely told us not to pluck them on Sunday, thereby saving one more day with the medicinal plant leaves, for its own sustainability and for the use of future generations. There are many medicinal plants in Manipur, many of them have also become extinct due to a lack of concern for the medicinal plants in the valley area. Bhim Bahadur Neopani, from Upper Samdong, Kaluk West Sikkim, treats all types of fractures and broken bones, jaundice and piles. He started healing patients at the age of thirteen. Now, being old, his two sons are learning the traditional healing practices. To date, he has treated more than 50,000 patients. He even treats patients who were not satisfied with their treatment in hospitals. He narrated his experiences: My patients come from Gangtok, Mangan, Gazing, Kaluk, Soreng, Nepal, Darjeeling and other places in and around. It is difficult to collect some herbal medicines, it takes three days to climb the mountains to collect some medicinal plants. I prepare the medicine and keep it for the treatment of the patient. Every fifteen days, I go to the mountains for the collection of medicine. Some treatments need a mixture of 108 medicines, which I prepare at home. I generally treat the patients at my own house and sometimes go to the patient’s house. I have bought some land and I am planning to build a herbal garden at my home. I did a training

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Fig. 22.4 Bhim Bahadur Neopani sharing his experiences and concerns (photo courtesy – Shefali Bharati)

course and got a certificate from the forest department way back in the year 1999. Even to collect the medicinal plants from the forest, we have to take the permit and pay a small royalty. We need to pay 500 rupees as a fee per month. I had asked for help from the government to build a herbal garden and to procure an X-ray machine in 2008. To date, I have not received any response and support from the government. The healers are expecting support from the government, some of them actively pursuing the government’s help, but there has been no progress. Local health traditional healers are at the bottom of the hierarchy, and it is difficult to convince authorities to aid them (Fig. 22.4).

The Isolated and Disintegrated Healers’ Association in Manipur N. Tombi Raj, the president of the Maiba and Maibi Association, shared the history of the association in Manipur: “Manipur is located in one of the most biodiversity-rich zones of the world, which is a genetic treasure house of plant, animal and microbial resources. And in it lies one of the richest traditions of local health practices known as the maiba-maibi system of treatment”. He emphasized how one should note it is different from amaiba and amaibi, who perform religious chanting of hymns and dances accompanied by traditional musical instruments. The uniqueness of the maiba-maibi system of treatment is that a particular method of treatment involves pressing on the abdomen for about thirty minutes to one hour or more continuously,

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known as puk suba, is not found in other methods of treatment. Manipur has huge age-old experiences of treating patients using locally available medicinal plants and animal organs, including insects, minerals and other natural products. There is a huge potential for research work in this field. He also talked about the origin of the maiba-maibi system of treatment and the seven elixirs, sida hidak taret, in accordance with the seven days of the week. This treatment is believed to be administered by the Sun God. This system of treatment continues till today. He also mentioned, “There are several manuscripts and books on the traditional healthcare practices (the maiba-maibi system of treatment). Yellow deals with physiology and parts of the human body, Hidaklon deals with formulary and medicinal plants, Laiwa Hidak Kanglon deals with psychotherapy and formulary, Wachetlon deals with the longevity of life, Hidak Yaichal deals with traditional medicine formulary. Manipur also has a rich culture of maintaining old records in the form of stone inscriptions and copper plates written in the Manipuri language”. This healing system is a codified system with rich texts available in the state. He further shared, “allopathy came into existence in Manipur only after the Britishers took over power in 1891. Prior to that, the maiba-maibi treatment was the only available healthcare system. The system still receives the respect and continuing support of the local people. For example, in Manipur, particularly in Meitei society, the death certificate issued by a modern doctor working in a government or private hospital has no traditional, cultural or religious acceptance. Even after the issuance of a death certificate by a doctor, the family members of the deceased will call a maiba to examine the body physically for a formal declaration of the death of the individual to take up the customary procedure of disposal of the dead body. On religious ceremonies related to death, known as lanna thouram or sorat and Phiroi, a designated seat is reserved for the maiba which cannot be occupied by any other person. It shows the strong support extended by Manipuri society to the traditional healers. Apunba Manipur Maibi Maiba Phurup (AMMMP), the Manipur Traditional Healers’ Association, an apex body of the traditional healthcare practitioners of the state of Manipur, came into existence in the early 1970s. It has been registered in 1984 under the Societies Registration Act (Regd.No.5492 of 1984). In 1985, the AMMMP organized a state-level conference at Gandhi Memorial Hall, Imphal, in which about 1,000 maibas and maibis attended and shared their traditional knowledge of healthcare practices among themselves”. The AMMMP used to gather every second Saturday to discuss matters related to their healing practices in Manipur at the president’s house. Life with the maiba and maibi traditions centre around culturally rich rituals that have significant meaning in the everyday life of the people in Manipur; there is a need to revive this tradition and association. Firstly, we need to consider how the AMMMP can be more effective, as they have not been as active and strong as they used to be earlier. Tombi Raj shared that many of the traditional healers are illiterate. There is also a move away from the traditional system into a codified system of healing. He, therefore, urged for a strong need for documentation work along with scientists’ support to save this dying profession. The modalities and collaboration between the scientists and healers for cross-sharing and learning to come up with innovative works have to be evolved, breaking the hierarchy

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between biomedicine and traditional healers. Many initiatives are also taken up in different parts of India to collaborate with traditional healers. Due to the many side effects of allopathic medicines, people nowadays prefer herbal medicines. So, ‘go herbal’ is the slogan for the modern era.

Recognition of Folk Healers and Traditional Healthcare Providers This section outlines the process of voluntary certification of the healers. Though the process is simple, yet for a healer who is uneducated and living in remote areas, the steps are not easy. Further, after getting the certification, there are no incentives attached to it, which implies the healers will not be interested in getting certified. The process of certification is well laid out with proper institutional arrangements. The North East Christian University (NECU), located in Dimapur, Nagaland, and the Trans-Disciplinary University (TDU) in Bengaluru are authorized to certify. NEIAFMR is given the mandate to certify 100 healers as a third-party personnel certification body. They have developed a course curriculum and formed a potential evaluation team, since NEIAFMR was constituted for folk healers, though Ayurveda has been added recently. IGNOU did pilot certification and this is now taken up by the Quality Control of India (QCI) and the Foundation for the Revitalisation of Local Health Traditions (FRLHT) and the AYUSH ministry has given a nod to it. Scientific validation is being done by both QCI and FRLHT. For more details about the certification process, see Debjani Roy in this volume. Certification is a voluntary scheme where healers can register and get evaluated and certified. There is a two-step process. An AYUSH doctor at NEIAFMR shared the process of recognition of traditional healers. The scheme of voluntary certification of traditional community health practitioners, funded by AYUSH, is advertised in local newspapers for traditional healers to apply for certification. QCI and FRLHT developed the project proposals to certify healers. However, it was observed in the field that this is not known to many healers and the elderly healers hardly feel the need to get the certification. There is a need for proactive certification of the healers by the QCI and FRLHT in every region across the country, which will map the traditional healer’s resources to ensure the health and well-being of the communities, especially of those located in far-flung areas. The NEIAFMR doctor further shared about the team of evaluators and the composition for evaluation. “They have to undergo three days of training for evaluation under one AYUSH doctor, with five years of experience, and two senior traditional practitioners. Evaluators should be from the same practice and domain, with twenty-eight years of experience. The QCI has introduced only six domains: arthritis, poison bite, traditional birth attendant, traditional bone-setting, jaundice and common ailments for evaluation and certification. They should also be trained for three days as evaluators. They should bring a letter from the gram panchayat for certification”.

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He further explained the four-part process of evaluating the healers. “We evaluate for one day for 100 marks. It is not a written test but only an oral test with a practical demonstration as many healers may not be literate or able to write. Basic knowledge and basic questions are asked for 10 marks. The evaluator, posing as a patient, will try to know the problem and diagnose, for example, a fracture or dislocation for bonesetters. There is also a viva voce on that case and they are required to share the process of medication”. Giving more details, the doctor shared that “out of 100 marks, if 70 marks are gained, then the next day, the evaluators will visit the traditional healer on-site without prior notification in order to check where he is working and how. The evaluators will also inspect the traditional medicinal preparation room, check if cleanliness is being maintained as it is important for preserving the shelf life of ingredients, check for fungus, evaluate the storage room and tools being used and look at the space where the patients are treated. The evaluators also go around the community to check if the healers have been practising. Without prior warning, they are visited and evaluated. If it is 100% foolproof, then only he/she is certified. This certification is valid only for five years. After that, they have to come back for reevaluation”. The NEIAFMR doctor gave further details of the evaluation, “Healers have to bring at least a 7.5 cm long root to show it to the evaluators to identify the plant. The guidelines of the QCI are on the website. It has a code of conduct, self-declaration for evaluators, prior consent forms and certification forms for the healers to be endorsed by the respective panchayats. This certification is useful; they are not forced—it is ‘voluntary’. In all other states, the register is maintained at the Biodiversity Board to keep a record of traditional healers. The Biodiversity Board will have a list of healers, and those who are certified by the QCI will be given priority for any training and meetings. The database will also help in further research. After certification, they will be valued more and can showcase their certificate on a wall at their practice. However, they cannot claim the title of ‘doctor’ for themselves and have not been given any title after certification. Any organizers for traditional healers will be given a chance. Madam Lego, a very well-known traditional herbal healer, is the chairperson of traditional healers of Arunachal Pradesh and also the deputy director in the agriculture department”. Explaining the process, the doctor said that only those healers who use herbal medicines and are naturopaths are certified. They should practice at the community level without commercializing their service. His idea of traditional healers is “He should use raw form of drugs; they are mostly not educated. They come from family lineage or learned on their own. Those who are business-oriented and practise Ayurveda are not certified. They do not give names to their medicine like Laxmi vilas ras, which is an Ayurvedic medicine used for centuries. Some of the healers are reading books, getting raw material, making medicine, writing their name, packaging and selling. So they were not given the certification. The first evaluation was done in Tripura, where eight healers got the certification by the QCI. One was not given certification as he was preparing Ayurvedic medicines; he took a certificate from Calcutta, he was calling himself a naturopath. When his place was visited, he was selling the products and doing business, whereas the traditional healers usually

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serve the community. He was not practising traditional medicine. In Chhattisgarh, out of fifteen healers who had applied, only seven were certified”. This process shows that it is tedious for the evaluators, so large-scale evaluation cannot be carried out. Also, for the traditional healers, the marking system is difficult to understand, and due to a lack of resources, not all healers will have enough space to keep the herbal medicines neatly stacked. Smaller healers who procure when needed will be ruled out. The certification will help the younger generation reinvigorate the art of traditional healing with proper documentation. The younger generation is not interested in pursuing this practice as it is not profitable; only a few are coming up for training. The doctor gave three recommendations. 1. The curriculum of evaluation needs an understanding of the Drug and Cosmetic Act so that evaluators can identify the true traditional healers from the ones who are using the established healing systems without getting the right certification as per the act. 2. In AYUSH doctors, Ayurveda, Siddha, Yoga, Unani, Homoeopathy, Use the acronym as AYUSH, only use Ayurveda doctors, as Homoeopathy doctors do not understand plant medicines, whereas Ayurveda doctors know about 5000 or more plants. 3. Ayurveda doctors with three years of training should be given a chance to evaluate, rather than those with five years of training. Currently, one doctor has been given charge of four North East states, which is difficult to cover. The need of the hour is to bring together the Ministry of AYUSH and Ministry of Tribal Affairs to map the healers using GIS, certify them by taking proactive steps rather than providing voluntary certification, helping disseminate information of knowledge hubs and creating healers’ associations for regular interactive meetings to exchange ideas and formulations. The ministries, with its database of healers who are certified, can be given financial support, training and help in building healers’ huts or a community healing hut (Reddy, 2021).

The Making and Unmaking of NEIAFMR NEIAFMR, being the only national institute set up by AYUSH in 2008 for folk medicine, can play an important role. Recently, Ayurveda has been added with a focus on research. However, at the time of the fieldwork in 2019, there were only four traditional healers, two Ayurvedic doctors, and an ethnobotanist under the director at NEIAFMR. Out of the three old women folk healers, one is a traditional birth attendant, who claims to have treated infertility cases. She makes the womb ready for birthing and claims to have made two infertile women conceive and give birth. The author observed during fieldwork, an infant was brought crying to a healer, and instantly stopped crying, after doing acupressure and massage by the woman healer (Fig. 22.5).

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Fig. 22.5 A woman healer treating the infant at NEIAFMR (Photo courtesy – Shefali Bharati)

Though it is a fifty-bedded hospital, there were no inpatients, no nurse, and not even a ward boy to run the inpatient services. Despite being a national-level institute, especially for folk medicine, it has remained underutilized, with only Out Patient Department (OPD) services. The institute is planning to propose the appointment of nine doctors—three for Homoeopathy, three for Ayurveda, three for Sowa-Rigpa, for five domains in specific. As per the director, however, they do not constitute folk healers. Comparing the hierarchy in the healing systems to that of biomedicine, one of the doctors shared: “At NEIAFMR, around forty patients come every day for massage and physiotherapy. The Ministry is not serious about this institute, as they compare allopathy institutes like AIIMs and CMC Vellore with that of Ayurveda, which they look down on, leave alone traditional healers. There are hierarchy and power relations between allopathy, AYUSH and the folk healers who are at the bottom. Yet, on the other hand, some of the doctors appreciate traditional healers. The topmost South East Asia institute, CMC Vellore, is showing interest in traditional medicine for rheumatoid arthritis”. The official from NEIAFMR shared his concerns, the initial contractual staff was shifted to outsource staff, for only one year. Fourteen outsourced jobs have been lost, there is no mali (gardener) and no chowkidar. The decisions are taken the centre in Delhi without coming to Arunachal Pradesh. There may be some sort of reservation of not recruiting the staff, but it is very important to put resources into reviving the national institute and the local health traditions. An ethnobotanist, who joined NEIFM to revitalize the herbal garden, said 60% of plants are from Western Himalayas. The Himalayan institute will be funding the

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herbal garden for all North Eastern states. In 2009, a herbal garden was started, planting a specimen from the Western Ghats, of which 60–70% died. She shared that the plants that grow in their native habitat will not survive much outside of them. The ethnobotanist shared that 3 acres are now being expanded to 8 acres for a herbal garden in NEIAFMR. They invite healers and ask them to plant the saplings which they are using. Later, they can come and take the herbs and also plants. They are starting a project to grow herbal medicinal plants. In all the forest areas, from Tamil Nadu to Jammu and Kashmir, Arunachal to Gujarat, we have botanical specimens in plenty, but now the use of zoological specimens has become a huge concern due to the amendment of the Wildlife Protection Act. A lot of animal and bird products being used in deep forest villages cannot be documented, and their practices cannot be scientifically validated. We are hardly left with a few specimens. An official from the Biodiversity Board said, “Arunachal is going slow, the Biodiversity Management Committees (BMC), is formed at the local villages, block and zilla level. Around 150 BMCs have been established so far. Proper training is not given; many healers are not ready to share their knowledge. Resources are there but are being taken away from the country. The biocultural protocol needs to be developed”. The official expressed that the “AYUSH ministry should have an MoU with NEIAFMR and QCI and also universities like JNU, which can get international exposure. Honestly speaking, if a homoeopath who has been working in Odisha is given charge, he cannot appreciate traditional practices. One should have knowledge of plant medicines, and someone from the North East region should be in charge to recharge this institute”. He further said, “here are a lot of claims by the healers for treating cancers and these seem to be curing patients. NEIAFMR should be documenting the patient testimonials for treating cancer by conducting follow-up studies of the patients and also doing a prospective study to see the processes of healing and cure by herbal medicine by the traditional healers. Private universities are showing keenness to document, though the ministry is not showing interest. For reviving and recognizing the traditional healing practices, collaboration with North Eastern institutes, biodiversity boards and universities across the region are a must”.

Issues of IPR, Training and Mistrust AYUSH is documenting folk healing systems across the country under a project of systematic documentation and drug development from local health traditions and ethnomedical practices. Audiovisual documentation is going to see if any new formulations which can contribute to the knowledge base (For more details, see Srikant and Goel in this volume). Analysing at the micro-level, the healers are sceptical about their recognition in the whole process as they have not received any incentives and assurance of getting any benefits.

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The AYUSH project itself is built around the idea of only focusing on new combinations and new compounds to build the drug inventory. If the herbs and the formulations match the Ayurvedic Sanskritic texts, then the project does not consider them and moves on; the healers are left behind to practice, with no incentives. This perception has crept into the minds of healers in all three states studied, where they are apprehensive about others taking away their knowledge and not even acknowledging them. Thereby, the healers are also not sharing their real knowledge. There is a trust deficit, and thus, the whole effort of the project would go in vain, as the real knowledge is not shared. Trust needs to be built by recognizing their knowledge, giving incentives by proactive certification, providing training and giving testimonials and acknowledging them. The healers in the field had proudly shown us their collection of photographs, certificates and their participation in the training workshops. A calendar of the workshop conducted by the FRLHT and Biodiversity Board was hung on a wall. One of the healers in Manipur also showed the brochure of Maiba-Maibi Association signing an MoU with the Biodiversity Board for collaboration; however, he was upset that nothing happened after that. The Indian Biological Diversity Act, 2002, and Indian Biological Diversity Rule, 2004, include provisions for access and benefit sharing (ABS), which regulate access to genetic resources and equitable benefits. “It is essential that the value of traditional knowledge is understood and valued appropriately by those who use it, and that the rights of indigenous and local communities are considered during negotiations over access and use of genetic resources. Failing to do this can put the knowledge, the resources and the communities at risk” (Secretariat of the Convention of Biological Diversity, 2011, p.3). But on the ground, none of the healers reported any benefits they got to date. Sharing the experience of a three-day training programme and his anxiety, Nar Bhadur Limbu, a herbal healer from Sikkim, said, “hey asked the details of medicinal plants. They did photography and videography of our medicinal plants and provided certificates. Healers were never taught anything. We were given the facilities of hotel stay and provided travel and dearness allowances (TADA). In the training, we were expecting to learn about the medicinal plants but they did not teach anything. When training started, all of us were sent to the forest by taking the permit from the forest department to collect all the medicinal plants, whatever the healers know. Once we collected medicinal plants, we were taken back to the training centre. All the healers then shared one by one what they knew about the medicinal plants and their purposes. During the explanation, photography, as well as videography, was done. This is how the training got over and on the last day, we were given certificates. We were a total of five to six healers. All the medicinal plants collected by the healers were packed and taken by the trainers”. He shared his concern that they did not share any real knowledge. Because of such training programmes, where the healers’ expectations are not met and transmitting knowledge is only one way with no benefit to the healers, it builds on the trust deficit with the outside officials. Many healers shared similar sentiments with the researchers during fieldwork. One of the recent development of the healers is to collect testimonials from the patients in a register to keep a record

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Fig. 22.6 Patients testimonials showed by a healer (photo courtesy- Shefali Bharati)

of patients visited and also their feedback. Many healers showed the author their testimonials, certificates and photographs with their patients and sometimes even the officials (Fig. 22.6). Prof N. Rajmohan Singh, former faculty in the chemistry department, Manipur University, stressed the need for the revitalization of traditional health care in Manipur. The different ethnic groups living in the hills and valleys have their own way of using plants and herbs for medical purposes. His work is based on trace elements of plants that have healing properties. He spoke on the need to protect the medicinal plant species available from this region such as smilax, which are pirated on a large scale from the state. He said that big companies like Dabur want to get hold of all available smilax in the region. He spoke on the need to protect the plant species available in our region, as many endemic species are available in Manipur such as the Shiroi lily. He recalled how a scientist friend from the UK posted in Nigeria once said how all the leaves of the plants in Manipur can be converted into gold by touch. He called the region a ‘Green Gold’ area, where the natural resources are our real resources. He shared how a team of scientists have collected plants from different parts of the world, extracted compounds and patented their products. Therefore, there is an urgent need for scientists and traditional healers to work together to find compounds for antidiabetic, antimalarial purposes. In this regard, proposals have been made from Manipur University to acquire equipment for research work up to the molecular level. He also talked about the different declarations which call for the protection of indigenous people’s rights.

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There are many cases of the clash between multinational corporations and indigenous people’s rights. He, therefore, stressed the need for the traditional healers and scientists to walk hand in hand. He stressed the point by saying “reen mindset is important for our green globe” and shared Rachel Carson’s words: “Man is a part of nature, his war against nature is inevitably a war against himself”. Prof. Singh suggested “The government can come up with introducing traditional knowledge systems in the school syllabus if we really want to protect the traditional knowledge system. For example, the work of Vandana Shiva, a physicist who has done tremendous work on traditional knowledge. I suggest a holistic approach must be adopted because only physics or chemistry alone cannot solve the problem but demands collaborative work”.

Recommendations to Revive Folk Healing Systems Literature and all the papers in this volume show that in all the states, the local healers are largely poor and do healing services without any monetary benefits (Bode & Hariramamurthi, 2014; Singh & Madhavan, 2015; Steinhorst et al., 2021; Subedi, 2019). They consider it as divine powers given by the Almighty and they can use these healing powers only for the service of humanity and these cannot be commercialised (Mishra & Nambiar, 2018; Rustamadji, 2000). If they charge more fees, then their divine powers will go away. They are facing challenges due to deforestation and further restrictions for collection of herbal resources. The younger generation is also lacking interest, as they do not see any profits in this profession. The elderly generation of healers with rich knowledge and wisdom of the biodiversity resources are leaving the world with all their treasured information (Cox, 2000). There is no state support for any healers in any way to promote and sustain their knowledge. Loss of traditional knowledge is in a way loss of biodiversity (Vidal, 2019; Wilder et al., 2016). Based on empirical research and discussion with the healers, officials of the Biodiversity Board, medicinal plant boards, AYUSH officials and officials from the NEIFM, the following recommendations were given. All these will help in revising and recognizing LHTs, achieving universal health care for all. • Formation of healers’ associations at state and national levels. • Proactive certification of healers rather than just voluntary certification and also confer a title “Registered Local Health Practitioner (RLHP)” to be displayed. • Monetary incentives to set up medicinal plant gardens for traditional herbal healers. • Monetary incentives to run health setups, and if they have already been built, support the healers to sustain them. • State and AYUSH ministry at the centre should support the construction of ‘healers’ huts’, ‘healing huts’, ‘community healing centres’ in situ, at the

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panchayat level, with few indoor patient facilities, where the patients can be admitted. For example, orthopaedic care, which requires staying. Fellowships/scholarships to the younger generation to learn the art of healing. More training and exchange programmes for healers to document and share their knowledge. Give the healers some tools or machines needed for pounding, grinding, drying and packing. The marketization of indigenous medicine through the modern-day machine would definitely enhance the treatment systems as liquid medicine, which is very effective for healing, cannot be put on the market. A proper channel to identify THCs in different states so that people can access these effective healing treatments. A dire need to document the knowledge and practices prevalent in LHTs, especially oral traditions as the healers are the ageing population. Preservation and transmission of local healers traditions, their skill assessment and livelihood support for healers. Research on the extent of local practitioners, their socio-economic conditions, lineage, outreach, training, social legitimacy and quality of care. Maintain autonomy of local healers and create an intergenerational transfer of knowledge systems. Dedicated websites, blogs and audiovisuals of folk healing by the Department of AYUSH. Advocacy with the concerned ministries and departments to revive, recognize and support LHTs. Follow with QCI, FRLHT and other agencies to take forward this agenda to recognize, respect, promote and integrate the folk healers. Revival of NEIAFMR with full strength and functional indoor patient facilities and also research laboratory. NEIAFMR can create an evidence base and document the authenticity of traditional healing practices and thus dispel all the doubts and suspicions about healers.

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