Readings in Indian Sociology: Volume IV: Sociology of Health 9788132113843, 9788132118749, 813211874X

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Sociology of Health

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Readings in Indian Sociology Series Editor: Ishwar Modi Titles and Editors of the Volumes Volume 1 Towards Sociology of Dalits Editor: Paramjit S. Judge Volume 2 Sociological Probings in Rural Society Editor: K.L. Sharma Volume 3 Sociology of Childhood and Youth Editor: Bula Bhadra Volume 4 Sociology of Health Editor: Madhu Nagla Volume 5 Contributions to Sociological Theory Editor: Vinay Kumar Srivastava Volume 6 Sociology of Science and Technology in India Editor: Binay Kumar Pattnaik Volume 7 Sociology of Environment Editor: Sukant K. Chaudhury Volume 8 Political Sociology of India Editor: Anand Kumar Volume 9 Culture and Society Editor: Susan Visvanathan Volume 10 Pioneers of Sociology in India Editor: Ishwar Modi

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READINGS IN INDIAN SOCIOLOGY VOLUME 4

Sociology of Health

Edited by Madhu Nagla

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Copyright © Indian Sociological Society, 2013 All rights reserved. No part of this book may be reproduced or utilised in any form or by any means, electronic or mechanical, including photocopying, recording or by any information storage or retrieval system, without permission in writing from the publisher. First published in 2013 by Sage Publications India Pvt Ltd B 1/I 1, Mohan Cooperative Industrial Area Mathura Road, New Delhi 110 044, India www.sagepub.in Sage Publications Inc 2455 Teller Road Thousand Oaks, California 91320, USA

Indian Sociological Society Institute of Social Sciences 8 Nelson Mandela Road Vasant Kunj New Delhi 110 070

Sage Publications Ltd 1 Oliver’s Yard 55 City Road London EC1Y 1SP United Kingdom Sage Publications Asia-Pacific Pte Ltd 3 Church Street #10-04 Samsung Hub Singapore 049483 Published by Vivek Mehra for SAGE Publications India Pvt Ltd, typeset in 10.5/12.5 Adobe Garamond Pro by Boson ITech Pvt. Ltd., Kolkata and printed at Saurabh Printers Pvt. Ltd, New Delhi. Library of Congress Cataloging-in-Publication Data Available

ISBN: 978-81-321-1384-3 (PB) The SAGE Team: Shambhu Sahu, Sushant Nailwal, Thomas Mathew, Asish Sahu, Vijaya Ramachandran and Dally Verghese Disclaimer: This volume largely comprises pre-published material which has been presented in its original form. The publisher shall not be responsible for any discrepancies in language or content in this volume.

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Dedicated to my Teacher Professor Yogendra Singh

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Thank you for choosing a SAGE product! If you have any comment, observation or feedback, I would like to personally hear from you. Please write to me at [email protected] —Vivek Mehra, Managing Director and CEO, SAGE Publications India Pvt Ltd, New Delhi

Bulk Sales SAGE India offers special discounts for purchase of books in bulk. We also make available special imprints and excerpts from our books on demand. For orders and enquiries, write to us at Marketing Department SAGE Publications India Pvt Ltd B1/I-1, Mohan Cooperative Industrial Area Mathura Road, Post Bag 7 New Delhi 110044, India E-mail us at [email protected] Get to know more about SAGE, be invited to SAGE events, get on our mailing list. Write today to [email protected]

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Contents

List of Tables ix List of Figures xi Series Note xiii Foreword by Yogendera Singh xvii Preface and Acknowledgements xix Introduction by Madhu Nagla xxi

1. Sociological Inroads into Medicine: A Tribute to Aneeta A. Minocha (1943–2007) 1 Ruby Bhardwaj 2. Food: The Immanent Cause from Outside—Medical Lore on Food and Health in Village Tamil Nadu 13 V. Sujatha 3. State Sponsored Health Care in Rural Uttar Pradesh: Grassroots Encounters of a Survey Researcher 34 Rajiv Balakrishnan 4. Gram Panchayat and Health Care Delivery in Himachal Pradesh 43 Sthitapragyan Ray 5. Occupational Attitudes of Physicians 60 A. Ramanamma and Usha Bambawale 6. The System of Hope: The Constitution of Identity in Medical Institutions 78 Roma Chatterji 7. Voice of Illness and Voice of Medicine in Doctor-Patient Interaction 95 Mathew George 8. Narratives of Sickness and Suffering: A Study of Malaria in South Gujarat 116 Purendra Prasad

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9. Caste Variations in Reproductive Health Status of Women: A Study of Three Eastern States Papia Raj and Aditya Raj

10. Informal Social Networks, Sonography and Female Foeticide in India Tulsi Patel 11. Perception and Work Ethos of Medical Experts Dealing with Infertile Couples: A Study in Medical Sociology Bela Kothari 12. ‘Correcting’ the Reproductive ‘Impairment’: Infertility Treatment Seeking Experiences of Low Income Group Women in Mumbai Slums Meghana Joshi 13. Risk Culture, Propertied Classes, and Dynamics of a Region: A Study of HIV/AIDS in East Godavari District (Andhra Pradesh) Asima Jena and N. Purendra Prasad 14. Prison Inmate Awareness of HIV and AIDS in Durban, South Africa Shanta Singh 15. Medicalisation of Mental Disorder: Shifting Epistemologies and Beyond Tina Chakravarty 16. ‘Indigenisation’ Not ‘Indianisation’ of Psychiatry: An Anthropological Perspective Renu Addlakha

138

156 177

192

211 232 251 273

Index 297 About the Editor and Contributors 307 Appendix of Sources309

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List of Tables

Chapter 4 Table 1 Socio-demographic Profile of Sample Districts Table 2 Socio-demographic Profile of Sample Blocks Table 4 District-wise Distribution of Sample Respondents Chapter 5 Table 1 Age Group of the Doctors Table 2 The Number of Children and Professional Situation Table 3 Total Income of the Physicians per Month (as Declared in Their Income-Tax Returns) Table 4 Hours of Work Put in by the Physicians  Table 5 Number of Patients Examined per Day Chapter 9 Table 2a Caste-Group and RHI—Bihar, 1992–93 Table 2b Caste-Group and RHI—Orissa, 1992–93 Table 2c Caste-Group and RHI—West Bengal, 1992–93

47 48 50

66 67 68 69 70

147 147 148

Chapter 10 Table 1 Trends in Female–Male Ratio (FMR) and 0–6 Year Sex Ratios in Selected States of India 157 Table 2 Infant Mortality Rates and Death Rates (0–4 Years) by Gender165 Table 3 Sex Ratio by Birth Order in Haryana and Punjab 165

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Chapter 13 Table 1 Caste-wise Ownership of Cinema Halls and Lodges in Rajamundry226 Chapter 15 Table 1 Ontological and Epistemological Shifts in Understanding Mental Illness and the Corresponding Practices

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List of Figures

Chapter 9 Figure 1 Schematic Framework for Analysing the Influence of Caste on Reproductive Health of Women 140 Chapter 12 Figure 1 Pathway of Initiation of Treatment-Seeking Figure 2 Treatment-Seeking Process

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196 203

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Series Note

The Indian Sociological Society (ISS), established in December 1951, under the leadership of Professor G. S. Ghurye at the University of Bombay celebrated its Diamond Jubilee in 2011. Soon after its foundation, the ISS launched its biannual journal Sociological Bulletin in March 1952. It has been published regularly since then. The ISS took cognisance of the growing aspirations of the community of sociologists both in India and abroad to publish their contributions in Sociological Bulletin, and raised its frequency to three issues a year in 2004. Its print order now exceeds 3,000 copies. It speaks volumes about the popularity of both the ISS and the Sociological Bulletin. The various issues of Sociological Bulletin are a treasure trove of the most profound and authentic sociological writings and research in India and elsewhere. As such it is no surprise that it has acquired the status of an internationally acclaimed reputed journal of sociology. The very fact that several of its previous issues are no more available, being out of print, is indicative not only of its popularity both among sociologists and other social scientists but also of its high scholarly reputation, acceptance and relevance. Although two series of volumes have already been published by the ISS during 2001 and 2005 and in 2011 having seven volumes each on a large number of themes, yet a very large number of themes remain untouched. Such a situation necessitated that a new series of thematic volumes be brought out. Realising this necessity and in order to continue to celebrate the Diamond Decade of the Indian Sociological Society, the Managing Committee of the ISS and a subcommittee constituted for this purpose decided to bring out a series of 10 more thematic volumes in such areas of importance and relevance both for the sociological and the academic communities at large as Sociological Theory, Untouchability and Dalits, Rural Society, Science and Technology, Childhood and Youth, Health, Environment, Culture, Politics and the Pioneers of Sociology in India.

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Well-known scholars and experts in the areas of the chosen themes were identified and requested to edit these thematic volumes under the series title Readings in Indian Sociology. Each one of them has put in a lot of effort in the shortest possible time not only in selecting and identifying the papers to be included in their respective volumes but also in arranging these in a relevant and meaningful manner. More than this, it was no easy task for them to write comprehensive ‘introductions’ of the respective volumes in the face of time constraints so that the volumes could be brought out in time on the occasion of the 39th All India Sociological Conference scheduled to take place in Mysore under the auspices of the Karnataka State Open University during 27–29 December 2013. The editors enjoyed freedom not only in choosing the papers of their choice from Sociological Bulletin published during 1952 and 2012, but they were also free to request scholars of their choice to write forewords for their particular volumes. The volumes covered under this series include: Towards Sociology of Dalits (Editor: Paramjit S. Judge); Sociological Probings in Rural Society (Editor: K. L. Sharma); Sociology of Childhood and Youth (Editor: Bula Bhadra); Sociology of Health (Editor: Madhu Nagla); Contributions to Sociological Theory (Editor: Vinay Kumar Srivastava); Sociology of Science and Technology in India (Editor: Binay Kumar Pattnaik); Sociology of Environment (Editor: Sukant K. Chaudhury); Political Sociology of India (Editor: Anand Kumar); Culture and Society (Editor: Susan Visvanathan); and Pioneers of Sociology in India (Editor: Ishwar Modi). Sociology of Health (edited by Madhu Nagla with Foreword by Yogendra Singh) is the fourth volume of the series titled Readings in Indian Sociology. This volume contains empirical and theoretical articles that apply sociological concepts and methods to the understanding of health and illness and the organisation of medicine and health care. The articles included in this volume have also tried to explore the understanding of the process by which social practices and human health are related. Health and illness are central to our lives and are major areas of work, policy and debate in society. This volume explores key topics including the experiences of health and illness; sociology of the healing professions: doctors as professionals; sociology of food and health; mental health; sociology of illness: illness behaviour and narratives of sickness and sufferings; medical institutions and health service organisations: the system of hope; reproductive health care, HIV and AIDS: social factors in fertility and mortality; sociology of physician–patient relationship; health delivery system: rural–urban health care, private and public provision of health care and so on.

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Series Notexv

It can hardly be overemphasised and can be said for sure that this volume as well as all the other volumes of the series Readings in Indian Sociology, as they pertain to the most important aspects of society and sociology in India, will be of immense importance and relevance to students, teachers and researchers both of sociology and other social sciences. It is also hoped that these volumes will be received well by the overseas scholars interested in the study of Indian society. Besides this, policy-makers, administrators, activists, NGOs and so on may also find these volumes of immense value. Having gone through these volumes, the students and researchers of sociology would probably be able to feel and say that now ‘We will be able to look much farther away as we are standing on the shoulders of the giants’ (in the spirit of paraphrasing the famous quote by Isaac Newton). I would like to place on record my thanks to Shambhu Sahu, Sutapa Ghosh and R. Chandra Sekhar of SAGE Publications for all their efforts, support and patience to complete this huge project well in time against all the time constraints. I also express my gratefulness to the Managing Committee Members of the ISS and also the members of the subcommittee constituted for this purpose. I am also thankful to all the editors and all the scholars who have written the forewords. I would also like to thank Uday Singh, my assistant at the India International Institute of Social Sciences, Jaipur for all his secretarial assistance and hard work put in by him towards the completion of these volumes. Ishwar Modi Series Editor Readings in Indian Sociology

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Foreword

S

ociology of health has assumed a major significance in the paradigm of development studies. It constitutes a vital measure in its success. The volume on ‘Sociology of Health’ by Professor Madhu Nagla reviews the literature in this field with a sharp eye not only on how researchers in this field have grown over time but also on the extent to which these have contributed to the development of new conceptual and methodological categories. Her survey is comprehensive and competent. I am sure this volume would impact positively on the direction and nature of future researchers in this field. Yogendra Singh Professor Emeritus J.N.U., New Delhi.

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Preface and Acknowledgements

H

ealth and illness are part of the innermost complexities of social existence, permeating the domains of social existence, national policies, economy of the society and faith and religion. Sociologists have been interested in the social roots and consequences of health and illness in their sociocultural-ethos. Sociological Bulletin, the journal of Indian Sociological Society (ISS), has published 16 articles on the varied themes of sociology of health. The texts of these articles have been reproduced as they were originally published by the Sociological Bulletin. The perspective on health and medicine bring together individual and collective realities in the way they are organised, narrated, contested and in every sense lived as social trajectories. The section in the present volume deals with the health and health care which revolves around the relationship between food and health care and how people utilised health care in different settings. The ethics and normative standard of the health professionals is an important part of the health delivery system. It brings the patient into the process of communication and interaction which in turn affect the doctor–patient relationship which has been discussed in the volume. The patient as the receiver of the health care is in an altogether different situation; therefore, the narratives of the patient are important in analysing the delivery of the health care in the given set-up. The sick person is surrounded by his family, social network and communities. The health problems of the women, particularly related with the reproductive system, have a direct bearing on the gender equality in the society. HIV/AIDS is regarded as the global miseries of human being and need explanation in terms of its causation and treatment. The section deals with the mental illness as an important facet of the bio-psycho-social outcome of illness, which is not limited

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to biological disequilibrium; rather, it emerges within the individuals who are a part of the whole system. It was very kind of Professor I. P. Modi, President of the ISS, who trusted me to undertake this academic endeavour and I owe special thanks to him for the same. My teacher, who constantly encouraged and inspired me to take up issues on the theme of health and medicine, deserves lots of thanks and I am grateful to him for writing the forward to the present volume. An important milestone or a life event takes place when you fulfil the dreams of life partner; Bhupendra Kumar, my husband, who made all this possible with all his love, understanding and academic support, helping me in completing this task. My Bauji has always inspired me to engage in academic pursuit and that gives me the strength for completing this volume. My parents’ blessings are always with me. My children, Gaurav–Archana and Rohit–Radhika always encouraged me to take up the academic challenges and are trouble shooters for my computer-related problems. My dearest Abhigyan who is an energy provider by simply giving a sweet smile makes my day full of commitment for the present volume. Madhu Nagla Professor Department of Sociology, M.D. University, Rohtak Haryana

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Introduction Madhu Nagla

S

ociology of health emerged late in the 1950s as a specialised area of sociology; it has subsequently developed rapidly, because the medical profession has recognised the importance of sociology in the education of medical students. It is important to distinguish between sociology in health and sociology of health as perspectives in research. The former involves the use of sociology to clarify health-related problems and diagnosis, such as the nature of compliance to medical regimens. Hence, sociology in health refers to studies that help to solve problems in health science or to provide knowledge about practical problem in health practice, the allocation of health resources, operation of health facilities and services. By contrast, the sociology of health has been more concerned with issues of power between doctors and patients, and between health and the state. It encompasses the use of medical settings, and health and illness to study such sociological phenomena as organisational role relationships, attitudes and values of persons involved in medicine (Coe 1970: 3). The institutional setting in which professional socialisation of the young recruits to the profession takes place, is also covered under the field ‘sociology of health’. The importance of this seemingly trivial distinction is understood, and is in fact a pantheon of subject matters; it includes far-reaching conceptual issues that relate social phenomena to health and illness matters. However, here we are using interchangeably the terms sociology of health, sociology of health and medicine. In fact, sociology of health has remained a neglected field of study and not much thought was given to explore the links between health and society. Health and illness cannot be separated from the normal social life and they are in fact part of the wider social system; therefore, like other aspect of life, the health aspects should also be studied with the same rigour and sincerity. It is for this reason we are including some collection of articles in this volume of sociology of health.

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The present volume intended to be an outlet for ongoing research in health and medicine in India. This volume is thematic, addressing the status of the field, providing possible prognosis and, at least, integrating fresh areas of research. The title of this volume itself speaks of its contents. It is intended of medicine to share its ideas and perhaps put them to use for the future health and welfare of the people. The past two decades have seen marked shifts in health paradigms and institutions. First, changes in welfare systems of health care in India are under transformation from the policy of globalisation which has turned health care into industry. Second, the voices of illness and medicine on treatment schedules is interacting in such a way with the demand for evidence based treatment and social support. There has been a corresponding shift in theoretical paradigms from symbolic interactionism and functionalism, which neglected the politics of medicine, to various Marxist paradigms which adopt a far more critical perspective on health service organisations and healing professions. Another radical perspective on medicine has come from feminism which regards inequalities in health provision and differences in illness behaviour as the products of patriarchy and gender. These critical perspectives in contemporary medical sociology argue that the health of human population is not a consequence of medical intervention but of the socio-political environment (Illich 1977, Navarro 1977). For all of these developments, it seems obvious that sociology presents itself as an important tool for understanding the complex interaction between different actors in the development of paradigms and the institutional structure of health services. Articles dealing with these issues on the macro- and micro-sociological levels in relation to health care are included in the present volume. In the above context, we feel that the need to untangle the literature on sociology of health that has accumulated over a period of 60 years in Sociological Bulletin and to provide a text at one place so that in some way student can glance over past and current trends in sociology of health. After screening the Sociological Bulletin since inception, that is, the 1950s, till present, we found 16 articles which are on the varied themes related with the sociology of health and medicine. We do not pretend to ‘cover all of the literature’ in the volume. Instead, these articles have limited themselves to the relevant issues of health and illness in the modern Indian society. Therefore, the volume covers a variety of topics: namely, sociology of the healing professions: doctors as professionals; sociology of food and health; mental health; sociology of illness: illness behaviour and narratives of sickness and sufferings; medical institutions and

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Introductionxxiii

health service organisations: the system of hope; reproductive health care; HIV/AIDS; social factors in fertility and infertility; sociology of physician– patient relationship; health delivery system: rural–urban health care, private and public provision of health care and so on. We could not find articles related with the important issues of health policies and planning, social constraints of health delivery systems, medical pluralism, ethnic differentiation and health belief and behaviour pattern and off course current issues in medicine and social change. The volume is divided into eight sections: These are: I. Medical Sociology and Its Significance, II. Health and Health Care, III. Doctors as Professionals, IV. Physician–Patient Relationship, V. Patients Narratives on Health, VI. Reproductive Health Care, VII. HIV/AIDS and VIII. Mental Health.

I.  Medical Sociology: Its Significance A simple layperson is not specialised in everything and it applies to the doctors also who are not experts in social sciences or in social policy. This duality between the medical doctors and social philosophies concerning health and medicine ultimately constitutes the scope of this book. This book is not a textbook on medical sociology as it does not deal with the concepts of health, illness or theoretical formulation for explaining the health behaviour of community or society at large. Instead, it deals with the sociology of health, which is particularly related with the varied themes ranging from food and health to delivery of health-care services and in between that their understanding of illness, interaction with doctors, reproductive health status of women and also mental illness and HIV/AIDS. Sociology of health and medicine is one of the important areas of special sociology. In the first Indian Council of Social Science Research (ICSSR) trend report of sociology of medicine, Anita Ahluwalia begins with a discussion of the importance of the sociology of medicine and then proceeds to bring out the significance of the study of conditions in which the modern system of medicine was introduced into India and the factors

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responsible for giving it an important place. The second ICSSR survey of research in sociology and social anthropology (1969–79) contains one of the trend reports on professions which covers a section on medical profession rather than being an independent trend report on health and medicine like the first one. In this second ICSSR trend report on professions, Sharma (1985) provides an overview of the field which highlights two sorts of studies, that is, of medical professionals and professional organisation. Taken as a whole, the research on the medical profession reflects two main theoretical orientations, namely role analysis and dialectical analysis. While the studies of professionals are informed by the role perspective, those of organisational aspects of medical profession are preoccupied with the Marxian perspective. Methodologically, most studies of the first category can best be characterised as descriptive surveys of the background and role of doctors with little attempt at the analysis of professional content, while most studies of the second category are largely of a speculative variety. There is not a single study in the ethno-methodological tradition which is hardly surprising considering that such a trend has not yet got going even in the West. Madhu Nagla presents ICSSR trend report on Sociology of Health and Medicine which represents the fifth round of the surveys covering the period since 2002 to 2010. She identifies the emerging issues in the development of sociology of health and medicine with the anticipation of future challenges and how they find their relevance in the healthy development of society. Most of the researches in India, during the early phase and confined to the caste, joint family and the village community and even in the later period were related to the other sociological issues baring medical sociology. In 1974, Ahluwalia conducted her first of its kind study in the hospital setting for her doctoral work. Aneeta Minocha has made original and insightful contribution in the area of medical sociology as quoted by Bhardwaj (2008) in her article on ‘Sociological Inroads into Medicine: A Tribute to Aneeta A. Minocha (1943–2007)’. Ruby has given the tributes to her in this article by putting her whole contribution in the field of medical sociology and benefitted the discipline of medical sociology as well as to the researchers and academicians. Mincoha strives relentlessly to highlight the significance of sociology in the understanding of health and disease. She emphasises forcefully for teaching of medical sociology. She views that the doctor and the patient interact not simply as diseased entity and curative agent, but also as social beings belonging to different cultural milieu. The understanding of patient as a social entity sensitises the doctor to a gamut of intervening social variables that impinge on the former’s health or sickness. The doctor’s

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training in sociology would enable him to not only learn about the impact of the cultural milieu on the behaviour of the patients but also have close look at himself in his own milieu. Minocha advocates conceptual and terminological rigour in academic research. The concepts of health, disease and medicine attained precision from her critical inputs and holistic perspective. The concept of medical pluralism in India is pioneered and popularised by Minocha. She analyses the multifarious dimensions of medical pluralism and its role in the availability of health services. In the light of limited knowledge and familiarity with the multifarious therapies, the real bases of choice are the availability, accessibility and the quality of medical care provided by the diverse systems. People are interested in an efficient curative system, and very often it is found that indigenous practitioners administer strong allopathic drugs for fast relief to the patients. Minocha is foremost in taking up a systematic and extensive study of the modern medicine, its institutions and its profession in India. She approaches even hardcore concerns of medical sociology, such as the study of the institutions and professions associated with modern medicine, from women’s perspective. Minocha never fails to express her views on the moral and ethical dilemmas of the medical world and their sociological world and also their sociological relevance. Her writings on various issues and concerns ranging from social fallout of trauma, organ transplantation and euthanasia to the consumer protection, informed consent are very much part of the field of medicine.

II.  Health and Health Care Sociology of health and health care is emerging as a more substantial area of research in sociology today. Such trends often have multiple causes. One influence may be the increasing awareness of nutritional problems both worldwide: on the one hand, it is a problem of under nutrition and on the other it is obesity which is rarely off in our television screens and within the developed and developing and underdeveloped societies. In the highly developed societies, the incidence of eating disorders including anorexia nervosa, bulimia and obesity is attracting more and more attention. A second influence may be the professionalisation of health and healthcare specialists, and the increasing concern with preventive medicine, which has involved sociologists teaching health-related courses to students training in these fields in the past. This particular rise is probably bolstered by social respectability afforded by a shift in analytic and empirical attention from the sociologies of industrialised production to those of industrialised

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consumption. In turn, this has reflected a great openness to other neighbouring disciplines, notably psychology and anthropology. This section deals two types of studies which reflect above two influences. First: Food and Health (Sujatha 2002) and second: Health Care (Balkrishnan 1996, Ray 2007).

II (a)  Food and Health A vaguely functionalist orientation also unconsciously underlies much collaboration between sociologists and nutritionists, a common form of research in recent decades, in which current nutritional science is used to evaluate the results of questionnaire or interview surveys of why people eat particular things, the resulting explanations often have a somewhat ad hock character. For instance, Yudkin and Mckenzie (1964: 15–19) contend that on the whole there is a direct relationship between palatability and good nutritional value; for example, protein-rich animal foods are in general tastier than starch-rich vegetables foods. But they admit that the activities of modern food manufacturers now permitted a very significant degree of dissociation between palatability and nutritional values. Besides, the correlation is plausible only if the standards of palatability which prevail in the familiar world of Europe, North America and similar countries are taken as yardstick. In fact, there are not only different ideas of palatability in other cultures but European-type standards are equally culturally conditioned and by no means unchanging. The great virtue of the structuralist approach is that it clearly recognises that ‘taste’ is culturally shaped and socially controlled. It, thus, avoids the adhockery, biological reductionism and implicit ethnocentrism found in some of the work. Its weakness, arguably, is that in avoiding any suspicion of ethnocentrism. It moves so far to the role of extreme cultural relativism that it overlooks any possibility of explaining differing food habits— particularly their origins—in terms of purpose, function or utility. Structuralism has made itself felt in the sociology of food and eating via the influence of anthropologists like Claude Lévi-Strauss and Mary Douglas, and the semiologist Roland Barthes. In contrast to the some utilitarian slant of the social nutritionists and the functionalist, the structuralists have always focused more on the aesthetic aspects of food and eating: in Fischler’s phrase, ‘while the functionalists look at food, the structuralists examined cuisine’ (1990: 17). Douglas defines the aesthetic as distinct from the nutritional aspects of food as ‘that part which is subject to

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pattern-making rules, like the rules of poetry, music or dance’, adding that ‘the explanation of any one such rule will only be found in its contribution to the pattern it helps to create’ (1974: 84). Structuralism since Lévi-Strauss has concerned itself more with variability and much less with universality, ‘no doubt retreating from the notion of “human nature” which was suspect in its eyes’, and it was ‘thus that cultural relativism gained its ascendancy in the study of human eating’ (Fischler 1990: 17). Lévi-Strauss’s structuralism has had less direct influence on the sociology of food and eating than that of Mary Douglas. All over the world food consumption is currently a public health issue. How much, and exactly what people eat, have become matters of concern to all governments. In richer countries there is concern that too many people are eating too much of the wrong things (health-wise). In poorer countries the concern is whether people are eating enough, regularly, and whether their diets are optimal (health-wise) given the foodstuffs that are available and affordable locally. De-traditionalisation (see Giddens 1991) may be contributing to nutritional problems in richer countries. Old beliefs and the related practices are being lost and replaced, for practical purposes, not by science, but by eating as much as you like of whatever you like and whenever you like. In the less-developed world traditional beliefs about food remain strong and influential, but despite these differences there may well be lessons of wider relevance that can be gleaned from a country such as India. These lessons concern the difficulties of using a combination of science, education and information campaigns to change people’s everyday behaviour. Everywhere, up to now, whether the aim has been to persuade people to eat or drink less, or differently, or to take more exercise, the campaigns have had limited success. In her article, ‘Food: The Immanent Cause from Outside Medical Lore on Food and Health in Village Tamil Nadu’, Sujatha (2002) analyses the ideas and practices about food in village Tamil Nadu and discusses the village-folk’s knowledge of health. The article is divided into three parts: the first part outlines the content of the villagers’ diet. For example, people in the studied village generally take rice. Among other items in the diet, maize, ragi, millet are taken with a vegetable or spicy gravy. Milk and milk products are conspicuous by their absence. The second part examines their ideas relating to food and its significance, and the norms governing food and eating. The people accord great importance to food; however, they do not seem to perceive its importance in terms of its basic need for existence. The conceptions of food are corporal and they seem to conceive the significance of food in terms of its vital functions for the body. Their conceptions are

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also wide in scope, encompassing the idea of intake of food. The third part highlights the features of medical lore as a knowledge system. The medical lore of the people consists of both inherited knowledge and incorporated knowledge. The entire process of reckoning with the available resources and making them compatible with needs yields a lot of knowledge and experience. There is constant interaction between the two components of the lore, namely what is inherited and what is incorporated, each reinforcing and modifying the other. The most crucial source of the villager’s incorporated knowledge is practice. The lore or which means health tradition is an ongoing process in which the confluence of inherited and incorporated knowledge is affected through the crystallisation of experience. Continued living in a habitat for several generations, and the conscious experience of the body, disease and the remedies have built up a knowledge tradition. By incorporating the food elements outside the body system, by inducing variety in food intake, by adapting to the ecological conditions, the body–food dialectic yields a health tradition, whose continuity is ensured by its orientation to informed practice.

II (b)  Health Care There are many evaluative studies on the efficacy of the public health systems in improving the health outcomes of different settings and the relative performance of various states in India. Relative efficiencies differ across states and this is due to differences not only in the health sector endowment, but also in its efficient use. It shows that states should not only increase their investment in health sector, but also manage it efficiently to achieve better health outcomes. It is time to recognise that the utter neglect of primary care and primary health care institutions has influenced the utilisation of health services and contributed to the worsening epidemiological profile in the country in recent years. In the present form, the proposed mission adds to the confusion about the approach to health care in the country. Cost-effective interventions such as the rational distribution of financial and medical resources, including drugs, effective manpower distribution and primary health-care approaches, should be a part of the vision. These are often brushed aside for ushering in the privatisation logic (Nayar 2004). In this section, we are discussing two studies on rural health care only since there is not a single study on urban health care reported in Sociological Bulletin. In his article, ‘State Sponsored Health Care in Rural Uttar Pradesh: Grassroots Encounters of a Survey Researcher’, Balkrishnan (1996) presents

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his field work experiences in the primary health centres and sub-centres of Uttar Pradesh. Auxiliary nurse midwives (ANM) are the backbone of the sub-centres. During the intensive interaction with the ANMs attached to the sub-centres, it is found that because of the targeted approach of family planning method, the entry of the acceptors in the records are often cooked up. The problems afflicting the public health services are by no means confined solely to infrastructural bottlenecks or derelict personnel. Medical officers are involved in the graft and malfeasances that plagues the public health service. The ANMs are often victim of this for offering bribe from recruitment to the transfers. It is not just that defaulters get away scot-free by giving bribes, but the system also harasses the dedicated and innocent as well. The public health system is also plagued by factionalism among its staff. The public health system not only requires the efficiency and competence but equally important is the accountability to the people. Thus, the public health care system is a failure in reaching out to the masses. In his article, ‘Gram Panchayat and Health Care Delivery in Himachal Pradesh’, Ray (2007) examines the role of gram panchayat in the delivery of health-care services in Himachal Pradesh. The gram panchayats are not performing well in the health delivery mechanism. They failed to translate the information advantage into an efficiency advantage. The passing of laws, formulation of policies and issuance of notifications have not served the purpose. There is a gap between the decentralised approach to health service delivery at theoretical level and action level. Lack of effective devolution of powers and resources on the panchayat; inadequate capacity building of gram panchayat members and poor involvement of active civil society groups are the main factors for the poor performance. However, the study calls attention to the political economy of decentralisation and the need for a high degree of political commitment or interest-group support for the success of any initiatives. Functional effectiveness of panchayats is quite low, particularly in the crucial area of primary health care. Therefore, new measures have to be taken up to redress the situation. The paradox of successful decentralisation involves, among other things, top-down initiatives for bottom-up implementation. We may view here that health-care delivery system broadly depends upon functioning of health institutions and role of doctors as professionals.

III.  Doctors as Professionals Health-care providers are the main actor in the therapeutic process of health-care delivery and solely responsible for the protection of the health of people in order to fulfil their rights and obligations as normal members

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of society who are a part and parcel of the larger social structure. These men are educated and trained as professionals by the society to take care of the sick and cure illness. As common man of society he bears, and influenced several social factors which directly or indirectly affect his behaviour. In short, socio-economic, political and religious behaviour of the people affects the making of ethical professional. Hence, any professional might have not freed himself completely from certain pre-professional attitudes and values which he acquired during the period of primary socialisation before entering the professional training. The sociologist in medicine often has to take the role of an applied scientist to solve certain problems of the medical scientists, like to help in finding out the social causes for an endemic spread of a disease in a locality or to find out why people of a community resist taking immunisations. His help may also be sought to explain why patients refuse certain treatment procedures in the hospital or run away from the hospital during the course of treatment. The article, ‘Occupational Attitudes of Physicians’ written by Ramanamma and Bambawale (1978) reveals that doctors are most respected persons in the society and that is why rewards are generally much more than in any other profession. They receive a great deal of importance and wielding a great deal of influence. Doctors also get psychological satisfaction while curing the sick, which could be much more than perceived in other jobs. Ramanamma and Bambawale draw some clear conclusions from their exploratory study: 1. The general practitioners (GPs) combine physical cure along with the psychological and emotional care of their patients. 2. Paid physicians (PPs) even though have less monetary gains are compensated by curing patients who have abnormal complications. 3. Usually the consultants (CPs) get patients with a case history from GPs or govern hospitals, so they start treatment sometime in the middle of a sickness.

The article depicts that occupational hazards seem to make or mar the career of a professional and yet none of the three categories of doctors have felt the need to stress on this part of their life. The maximum degree of interaction between the physician and patient is between the GP and his patient and on a lesser degree between the CP, PP and their patients. In her article, ‘The System of Hope: The Constitution of Identity in Medical Institutions’, Chatterji (1993) discusses about three documented monographs which deal with the medical institutions in Netherlands. The author basically addresses two questions that why should doctors actively

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involved in medical practice choose to write sociological accounts of institutions in which they work. And the second is why the report on the cancer research institute was withdrawn. The work in these monographs is not merely ethnographic but critically evaluated the increasing professionalisation of care in Dutch society which leads to the diminution of personal responsibility and initiative in the management of problems. In the nursing home situation the relations are characterised by conflict or equilibrium and by an experience of disjunction between the past and present. The three major areas in which this disjunction is perceived is in terms of the body (health versus sickness), mental status (autonomy versus dependence) and social state (home versus institution). It suggests that institutions should structure their work routine so as to be able to handle this disjunction therapeutically. In the report on cancer hospital, it is believed that the ‘system of hope’ may be the only mode of care available in the medical context. It looks that their critique of medical institution as being part of a larger critique of the professionalisation of care in society in which experiences of suffering and death have been removed from the familial domain and placed within the regime of experts. The reports like to see more openness in medical institutions and a more personalised approach to medicine in which the patient is central not merely in terms of his or her disease but in terms of his/her whole life experiences. Medical personnel are not as mere technicians for the treatment of the body but also as spiritual advisors and sympathetic witness to the patient’s suffering. Chatterji laments that the all three reports are exclusively on verbal communication for their research. If they had been more sensitive to non-verbal communication they would have realised that it is characterised by a tentativeness that cannot be structured in the manner in which the work routine can be bureaucratically structured. The ideal that stands behind the critiques of these reports must be understood in terms of moral value that the medical institutions has in this society. Individual personality could not only be articulated in the cracks of bureaucratic organisations.

IV.  Physician–Patient Relationship Physician–patient relationship is an important theme of sociological interest. In every social system, the interaction and interrelationship between its members in accordance with the goals and the institutional sanctions is the basis for the functioning of the system. The hospital is considered as a social system and the physicians and patients are the sole occupants who mutually interact to form relationships directed by their specific goals and the general

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goals of the system. The entire organisation and instrumentality within this system has its concern with the social aspects of human behaviour. In fact, the forms, patterns and directions of the relationship with their bearing on the goals and the norms of this collectivity have to be ascertained in relation to the functioning of the system with reference to the physicians, patients and their satisfaction in a given situation, existing in a hospital at a particular time. Physician–patient relationship is of utmost significance in medical science. In this context the first and foremost requirement is that the doctor need to develop a good rapport with the patients, which would enable him to know about him. There are large number of questions in the mind of the patient, which are creating problems and bad health. Physician can improve many of patients doubt through communication. It is of great significance for the physician to take the patient in confidence. Physician and patients are intimately connected as the existence of one without the other is not possible. The harmonious relationship depends on the sincerity, earnestness and co-operation between the physician and the patient. The achievement of good relations between the physician and the patient is a matter that does not depend by any means solely on the conduct of physicians. It equally depends on the attitude of patients and thus their relations. People must behave well towards physicians. If loose and unsubstantiated allegations are made about their incompetence, dishonesty, laziness and indifference to the public interests, it is unlikely that physicians will develop or display qualities of integrity, industry and public spirit. Both the physicians and the public must exhibit harmonious relationship between them. This would promote good rapport between the two, which would prove good relationship. Physician–patient relationship means the development of cordial, equitable and therefore, mutually profitable relations between the two which depends upon doctor–patient interaction. Medical care achieves its silence through the process of diagnosis, treatment and follow-up. These are usually accomplished by the active group effort of doctors, patients and other paramedical staff through health institutions. The role played by doctors and patients become pivotal in the process of medical care. In his article, ‘Voice of Illness and Voice of Medicine in Doctor-Patient Interaction’, Mathew (2010) examines the interaction between doctors and patients in the process of fever care rendered by the allopathic hospitals of Kerala. The article is based on Mathew’s PhD thesis on the various facets of the problem of fever in Kerala of which ethnography of bio-medical clinics was one component. Mathew uses narrative

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analysis for presenting the meanings given by doctors and patient to the common illness by taking three cases. There can be different voices that are in constant interaction in doctor–patient interaction like voices of illness and voices of medicine. Voices of illness are again divided into lifeworld voice of illness and musicalised voice of illness. Voice of medicine is divided into voice of science and voice of experiences. Most of these voices get articulated in a clinical interaction. Ultimately the dynamics of these various voices depend on the context of interaction and the actors involved. Mathew argues that clinical interaction is not merely a two-way communication desired for exchange of information; rather it is an outcome of the socialisation of doctors and patients about an illness within their respective contexts. However, it is not possible to draw a general pattern from these interactions, but the meaning of illness/disease or in turn outcome of medical care will be determined depending on the institutions prevalent in which clinical interactions occur and the actors involved. In the ensuing section, we would like to present the narratives of patients which reflect their sickness and sufferings.

V.  Patients Narratives on Health The patient is helpless and needs help in terms of technical competence and emotional involvement. Parsons (1951) suggests that the patient’s expectations apply to a greater or lesser degree, depending on the severity of his illness: that he avoids obligations with many exacerbate his condition; that he accepts the idea that he needs help; that he desires to get ‘well’ and that he seeks technically competitive help in getting well. An adequate sociological definition of illness must go beyond the capacity in normal relationship and include all the four components listed by Parsons as necessary for a system of action—the organism, personality, social system and culture. Further, Parson’s inclusion of the expectation to seek professional care as a component of the sick role is merely an indication of a possible social response to the deviant nature of illness. The legitimisation of the patient status-role is itself a tension-management device for the patient. Considering the needs of the patient Loomis points out that although the relationship between physician and patient tends to be functionally specific the medical people usually must take into account factors about the patient besides his sickness—need to return to work, the kind of care he is likely to receive after discharge and so on. The goal of the sick person is recovery—a goal to be obtained not only by the patient but by all the relevant collectivities.

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Implicit is his relation to the patient is the physician’s goal of facilitating the latter’s recovery to the best of his ability. Great physicians in every age have recognised that patient must be seen as a whole, that is, in terms of his interpersonal relations and his social environment. Although the conception of the patient as a person is long established and generally acknowledged in medical circles, it is also said to be conception more honoured in the breach than observance. Many physicians continue to regard the patient as a case of sickness rather than a person’s collaborative health care as a process which is integrated with the people and society. In his article, ‘Narratives of Sickness and Suffering: A Study of Malaria in South Gujarat’, Prasad (2005) tries to understand why Malaria has remained alarming in India even to this day. He has used the conceptual framework of sickness to study malaria. Sickness identification and prolongation of sickness are major concerns for policy-makers. However, the whole discourse of preventive and curative models fixes the blame on individuals and prescribes several health-education and behaviour-change programmes as remedies, instead of understanding and addressing the social conditions of disease production. Pursuing this line of argument, Prasad explores human suffering from Malaria and its various intervention strategies. The narratives of people are taken and analysed in terms of semantics in the local context. The article concludes that despite significant scientific and technological advancements and interventions by both state and nonstate agencies, malaria is still alarming. It argues that the conceptualisation of sickness and suffering, or for that matter of health, varies greatly between groups of sufferers and groups of healthcare providers, including the policymakers. Moreover, in addition to the inaccessible health services, unequal resource availability, lack of education and so on the very process of identification of sickness—in this case malaria—also contributes to the worsening of disease situation leading to high morbidity and mortality in rural India as substantiated from this study of Surat District of Gujarat.

VI.  Reproductive Health Care The role of socio-economic and demographic factors in influencing demand for and utilisation of several reproductive health services in India is clearly brought about by earlier studies. Most of the studies reveal that besides education of the woman, other socio-economic factors affecting the process of reproductive health care, particularly the factors such as living standard of the household (Ghosh et al. 2007) and quality of care (IIPS:2000).

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Additionally, accessibility to services has also been found as an important factor determining the utilisation of health services (Ghosh et al. 2007). The frequency of contact with health provider is more among the women having problems (Matthew et al. 2001). However, past studies lack consensus over the association of Antenatal Care (ANC) with maternal health. Ram and Singh (2006) have found ANC as a strong predictor of safe delivery in the rural areas. Women bear their health problems in a ‘culture of silence’ and do not seek timely health care. They often cannot travel beyond the area of their normal activities to obtain services. They usually cannot approach male health providers. In general, families, including the women themselves, spend less time, effort, and money seeking health care for women and girls than for men. In this section, we would like to discuss four studies of Raj and Raj (2004), Patel (2007), Kothari (2012) and Joshi (2008). These studies highlight four major issues of reproductive health care. In India, caste plays a major role in the life of the people, influencing their socio-economic activities, and in turn regulating their health status. In their article, ‘Caste Variations in Reproductive Health Status of Women: A Study of Three Eastern States’. Raj and Raj (2004) analyse the reproductive health status of women across various caste groups in three eastern states of India: Bihar, Orissa and West Bengal. The data are compiled from National Family Health Survey (NFHS)-I (1992–93). Women and child health received a major impetus after the International Conference on Population and Development (IPCD) in Cairo in 1994. In the IPCD, reproductive health was defined as the state of complete physical, mental, and social wellbeing, and not merely the absence of disease infirmity, in all matters relating to reproductive system and to its functions and processes. In the continuation of this, the Government of India has introduced the Reproductive and Child Health (RCH) Approach. This approach includes the ability (of couples) to reproduce and regulate their fertility. Women can go through pregnancy and childbirth safely, the outcome of pregnancy is successful as for maternal and infant survival and well-being, and couples can have sexual relations free of fear of pregnancy and of contracting diseases. Indian women, by and large, have a poor reproductive health status. The study concludes that, despite government programmes and intervention, the reproductive health status of women in India presents a sorry scenario, mainly because of the socio-economic forces that influence reproductive health. Caste is one social institution whose impact on the life of her people cannot be exaggerated. Raj and Raj developed a framework to understand caste influences on the lives of people. This framework represent that caste influences socio-economic variables that includes educational status, work

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status and standard of living. These variables, in turn, have an impact on knowledge and utilisation of contraception and reproductive health care services, ultimately affecting the reproductive health of women. The late 20th-century advances in New Reproductive Technologies (NRTs) have generated a great deal of interest in social anthropology. In this context, the article by Patel (2007) on ‘Informal Social Networks, Sonography and Female Foeticide in India’ explores the manner and processes of the relationship between NRTs, particularly the ultrasound technology, and the culture of reproduction mediated by informal social networks. Multilayered relationship between community members and their relationships in organising social and biological reproduction is looked into the study. Gender and family size issues bring about a convergence of culturally imbued interest and socio-economic purpose among different categories of people in the society with respect to provision, acceptance and accessing of sex-determination technology, and aborting undesired foetuses. The social ties among medical practitioners and the state officials are such that law enforcement officials and medical practitioners are friends if not relatives. The combination of legal abortions (also possible in government hospitals at government cost) with the illegal foetal sex test (done privately) is managed in ways other than mediated through local health functionaries, that is, through relatives or friends. It has brought about a unity of purpose between the Family Welfare Programme and the people’s aim. The family obtains the desirable sex composition of children, government health staff posted locally fulfils their targets, and private medical practitioners make money, while the female foetus disappears. The article by Bela Kothari (2012), ‘Perception and Work Ethos of Medical Experts Dealing with Infertile Couples: A Study in Medical Sociology’ examines the influence of social perceptions of medical specialists in the management of infertility and the extent to which they find infertility to be a social rather than a purely medical problem. Infertility is a unique social problem and regarded as more of a life style disease. It is a unique medical problem in which the ‘patient’ is a unit of two dissimilar individuals—the husband and wife. Kothari concludes that infertility problem can be managed by the couple itself. She emphasises on education in reproductive health, gender-neutral doctor–patient relationship, checking unfair competition and malpractices in the medical practice at different levels and advocacy for adoption. Infertility remains a major gynaecological problem, particularly in the Indian context. In this context, in her article ‘Correcting the Reproductive Impairment: Infertility Treatment Seeking Experiences of Low Income Group Women in Mumbai Slums’, Joshi (2008) tries to look into the infertility

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in the context of reproductive health services. The study assess the experiences of women who are unable to bear children in their personal, social and cultural contexts and to suggest interventions which will in turn help in reducing the physical, psychological and social burden associated with childlessness. Joshi concludes that women’s health is usually the last priority; however, in case of resolving the problem of infertility; women are rushed to the hospital for treatment. In this study, women accessed different forms of treatment at different points in time depending on the accessibility to that resource. Within a hospital, it is observed that there is no simple, smooth procedure of diagnosis and treatment that follows the woman’s visit to the doctor. Several factors aid or decelerate or put a break to or change the course of treatment for women. The complex interaction of personal and family perceptions, community consequences, doctor–woman interaction, women’s interaction with other medical staff, women’s access to information, nature of treatment and financial resources available to the woman, which play a role in determining the treatment-seeking process and experiences for women. Recognition of problem also depends upon several psycho-socio-cultural factors besides the biological evidence of a medical condition and which in turn determine the decision to seek treatment.

VII. HIV/AIDS The broad-brush examination of the past, present and future of research opportunities germane to the interests of medical sociologists would be incomplete without at least a mention of the sociological ramifications of the Acquired Immunodeficiency Syndrome (AIDS) epidemic. No other single health problem in this century is likely to have comparable consequences for our social structure, for interpersonal relations, and for health resource allocation. Every aspect of the AIDS phenomenon has sociological import, from its aetiology (Kaplan et al. 1987) to provider’s behaviour and patient care (Lewis and Freeman 1987)—indeed to the possible resort to authoritarian means to identify and contain AIDS cases, the advent of massive discrimination against homosexuals and persons with ‘pre-AIDS’ symptoms and tests results, and restricted access to care and third-party insurance of high-risk groups. In this context, this section deals with the three articles by Jena and Prasad (2009), and Singh (2008) related to the problems of HIV/AIDS. In their article ‘Risk Culture, Propertied Classes, and Dynamics of a Region: A Study of HIV/AIDS in East Godavari District (Andhra Pradesh)’,

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Jena and Prasad (2009) attempt to understand the politics of defining the boundary between risk and non-risk groups in the discourse on HIV/AIDS. Sketching the intricacies in demarcating these groups, through historical accounts of the propertied classes have played an active role in perpetuating the ‘risk culture’ and institutionalising an ‘entertainment culture’. It traces the links among agrarian surplus, entrepreneurship, popular culture industry, religious tradition, caste alliances and political system that have contributed to the shifting identities of the sex workers and risk culture. A popular mode of understanding risk zones within HIV/AIDS discourse is to categorise them in terms of social actors such as sex workers, truck drivers or migrants and poor. This discourse presumes that the identity of the woman as a sex worker is fixed, coherent, and essential rather than as managed and constructed. The article explores the different categories of social capital which show the connection between the risk and non-risk zones with reference to HIV/AIDS. The article titled ‘Prison Inmate Awareness of HIV and AIDS in Durban, South Africa’ written by Singh (2008) is based on group discussion with male inmates at the Westville Prison in Durban. It aims to record the voices and ascertain the knowledge that prison inmates have of the Human Immunodeficiency Virus (HIV) and to identify the predictors of HIV and AIDS-related risk behaviour during incarceration. The relationship between sexual behaviour, disease transmission, sexual violence and correctional operations issues are explored. Although in theory prisoners have access to medical care, but in reality there is clear shortage of medical staff, and the problem is compounded by the overcrowding in the prison. Prisons are also a breeding ground for opportunistic diseases, which lead to shorten the progression from initial HIV infection to full-blown AIDS. Thus, conditions in prison are such that HIV easily takes advantage of its victim. The evidence in this article compliments the existing body of literature about the desperate conditions in South African prison. But, Singh highlights the need for more research to be done on health-care policies within the prisons, the dynamics and manifestations of overcrowding and for researchers’ easier access into prisons.

VIII. Mental Health Today mental disorders stand among the leading cause of disease and disability in the world. One in four people in the world are affected by mental or neurological disorder at some point in their lives. World Health Report

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(2001) which was dedicated to the theme of mental health shows that these disorders are estimated for about 12 per cent of global burden of disease and also represent four of the ten leading causes of disability worldwide. It is estimated that 6.7 per cent of population suffers from mental disorders, together these disorders account for 12 per cent of global burden of disease and an analysis of trends indicates that this will increase 15 per cent by 2020. One in four families is likely to have at least one member with a behavioural or mental disorder. Demographic projections suggests that mental illness along with heart diseases, AIDS and cancer will account for the top four illnesses around the globe very soon (Davar 1995). The National Institute of Mental Health and Neuro Sciences (NIMHANS) in Bangalore estimated that two crore Indian need help for serious mental disorder, while a further five crore suffer from mental illness not considered very serious. These figures do not include neurological age–related progressive disorders such as Alzheimer’s and Parkinson’s. It also estimated that at least 35 lakh Indians need hospitalisation on account of mental illnesses. But the country has only 40 institutions that are equipped to treat patients suffering from mental disorders. Moreover, many of them are medieval-era, asylum-style institutions with high boundary walls, artificial barriers and patients kept in solitary confinement (India Today 2011). India needs at least 12,000 psychiatrists, and in actual position, there are only 3,500 registered psychiatrists in the country, which means approximately one psychiatrist per 300,000 people. In this context, we would like to discuss here five major writings which have been published in Sociological Bulletin. These are: Chakravatry (2011) and Addalkha (2010). The aetiology of mental disorder has been significant in determining the corresponding paradigms of treatment. The historical shift from madness to mental illness involved paradigmatic changes along with the emergence of distinct conceptual categories have been highlighted by Tina Chakravatry (2011) in her article ‘Medicalization of Mental disorder: Shifting Epistemologies and Beyond’. She examines the historical conditions that facilitated these shifts but also ontological and epistemological. It shows that these shifts are not of a lineal order, rather they involve a precarious coexistence of differing ontologies and epistemologies, and these shifts, while distinct, are not or rather have not been complete or absolute. The interface between differing ontologies and epistemologies, on the one hand, and the corresponding treatment practices, on the other, has given rise to multiple approaches to the treatment of mental disorder. This has important implications not just for the treatment and practices concerned with mental disorder,

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but also for sociology of knowledge as a sub-discipline. Within sociology of knowledge perspective, what this article has attempted to do is to underline that the relationship between the passage of time and growth of knowledge is not random. Historicity is an important facet of any knowledge system. In her article ‘Indigenization not Indianisation of Psychiatry: An Anthropological Perspective’, Addalkha (2010) presents indigenisation of psychiatry which is based on the content analysis of the Indian Journal of Psychiatry over the past four decades. It has highlighted the multiple levels of engagement between psychiatry, culture and the political economy in the Indian context. The first part of the article is a short overview of the development of psychiatry in India from the colonial period to the present. The second part focuses on the interface between culture and psychiatric practice at the micro level. This is not to say that there was no interface between psychiatric practice and cultural imperatives during the colonial era. Indeed, there is always an ineluctable interpenetration between culture and discourse. But the difference lies in the degree of interpenetration. Maintenance of law and order and political control in the colonial period dominated the practice of psychiatry. With the attainment of Independence, the psychiatrists engaged more actively with the local context. Furthermore, the development of newer generation of psychoactive drugs leading to community psychiatry and the international human rights movement not only undermined the traditional segregation of the mentally ill but also compelled practitioners to question the social, cultural, and economic underpinnings of their own practice. However, distinctive Indian tradition of psychiatry with explanatory validity and therapeutic force to replace key constructs of the Western discourse could not take place. In addition, the forces of globalisation and the proliferation of the internet have resulted in the circulation of knowledge systems making explicit enculturation even more difficult. So, while indigenisation is an inevitable process, especially in disciplines dealing with human behaviour like psychiatry, the possibility of a unique culturally embedded Indian school of psychiatry may not be a realisable goal. We may infer here that until quite recently, few sociologists have given much attention to health and illness as topics of serious intellectual interest in the discipline of medical sociology. Perhaps the sheer biological necessity for human beings to stay away from illness and even the care taken for health in life of most human societies, were so obvious that they were simply taken for granted—part of the background of ‘what everyone knows already’. However, sociologists have traditionally studied mainly their own societies, but later on they become interested in knowing the health,

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health-care distribution in other societies too. At any rate, anthropologists have in the past shown more curiosity about these questions, though sociologists have now begun to follow their lead. Research by sociologists into health and illness has been predominantly empiricist, usually motivated by a concern with social welfare and the unequal distribution of health-care facilities. This concern with health and illness has more recently been transported on to the global level, and given new impetus by saying that there should be right to universal access to public health care. Amratya Sen contends that the state has a role in delivering basic health care and that recognition is lacking in India. Over-reliance on the private sector in health-care has led to the situation in which quite often poor people get marginalised and deprived of basic health care. India has prematurely entered into the private health-care sector.

References Ahluwalia, Anita. 1974. ‘Sociology of medicine: a trend report’, A Survey of Research in Sociology and Social Anthropology, Vol. II. Bombay: Popular Prakashan. Coe, Rodney M. 1970. Sociology of medicine (p. 3). New York: McGraw-Hill. Davar, B. 1995. ‘Mental illness among Indian women’, Economic and political weekly, 30: 2879–86. Fischler, Calude. 1990. L’Homnivore. Paris: Edition Odile Jacob. Ghosh, S. et al. 2007. ‘Maternal health care seeking among tribal adolescent girls in Jharkhand’, Economic and political weekly, 42(48): 48–55. Giddens, Anthony. 1991. The consequences of modernity. Cambridge: Polity Press. IIPS. 2000. Heath survey-2. Mumbai: International Institute of Population Sciences and ORG. Macro. Illich, I. 1977. Limits to medicine. Harmondsworth: Penguin Books. India Today. 2011. India Today, 11 July 2011. Kaplan, Mark H. et al. 1987. ‘Dermatologic findings and manifestations of acquired immunodeficiency syndrome (AIDS)’, Journal of the American academy of dermatology, 1(3, Part I, march): 485–506. Lewis, C. E. and H. E. Freeman. 1987. ‘The Sexual history of-taking and counseling practices of primary care physicians’, Western journal of medicine, 147(2, August): 165–67. Matthew et al. 2001. ‘Antenatal care, care seeking and morbidity in rural Karnataka, India: results of prospective study’, Asia-Pacific population journal (June): 11–28. Nagla, Madhu. 2013. ICSSR trend report on ‘sociology of health and medicine’ (in Press). Navarro, V. 1977. Medicine under capitalism. London: Croom Helms. Nayar, K. R. 2004. ‘Rural health: absence or vision’, Economic and political weekly, XXXIX(45, November 6).

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Parsons, Talcott. 1951. The Social System. Glencoe, III: The Press. Ram, F. and A. Singh. 2006. ‘Is antenatal care effective in improving maternal health in rural Uttar Pradesh? evidence from a district level household survey’, Journal of biosocial science, 38(4): 433–48. Rosengren, William R. 1980. Sociology of medicine: diversity, conflict and change. New York: Harper and Row. Sharma, S. L. 1985. ‘Sociology of profession in India’, Survey of research in sociology and social anthropology, 1969-1979. New Delhi: Satvahan Publications. Sigerist, Henry. 1962. Civilization and disease. Chicago: University of Chicago press. World Health Report. 2001. Mental health: new understanding, new hope. Geneva: WHO. Yudkin, John and J. C. Mckenzie. 1964. Changing food habits. London: MacGibbon and Kee.

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1 Sociological Inroads into Medicine: A Tribute to Aneeta A. Minocha (1943–2007) Ruby Bhardwaj

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edical sociology stands enriched by the original and insightful contributions of Aneeta A. Minocha (née Aneeta Ahluwalia) who passed away on 5 October 2007. For over four decades she contributed to the enhancement and enrichment of medical sociology in India, and it would not be incorrect to say that her research, reports, debates, discussions and critical inputs helped nurture and fortify the discipline when it was still budding. In the early 1970s, she prepared a trend report on ‘Sociology of Medicine in India’ in which she identified several key areas of research, which were later taken up by scholars as research themes. This helped stimulate and shape the emergence of medical sociology in India. Minocha (b. 9 September 1943) was associated with the Department of Sociology, Delhi School of Economics, University of Delhi for over four decades. She joined the Department as a Master’s student in 1963 and later pursued her doctoral research under the supervision of A.M. Shah. As a PhD candidate, she brought laurels to the Department. Charles Leslie, an eminent medical sociologist, who was one of the examiners of her doctoral thesis, rated her work as first class. In an encouraging gesture he offered the honorarium that he was to receive from the

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University of Delhi for evaluating her thesis as a reward for her commendable work. He requested Shah to ‘give the money to Dr Minocha as a little surprise reward for work well done, and return gift to her for her gift of pleasure to me in reading her research’.1 Leslie recommended her thesis for publication in the monograph series, ‘Comparative Studies of Medical Systems and Health Care’, at the University of California Press. She joined the Department, where she was a student, as a faculty member in 1968 and also served as the Director of the Delhi School of Economics for a short while before her illness. In addition to teaching the masters’ course at the Department, she supervised the research of twenty-one MPhil and eleven PhD candidates. As an eminent medical sociologist, she was a member of a large number of advisory committees at the World Health Organisation, the Indian Council of Medical Research, and the Indian Council of Social Science Research. Minocha had a wide range of interests besides medical sociology. She wrote on population studies, sociology of professions and sociology of education. The endeavour in this paper, however, is to highlight her contributions to medical sociology. Minocha strived relentlessly to highlight the significance of sociology in the understanding of health and disease. In her first paper, published in 1967 in Economic and Political Weekly (Ahluwalia 1967), she lamented the fact that sociology of medicine was a neglected field of study and that not much thought was given to explore the links between medicine and society. In this paper, she systematically established that health and sickness are not isolated from the general social life and that they are an aspect of the wider social system of which they are a part: ‘the sphere of medicine has been subject to social processes similar to those which characterise the society at large’ (ibid.: 1009). She explained the heterogeneity in the medical field by subjecting it to the same scheme of analysis that is used to analyse the larger society and culture. The co-existence of the allopathic system introduced by the British in India with other indigenous systems, she explained through M.N. Srinivas’s concepts of ‘spread’ and ‘sanskritisation’ (ibid.: 1008). Having established the case for a sociological approach to medicine in India, she emphasised, along with Shah, the need for teaching sociology to medical students who, on graduation, have to take up the social role of a doctor. She argued that the doctor and the patient interact not simply as a diseased entity and curative agent, but also as social

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beings belonging to different cultural milieu. The understanding of the patient as a social entity sensitises the doctor to a gamut of intervening social variables that impinge on the former’s health or sickness. The ‘doctor’s training in sociology would enable him not only to learn about the impact of the cultural milieu on the behaviour of patients but also have close look at himself in his own milieu’ (Shah and Ahluwalia 1970: 2). Sociology taught to doctors should include comparative studies of social aspects of health, and disease and its cure in different countries. Knowledge of the sociology of organisations, in particular of hospitals, can also equip the doctors better. Department of social and preventive medicine in medical colleges can play a significant role in teaching this social science component. In this mutual give and take, sociologists also benefit immensely in advancing the frontiers of their discipline. On account of her efforts in the form of seminars and workshops and research papers highlighting the crucial role that sociology could play in strengthening health and medicine, several medical scientists evinced interest to interact with social scientists. In an endeavour to establish institutional inroads into medical sciences, as early as 1970, Minocha requested the Vice-Chancellor of Delhi University to make arrangements for inter-faculty collaboration for the training of medical personnel interested in sociology. The concern for the teaching of social sciences was also expressed in an article, where she vehemently opposed the tendency to underplay the study of humanities and social sciences because they are not as lucrative in the job market as compared to subjects like commerce and trade (Minocha 1995). She advocated conceptual and terminological rigour in academic research. The concepts of health, disease and medicine attained precision from her critical inputs and holistic perspective. She and her husband, who is a doctor, jointly reviewed The World Development Report 1993 (see Minocha and Minocha 1993). This Report received a negative assessment from the Minochas mainly because it overlooked the analytical distinction between medical interventions and healthpromoting non-medical interventions. Her arguments stemmed from her keen observation of empirical facts. This is evident in her critique of the government policies, plans and projects that failed to take cognisance of ethnographic realities. She criticised the Health for All Report, prepared jointly by ICSSR and ICMR (see Minocha 1987)

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for its unrealistic and impractical proposals incompatible with the Indian context. Minocha pioneered and popularised the concept of medical pluralism in India. In her paper entitled ‘Medical Pluralism and Health Services in India’, published in Social Science and Medicine (1980), she analysed the multifarious dimensions of medical pluralism and its role in the availability of health services. Medical pluralism denotes (i) the co-existence of multiple systems that may range from the folk, popular and traditional professionalised systems such as Ayurveda, Siddha and Unani to those borrowed from the west such as homeopathy and allopathy, and (ii) the choices within a particular system. It follows, therefore, that the patient has the option to select any of the available options, that is, seeking the services of a Vaid, a Hakim, a homeopath or an allopath, and then further option is made in terms of what kind of practitioner is to be consulted. For example, if the decision is made to consult an allopath, there are multiple settings within which the patient can meet the practitioner—in the village clinic, or in a government-run hospital or dispensary or a private clinic in the city. Within the state-funded health services there are multiple bodies engaged in providing health services—Central and State Health Services, Central Government Health Scheme, Railway Medical Service, Army Medical Corps, Employees State Insurance Scheme, the Rural Health Scheme and so on. Pluralism characterises even the types of practitioners and other personnel associated with Allopathy. Besides the hierarchy between the specialists and generalists, the doctors may have different qualifications; they may hold an MBBS degree, or may just be Licentiates and Registered Medical Practitioners without any qualification. In addition to these, there are para-medical personnel, including nurses, dispensers, pharmacists, physiotherapists and other technicians. Besides the above mentioned formal and technical dimensions of pluralism, Minocha drew attention to the adaptations made by the individual practitioners to make their practice more appealing to their clientele. For example, a traditional medicine practitioner incorporates in his practice a stethoscope, ophthalmoscope or other instruments associated with modern medicine to impress the patients of his adeptness with modern technology. Similarly, a practitioner of modern medicine subscribes to the dietary prescriptions based on hot-cold dichotomy of the Ayurveda to appeal to the patient’s mindset attuned to such proscriptions.

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Looking through the lens of pluralism, Minocha detected fundamental anomalies in the assumptions regarding distribution of medical facilities. As she wrote, Much ink has been spilled repeating that 80 per cent of the population lives in the rural areas and 20 per cent in the urban areas, and that the distribution of doctors is in the reverse order. Therefore, it is concluded, urban areas and the ‘elite’ are far better served than the rural areas and ‘underprivileged’ people. However, these figures are about the distribution of doctors trained in modern medicine, and not about medical men in general. If one were to consider the figures on traditional and other practitioners of various sorts, one would see that, after all, rural areas are not so badly provided for, at least as far as the number of persons engaged in some sort of medical practice is concerned (1980: 218).

Minocha explained the concentration of medical facilities in the cities by drawing attention to the better infrastructural facilities in the cities to run clinics and hospitals. She argued further that medical professionals are drawn to the cities not because of their disdain for villages, as is generally assumed, but, like other entrepreneurs, they are also guided by forces of market that operate in the cities. She urged that, for understanding medical pluralism, proper statistics about the distribution of various medical resources and humanpower are essential. Moreover, it is not enough to know how many practitioners are available, but also in what capacities and institutions they are available. Pluralism has extensive ramifications on the patients, confronted as they are with a multiplicity of therapeutic choices. It is generally, and simplistically, assumed that people prefer traditional systems of medicine because they are in sync with their cognitive categories, and that they are sceptical about modern medicine because it is alien to their mindset. On the contrary, Minocha observed that, in light of limited knowledge and familiarity with the multifarious therapies, the real bases of choice are the availability, accessibility and the quality of medical care provided by the diverse systems. People are interested in an efficient curative system, and very often it was found that indigenous practitioners administer strong allopathic drugs for fast relief to the patients. People’s responses to multiple systems have far-reaching implications on the state policy. In this context, Minocha raised important questions: (a) Is it possible to integrate various medical systems despite their contradictory principles? (b) Does integration imply a combination

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of all successful remedies from all systems? (c) Should the state provide parallel medical services in each system? (d) What costs do these services entail? Besides providing fresh insights into the concept and understanding of pluralism, Minocha was foremost in taking up a systematic and extensive study of the modern medicine, its institutions and its profession in India. She approached the study of the modern hospital through the gender-centric perspective. In an intensively researched article, ‘Women in Modern Medicine and Indian Tradition’ (1996c), she traced the history of modern medicine in India. Here, she busted the popular misconception that accused the British of forcing on Indians their colonial medical system and of providing medical care to their own personnel while depriving the Indians of the same. She illustrated, through historical data, the growing demand for these medical services from Indians, especially for women. The accounts of missionaries and administrators made it evident that Indian women had no access to the services of trained doctors even when they needed them most. This was because of the traditional restrictions on women seeing male doctors. The British tried to redress this problem by making modern medicine available to women through women doctors. In an attempt to alleviate the suffering of sick women, Lady Dufferin, at the behest of Queen Victoria, initiated a fund that was to be utilised to establish hospitals and maternity homes for women, to train women as nurses and midwives, and to provide scholarships to attain medical education. As a consequence of consistent efforts of the British, Lady Hardinge Medical College for Women was set up in Delhi in 1916. It was meant exclusively for women medical students with an attached hospital and nurses’ training school. In the design and running of this institution, the British took care to address women’s need for seclusion. The college hostel also had separate blocks, kitchens and dining area for Hindu, Muslim, Christian, and Sikh women. It was in one of the wards of this hospital that Minocha conducted intensive fieldwork for her doctoral dissertation. Completed in 1975, this study was the first of its kind to be conducted in India. It was conducted at a time when most researchers in sociology were focussing on three fundamental structures: caste, joint family and the village community. As matter of conscious and far-sighted strategy by her supervisor, she was encouraged to study the hospital setting. This was in consonance with Srinivas’s objective to open new arenas of study

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through the fieldwork method. Her doctoral research was published later as a book—Perceptions and Interactions in Medical Setting: A Sociological Study of  Women’s Hospital (1996b). The study ‘demonstrates essentially the dovetailing of medicine into other aspects of social life’ (ibid.: vii). It focused on the process of construction of medical reality by women in all women medical spaces: as patients, professionals, semi-professionals, administrators and lower-level workers. It is a study in interpretative sociology that, as the title suggests, examined the societal forces and their role in shaping the perceptions and interactions of the patients in the hospital ward. It narrates how the social and cultural orientations towards the caste system, that the patients are socialised into, help recreate in the hospital, a microcosm of the society at large. This is not to say that the hospital as a modern institution had no role to play in bringing about change in the attitudes of the people. Patients also used their stay in the hospital to try out new food items that were tabooed at home. However, their attitudes towards interaction with others were couched in caste prescriptions. Patients were seen to interact more freely and in a friendly manner with their own caste mates. They even tried to guess each other’s caste from their manner of dressing and other habits. Most of them were disgruntled about the common uniform for the ayahs who dealt with food and other items and for those performing defiling jobs, and wanted a clear segregation between the two. This multi-faceted research also revealed Minocha’s skills as a participant observer in the hospital and her ‘varied roles in the field’ that elicited the rich and extensive data (Minocha 1979). Since most of the doctors and patients were not conversant with the role of a sociologist, the patients took to her easily and identified her as a doctor; the doctors regarded her as a social worker, while the nurses treated her more as a friend whom they could allow to participate in their cliques and get-togethers. The patients soon came to realise that she was a ‘different’ kind of a doctor who was concerned not just with their disease, but was also there to enquire about their welfare. They, therefore, referred to her as a ‘doctor who comes to talk to patients’. Her rapport with the patients and identification with the doctors helped her to mediate between the two. The informal roles helped her in grasping the extent and intensity of information which would not have been otherwise possible. Although better known as a medical sociologist, Minocha was particularly interested in women’s issues. Her views on the issues of sexratio and sex-selective abortions were out of the ordinary. It is generally

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assumed that a sex-ratio that disfavours women is generally associated with female neglect and their low status, and conversely a sex-ratio that favours women is indicative of their high status and lesser son preference. But Minocha’s study of the quality of life of women in Uttaranchal2 falsifies this popular assumption. She found that, despite women outnumbering men in eight out of the thirteen districts, the women’s lot in Uttaranchal is onerous and burdensome. In her report, she advised that the women’s’ lot would improve only if the number of men gainfully employed in the local area in relation to women increases in districts where they outnumber men. The sex-ratio is analysed holistically in the light of larger developmental and employment facilities. Similarly, in the case of sex-selective abortions, she not only concentrated on the adverse effects of the skewed sex-ratio, but also drew attention to their implications for the women’s health which is depleted and endangered because of recurrent pregnancies and abortions. Minocha approached even hardcore concerns of medical sociology, such as the study of the institutions and professions associated with modern medicine, from women’s perspective. This is evident not only in the choice of the women’s hospital for her doctoral research, but also in the large number of papers she presented and published on women medical professionals—both doctors and nurses. In a paper entitled ‘Triumphs and Travails of Indian Women Professionals: A Sociological Perspective on the Glass Wall and Ceiling,’3 she identified the hurdles women professionals face in entering professional careers pertaining to science, medicine and technology, on account of the traditional attitudes of the family that, for women, accord primacy to marriage and raising of family. Furthermore, she notes that a few lucky women, who did manage to enter the professions and persisted despite family pressures, have generated a series of societal changes that have impacted the division of labour and interpersonal roles within the family. Minocha’s interest in medical sociology was grounded in realistic and practical contemporary concerns. Writing on the medical profession in India, she argued that, in recent times, there is a growing hiatus between the societal expectation from doctors who are expected to devote their life to selfless service to humanity, on the one hand, and their own aspirations governed by monetary considerations, on the other. This, together with the changing nature of the profession, greater ‘politicisation’ and bureaucratic intervention, has resulted in erosion of

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the doctors’ esteem as well as power and authority enjoyed by them. The case of medical professionals is that of an elite group whose traditional basis for elite position, which lay in its tradition of nobility in character and work, has gradually shifted to monetary rewards its members can accrue. It is an elite group whose power to influence and give shape to public policy has been eroded . . . (Minocha 1989: 84).

According to Minocha, the doctrine of ‘informed consent’ and the Consumer Protection Act4 served to further wear away the doctor’s position. She noted that the doctor-patient relationship in the western countries is being altered from the traditional and paternalistic position, where the patient was a passive and submissive recipient of the doctors’ orders, to a more egalitarian one, where the patient is informed, empowered discerning and having the right to know about the doctor’s line of treatment. In the latter position, the patient should be informed about the diagnosis, the therapy in use and its effect on prognosis. This doctrine of informed consent is gaining popularity in India, but Minocha is not too convinced about its appropriateness without qualifications in the Indian context. On the basis of ethnographic evidence, she argued that the patient and his well-wishers are not interested in the technical details of the treatment process for which they repose full faith in the doctor’s acumen. Indians, by and large, adhere to the classical fiduciary doctor-patient relationship where faith and trust in the doctor is the hallmark of the relationship. The average Indian patient is involved in the psychological and social dimension of illness, leaving the doctor to deal with the medical concerns. Furthermore, her observations revealed that many patients are unable to comprehend or handle the information, and having learnt about bad prognosis, they give up the treatment altogether. It is on account of this that the doctor’s job becomes even more challenging; she has to decide how much information to give and to which patient, so that the exercise does not prove counterproductive. The doctrine of informed consent, therefore, has to be analysed in the cultural context. In a similar vein, in the context of the Consumer Protection Act, Minocha (1998) disapproves of the doctor-patient relationship being reduced to that of trader and consumer, for the two belong to diverse discourses and the equation between them will prove detrimental and counterproductive in the therapeutic process.

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Minocha never failed to express her views on the moral and ethical dilemmas of the medical world and their sociological relevance. Her writings on various issues and concerns ranging from social fallout of trauma, organ transplantation and euthanasia to the consumer protection bill, reveal her anxiety and, hence, her participation in the contemporary debates in the field of medicine. Her perspective is shaped by her keen observation of empirical facts and her deep sensitivity to the Indian reality. In a cogently argued paper,4 she debated on euthanasia, one of the most contentious medico-social issues in recent times. With increasing emphasis on the doctrine of informed consent, the individual’s right to die is being upheld as a human right. Besides the greater intervention of medicine and technology in health and illness, attitudinal and ideological outcomes of modernism that uphold individualism together with the inability of the family to support vegetative members are all forces that are conducive to the trend. However, Minocha argued that a terminally ill person is not in a state to take an appropriate decision with respect to life and death. More importantly, the individual is also a member of a family, a community and the society at large, and therefore the decision to end one’s life cannot be absolutely personal. Euthanasia has to be contextualised with reference to religion, and the moral and cultural traditions. It is an emotive issue with controversial and irreconcilable ideological stances. Recently, the police and the media have unearthed numerous rackets of illicit organ trade involving doctors. In a book co-authored with Shikha Batra, Minocha examined in depth the sociological and ethical concerns pertaining to organ transplantation (see Batra and Minocha 2002). The ideological notions prevalent in different countries with respect to organ donation have been illustrated here. The most significant is the attempt to highlight the controversy between gift and market paradigms, that is, the dilemma between altruism and commercial incentives in organ exchange. Should organs be treated as commodities or should they be governed with more humanitarian obligations? What are the implications of cultural controversy between altruism and market forces on social policy and transplant legislation? What are the preconditions for launching cadaver transplantation? These are some of the core issues to which the reader is sensitised. In this book, Batra and Minocha have succeeded in establishing that organ transplantation is a cultural, ethical and medico-legal issue that has serious socio-cultural ramifications.

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Minocha’s contributions to the field of medical sociology have benefited the discipline of sociology in many ways. Not only have her writings enriched the discipline, but have also kindled the interest of other researchers—both medical and social scientists—to it. Her ability to approach the issues in a holistic manner has helped to sensitise the academia to issues and concerns that have long been overlooked, and to shatter some conventional misconceptions. For example, contrary to the popular view that visitors to the hospital are an unnecessary nuisance, in her article published in The Hindustan Times (1983), Minocha illustrated how the relatives and friends visiting the patient in the hospital serve to boost the patient’s morale and help speed up the recuperation process. Her research on the hospital setting and the ramifications of the cultural norms through which the medical spaces are created is the first and best of its kind in India. The sociological analysis of the medical profession and a perceptive understanding of the doctor-patient relationship in the light of the on-going ethical debates on euthanasia, informed consent, the consumer protection act and organ transplantation demonstrate her ability to engage with the discipline in intensive and holistic manner. Her arguments were backed by profound observation and understanding of the context that is distinctively Indian.

Notes 1. Quoted from a letter written to Prof A.M Shah by Charles Leslie. 2. ‘Environment, Society and Population Stabilisation in Uttaranchal’, Report prepared for the Population Foundation of India, presented at the state level conference on ‘Health, Development and Population Stabilization issues in Uttaranchal’ in May 2001. 3. Paper accepted by the National Institute of Science, Technology and Development Studies, New Delhi for publication in a forthcoming volume. 4. ‘Euthanasia: A Sociological Perspective’, Manuscript accepted for publication by Vidyasagar Institute of Mental Health and Neuro Sciences, New Delhi.

References and Select Works of Aneeta Minocha Ahluwalia, Aneeta. 1967. ‘Sociology of medicine in India: An approach’, Economic and political weekly, 1 (42): 1007–12. ———. 1974. ‘Sociology of medicine’, in M.N. Srinivas, M.S.A. Rao and A.M. Shah (eds.): A survey of research in sociology and social anthropology—Vol. II (401–30). Bombay: Popular Prakashan.

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Batra, Shikha and Aneeta A. Minocha. 2002. From one body to another: Sociological issues on transplantation of human organs. New Delhi: Rajat Publications. Minocha, Aneeta A. 1979. ‘Varied roles in the field: A hospital in Delhi’, in M.N. Srinivas, A.M. Shah and E.A. Ramaswamy (eds.): The field worker and the field (201–15). New Delhi: Oxford University Press. ———. 1980. ‘Medical pluralism and health services in India’, Social science and medicine, 14B: 217–24. ———. 1983. ‘How pain visits a patient’, Hindustan Times (New Delhi), 24 April: 5–14. ———. 1984. ‘Mother’s position in child feeding and nutrition: Some sociological considerations’, Economic and political weekly, 19 (48): 2045–48. ———. 1985. ‘Spiritualism as a component of health: Some considerations’, in D.B. Bisht (ed.): The spiritual dimension of health (38–41). New Delhi: Directorate General of Health Services, Government of India. ———. 1986. ‘Social science perspectives on the health care delivery system’, Journal of social and economic studies, 3 (4): 339–44. ———. 1987. ‘Health for all: An appraisal’, in Sheo Kumar Lal and Ambika Chandani (eds.): Medical care: Readings in medical sociology (43–59). New Delhi: Jainsons. ———. 1989. ‘The medical profession in India: Elite without power’, in Khadija Ansari Gupta (ed.): Power elite in India (76–85). New Delhi: Vikas. ———. 1991. ‘Socio-economic equity and health: Examination of a few key concepts’, in T.M. Dak (ed.): Sociology of health in India (173–76). New Delhi: Rawat. ———. 1995. ‘Universities and the vocationalizing of education’, Journal of higher education, 18 (3): 409–14. ———. 1996a. ‘Managing social fallouts of trauma’, in A. Bhattacharya, R. Chawla and A. Gurnami (eds.): Trauma, anaesthesia and critical care (191–99). Delhi: University College of Medical Science. ———. 1996b. Perceptions and interactions in a medical setting. New Delhi: Hindustan Publishing House. ———. 1996c. ‘Women in modern medicine and Indian tradition’, in A.M. Shah, B.S. Baviskar and E.A Ramaswamy (eds.): Social structure and change—Vol. 2: Women in Indian society (149–77). New Delhi: Sage. ———. 1998. ‘The Consumer Protection Act and the medical profession: From doctorpatient to trader-consumer relationship’, in J.S. Gandhi and Arun P. Bali (eds.): The prime movers of Indian society: A Focus on the sociology of professions (139–56). New Delhi: National Book Organization. ———. (forthcoming). ‘The socio-cultural context of informed consent in medical practice’, in B.S Baviskar and Tulsi Patel (eds.): Understanding Indian society—Past and present: Essays in the honour of A.M Shah. Delhi: Orient Longman. Minocha, Aneeta A. and V.R. Minocha. 1993. ‘Investing in health: A review South Asian regional group’, World development report—Occasional papers Vol. 1: 7–16. Shah, A.M. and Aneeta Ahluwalia. 1970. ‘Role of sociology in medical education and research’, Economic and political weekly, 5 (17): 705–10.

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2 Food: The Immanent Cause from Outside—Medical Lore on Food and Health in Village Tamil Nadu1 V. Sujatha

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  edical lore, denoting the medical knowledge and health practices of the village folk, is an important aspect of indigenous medicine in India. It is a body of knowledge emerging from the living experience of the people and is not necessarily a diluted version of the medical systems such as Ayurveda and Siddha. The common people in Indian villages have immanent necessity and greater opportunity to address their own health problems, and have thereby acquired considerable knowledge of health and disease. Their health concepts are constantly validated in practice in their quotidian life. At the same time, they coexist with the centuries old textual traditions which have elaborate formulations in the same domain (Radhika and Balasubramanian 1989 and 1990). It is, therefore, necessary to view the medical knowledge of the people in its own right without negating its relation to the formal, textual medical traditions. A brief look at the important studies on the subject—in anthropology, policy studies and the modern sociology of knowledge—would help appreciate this point. Ethnographic accounts of shamans and rural medicine men have been a favourite subject for the anthropologists:

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Elwin (1955) has given an account of male and female shamans among the Saora tribe of Orissa. In his study of folk medicine in a north Indian village, Carstairs (1955) has argued that traditional medicine persists because it establishes ‘faith’ and ‘assurance’ in the patient; lacking this ‘aura of conviction’, modern medicine is required to justify itself in these terms. Marriott (1955) has also argued that it is not so much the technical skill that gives prestige to the healer, but his spiritual power gained through piety. Jaggi (1973) highlights the role of religious belief, superstition and ritual in village medicine. The changes in traditional medicine caused by the coexistence of allopathy have also been studied (see Hasan 1967 and Leslie 1968). These and similar studies point to the social, emotional and religious functions of folk medicine; the success of folk medicine, if acknowledged, is attributed to factors other than medical efficacy. Policy studies (see Banerji 1974 and 1976; Djurfeldt and Lindberg 1976; Kakar 1977; Priya 1990; Qadeer 1985 and 1990), which aim at identifying the health needs of the population and evaluating existing policy measures on health, tend to view the common people as ‘poor and ignorant masses’ needing policy attention. In these studies medical lore is characterised as ‘layperson’s perception or belief ’, whose knowledge ‘can play an important role in orienting social marketing strategy around key cultural concerns and associations’ (Nichter 1980: 232). This is understandable as these studies ‘assume the supreme efficacy of western medicine’ and their main aim is ‘to make it more available to the villagers’ (Leslie 1988: 1–2). Furthermore, the word ‘layperson’ projects the villager as incapable of any discrimination. While in some villages many systems of cure may coexist, a villager’s choice of an appropriate system will be conditioned by her/his analysis of the role that medicine plays in altering the balance within her/his system and between her/him and the environment. In this the villager draws on her/his ‘knowledge capital’. Influenced by the developments in sociology of knowledge, a new class of social scientists trained in Indian systems of medicine has analysed the content and form of medical texts and the manner in which these are interpreted in practice by professional vaidyas: Francis Zimmerman (1978, 1980 and 1988), an apprentice under Shri Vayaskara N.S. Mooss, a hereditary practitioner of Astavaidyar caste in the Kerala School of Ayurveda, working in the academic traditions of

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Gaston Bachelard and Michael Foucault; Margaret Trawick Egnor (1983 and 1987), who studied with Shri Mahadeva Iyer, a master practitioner in a village near Kanyakumari in Tamil Nadu; and Daniel Tabor (1981), a student of Shri Bapalal Vaitya, the retired principal of an Ayurvedic college in Surat. Studies of this genre, which focus on the textual and formal dimensions of Ayurveda and Siddha, have considerably enhanced the epistemological status of Indian medicine. However, studies on the medical lore of the village folk as a system of knowledge in its own right are hard to come by. This paper explores the folk-health tradition in Tamil Nadu where food is conceived of, as in other rural areas in the country, as the primary cause of health and disease. It is part of a larger effort to understand the medical knowledge and practices of the village folk in Pasumpon Thevar Thirumagan District of Tamil Nadu (see Sujatha 1994). The locus of field work was a group of villages of Thirukolakudi Panchayat situated north-west of Tirupatur town, in the foot of a hill locally called Suramalai. All villages in this panchayat suffer from economic handicaps endemic to the area caused by small land holdings, infrequent and unreliable rains, lack of a permanent source of irrigation and poor productivity of the soil. Dry-land farming and coolie labour are the main sources of livelihood for the majority of the inhabitants, though a few cultivate paddy in their well-irrigated lands. In this area, extremes in social (caste) and economic (class) differences are less; powerful lobbies of Brahmin and Chettiyar castes are absent. The area is populated by caste groups like the Maravars, Kallars, Valayars, Paraiyars and Pallars. The Valayars are a numerically large caste group in the villages of Thirukolakudi panchayat, and they form about 50 percent of our informants. There seems to be no distinct upper class in the area.

I Diet Content It is well known that the staple food of most south Indian villagers consists of rice, ragi, maize and millet cooked and taken with a vegetable side dish or sambar (spicy gravy). Underlying this apparently simple diet

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are certain principles which have largely remained uncodified. Variety, for instance, seems to be the most fundamental of such principles. Variety in diet, however, is limited to whatever is available in the habitat according to seasonal changes. Moreover, variety is sought more in those foods that are consumed in large quantities and frequently, and less in those foods that are consumed in lesser quantities and infrequently. The villages are in a drought-prone area where dry-land farming is the only major source of sustenance, and wetland farming, particularly rice cultivation, is very less. Finger millet, pearl millet, kodo millet, little millet, maize and sorghum are the food grains cultivated on dry land; besides, pulses like cowpea, green gram, carpet legume, etc. are cultivated side by side. These are the only reliable and perennial sources of food for the people here. Rice and vegetables grow only during specific seasons. With such constraints imposed by ecology and the seasons, how can the variety principle operate? The dry-land food grains are processed, pounded and cooked. Every day a different food grain is cooked; sometimes two are cooked in one day, separately for the day and the night. Somehow, a rotation of all the available food grains is achieved during the week. A similar, if not more intensive, drive for variety could be found in the consumption of greens: in most households four to 10 varieties of greens are cooked together in the water with which the food grain has been washed. Often, the villagers collect the leaves of any plant that they know is edible and add it to their collection of greens. The greens may not all be tasty; some are quite bitter, while some have a strong smell. Adults and children alike consume a variety of greens of different tastes as often as once a day or at least thrice a week. An exclusive vegetable side dish is not a regular feature in their daily fare. The vegetables grown in their farms, if any, or bought from the weekly village market are cooked along with a spicy gravy made of tamarind juice, known as sambar. The sambar may consist of two or three pulses. The non vegetarian food that the Valayars (originally hunters) living in Thirukolakudi consume consists of what they get from hunting— rabbits, squirrels, bandicoots, and cranes and some other birds. The others at times buy some kinds of meat from the Valayars. Thus, the people see to consume a variety of meats. Some variation from the set pattern of diet in response to seasonal changes was observed: With the onset of rains, many plants grow on the foot of the hill (Suramalai) lending a lush green colour to the landscape.

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During this time, several herbs and mushrooms are collected and used in daily cooking. Most villagers cannot afford to buy fruits from the market. They consume the locally available palm fruit, cashew fruit, ripe cucumbers, and other local fruits. They eat fruits like bananas, oranges, etc. only when they get it cheaply or in case of illness, especially those that require hospitalisation. Groundnut, tamarind seed with jaggery and roasted green gram are consumed as small eats. Eesal (winged termites) is the choicest of all small eats. Foods cooked for festive occasions have perhaps the least variety. Most of the special food is cooked and not deep fried. A majority of Valayars and certain scheduled caste groups in the area observe a religious taboo about deep frying in the household; they have to go to the ‘forests’ to prepare fried foods. Omissions in the diet have as much to say as inclusions. Milk and milk products are conspicuous by their absence. This does not mean that they are never consumed; it only means that they do not form a part of the regular fare of most of the villagers. They may be used for medicinal purposes or in special cases, such as a nursing mother. The villagers are not particularly fond of milk, curds and ghee: some people are averse to milk products, others simply avoid them. Many people nauseate at the smell of curds and buttermilk. It is difficult to ascertain whether this aversion has a physiological or socio-cultural basis. Perhaps an insight into their ideas about food-body relationship could throw some light on this matter.

II The Significance of Food While the people of Thirukolakudi accord great importance to food, they do not seem to perceive its importance in terms of its basic need for existence. That is, their ideas about the significance of food are not built around the assertions about its absolute necessity for survival. They do not say, for example, that food is primary because there can be no life without it; rather, their conceptions of food are corporal: they seem to conceive the significance of food in terms of its vital functions for the

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body. Furthermore, their conceptions are wide in scope, encompassing the idea of ‘intake’ in general. The villagers assert, ‘For all living beings, food is the source of health and disease’.2 This seemingly general and an ordinary statement gives an important clue to their ideas of health and disease. It implies that other causes of health and disease, namely, heredity, climate, environment, habits, etc. are only of secondary importance; in the final analysis, food is the determinant of health and disease. While the villagers would be open to discuss other factors related to health and disease, they would inevitably end the discussion by drawing attention to the primacy of food over other causes: ‘What are all these? Our intake is the cause for every thing. Disease does not come from body constitution or heredity; it comes from what we eat’. Proverbs quoted by the informants also signify how ‘intake’ is vital not only for human beings, animals and plants, but also for the earth and even for mechanical objects like, e.g., petrol for a car. So pervasive is the notion of the primacy of food that it figures as analogy even in discussions not directly concerning food. For instance, on the necessity of manure in agriculture it was said: ‘You should have eaten well to lift more weight. Can you eat little and lift more? So is the earth. Only if you feed it with manure will it lift the yield high?’ From various accounts and comments of the villagers, we may delineate two dominant lines of explanation for this overwhelming importance attached to food. Of the various factors that could be associated with health, such as living conditions, hygiene, environment and the like, food alone goes directly into the body, interacts with the body system, and becomes ‘internal’ to the body system itself. The others do have an effect, but their effect is restricted in comparison with food which, though originating ‘outside’, gets right into the body metabolism and is later assimilated into it. In other words, it is food which establishes a link between what is external to the body system and what is internal to it. Food gets transformed from being an external input to an internal feature of the body. As an informant remarked: ‘Everything germinates from the chemicals we use. We add them to the very seeds we sow on earth. The baby has it when it is born. All we eat; where else will it go?’ The ‘seeds’ that go to make the foetus contain the chemical inputs used in cultivating the food grain consumed. To be able to affect the semen from which the foetus originates, the chemicals in food should themselves have become an innate feature of the body system.

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Another line of explanation stems from the recognition of the formative role of food in the very genesis of the foetus. The dietary habits of the parents are said to determine the properties of their reproductive fluids directly, and the diet pattern of the mother is regarded as having tremendous impact on the body constitution of the foetus. A cryptic comment made by an old man about the older generation paraphrases this idea: ‘We are not made of coffee and snacks. Our parents ate food grains and porridge and from it we were made’. In brief, the relation between body and food is considered so profound and far-reaching as to be able to mould the calibre of an entire generation. Considering the cardinal importance assigned to food as a cause for health/illness, one would expect a meticulous classification and wellformulated prescriptions about foods to be eaten or avoided, etc. However, our informants did not have much to say on types of food to be eaten or avoided, that would be applicable to all. One would tend to attribute this relative absence of universalistic norms to poverty, which could have forced them to accept any food as fit for eating. However, the relative absence of norms concerning food seemed to be compensated by the firm insistence on norms regarding eating. The type and nutritive value of food, which are a matter of quality, vary from culture to culture, depending on a number of local conditions like climate, ecology and lifestyle. It would, therefore, not be wise to have norms that would be applicable to all. On the other hand, it would be necessary to have fixed norms about eating as an activity. Accordingly, we find that norms that are categorically stated and said to hold good for all are those that relate to the latter; the more conditional ones, to the former. Conceptions on the quantity of food to be consumed, however, intersect both—the universal and local conditions.

Eating: The Universal and Mechanical Dimensions The most fundamental norm according to the villagers, is regularity in eating. Eating at fixed hours of the day is regarded as essential. What is eaten is secondary; that something is eaten in time so that the stomach is not left empty is primary. This norm invokes a mechanical conception of the digestive system as the informants stressed the necessity of eating something at the ‘eating time’ even when no hunger is felt. The digestive system is likened to a machine and the most basic requirements for its functioning are highlighted. While there could be

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exceptions to some health norms, the violation of which may not be very harmful, no exception is provided for the norm ‘eat at regular and fixed timings’: Without food you cannot do a thing. If your stomach is empty, the digestive fluids that are secreted will cause burning sensation inside the stomach, the digestive organs would contract, and from these disease would start. If you go and have food later, you will feel the stomach churning and aching. So whatever happens, you must take food in time, at least a little to give some input to the stomach and keep it cool. Three meals a day for all living beings [sic]. From food comes life, disease, and everything (Azhagammai, a female informant).

That food must be taken at least thrice a day, is the second norm; though a fourth meal is said to be necessary when work is heavy. This does not mean that overeating is generally encouraged. One is to eat only after the previous meal is fully digested. Overeating and eating between meals are strongly discouraged. That is, moderation in eating is stressed. These norms are regarded as important and the villagers claimed to take great care to follow them. They, no doubt, adjust the timing of their meals to suit their convenience and habit. Yet there was constancy in the meal-timings and the basic norm of ‘eating thrice a day at fixed hours’ remained unchanged. Regularity, moderation and constancy are thus highlighted as the fundamental principles underlying the cultivation of eating habits. The term constancy suggests something about the quantity of food to be taken. Can this quantity be specified (similar to the minimum and maximum calorie intake specified in biomedicine)? The villager’s conception of the food-body relationship initially leads us to think that the quantity of food to be taken is based on the amount of work done. While it is held that people who do more physical work have to and do eat ‘more’ and that one cannot work if one does not eat ‘enough’, the villagers pointed out that the actual amount of food consumed by a person is not determined by the amount of work done by her/him: there are persons who eat less always and yet do as much work as anybody, and vice versa. What is important in this regard is the ‘capacity of the stomach to hold’, that is, the requirement of the stomach is considered to be the criterion for the quantity of food to be eaten. The term kannaku (measure)

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used frequently in this regard connotes the capacity of the stomach as a standard measure of the quantity of food to be consumed: You can eat only as much as your body system can assimilate. That is the measure. A big tank can hold more water; a small one cannot. If you forcibly fill more into the tank, it will break. So if you consume more than your stomach can hold, you would vomit. Everything is indeed measured (Chinnakaruppan, a male informant).

This criterion is stated in unequivocal terms. Even if the question is twisted—‘Do we have to eat less when we work less, or vice versa?’—the answer is straight: ‘Do we have two stomachs, one when you work and one when you don’t? You eat the same amount always, don’t you?’ (Ibid.). While the injunction that one should eat as much as the stomach holds may appear to be a universal prescription, subjecting the capacity of the stomach to some specific conditions ‘localises’ the criterion.

Quality of Food: The Local Dimension Initially, the digestive system is perceived as an entity per se and the purely mechanical aspects of its functioning are spelt out. However, the machine (digestive system) is inside a larger system (body system), it receives inputs (food) from outside (ecology and environment), and its functioning depends on many other factors—the operations of the larger system (work done by the person), the capacity of the larger system (body constitution of the person), and the availability of inputs from outside (economic, geographic and seasonal conditions). These conditions having a bearing on the ‘machine’ are local’ in nature; local to a group of people living in similar conditions. These are highly variable and dynamic conditions experienced, comprehended and handled by the group of people living under them. These are conditions relating to the quality of food. The variety principle and body constitution: Questions like ‘What foods are good?’, ‘What foods are nutritious?’, ‘What foods are harmful to health?’ and so on, evoke responses like: ‘Everything is edible, man eats even mud and stone with food, even that goes inside, what is not edible?’ (Pothichi, a female informant). ‘What is not eaten? Snakes are not eaten. But they say that the white man eats that; what is left that man does not eat?’ (Kaari, a male informant).

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The argument that all foods are good apparently implies that there is nothing inherently wrong about a foodstuff. Each foodstuff possesses certain properties and it becomes good or bad when these properties agree or disagree with the eater’s body constitution. Since what is agreeable to one may not for another, each person has to decide what is good for herself/himself. It is considered better to eat as many kinds of food as possible to acquire the ‘goodness’ of all of them. Thereby the body gets used to the various properties, good and bad alike, that any further dose of those properties may not cause harm. Thus, the harmful elements can also give strength to the body by conditioning it against further doses of the same. In this way, the variety principle paves the way for the control of diseases carried by food. This is particularly true of foods which are part of the daily diet, because it is necessary to familiarise the body to foods that will constitute the bulk of the daily consumption. It is said that people who eat variety of foods are healthier than those who are very choosy. So, for one month after delivery the mother is given all kinds of vegetables and foodstuffs (though in limited quantities) to accustom her breastfed baby to variety in the early stages of its life. The increase in skin diseases in the past 10 years, which the allopathic doctors attribute to the ‘unhygienic lifestyle’ of the villagers, is held by the villagers to be the consequence of violation of the variety principle. The depletion of the traditional food grains and loss of many dry-land pulses (due to commercial cropping) have forced them to eat only some varieties of pulses and vegetables (like the red pumpkin, brinjal, etc.) which are available, and which are all karrapan (foods that cause skin problems). These are said to vitiate neer (water) in the body system and in the absence of neutralising properties, lead to skin infections of various kinds. The variety principle when carried to its extreme represents an ideal for the villagers. ‘Indiscriminate diet’, as we may call it, would mean eating the maximum possible kinds of foods. ‘A man who eats anything, almost everything without feeling any aversion to smells and tastes becomes the strongest. Nobody can beat him’ (Kottaiyan, a male informant). As a rule, informants referring to this ideal inevitably cite the diet of the goat as being typical of the condition of indiscriminate diet: The goat, of all animals, is known to eat all kinds of leaves including the poisonous Kancarai (Strychnine tree). It is said that excepting the plant locally known as aadu todaa ilai (Adathoda Vasaka), there is no plant that the goat does not eat. The goat is so adaptive, the villagers add, that during times of drought,

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when pastures are scarce, it eats leeches and even bits of paper, though basically it is a vegetarian. It is enriched by the properties of all those various substances it eats, and the noxious elements, if any, neutralise each other. The goat’s milk is, therefore, said to be ‘free from disease’. Despite being a pervasive ideal, ‘indiscriminate diet’ is not fully achieved in practice, as is evident from the fact that the villagers avoid certain foods and are averse to some. The villagers acknowledge that lifestyle, kind and amount of work done, time available, availability of foods and their compatibility with the body constitution, and so on have a crucial role to play in the realisation of this ideal. While the villagers say that all food items are good, they would not take milk, curds, ghee and some vegetables, even if they are available. A closer scrutiny reveals that these rich foods are said to be good for the body and its shine and glow, but they do not seem to be regarded as strengthening the body system. The term caturam (body frame), connoting the outer appearance of the body, as opposed to the terms tiregam and mel used to characterise the body system and its inner metabolism, provides the clue to this implicit distinction: milk, curds and the like contribute to the frame only. Growth of the frame (body size) is considered harmful to health and especially antithetical to their lifestyle based on hard work. The villagers, however, are not negating the nutritive value of the foods like milk; ‘it is inadequate for us’ is what they say. For the kind and amount of physical work they do, they require foods that are bulky enough to keep their stomachs full during work. Foods like milk, fruits, egg, etc. do not meet their requirement for bulk foods, that is, they are not filling, it is said. All the food grains, cereals, pulses and greens that they eat regularly are said to supply the needful at low cost. ‘We eat all the nine kinds of grains, all available varieties of cereals and pulses; moreover, we eat “mixed greens” at least twice a week and so our blood would be as good and bright as the sparrow’s blood’ (Raasu, a specialist in treating snake and insect bites).

The Nexus of Food, Body, Work, Ecology and Lifestyle The villagers do not seem to view the body in terms of anatomy and physiology. They talk about processes and entities, the crucial ones among them being body constitution and quality of blood. Blood, here,

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does not have a literal meaning; it is used as an umbrella concept to subsume several body constituents—reproductive fluids, fat, bone marrow, hormones, besides blood proper. Thus, blood is regarded as virtually constituting the important fluid contents of the body system, and hence, a vital force in its functioning. Body constitution, on the other hand, is said to include heredity and genetic factors. Basically, it refers to certain tendencies in the body system which give a person her/his physical, physiological and mental traits and ‘proneness’ to some kinds of ailments. The relation between blood and body constitution is not made clear to us by the informants, except that the tendencies of the body system are generally manifest in blood. A thing, before it becomes food to us, is part of nature and, hence, an entity external to our body. All substances in nature and, thereby, food also, are considered to possess some properties like heat, water and so on, which are regarded as neither good nor bad. The contact between food and body is first established physically when the food is consumed and digested. Later, food assimilates with the body system; more precisely, it is said to combine with blood and rejuvenate it. It is as though the blood and the body constituents get constituted by the food consumed. In this sense, the body itself is conceived of as being constituted by food, and the relation between food and body is established in the most fundamental way. Both food and the body constitution seem to be governed by a common classification system whose main elements are heat producing, watery and wind producing. So wise eating calls for a compensatory eating principle to avoid vitiation of the prone tendency. Since the goodness/ badness of foods is ascertained only in their relation to the body (of persons), universalistic criteria for classifying good and bad foods are not applied. However, by relating food consumed to body constitution, the food-body relation is not reduced to the level of individual bodies. There are patterns in body constitution (‘hot bodies’, ‘cool bodies’ and so on) which raise the food-body relation to the level of interaction of properties. Furthermore, the body constitution and food eaten are not individual entities but they are themselves a function of larger forces in the ecology, heredity and social background. Thus, food which seems an innocuous entity from outside, becomes the source of health and disease when it gets into the body and interacts with it. However, the relation between food and body is said to be

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incomplete without incorporating the functions of the body (that is, work). Food consumed has to be in proportion to the work done, and this is regarded as an important physiological requirement of any body system. Physical work is said to perform the indispensable catalytic role in the assimilation of food and the expulsion of wastes from the body. Any excesses in the foods consumed are said to be expelled from the system through sweat, thus avoiding the possibility of vitiation of constitutional tendencies resulting from food intake: ‘The more you sweat, the better, the body will eject the unwanted fluids through sweat. To bring these fluids out, some amount of hard work is absolutely essentially for anybody’ (Chinnakaruppan, a male informant). Thus, physical work is another neutralising mechanism in the complex relationship between food and the body (the others being the variety principle and indiscriminate diet, discussed earlier) which is considered to reinforce continually the capacity to work by processing the food in the appropriate manner. There is more to this interaction between food and work. We know that various food grains are included in the villagers’ diet by rotation. These food grains are allocated for the day and the night: finger millet, kodo millet and little millet are consumed during the day; maize and rice are consumed at night. Similarly, a greater combination of food grains is consumed during the latter half of the year (i.e., during the agricultural season), and lesser combination is found in their diets in the first half. The villagers acknowledge these adjustments and explain that heavier and bulkier foods that could withstand ‘the absorbing power’ of hard physical work will have to be consumed when there is more work. However, the food intake is not necessarily reduced when work is less: ‘What we eat in the day is burnt up in work. What is eaten in the night only “stays” and assimilates with the body. So we can eat heavily, as much as we want in the night’ (Konamuzhichi, a female informant). As we have seen, the amount of food eaten is said to be determined by the capacity of the stomach, irrespective of work done. Nevertheless, this does not seem to be put into practice, because the foods consumed during the day are ‘heavy’ and those consumed in the night are ‘light’. It was clarified that the phrase, ‘we can eat heavily in the night’ means ‘we can eat more of the light foods in the night’. The quality of food eaten, namely, whether it is heavy or light is what is to be synchronised with the work done. Adjustments in the quantity of food taken need not be made according to work done, it is felt.

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Apparently, the amount of work done has nothing to do with the quantity of food taken. After all, the quantity of food that a person can eat is said to be related to the capacity of her/his stomach. But, there is a subtle twist here: the capacity of the stomach is itself said to be determined by the amount of work done. Instead of postulating a direct and simple relation between work and food, thereby reducing it to the level of the individual, it is conceived at a much higher level of generality. The capacity of the stomach, according to the villagers, does not seem to refer to the capacity of individual stomachs. It is subject to the proportion of work in one’s lifestyle as a whole. Thus, a group of people leading a similar lifestyle and doing the work of similar intensity is likely to have stomachs with similar capacity to hold food. This idea is almost reduced to an equation by our informants: Less or more work seems to activate the digestive system accordingly, and the food eaten is balanced with the amount of work done. If this is so, why should such great importance be attached to physical work? For an answer, we are taken back to the initial statements about the catalytic role of physical work. The absence of physical work in one’s lifestyle, it is said, cannot be compensated by any improvements in nutrition, hygiene, etc.: ‘The more you work the more healthy you are. Even if you eat the best and the most nutritious of foods, but do not work enough, the foods eaten will themselves become sources of disease’ (Fatima Bheevi, a female informant). Thus, a lifestyle of more work, more food, is always considered preferable. The food-body relation mediated by work is to be understood in the context of their common existence in ecology. It is said that human beings and the food they consume are of the same order in that they are both living things. Food comes from plants and animals, which are living things. At this level, the body and the food to be consumed are affected individually and collectively by any stimulus to the ecology of which they are a part. It may even be said that they react similarly to such stimuli, and that the reaction to the stimuli by one of them could be a basis for understanding and explaining the same in another.3 The following comment illustrates this point: ‘If the chemicals can be so powerful as to raise the yield from five bags to eight, will its potency not act on the delicate digestive organs at least with half its force, when the food so cultivated is eaten regularly?’ (Nalli, a female informant). The earth is here a metaphor for the body. The effect of chemical inputs on earth becomes a means of comprehending the effect of food

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‘infested’ with chemicals on the body. The similarity in the reactions of the human body and other elements in ecology (such as the earth, plants and animals) to stimuli signifies the ‘internalisation’ of ecology by the body. Food is the vehicle of this internalisation: originating in ecology, or rather, itself being ecology, food takes ecology into the body. This internalisation is established and sustained over a period. In other words, a process of conditioning the body system to the food and thereby to the ecology has to precede internalisation. By eating the foods prevalent in one’s ecology over a period, the body gets conditioned to them and becomes immune to the effects of minor imbalances that may be caused by the foods so consumed. The conditioning to the inputs coming from their ecology, the villagers say, enables them to identify the sources of new ailments. For instance, when they say that chemical fertilisers and pesticides cause particular kinds of illnesses, it is not out of sheer resistance to change, but because of the fact that they produce reactions within the body which they have hitherto not experienced. That is, they know the reactions produced by the foods to which they are conditioned. Thus, experience and the logic of elimination have helped them conclude that the food ‘infested’ with chemical inputs causes a host of ‘heat-related’ disorders which their organic foods never did. The following remark of Azhagi, a female informant, illustrates this: The crops, greens and grains cultivated with chemical fertilisers and pesticides cause excessive production of wind inside the system. It never used to be like this those days. Nowadays poisonous medicines are used in agriculture. We eat the food thinking, after all it comes from our land, what harm can it do? To our surprise the food from our land has itself become a source of disease!

Conditioning to ecology through food can thus keep one perfectly at ease with their ecology. A remark such as, ‘we eat it thinking it comes from the earth, after all, what harm can it cause?’ brings out the rapport that the villagers have established with the ecology. This conditioning seems to have a crucial function in the occurrence or otherwise of disease. When asked why they continue to drink the unprotected water from the tanks, which the medical personnel in the area consider as the main cause of infections, the villagers would reply: ‘They say that there are germs in our tank water; true, but drinking this tank water for years together, we have ourselves become germs’ (Meyyan, a male informant).

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In other words, conditioning can internalise the disease causing agents themselves; by acquainting, or rather, befriending itself with the potential sources of disease, the body controls them. There is yet another dimension to the nexus in which the conditioning process acquires a wider and profound meaning than before. The body is said to secure a relation to the ecology not only through food (in the sense of meal); the air inhaled, the water used for drinking and bathing, and the herbal medicines taken are also forms of ecology going into the body, reinforcing the internalisation of the ecology. A whole generation of people being so intensely conditioned to the ecology can be expected to pass on the conditioning, to an extent, to their offspring: ‘We are not born out of coffee and snacks. Our parents ate food grains and porridge and from it we were made’ (Ambalam, a male informant). Thus, the conditioning process is said to thrust its roots into the formative stages itself, presetting the rudiments of a whole generation to come. Not only do the body and food get conditioned, the water and medicines consumed and the air inhaled by a person get conditioned to each other. Living in a habitat for several generations moulds the body system of the inhabitants, conditions them to its ecology and binds together the various inputs from the ecology consumed by them, thus creating a nexus of interpenetrating relations. At a specific level, the implications of the nexus would be like this: the kinds of food eaten (for example, organically grown) and the kinds of medicines taken (for example, herbal) would be so conditioned to each other that if a new type of medicine is taken, the medicine may not work well. A whole lifestyle evolves in this nexus of compatible relations between one’s body, the foods eaten, the water drunk, the medicines taken, the work done, and the ecology in which these exist and operate. Any radical change in any one of these, not accompanied by proportionate modifications in others, is said to result in incompatibility. The cumulative effect of incompatibilities, in the villager’s view, could spell disaster to a whole community by distorting the very rudiments of their life. We can, thus, understand why the villagers so intensely abhor foods ‘infested’ with chemical fertilisers and pesticides. The chemical inputs in the foods consumed are said to vitiate constitutional tendencies of heat and wind. Over a period there is an accumulation of the effects of that vitiation. Usually foods consumed over a period ought to get conditioned to the body. Despite taking ‘chemicalised’ foods for more than 15

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years, no conditioning seems to have taken place, the villagers complain. This is because of the gross distortions in relations among food, body, work and ecology that have taken place. The villagers explain that ‘chemicalised’ foods are immensely heat producing; they further heat up their bodies already exposed to the sun during the day. The heat so generated could perhaps be offset by consuming more of the ‘cooling’ foods like milk, curds, ghee, fruit-juice, etc. However, as we know, these foods are compatible neither with their lifestyle of hard work nor with their financial resources. Also, these ‘chemicalised’ foods are not compatible with their herbal medicines, which are ‘cool’ in nature. Consumption of such foods requires resort to hospital medicines which are again heat producing and costly. The net effect of all this is that their diet becomes incompatible with their way of life which involves working in the hot sun. The informants thus establish that the chemical inputs in food violate the very nexus of food, body, work and ecology. As always, the villagers do not reject anything saying it is absolutely bad. They point out that the ‘chemicalised’ foods could perhaps be less harmful to the middle-class urbanites, who need not have to work in the hot sun, and who can consume ‘cooling’ foods such as milk, curds, etc., and who can manage with and afford hospital medicines. According to the villagers, compatibility is thus the crucial condition of health and disease.

III Inherited and Incorporated Knowledge At any particular point in time, the medical lore of the people consists of both inherited knowledge and incorporated knowledge. The knowledge that is already there, handed over or acquired, is what is inherited: Medical texts and other reading material on the subject, the teachings of saints and sadhus who are well versed in medical texts, and the fund of knowledge transmitted from one generation to another constitute knowledge that is inherited. On the other hand, incorporated knowledge is what is created, modified and transformed in the ongoing process of life. The entire process of reckoning with the available resources and making them compatible with needs yields a lot of knowledge and

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experience. There is constant interaction between the two components of the lore, namely, what is inherited and what is incorporated, each reinforcing and modifying the other. The most crucial source of the villager’s incorporated knowledge is practice. Conventional sociology of knowledge distinguishes between ‘theory’ and ‘practice’ (see Merton 1972; Parsons 1970). However, the medical lore is not a diluted version of the texts, nor is it the mere application of textual tenets in actual practice. It is a system of knowledge that has evolved from practice and living experience. This practice is not antithetical to theory, but is itself its source and its end, like Bourdieu’s (1990) ‘habitus’, Marglin’s (1990) ‘techne’, and Lévi-Strauss’s (1962) ‘bricolage’. The concept of compatibility discussed above is central to other local health traditions (Nichter 1980) and the textual traditions (Dasgupta 1975; Dwarakanath 1967; Dwarakanath and Vaidyanathan 1977; Govindananda 1989;4 Pillai 1929; Shanmugavelu 1987). There are many more basic principles on which the different health traditions in India converge. The medical lore of a particular region, however, is an independent working out of concepts and practices by its people, within a broad framework of basic common principles. The villagers constantly try to comprehend and solve their health problems; their health concepts are a by-product of this very experience of living. For instance, physical work which is assigned such great importance in health in the folk tradition of Thirukolakudi, does not seem to find equivalent emphasis in the conceptions of the Ayurveda and Siddha practitioners in the locality. Each villager can discuss for hours how his body responds to changes in seasons, food and habitat with analogies drawn from nature and other human beings. The older women can distinguish about 12 types of effects of indigestion in infants by feeling and patting the stomach and hearing its sound, by observing the stools and by the sound of the infant’s cry. The knowledge so gained is constantly reinforced and refined by use in daily life. By virtue of its validation in living experience, it renews itself through adaptation. Edible oils, beverages, and chemical fertilisers and pesticides introduced in the region have been analysed and incorporated into their ‘materia medica’. Their diet patterns have helped them survive 10 years of drought in the past without problems of malnutrition and deficiency (see Sujatha 1993). This adaptation seems to be built into their health culture as in the case of many other village communities in India (Jodha 1991).

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The lore is a health tradition in the sense of Lath’s (1988 a and b) Parampara, an ongoing process in which the confluence of inherited and incorporated knowledge is effected through the crystallisation of experience. Continued living in a habitat for several generations, and the conscious experience of the body, disease, and the remedies have built up a knowledge tradition. By ‘befriending’ food elements outside the body system, by inducing variety in food intake, by adapting to the ecological conditions, the body-food dialectic has yielded a health Parampara, whose continuity is ensured by its orientation to informed practice.

Notes 1. I am grateful to Prof. G. Sivaramakrishnan, Department of Sociology, Bangalore University, for his comments on an earlier draft of this paper. The people of Thirukolakudi village, where the fieldwork for this study was conducted, are among the most important contributors to this paper. Their knowledge and skills provide information for this work; their sense of values gives valuable insights into life. I am also thankful to the anonymous referee for his/her valuable comments and suggestions. 2. The interviews on which the present study is based were conducted in Tamil. Informants’ statements reproduced here are free translations into English rendered by the author. 3. If the effect of chemical fertilisers and pesticides on the soil is translatable into the effect of a similar intake on the body, it connotes a fundamental unity underlying the functions of intakes for the various ecological systems—human body, plants and animals. 4. Personal communication in 1989 by Vaidyar Govindananda, Head, Sri Narayana Guru Ayurveda Hospital, Pillayar Patti, Tamil Nadu.

References Banerji, Debabar. 1974. ‘Social and cultural foundations of health services systems’, Economic and political weekly, 9 (32–34): 1333–43. ——— 1976. ‘Health services and population policies’, Economic and political weekly, 11 (31–33): 1247–52. Bourdieu, Pierre. 1990. The logic of practice. California: Stanford University Press. Carstairs, G.M. 1955. ‘Medicine and faith in rural Rajasthan’, in B.D. Paul (ed.): Health, culture and community (107–34). New York: Russell Sage Foundation. Dasgupta, Surendranath. 1975. ‘Speculation in the medical schools’, in Surendranath Dasgupta (ed.): A history of Indian philosophy (273–436). New Delhi: Motilal Banarsidas. Djurfeldt, Goran and Staffan Lindberg. 1976. Pills against poverty. New Delhi: Oxford and IBH Publishing Company.

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Dwarakanath, C. 1967. Digestion and metabolism in Ayurveda. Calcutta: Baidyanath. Dwarakanath, C. and B. Vaidyanathan. 1977. Nutritionology in Ayurveda (Mimeo). Egnor, Margaret Trawick. 1983. ‘Death and nurturance in Indian systems of healing’, Social science and medicine, 17 (14): 935–45. ——— 1987. ‘The Ayurvedic physician as scientist’, Social science and medicine, 24 (12): 1031–50. Elwin, V. 1955. The religion of an Indian tribe. London: Oxford University Press. Hasan, Khwaja Arif. 1967. The cultural frontier of health in village India. Bombay: Manaktalas. Jaggi, O.P. 1973. ‘Folk medicine’, in History of science, technology and medicine in India (Vol. 3), New Delhi: Atma Ram and Sons. Jodha, N.S. 1991. ‘Drought management: Farmer’s strategies and their policy implications’, Economic and political weekly, 26 (29): A 98–104. Kakar, D.N. 1977. Folk and modern medicine. New Delhi: New Asian Publishers. Lath, Mukund. 1988a. ‘The “modern”, the “traditional” and criticism in the Indian musical tradition’, Lokayan, 16 (5): 23–36. ——— 1988b. ‘Folk and classical music: A dichotomy that does not quite work in India’, Sangeet natak, 88: 44–46. Leslie, Charles. 1968. ‘Professionalisation of Ayurvedic and Unani medicine’, Transactions of the New York Academy of Sciences (Series 2), 30 (4): 559–72. ——— 1988. ‘Social research and health care planning in South Asia’ (Parts I and II), Ancient science of life, 8 (1): 1–12 and 8 (2): 75–91. Lévi-Strauss, Claude. 1962. The savage mind. London: Neidenfeld and Nicholson. Marglin, Stephen. 1990. ‘Losing touch: The cultural conditions of worker accommodation and resistance’ in Frederique Appfel Marglin and Stephen Marglin (ed.): Dominating knowledge (217–82). New Delhi: Oxford University Press. Marriott, McKim. 1955. ‘Western medicine in a village of north India’, in B.D. Paul (ed.): Health, culture and community (239–68). New York: Russell Sage Foundation. Merton, Robert K. 1972. Social theory and Social structure. New Delhi: Amerind Publishers. Nichter, Mark. 1980. ‘The lay person’s perception of medicines as perspective into the utilisation of multiple therapy systems in the Indian context’, Social science and medicine, 14B: 225–33. Parsons, Talcott. 1970. ‘An approach to the sociology of knowledge’, in James E. Curtis and John W. Petras (eds.): The sociology of knowledge. A reader (282–306). London: Praeger. Pillai, Muthukarrupan. 1929. Vaidya saara sangiraham (in Tamil) Madurai: Madurai Tamizh Sangam. Priya, Ritu. 1990. ‘Health care in the eighth plan: dubious package deal’, Economic and political weekly, 25 (33): 1820–23. Qadeer, Imrana. 1985. ‘Health system and socio-economic inequalities’, Social action, 35 (3): 199–223. ——— 1990. ‘Beyond medicine: An analysis of health status of Indian people’. Think India 2 (1): 94–107. Radhika, M. and A.V. Balasubramanian. 1989. Local health traditions. (Lok Swasthya Parampara Samvardhan Samiti [LSPSS] Monograph No: 1). Madras: LSPSS. ——— 1990. Ayurvedic principles of food and nutrition (Part I) (Lok Swasthya Parampara Samvardhan Samiti [LSPSS] Monograph No: 2). Madras: LSPSS.

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Shanmugavelu, M. 1987. Siddha maruthuva noi naadal, noi mudhal naadal thirattu (in Tamil) (Part I). Madras: Tamil Nadu Siddha Commission. Sujatha. V. 1993. ‘Underdevelopment and ill-health—A dubious association’, in Proce­ edings of the Interdisciplinary Research Methodology Workshop (384–94), Madras Institute of Development Studies, Chennai. ——— 1994. Health and disease in village India. A study in medico-cultural compatibility. Unpublished Ph.D. thesis in sociology, Bangalore University. Tabor, Daniel. 1981. ‘Ripe and unripe: Concepts of health and sickness in Ayurvedic medicine’, Social science and medicine, 15B: 439–55. Zimmerman, Francis. 1978. ‘From classic texts to learned practice: Methodological remarks on the study of Indian medicine’, Social science and medicine, 12B (2): 97–103. ——— 1980. ‘Rtu-Satmya: The seasonal cycle and the principle of appropriateness’, Social science and medicine, 14B: 99–106. ——— 1988. ‘The jungle and the aroma of meats: An ecological theme in Hindu medicine’, Social science and medicine, 27 (3): 197–215.

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3 State Sponsored Health Care in Rural Uttar Pradesh: Grassroots Encounters of a Survey Researcher Rajiv Balakrishnan

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n a mercilessly hot summer afternoon in Bah, Agra, a pipal tree outside the Community Health Centre provides merciful shade to a confabulating group of tired people. It is a motley group, made up of lower level staff of the Centre who have in their midst a group of newcomers—members of a team conducting a baseline survey of the state of health and family planning in rural Uttar Pradesh. The newcomers’ agenda, sponsored jointly by the India branch of the New York based Population Council and by the Council for Social Development, a Delhi based quasi-governmental NGO, is two-pronged, gathering of data from the staff of the public health system, and from the rural recipients of health and family planning services. As regards the latter task, the Centre has promised to assist the team in locating the village beneficiaries. The team’s members, gossiping under the pipal tree, are in fact awaiting a health worker assigned to accompany them to the field. Presently, the health worker arrives and everyone piles into a jeep to begin the search for beneficiary households.

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Assuring the team’s coordinators of cooperation at their rural destinations, the health worker points out, his voice reeking of an urbanite’s condescension towards rural folk, that the team would be received with the reverence villagers habitually extend to government functionaries. The group’s mode of transport—the jeep, he says by way of explanation—is inevitably seen as a symbol of governmental authority. As a member of the team and one of its coordinators, I discover in due course that this indeed is true. I also encounter the other side of the coin; I was, on many occasions, approached with folded palms and beseeched to do something about such problems as the inadequacy of water, erratic electricity supply, and about the crimes of omission and commission of public health service staff. Like the villagers we met, Agra’s public health staff suspected us of being representatives of the government in Delhi, and we were received with utmost courtesy and solicitousness at the PHCs (Primary Health Centres). Our field strategy had centered around visits to PHCs, partly with a view to canvassing schedules among the medical staff there, and partly with the intention of examining records so as to obtain information that would enable us locate and interview the acceptors of family planning services. Names and addresses of acceptors, obtained from records maintained by a PHC official known as a ‘Computer’, were based on information periodically received from the Auxiliary Nurse and Midwife, who bears by far the greater part of the responsibility for initiating and sustaining contact with the intended beneficiaries. The Auxiliary Nurse and Midwife, or ANM, operating typically from far flung health outposts known as sub-centres is, theoretically at least, the backbone of this health outreach system. We relied heavily upon her rather for the actual identification of acceptor households in the villages. Our modus operandi, as all this suggests, entailed considerable dependence on public health staff. As we had obtained permission for our survey from the state government and were armed with a letter from Agra’s Chief Medical Officer which directed the district’s public health staff to assist us, we assumed that we would get a good deal of cooperation. And cooperation we did get in abundant measure. The team’s presence also evoked a different type of reaction, however—one of palpable unease, as is vividly illustrated by events of May 30, 1995. That morning, I proceeded to a PHC with a team of investigators. Even as some of the team’s members obtained acceptor’s names and addresses from the PHCs computer, three ANMs, each attached to a

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sub-centre of the PHC, made their appearance. Though instructed to accompany us to the villages falling under their jurisdictions to help us locate beneficiary households they clandestinely made off, leaving us high and dry. They had, it was subsequently discovered, gone into hiding in the nearby residence of their colleague, a fellow PHC worker. This we learnt when a member of our team spotted the missing ANMs moving about furtively near the colleague’s residence. The matter was brought to the attention of the PHC staff, whereupon the absconding ANMs were apprehended. Somewhat abashedly, one of them, an elderly lady, confessed to being afflicted by ‘gabrahat’ (anxiety). Why did these ANMs panic? The colleague in whose residence they had concealed themselves, a lady with whom I unwittingly established rapport on the basis of common cultural roots in Kerala, informed me that there was in fact nothing mysterious about the missing ANMs. They did not maintain proper records and were also derelict in the discharge of their duties, she explained, adding that as they feared that their lapses might come to light they took to such a bizarre game of hide-and-seek.

Dereliction of Duty What, then, are the lapses the ANMs were so anxious to conceal? Our fieldwork experience has given us some idea of the skeletons in their cupboards. One such, a common one, is that under the pressure to enlist targeted numbers of sterilization, oral pill and IUD acceptors, many ANMs have cooked-up records. The ANMs are however not to be entirely blamed, as is illustrated by this story of an ANM attached to a sub-centre which I visited during the course of our survey on the May 5, 1995. It took a good ten minutes of struggle before the lock to the sub-centre’s premises, rusty due to disuse, could be wrenched open. The floor inside was unswept, and the room cobweb infested. Sparse pieces of furniture were littered about. The ANM attached to the centre had, by her own admission, last visited it on January 15, 1995, when her son met with an accident and had to be hospitalised. The financial liability involved, she says, had been a source of great anxiety which prevented her from meeting her target of eligible candidates for a family planning method. This, coupled with the fear of losing her job and income for not fulfilling those targets made her take recourse to the stratagem of cooking up the records. There were other attenuating circumstances as Well.

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The ANM’s fear of losing her job had been exacerbated by her suspension in April 1994. She stated that no reason had been given for her suspension, but a team member later informed that it happened after a child she had treated had died. The ANM said that after she was suspended, she was asked to pay a bribe of Rs 4,000 for getting reinstated. She maintained that she refused to pay but was eventually reinstated only in January 1995. From April 1994 till the time of her reinstatement, she received no salary. Consider also this tale involving an ANM who, for several years, lived with her family in the village where her sub-centre was located and served the inhabitants there with dedication. She was, in her professional capacity, available around the clock to the people of the village. But on more than one occasion, she was harassed by some bad elements while outdoors procuring water for her household from the village well. These bad elements reacted to the ANM’s protests and complaints against them by accusing her of being immoral and lodging a complaint against her with the powers that be. It resulted in the ANM’s transfer to another posting. On the intervention of the village headman (the father of this informant) the ANM was subsequently brought back to the village. But she decided she would no longer reside there, choosing instead to live elsewhere and commute to work. Given the difficulties that commuting involves, she now visits her village constituents only once or twice a week. This is apparently one instance in which availability of efficient and time saving transportation could go a long way in ensuring the availability of services.

Graft and Malfeasance The problems afflicting the public health service are by no means confined solely to infrastructural bottlenecks or derelict personnel. This story of a truant ANM who rarely visited the sub-centre to which she was assigned, as narrated by an agitated and belligerent informant, illustrates what is involved. Residents of the village in which the sub-centre was located, who rarely saw the ANM, brought the matter to the attention of the Medical Officer of the appropriate PHC. The administrative machinery whirred, and in due course she was transferred. Within a few months, she was posted back, after she reportedly greased the right palms in the upper reaches of the

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public health hierarchy. She allegedly continues to be derelict, and as before, rarely makes an appearance at her sub-centre or the villages falling under its jurisdiction. A medical officer informant talks more generally of the graft and malfeasance that plagues the public health service. It is, he says, focused around the centralization of authority in the system, which empowers the incumbents at the rarefied heights of the health services hierarchy to extract enormous bribes. These notables allegedly pay bribes to those above them, and so are driven to extract ‘tribute’ from those below. This misuse of public office hinges upon the unconditional power of transfer enjoyed by senior medical officers. The idea, he says, was a good one, intended to facilitate the appropriate utilization of manpower resources. But the power of transfer, the doctor goes on to add, has been misused to an unimaginable extent, with those in high places using its threat, and the prospect of disorientation that transfers bring to settled ways— or the inducement of transfers to postings aspired for—as instruments for the extraction of bribes. In these circumstances, even well intentioned officials are unable to enforce their writ against erring ANMs, as seems to be the case with a medical officer I met, whose uprightness and probity are such that his subordinates fondly criticize him for being ‘too good a man’—the implication being that such an individual cannot effectively function in the system. The ANMs for their part—not counting laudable exceptions— lack even a rudimentary allegiance to the work ethic. The recruitment process itself militates against that. I am told by a PHC informant that recruitment as an ANM nowadays means having to shell out a bribe of Rs 20,000. It is evidently paying power that counts, not merit and dedication. And if an ANM can draw a salary of Rs 3,000 or so a month without being accountable for the responsibilities of her posting, the ‘recruitment bribe’ of Rs. 20,000 becomes little more than an investment on which lucrative returns can be expected.

Staff Morale It is not just that defaulters get away scotfree by ‘greasing’ the right palms, or that public office becomes a lucrative and purchaseable commodity; the system works to squeeze the innocent and the dedicated as well. A source, apprehensive of reprisals if his identity be known, fills me

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in on some of the sordid details. He tells me that TA (travel allowance) grants are released at the last moment, towards the completion of the financial year on the last day of March. As TA should should be claimed before March 31 or else it lapses, those who wish to claim TA are under pressure to pay bribes. Delay in the release of salaries is another way in which karmacharis (workers) can be harassed. Salary arrears can be claimed only after the annual budget is passed, so delays in salary payments can be a source of great inconvenience, and the promise of official intervention to expedite the matter a lever for extracting bribes. All this demoralises the health services staff to the point where they lose interest in work.

Factionalism among Medical Staff As if malfeasance, endemic graft and poor staff morale were not enough, the system is, I am informed, plagued also by factionalism among its staff. My medical officer informant tells me that within a PHC, factions coalesce around the Medical Officer-in-Charge (MO1), and his immediate subordinate, MO2. This has deleterious consequences for the provision and quality of health services. By way of illustration my informant mentions that if MO1 wishes to take punitive action against an indifferent or errant ANM, the other faction supports her just in order to oppose MO1. Thus MO1 cannot improve the quality of services—an endeavour that carries the potential of enhancing his professional reputation. What fuels all this, my informant adds, is the fact that the MO2’s confidential report is not written by MO1, but by a senior officer of the health services bureaucracy.

Provision of Services: Accountability and Affordability Reforming the ailing public health system, it becomes clear, is not a just a matter of better management to ensure efficiency and competence in the provision of services; it is, more importantly, one of making the system accountable to the people. The system currently lacks credibility to the point where, latent demand notwithstanding, people are not forthcoming in demanding services. This comes through quite

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forcefully during the course of a conversation I had with the son of the aged pradhan (headman) of Digner village. Having taken the responsibilities of the pradhanship upon himself, the pradhan’s son was well informed of village affairs. He informed me that a number of Digner’s residents wanted to go in for sterilization, but were holding back for lack of faith in the public health system. The pradhan’s son cited two instances of why faith in the system has been eroded. The first involved a woman in a nearby village who had given birth to a child after she underwent sterilization. In the second case, a woman who underwent sterilization at a government hospital developed medical complications had to be hospitalised for several days, and was required to incur medical expenses to the tune of Rs. 6,000—a formidable sum for the average villager. One might ask why these potential seekers of services did not go elsewhere. Conversations with the pradhan’s son in Digner lead me to believe that adequate knowledge of alternatives to the public health system may well tilt the balance. The potential for that certainly seemed to exist in Digner village. I cited to my informant a well known and reputed private agency actively catering to family planning needs in the rural and urban areas of Agra district—the Marie Stopes Clinic. On my mentioning the name the pradhan’s son and other hangers on evinced an immediate and keen interest. They had heard about Marie Stopes, but, were under the impression that it only performs abortions. They did not know that it also carried out sterilizations and IUD insertions. The regard in which the Marie stopes Clinic is held was first brought to my attention during my conversations with a Computer who had on his records cases of family planning acceptors routed through it with ANMs performing a referral function. Marie Stopes, I was subsequently given to believe, enjoys the people’s confidence because of its professionalism and the high success rate of the operations it carried out. The fact of the agency’s existence also suggests that it can be worthwhile for health professionals in the private sector to bring affordable medical technologies to the masses. ‘Affordable’ is however a subjective term, and it is not clear as to how it relates in this context to a policy framework wherein access to health services is envisaged as a fundamental right rather than a matter of purchasing power. Marie Stopes’ success may also to a significant extent be made possible by a disguised government ‘subsidy’. The costs Marie Stopes incurs for a sterilization operation are defrayed by the monetary ‘incentives’ acceptors of sterilization are entitled to

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receive from the government; the agency collects these ‘incentive payments’ directly from the concerned governmental department on behalf of clients, who are required to pay only the balance. Moreover, the clinic draws upon the outreach resources of the public health service as well, in that some of its clients are referred by ANMs operating in far away villages. Persist as they do, this is to a great extent due to the absence of institutional mechanisms to channelize popular resentment and hold the system accountable as is the case in Kerala. The new powers given to the panchayats however, and particularly the involvement of women in panchayati bodies, would appear to augur well for such beginnings.

Transport Facilities for Health Outreach Functionaries One of the major deficiencies of the health outreach system, as mentioned earlier, is that many of the ANMs face a formidable commuting problem. Providing them with a means of transport, such as mopeds will go a long way in improving their effectiveness, particularly as far as the dedicated among them are concerned. As for the less motivated, it would perhaps improve their efficiency too. A health worker I chatted with makes this point when he tells me that it is possible for him to shirk his clerical duties by making the excuse that he has not been given a pen to write with, but that if he is officially provided with a pen, he would thereby be deprived of an excuse. While acknowledging my contention that official transport, generally speaking, tends to be notoriously misused for personal trips, my informant argues that ‘if it is misused properly to the extent of 60 per cent, at least it will be used to the extent of 40 per cent’. The importance of transport for the ANMs is indeed crucial to the functioning of the health outreach system. Transport carries the potential of making the ANMs more effective. This is underscored by the fact that ANMs who reside in their sub-centre villages, and who are consequently accessible to their flock, can be a great boon to the local populace, as the case of the ANM of Doki vividly illustrates. This ANM, who has won honours for her dedication, places herself at the beck and call of the local community at all hours of the day and night. But that cannot always be the case, as village residence cannot be imposed on the ANMs without it attracting some form of evasive action.

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Role of the Health Professional While stressing institutional and infrastructural factors for reform, one must also acknowledge the devotion to duty demonstrated by some of the unsung heroes of the public health service staff. The example of an Etmadpur ANM may be cited here. Accompanied by three investigators, I arrived at the ANMs sub-centre village, after having been informed that the ANM had been instructed by her PHC doctor to await us there. Initially unable to find her, we proceeded to the village pradhan’s residence to seek his assistance in locating acceptor households. On a verandah outside the pradhan’s residence, we were extended the hospitality of being seated on a charpoy (stringed cot) and having our thirst quenched. In the course of the ensuing introductory conversation with the pradhan and the other village folk who had gathered around, the impression that we were on a ‘checking’ tour gained ground. Responding to this, the pradhan and others spoke in defense of their ANM, praising her for her dedication and devotion to work. At this point, the ANM herself arrived on the scene. Later, She escorted us to her sub-centre, housed in a neat and tidy room in the village. There we had an opportunity to observe the premises, a stipulated requirement for canvassing ‘sub-centre schedules’. Subsequently, the ANM trudged village lanes with the team to locate houses of family planning acceptors. The group proceeded also to a second village falling under the sub-centre’s jurisdiction, to canvas acceptor and other schedules there. In both villages, the local people spoke highly of this ANM of Etmadpur and were even somewhat protective and defensive when the impression went around that the team was there for ‘checking’ her activities. The ANM, for her part, did not seem unduly deterred by the difficulties of her situation, such as the necessity of trudging weary miles on foot in inhospitable weather and over rough terrain and combining her official responsibilities with those of caring for her toddler son. She had brought him along to the field on the day of team’s visit, as there was no one at home to care for him. The testimony of the locals suggests that difficulties notwithstanding, she sees to it that she honorably discharges her duties, and that rather than being cowed by difficult circumstances, she strives to carry on despite them. It is a case which suggests that even when the system is deficient, the people who run it do matter.

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4 Gram Panchayat and Health Care Delivery in Himachal Pradesh Sthitapragyan Ray

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he right to health is generally seen as the state’s obligation to deliver affordable and accessible health services to all (Cornwall et al. 2002). Under the Constitution of India, public health care is a responsibility shared by the central, state and local governments, although effectively it is a state responsibility in terms of delivery. Increasing people’s voice and influence in the health sector is believed to be an effective way of improving the performance of health system to meet the right to health—by increasing access to services to the most vulnerable and disadvantaged groups, by improving health outcomes generally, and by reducing health inequities. Active community participation through ownership and implementation of local health services is now gaining ground as a way of ensuring such influence (Das Gupta et al. 2000). The Alma Ata Declaration of 1978 and the 1994 International Conference on Population and Development (ICPD) have been key motivating factors for public health service decentralisation. The importance of decentralised health care delivery systems operating through elected local governments (Gram Panchayats) in which the rural people are not only enfranchised but also empowered has been well recognised in the Constitution 73rd Amendment Act, 1992.

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This Act, which paved the way for the creation of statutory institutional structures at the village level—Gram Sabha (GS) and Gram Panchayat (GP)—basically aims at initiating a process of democratic decentralisation of governance and accelerating the socioeconomic development of rural areas within a participatory framework. With the insertion of Part IX in the Constitution of India, the GP is empowered to manage health and sanitation, including hospitals, primary health centres and family welfare, which are among the twenty-nine vital ingredients of rural development, listed out in the Eleventh Schedule (Article 243 G) of the Constitution (GOI 1992). Other policy initiatives in this direction include the National Population Policy (NPP) 2000 and the National Health Policy (NHP) 2002. The NPP, 2000 emphasises decentralised planning and programme implementation with high involvement of the panchayati raj institutions (PRIs), community groups and NGOs. The NHP 2002 lays great stress on the implementation of public health programmes through local self-government institutions (GOI 2002a).

The Himachal Pradesh Scenario Himachal Pradesh (HP) is predominantly a rural state—about 91 per cent of the state’s population lives in rural areas. The achievement of the state on a number of social indicators, including that of health, is quite impressive. The infant mortality rate (IMR) of HP, at 54.2, is lower than the national average of 72.0; the crude birth rate, at 21.2, is lower than the allIndia average of 28; the crude death rate, at 7.0, is lower than the national average of 9.0; women with anaemia, at 40.5, is lower than the national figure of 51.8; and children receiving vaccination, at 83.4, is higher than the all-India average of 42.0 (GOHP 2002a). The rural literacy rate of HP, at 74.38 per cent, is much higher than the all-India rural average of 59.21 per cent. Only 7.94 per cent of the rural population of the state lives below the poverty line, as against the national average of 27.09 per cent (GOI 2002b). In HP, statutory local governments (PRIs) were established in 1954 under the HP Panchayat Raj Act, 1952. With a view to bringing about uniformity by establishing the two-tier panchayat system, the HP Panchayat Act, 1968 was enacted, and it became effective in 1970. The HP Panchayat Raj Act, 1994, enacted in the light of the

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73rd Constitutional Amendment Act, 1992, came into effect from April 1994. With this, the existing two-tier system, with GP and Panchayat Samiti, gave way to the three-tier system, with the addition of the Zilla Parishad (ZP). Accordingly, the State Election Commission, State Finance Commission and the District Planning Committees have been constituted; the District Rural Development Agencies have been merged with the ZPs, headed by the President of the latter and the panchayat elections were been held in 2000 (GOI 2001; GOHP 2002a). The GP as the executive committee of the GS consists of a minimum of seven and maximum of fifteen members, including the Pradhan and Up-Pradhan. Seats have been reserved for women, Scheduled Castes (SCs) and Scheduled Tribes (STs) in the GP. A GP consists of a village or a group of contiguous villages with a population of not less than one thousand and not more than five thousand. Under the HP Panchayat Raj Act, 1994 the GPs have been empowered to enquire and make report on the physical attendance and misconduct of certain public personnel, including male and female health workers. The GPs have to keep a tab on the functioning of sub-centres, including their regular opening and immunisation programmes. Since July 1996, the HP government has devolved certain health functions and powers to PRIs, since July 1996. These powers relate mainly to execution and monitoring of rural health and sanitation programmes. The GPs have been made the appointing authority in respect of certain village-level staff, like anganwadi workers, swasthaya sahayaks, panchayat sahayaks, etc. and their honorarium is to be paid by the GP. The GPs have to prepare development micro plans, including Annual Health Micro Plans, based on the felt needs of the people for improving rural health and sanitation. The GPs can also decide on the location of health institutions, anganwadi centres, etc. and take care of their maintenance and improvement. They are also expected to help in awareness-generation about reproductive and child health; maintenance of village population records, including that of births, deaths and marriages; maintenance of village sanitation and drinking water sources; and provide assistance in prevention of contagious diseases (GOHP 2002a). The Standing Committee on Health and Family Welfare of the GP is expected to take a special interest and play a key role in the health sector activities of the panchayat. To enhance the effectiveness of this Committee, necessary amendments in the State Panchayat Raj Act,

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1994 have been carried out. The functions of the Standing Committee depend on the extent of power delegated to it by the GP. The Parivar Kalayan Salahakar Samiti (PARIKAS)—the Health and Family Welfare Advisory Committee—created by a HP Government Notification (No. HFW-B(F) 7-2/2001, dated 10 December 2001) in December 2001 is expected to further boost the health and family welfare activities of village panchayats. The sincerity of the state government to give powers to local bodies in health matters is evident from the fact that it has issued notifications instead of executive orders, which do not have the legal validity that notifications have. That makes it more difficult for the bureaucracy to ignore them. At the panchayat level, the PARIKAS is headed by the pradhan, with the health worker, male or female, as the secretary, and the membership includes the GP ward members, local NGO representatives, village opinion leaders, local social workers, office bearers of mahila mandals/women SHGs, local school teachers, forest guards, anganwadi workers and Ayurvedic doctor. The Notification provides for the meeting of the PARIKAS once in a month. Its functions broadly include the monitoring of rural health and family welfare programmes and supervision of the sub-centre. Thus, by institutionalising community monitoring of health care delivery, the PARIKAS seeks to enforce social rather than mere bureaucratic accountability. Thus, the policy of the government on paper reflects a definite move away from the top-down, target-oriented approach to a more participatory, process-oriented approach. But to what extent changes in policy conceptualisation are reflected in implementation? The GPs have apparently been empowered to plan, implement and monitor certain key rural health activities. The crux of the matter that needs to be examined is the actual and effective role of the GPs in carrying out the assigned functions. The social capital argument in explaining the success of local democracy (Putnam 1993; Woolcock 2000; World Bank 2001), particularly in the context of the rural health care initiatives of the panchayats in HP, is also sought to be looked at in this paper using the fieldwork data. The following were the objectives of the study: (i) Analysing the extent of devolution of health care functions and powers on the GPs. (ii) Examining the rural health care contributions of the GPs. (iii) Identifying the GPs’ constraints in managing rural health care.

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The Research Context and Methodology Four districts in the non-tribal lower areas of HP, which constitute 60 per cent of the state’s area and account for 96 per cent of its population (Sharma 1999: 2465) were identified for the study. Two of these districts—Kangra and Una—are relatively developed (in terms of indicators like literacy rate, percentage of SC population, sex ratio, etc.) and the other two districts—Sirmaur and Solan—are comparatively backward. One block from each of the four districts was randomly selected for the study. Kangra, the most populous district in HP, accounts for 22 per cent of the state’s population and about 10.3 per cent of its area. The district has the second highest sex ratio of 1027 in the state. It has a literacy rate of 80.68 per cent and the SCs constitute 21.17 per cent of its population (Table 1). Baijnath, a backward block of the district, consists of 51 panchayats. The sex ratio and the literacy rate (for both sexes) of the block are much lower than the district average (Table 2). Sirmaur is one of the most backward non-tribal districts in HP; in fact, it figures in the list of 150 most backward districts identified by the Planning Commission, Government of India. It consists of 5 per cent of the state’s area and has witnessed a high decadal population growth rate. It has a literacy rate of 70.85 per cent. The district has one of the lowest female literacy rates (60.93%), just above the tribal district of Kinnaur. Table 1 Socio-demographic Profile of Sample Districts Literacy Rate*

District

Sex Ratio*

Female

Male

Total

Percentage of SC*

Percentage of ST**

Kangra

1027

73.57

88.19

80.68

21.17

0.14

Una

977

73.85

88.49

81.09

22.47

0.01

Sirmaur

901

60.93

79.73

70.85

30.17

1.16

Solan

853

67.48

85.35

77.16

31.27

0.64

HP

970

67.08

84.57

75.91

25.34

4.22

Note: * Data pertaining to 2001 Census; ** Data pertaining to 1991 Census; Sex Ratio = No. of females per 1000 males; SC = Scheduled Caste; ST = Scheduled Tribe. Source: Census of India 2001, 1991.

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Table 2 Socio-demographic Profile of Sample Blocks Baijnath/ Kangra

Shilai/ Sirmaur

Dharampur/ Solan

Gagret/ Una

Panchayats

51

28

39

41

Population

82917

32923

71173

106893

Female

40411 (48.74)

15341 (46.60)

31692 (44.53)

53917 (50.44)

Male

42506 (51.26)

17582 (53.40)

39481 (55.47)

52976 (49.56)

950

872

802

1017

Scheduled Caste

15263 (18.4)

NA

NA

23516 (22)

Scheduled Tribe

536 (0.65)

NA

NA

NA

Infant Mortality Rate

22.2

NA

4

Block/District

Sex Ratio

Institutional Deliveries

NA

NA

NA

24

Literacy Rate (%)

56.85

56.74

79.71

NA

Male Literacy (%)

69.33

66.85

86.83

NA

Female Literacy (%)

44.99

44.81

71.04

NA

Note: Percentage in parenthesis; NA—Not Available; Infant Mortality Rate = Number of deaths per thousand live births. Source: BMO/BDO Offices, Baijnath, Shilai, Dharampur, Gagret.

It has also very low reproductive and child health indicators. It has also one of the largest concentrations of the SC population (30.17%) in the state (Table 1). Shilai block of this district has very low literacy levels, for both males and females, and a sex ratio lower than the district average (Table 2). Solan constitutes about 3.5 per cent of the state’s area and has witnessed one of the highest population-growth rates. With a combined literacy rate of 77.16 per cent and female literacy rate of 67.5 per cent, the district has experienced a steep decline in sex ratio from 909 in 1991 to 853 in 2001. This is despite the higher-than-average level of urbanisation and work-participation rate in the district. It has a large percentage of the SC population (31.27%) of the state and the gap between male and female literacy rates is one of the highest in the state (Table 1). The

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literacy rate in Dharampur block of this district is higher, but the sex ratio is lower than the district average (Table 2). Una district, having a decadal growth rate of 18.43 per cent, constitutes about 2.76 per cent of the state’s area. It has a combined literacy rate of 81.09 per cent and has seen a sharp decline in sex ratio from 1017 in 1991 to 977 in 2001. The SCs constitute 22.47 per cent of the district population (Table 1). Gagret block of this district has a sex ratio higher than the district average, but the crucial 0–6 age-group sex ratio in the block is a matter of concern (Table 2). From each of the sample blocks, six GPs were selected for detailed study, taking the total number of GPs to twenty-four in the four districts. The socio-demographic indicators of the selected GPs, including the presence of CBOs (as indicative of social capital are presented in Tables 3.1, 3.2, 3.3 and 3.4*). All the stakeholders associated with the functioning of panchayats and delivery of health services were included in the study. An attempt was made to include one GP headed by a woman pradhan and one by a SC pradhan in every district. In each GP, the following categories of respondents were covered: six villagers from each ward or up-gram sabha (UGS), including three males and three females, were selected. Out of these, one male and one female belonged to the below poverty line (BPL) category and one each to the SC category. Apart from the GP pradhan, the ward panch and the GP secretary formed part of the study. Among the health functionaries, the Anganwadi worker, the Auxiliary Nurse Midwife (ANM), the Male Health Worker (MPW) and the Ayurvedic doctor, where available, were included in the survey. After making allowance for field-level constraints, the final sample consisted of 144 villagers, 24 GP pradhans, 23 ward panchs, 23 GP secretaries, 23 Anganwadi workers, 18 ANMs, 12 MPWs and 6 Ayurvedic doctors (Table 4). A set of both conventional and participatory tools was used for collection of data: (i) Information on various aspects of the functioning of rural health programmes and services, and the role and performance of GPs in it, as perceived by the villagers, was obtained by canvassing a specially designed schedule among the sample villagers. Focus group discussions were also held with villagers to generate desired information. Information on local mahila mandals, kisan sabhas, youth clubs, etc. (as indicative of social capital) across the panchayats was collected. * Due to archaic nature of the articles some tables in this chapter are not available and could not be reproduced.

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Table 4 District-wise Distribution of Sample Respondents Category of Respondents

Kangra

Sirmaur

Solan

Una

Total

36

36

36

36

144

GP Pradhans

6

6

6

6

24

Ward Panchs

6

6

5

6

23

GP Secretaries

6

5

6

6

23

Villagers

Anganwadi Workers

6

5

6

6

23

ANMs

5

3

4

6

18

MPWs

1

3

3

5

12

Ayurvedic Doctors

2

1

2

1

6

68

65

68

72

273

Total Source: Field Survey.

(ii) Data relating to the role played and constraints faced by the GP in the implementation of health programmes were collected from elected GP members at the panchayat and ward level and from the panchayat secretary also, with the help of specific schedules and informal discussions. (iii) The views and perceptions of health functionaries at the GP/sub-centre level were also gathered through schedules and discussions with the help of appropriate checklists prepared for the purpose.

While primary data had been collected from stakeholders by administration of structured schedules and holding of discussions on above lines, secondary data and information were obtained from various offices and reports of the state and central governments and other published sources and websites, wherever feasible, with due acknowledgement. The study was carried out during June–November 2003.

Background Characteristics of Sample Respondents There were equal number of men and women among the sample villagers. More than half of them (53%) were SCs, about 8 per cent were OBCs and the rest (39%) belonged to general categories. About 42 per cent of the respondent villagers were in the official BPL category. A large majority

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(88%) of them were literate. Many of the sample villagers (64%) were having membership in or association with civil society groups like mahila mandals, youth clubs, kisan sabhas, NGOs, SHGs, etc. (Table 5). Out of the twenty-four GP Pradhans interviewed, fifteen (62.5%) were men and nine (37.5%) were women; 29 per cent of them belonged to the SCs and 8.3 per cent to the OBC categories; and 12.5 per cent of them were from the BPL families. A large number of them (62.5%) were having membership in or association with civil society groups. While a majority of them were educated up to higher secondary or higher level, only one was found to be illiterate. Of the twenty-three ward panchs, thirteen (56.5%) were male and ten (43.5%) were female, and 43.5 per cent belonged to the SC and 13 per cent to the OBC categories. While 22 per cent of them came from BPL families, 44.34 per cent reported membership in or association with local civil society groups. Of the twenty-three anganwadi workers (all women), 26 per cent were SCs and others belonged to the general category. A majority of them (78.3%) have studied up to higher secondary level. Of the six Ayurvedic doctors, four were men, two belonged to the OBC category and none of them had been provided with official residence at the place of work. Out of the sample of twenty-three GP Secretaries, twenty-one (91.3%) were men. While about 29 per cent of them were SCs, the rest belonged to the general category. Out of the total of 18 ANMs covered, about 21 per cent belonged to the SCs, 12 per cent to the OBC and the rest (about 67%) to the general category. While the majority (61%) was given official residence near the sub-centre, just about 17 per cent were making use of it. Of the twelve MMWs interviewed, one-fourth belonged to the SC category, half to the OBC category and the rest to the general category. None of them had been provided with official accommodation.

Findings of the Study Role of Gram Panchayat Only about 6 per cent of the sample villagers said that they had gone to the GP with a health issue and just about 3 per cent reported lodging a complaint against the health staff with the GP. But just about 1 per cent

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of the villagers interviewed replied in the affirmative about some action being initiated by the GP on their complaints. About 60 per cent of the GP pradhans reported having discussed health issues in the GP/GS meetings. Potable water and sanitation seemed to be the most discussed issue. Even so, in most cases, villagers had looked after their own sanitation without much assistance from the GP and its role in drinking water was limited to purifying water sources. Just about 45 per cent of the ANMs and MPWs reported getting GP assistance in community mobilisation and related health activities. While about 90 per cent of MPWs reported attending GS meetings during the last one year, about 60 per cent of the ANMs reported so. More than 90 per cent of the villagers interviewed denied having any knowledge about organisation of health camps or community mobilisation efforts by GP. Panchayat swasth sahayak, a grass roots level health worker—appointed by and accountable to the GP—had not been appointed in most of the study panchayats. More than 90 per cent of sample villagers, 80 per cent of GP pradhans and 75 per cent of subcentre level health staff said that there was no appointment of a swasth sahayaks in their panchayats. GP’s role in resource generation for health and related activities is negligible. The role of GP in the registration of births, deaths and marriages seemed to be up to mark. But, here also, the lack of co-ordination between GPs and the grass roots level functionaries of sectoral departments involved in the registration process, like the ANMs and the anganwadi workers, is quite palpable. Only about 28 per cent of GP pradhans and ward panchs reported discussing infant- and child-mortality matters in GP and ward meetings. As far as family planning is concerned, GP’s role was negligible. Even in matters of information dissemination, the anganwadi workers and ANMs are the primary sources for villagers. Nevertheless, a large majority of villagers (69%), ward panchs (75%) and GP pradhans (85%) still believed that effective involvement of GPs would improve health service delivery in terms of greater participation of people in health programmes, more people friendly service delivery and greater accountability at the cutting edge level, and better maintenance of sub-centre facilities, including medicine availability and greater popular willingness to pay user fees. But, typically, public health functionaries had low expectations from panchayats, as just 9 per cent of Ayurvedic doctors and less than half of the MPWs, ANMs and anganwadi workers believed so.

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Role of Standing and Advisory Committees As many as half the GP pradhans interviewed reported that there was no standing committee on health in their panchayats. While just about onethird of the ANMs and MPWs reported having a standing committee in their areas, more than half of them said that the committee had not involved them in any discussion or programme. As far as the constitution and functioning of the health advisory committee (PARIKAS) is concerned, there is considerable variation in the responses of sample villagers and public functionaries at the grass roots level. While just 16 out of 144 villagers (about 11%) were aware of PARIKAS, 44 out of 59 public functionaries (about 75%), including panchayat secretaries, ANMs, MPWs and Ayuvedic doctors were aware of the same. This is natural considering the fact that PARIKAS has been created by a notification of the Government of HP. Hence, the public functionaries, even at the grass roots level, were more aware of its existence than the villagers. Thus, the high degree of ignorance about the PARIKAS among the sample villagers is particularly telling because it is designed as a civil society watchdog body to make health service providers accountable to their clients.

Role of Civil Society There is a significant presence of civil society groups in the study villages in the form of mahila mandals, SHGs, kisan sabhas, youth clubs, etc. All the interviewed villagers, panchayat pradhans, ward panchs, ANMs, MPWs, Ayurvedic doctors and anganwadi workers acknowledged the existence of these community-based organisations in the study villages. A large majority of the sample villagers, panchayat pradhans and ward panchs (about 60%) confirmed their association with or membership in these organisations. However, no concerted effort has been made by the panchayats to involve the community-based organisations in their health efforts.

Annual Health Micro Plans In a decentralised system of health service delivery, the GPs are expected to play a key role in planning for the health needs of the villagers, based on a participatory community needs assessment (CNA) approach. With

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a shift from the target-oriented to a more process-oriented approach, there is greater premium on it. However, over 75 per cent of villagers had no idea of the CNA, as their health needs had not at all been assessed by the GPs. Interestingly, a little less than half the GP pradhans and about half the GP secretaries and ward panchs claimed that the CNA had been carried out. A majority of the ANMs and MPWs (85%) claimed so.

Capacity Building Training and capacity building of panchayat members or at least of the members of the GP health committees can go a long way in empowering them and in enhancing the accountability of local public service providers. However, this emerged as a highly neglected area, notwithstanding claims to the contrary. Only about 15 per cent of panchayat pradhans and ward panchs reported having received any training on the role of panchayats in the rural health sector. About 58 per cent of ANMs and MPWs received training on the role of panchayats in the health sector. None of the panchayat secretaries and Ayurvedic doctors interviewed had undergone any training in this field. Among other factors, the neglect of capacity building of the key stakeholders had taken its toll in terms of non-preparation of CNA, low awareness levels, defunct health committees, etc.

Anganwadi Centre A large majority of the villagers (94%) expressed satisfaction with the performance of anganwadi workers. They had not only ensured adequate nutrition to children, but also played a key role in immunisation programmes and in awareness-generation about antenatal services. While there is adequate coordination between the anganwadi workers and the ANMs, the same was conspicuous by its absence between the panchayats and the anganwadi workers. None of the sample anganwadi workers bothered to inform the GP about cases of malnutrition, while the ANM concerned was informed about the same. About 48 per cent of panchayat pradhans had no clear idea of the role of anganwadi centre and its workers.

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Discussion C. Collins rightly points out that ‘decentralisation is a complex process and can’t be recommended across the board, without taking into account historical, political, social and geographical realities’ (1989: 170). Unlike the north Indian states such as Bihar, Madhya Pradesh, Rajasthan and Uttar Pradesh, HP has a relatively less polarised social structure and a well-developed primary education and health infrastructure which compares favourably with that of Kerala. While HP villages are far from egalitarian, the divisions of caste, class and gender that have been so pervasive elsewhere in North India are not so sharp here (L.R. Sharma 1987: 68; Singh 1998: 207; PROBE Team 1999; Dreze and Sen 2002: 107). The positive features of HP rural social structure, like the less hierarchical and divisive caste relations, very low incidence of landlessness, relatively equal access to productive resources like common property resources, and progressive gender relations, have not only created favourable conditions for collective local action and village democracy, but also reduced the danger of ‘local capture’ by local elites and the consequent derailing of positive public interventions by social divisions and privileged local interests (L.R. Sharma 1987: 158; Singh 1998: 207; Dreze and Sen 2002: 109). The sense of village community in HP has also facilitated the emergence of consensual social norms on local village institutions and public services, including health centres, panchayats, mahila mandals, etc. (Sarkar 1999). Here the notion of ‘social capital’ assumes significance in explaining the success of local governments (Putnam 1993: 182; Evans 1997; Sundaram 1997: 48; Woolcock 2000; World Bank 2001). Social capital refers to the relations of trust and co-operation and networks and organisations which can promote co-operative actions (Putnam 1993: 167; Woolcock 2000). Social capital, it is argued, promotes development by making local governance and public service delivery more effective in terms of enhancing popular participation, accountability and transparency (Putnam 1993:182; Fukuyama 1995: 356; Krishna 2000: 72; Uphoff 2000: 215; World Bank 2001). In the case of rural HP, as Jean Dreze and Amartya Sen put it succinctly, ‘the general concern with social capital can be extended . . . to more precise links between co-operative action and development and also to the historical and material roots of social co-operation’ (2002: 108).

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Our findings also attest to the rich social capital base of the study villages, as all the sample respondents confirmed the existence of and a large majority (about 60%) acknowledged their membership in or asso-ciation with mahila mandals, SHGs, kisan sabhas, youth clubs, etc. To use the language of social capital advocates like the World Bank (2001), we find the existence of two types of social capital, namely, the ‘bonding’ and the ‘bridging’, in the civil society of the study villages. The bonding social capital that is, the relations of trust, based on neighbourhood, kin and gender having been transformed into the bridging social capital, that is, the relations of trust across the different socio-demographic groups (like the SHGs, mahila mandals, etc.) in the rural areas. The bridging social capital is expected to provide the basis for what the World Bank (2001) calls the ‘linking social capital’, which links the rural people to the state apparatus, including the public service providers. That linkage was conspicuous by its absence in the rural health care sector of the study areas. The panchayats could have provided the platform for building up of relations of trust and cooperation between villagers and the local public health personnel and thereby could have enhanced the embeddedness of the public health functionaries among their client groups. The potential of the local SHGs, mahila mandals, youth clubs and the specially designed bodies within the panchayat framework to ensure civil society participation in its health activities, like PARIKAS, could have been utilised for deriving synergy and ensuring complementarity between their actions. There is a need to recognise that social capital inheres not just in civil society, but also in an enduring set of relationships that spans the public-private divide (Evans 1996: 1122). The proponents of social capital would have us believe that the HP villages provide the perfect setting, with their rich social capital base, relatively egalitarian social relations, popular participation in local body elections (more than 75% voter turnout in the 2000 panchayat elections), functioning of a grass-roots level non-party democratic system and nonpolitical electoral mobilisation in panchayat elections, in which candidates are judged primarily on the basis of their merit, performance and also caste factors (Sud 2001: 2126–27), for a certain magic to work— enhancing local government (GP) performance through higher levels of accountability and participation. However, that magic had failed mainly because of a failure to derive synergy from a three-way dynamics between local government (GP), civil society and the state government.

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While the synergy between state initiative and co-operative action has been one of the cornerstones of the schooling revolution in HP (PROBE Team 1999; Dreze and Sen 2002: 109), the absence of these elements, has led to very disappointing results in the case of health care delivery. The synergy between state initiative and co-operative action has also been one of the key factors underlying the success of decentralised rural health care initiatives in Kerala, with which HP shares the common asset of ‘social preparedness’ (Dreze and Sen 2002: 110; see also Harriss 2001: 123–24). This thesis is also very convincingly demonstrated in another developing-country context by Judith Tendler (1997): in the Ceara province of northeast Brazil, one form of strategic state intervention in the primary health sector involved deliberate efforts at building up of relations of trust (or linking social capital) between officials and people, which was earlier lacking. Once established, these trust relations led to productive and mutually beneficial interactions between them, resulting in better performance of public health programmes and reduction in infant mortality. All this highlights the fact that the realisation of the potential of participatory grass roots democracy, even under otherwise favourable conditions, depends crucially upon the establishment of a positive political context and external linkages or what is called the linking social capital. There is no short cut to successful decentralisation initiatives, particularly in the health sector. Successful and sustainable decentralisation cannot be achieved by administrative fiat, for it involves a political process, which ironically has to be initiated and, if necessary, sustained from the above. Romantic communitarian visions to the contrary represent a gross political misjudgement.

Conclusion In terms of the criteria for assessing local government (GP) performance— formulation of local (health) plans based on community needs assessment; mobilisation and management of resources (financial, human, material and ‘social capital’); communication and awareness generation and (health) programme implementation—the GPs in the study areas have performed poorly. They have failed to translate the information advantage into an efficiency advantage. The passing of laws, formulation of policies and issuance of notifications have not served the purpose.

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Thus, there is a gap between the decentralised approach to health service delivery on paper and the form it has taken on the ground. Three distinct yet related sets of explanatory factors have been identified: lack of effective devolution of powers and resources on the panchayats; inadequate capacity building of GP members, and poor involvement of active civil society groups. However, more important than all this, the study calls attention to the political economy of decentralisation and the need for a high degree of political commitment or interest-group support for the success of these initiatives. Further studies might attempt to understand better the mechanisms that link such support, or lack of it, to the implementation of decentralised health care initiatives in rural HP.

Acknowledgements Data used in this article are part of a larger study commissioned by the National Institute of Rural Development (NIRD), Hyderabad. I am grateful to the Director General, NIRD for giving me the opportunity to work on this project. The study was carried out under the supervision of S.K. Alok. I thank him for his support and encouragement. Helpful and detailed comments on earlier drafts of this paper from the anonymous referee and P. Durga Prasad are gratefully acknowledged. The usual disclaimers apply.

References Collins, C. 1989. ‘Decentralisation and the need for political and critical analysis’, Health policy and planning, 4 (2): 168–71. Cornwall, A.; M. Leach, I. Scoones, A. Shankland and R. Subrahmanian. 2002. ‘Sectoral dimensions of participation in policy: A comparative view of education, health and environment’, IDS Workshop Draft. Brighton, Sussex: Institute of Development Studies. Das Gupta, M.; H. Grandvoinnet and M. Romani. 2000. ‘State community synergies in development: Laying the basis for collective action’, World Bank Policy Research Working Paper 2439. Washington DC: World Bank. Dreze, J. and A. Sen. 2002. India: Development and participation. New Delhi: Oxford University Press. Evans, P. 1996. ‘Government action, social capital and development: Reviewing the evidence on synergy’, World development, 24 (6): 1119–32. Evans, P. (ed.). 1997. State-society synergy: Government and social capital in development. Berkeley, CA: University of California Press.

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Fukuyama, Francis. 1995. Trust: The social virtues and creation of prosperity. New York: The Free Press. GOHP (Government of Himachal Pradesh). 2001. ‘PARIKAS’—Notification dated 10 December 2001. Shimla: Department of Health and Family Welfare. ———. 2002a. Status of panchayati raj in Himachal Pradesh. Shimla: Department of Panchayati Raj, GOHP. ———. 2002b. Human development report, 2002. Shimla: GOHP. ———. 2003. Himachal health vision—2020. Shimla: Department of Health and Family Welfare, GOHP. GOI (Government of India). 1992. The constitution 73rd amendment act, 1992 on the panchayats. New Delhi: Ministry of Rural Development. ———. 2002a. National health policy—2002. New Delhi: Department of Health, Ministry of Health and Family Welfare, GOI. ———. 2002b. National human development report. New Delhi: Oxford University Press. Harriss, John. 2001. De-politicizing development: The World Bank and social capital. New Delhi: Left Word Books. Krishna, Anirudh. 2000. ‘Creating and harnessing social capital’, in P. Dasgupta and I. Serageldin (eds.): Social capital: A multifaceted perspective (71–93). Washington DC: World Bank. PROBE Team in association with the Centre for Development Economics, Delhi School of Economics. 1999. Public report on basic education in India. New Delhi: Oxford University Press. Putnam, Robert. 1993. Making democracy work: Civic tradition in modern Italy. Princeton: Princeton University Press. Sarkar, R. 1999. Poverty, governance and reliance on local forest resources. Draft report of a pilot survey of the Bharmour region of Chamba district. Delhi: Centre for Development Economics, Delhi School of Economics. Sharma, L.R. 1987. The economy of Himachal Pradesh. Delhi: Mittal. Sharma, T.R. 1999. ‘Local configuration and national parties in Himachal Pradesh’, Economic and political weekly, 34 (34–35): 2465–71. Singh, Chetan. 1998. Natural premises: Ecology and peasant life in the Western Himalaya 1800–1950. New Delhi: Oxford University Press. Sud, V.P. 2001. ‘Himachal Pradesh: Panchayat polls 2000—Some trends’, Economic and political weekly, 36 (24): 2126–27. Sundaram, K.V. 1997. Decentralised multilevel planning principles and practice: Asian and African experiences. New Delhi: Concept. Tendler, Judith. 1997. Good government in the tropics. Baltimore: The John Hopkins University Press. Uphoff, Norman. 2000. ‘Understanding social capital: Learning from the analysis and experience of participation’, in Partha Dasgupta and Ismail Serageldin (eds.): Social capital: A multifaceted perspective (215–52). Washington DC: The World Bank. Woolcock, M. 2000. ‘Social capital in theory and practice: Where do we stand?’ (Paper prepared at the 21st Annual Conference on Economic Issues.) The World Bank Social capital Website. World Bank, The 2001. World development report, 2000–2001. Washington DC.

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5 Occupational Attitudes of Physicians A. Ramanamma and Usha Bambawale

Introduction

A

physician’s role, as a healer is considered all important in society. In the most general terms medical practice may be said to be oriented to coping with disturbances to the health of the individual. We may say that illness is a state of disturbance to the normal functioning of the total human individual. This includes the indisposition of the state of the organism as a biological system and of the patient’s personal and social adjustment. Yet the two—medicine and sociology, have come together only in recent years, and now depend on each other to some extent. Both the sciences deal with man, one with his anatomy and the other with his environment, interactions and actions. A physician himself is a social being with role sets that enable him to interact with individuals in the correct perspective. When we view a physician’s training, we find that he has a longstanding directional education programme. The medical subculture covers a wide range—from matters of relations to patients, colleagues and the community—and it is the function of the medical school to transmit this subculture to successive generations of neophytes (Merton 1976: 65). A student of medicine has to put in a minimum of 51/2 years of channelized study before he takes the ‘Hypocratis oath’ to serve ailing

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humanity. The medical student in the hospital environment has his attention drawn to the important interaction between social conditions, disease and health. Caring for the sick is thus not an incidental activity, but this professional training is essentially occupation-oriented and the individual is expected to fulfil a particular role, for he has functionally specialized in this full-time job. It would be well worth mentioning that in India, the amount spent on each practitioner of medicine by the government is approximately Rs. 80,000/- along with the private expenditure of the students. Therefore, there are restrictions on admission and hence only those who are high-achievers make the grade. Indeed the process of learning to be a physician can be conceived as largely, the learning of blending—the seeming or actual, incompatibilities into consistent and stable patterns of behaviour. “Like other occupations, the profession of medicine has its own normative subculture, a body of shared and transmitted ideas, values and standards towards which the members of the profession are expected to orient their behaviour. The norms and standards define technically and morally allowable patterns of behaviour, indicating what is prescribed, preferred, permitted or proscribed.” (Merton 1976: 65). Merton further feels that the composition of values involved in the medical subculture probably varies somewhat in detail and emphasis among medical schools, but there nevertheless appears to be substantial agreement among them. The years of education no doubt bring in interaction at various levels—those between students, between students and teachers, between the individual and hospital authorities and between individual and patients. Thus the total outcome is a sound theoretical and practical training of the basic necessities in treating an ‘all-human’ being. Deodhar (1971: 8) has pointed out that “the practice of medicine has evolved since ancient times, and has been greatly influenced by scientific progress and thinking. During the last 25 years there has been an appreciable change. With the increased specialization the practice of medicine has become more impersonal and patients are liable to be regarded as ‘cases’ rather than human beings.” But this, we feel, could easily be explained. Parsons (1952: 435) feels that effective neutrality is also involved in the physicians’ role as an applied scientist. The physician is expected to treat an objective problem in objective, scientifically justifiable terms. The values and norms are defined by the profession in terms of how they are put into effect. Since many physicians will find themselves in situations

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where it is difficult to live up to the role requirements from the standpoint of the profession, it becomes even more important that they thoroughly acquire the values and norms that are to regulate their behaviour. Four and a half years of education and an year of internship qualifies the physician to set up his general practice, but a few prefer to go for higher qualifications and specialize in any of the several branches of medical studies. This specialization may even be concerned with a detailed study of one organ. Specialists set up consultancy practice—a type of practice wherein the general practitioners refer their cases for prognosis to an authority. Thus we find, there is a broad division of these consultants into physicians and surgeons. We have devoted this study to practitioners of medicine and not included the other branches of the medical field essentially because, these physicians have an important role to perform in the healing process of the total individual that includes physical, psychological and social aspects. In terms of the relation of the physician’s occupational role to the total instrumental complex, there is an important distinction between the two types of physicians. One, the ‘Private Practitioner’ and the other who works within the context of an organization. The important thing about the former is that he must not only care for sick people in a technical sense, but also settle the terms of exchange with them because of his direct dependence on them for payment for his services. The physician in this case must, to a high degree, also employ his own infrastructural facilities for carrying out this function. With this background in mind it would be worthwhile mentioning the purpose of this work. We have not come across any prior studies in India which deal with this particular aspect in medical sociology. But we could mention a few studies made outside India that help to throw some light on these aspects of medical sociology. Peterson and associates (1956, Ed.) in their study of 94 North Carolina General Practitioners have examined physician’s training in medical schools, training in hospitals, age, office-care arrangements, type of medical school attended and many other characteristics to determine their relationships to the quality of patient care. Morehead, Donaldson and Burt (1964) in their Teamster Family study have explored impact of physicians’ training and type of affiliated hospitals and their performance in patient care. Roemer and Friedman (1971) in their study of ‘Doctors in Hospitals’, have determined the relationship between the level of medical staff organization and the quality of hospital care. Thus all these studies concern themselves with patient care.

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Friedson (1972) has concluded that too much attention has been paid to the personal characteristics and attitudes of individual workers and too little attention has been given to work setting factors. As far back as in 1935, Henderson traced the physician and patient as a social system. Weswager (1952) tried to measure job satisfaction of professional nurses, but a similar study has escaped notice in connection with medical practitioners. This background leads us to clarify the nature of this study.

Aim of This Study It is the aim of this paper to study the occupational attitudes of the physicians. It examines: (i) Whether the amount of time spent per patient by doctors is in relation to (a) patient’s illness, (b) doctor’s rewards; (ii) the degree of interaction between the physician and the patient in order to perform the role obligations of a physician; (iii) whether the physicians are able to attain effective neutrality in their interaction with their patients, in order to fulfil their role obligations.

Before we analyse the data, the methodology applied in this study would be explained.

Methodology This is essentially a comparative study. It has included three types of physicians: (1) The general practitioners (G.P.), (2) the paid physicians (P.P.) attached to hospitals on a salary basis, and (3) Consultants (C.P.), who have one or more hospital attachments—whether paid or honorary, or a private consultant practice. In the Parsonian sense, the first and third categories are those of ‘Private Practitioners.’ It would be in order to define what we mean by these terms: general practice, paid physicians and consultants. General practice has been defined by John Hunt as “that field of medicine in which a doctor accepts the continuing responsibility of providing or arranging for the patients total medical care, which includes prevention and treatment of any illness or injury affecting the mind or any part

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A. Ramanamma and Usha Bambawale of the body. Continuous care, and the comprehensiveness or totality of coverage and the direct access to the doctor are the chief characteristics of general practice. A general practitioner is often known as the doctor of first contact as the sick go to him first for treatment. The patients are generally suffering from simpler ailments and from early disease compared with the patients attending the hospitals or specialists clinics.”

Hospital practice is run by Government or social organisations and physicians function as a group of specialists assisted by a group of other doctors, paramedicals and auxiliary staff. To a large extent this is necessitated by the technological development of medicine itself and above all the need for technical facilities beyond the reach of individual practitioners. General hospitals include consulting rooms, clinics and nursing home often involving complex cooperation of several different kinds of physicians. Consultant practice belongs to a specialist doctor, who limits his practice either wholy or partially to particular disease entities or age groups. Patients come either directly or are referred by G.Ps.

Size and Selection of the Sample The sample size consists of 25 doctors in each category, who practice allopathic medicine and have a minimum of an MBBS degree. Therefore, this study emphasises the results of 75 doctors’ opinions and attitudes. The local medical council was approached to give us the correct figures of registered medical practitioners. They provided a total list of doctors practicing medicine and that was more than 7000 doctors. But this consists of RMPs, LCPs, LMS, Ayurvedic and Homeopathic practitioners. A list of the total consultants was obtained from the same body and every 8th quote was approached as there is a total of 200 physicians. Similarly a list of doctors working as paid physicians was made by acquiring the list from various hospitals. There are a total of 50 paid physicians. Every 2nd quote was approached from a total of 8 hospitals. As for the general practitioners an areawise list was obtained from the medical council and every 30th quote was enlisted as a respondent, from Poona City only. Every care was taken to omit, LPs, LCPs and those who were Ayurvedic aud homeopathic medicine graduates. Similarly every care was taken to omit, Surgeons, Gynaecologists, ENTs,

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Paediatricians, Radiologists and those who practice other branches of medicine. The entire sample is drawn from Poona city. This city has two medical colleges and several large hospitals. There are also a few hospitals of medium size that are run by trusts. There are paid physicians and consultants working in these hospitals.

The Questionnaire Though Marathi is the regional language, for uniformity in interpreting the data, it was decided to collect the data through an English language questionnaire. As all the respondents were well educated it was easy to do so. In all, there were twentyone questions with one or two sub-questions. The whole questionnaire comprised of three broad sections—bio-data, professional data and need gratification. It was hoped that the details obtained would give us a conclusive and cohesive picture of the trends in the occupational attitudes of physicians.

Analysis The collected data was analysed under six broad categories and each finding was compared and correlated with the different groups: General Practitioners (G.P.), Paid Physicians (P.P.) and Consultants (C.P.). We, therefore, present—first and foremost, the data regarding the socioeconomic background of our respondents. We believe this to be important as it bears direct relation to need gratification and occupational attitudes of the doctors.

Socio-Economic Data The age group of these 75 physicians ranged from 26–60 years. When segregated in their respective categories, we find the highest number of G.Ps. (40%) were in the 26–35 years age group. The P.Ps. were found to be in two age groups, i.e., 80% in 26–35 years and 20% in the 36–45 years group. The C.Ps. were in the largest numbers (48%) in 36–45 age group. Table 1 clarifies the position about the various age groups.

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Table 1 Age Group of the Doctors Age

No.

G.P. Percentage

No.

P.P. Percentage

No.

26–35

10

40

20

80

2

C.P. Percentage 8

36–45

9

36

5

20

12

48

46–55

4

16

−

−

9

36

56–60

2

8

−

−

2

8

25

100

25

100

25

100

Total

This particular age group demarcation is evidently so, because the G.Ps. set up practice soon after they are awarded the MBBS degree. The consultants take a little longer to specialize, gain some experience in a hospital or under a senior well-established C.P and set up a consultant’s practice. The P.P take up jobs in hospitals as soon as they finish their graduation/post-graduate study and many a time leave these posts to set up independent practice by the time they are 40 years old. There were 76% males among G.Ps. and P.Ps, while 24% females were found each among G.Ps. and P.Ps. As against this, all the consultants in our sample were males. The reason for this dearth of women among consultants was due to the fact that women practitioners of medicine chose other branches: Paediatrics, Gynaecology, Obstetrics, Anasthesia, Pathology and many went in for teaching posts in the colleges. All our G.Ps. and consultants were married, while 76% of P.Ps. were married and 24% were unmarried. When we examine the pattern with regard to the number of children these doctors have, we find it varies to some extent according to their situation. Table 2 shows these trends. There were 6 G.Ps. who had no children but the rest together had 39 children, which meant a mean of 1.7 per family of the doctor. Six P.Ps. did not have children and the rest had a total of 34; thus the mean was 1.6 per couple. All the consultants had children and had a total of 63, thus having a mean of 2.5 per couple. This trend of a greater number of children among C.Ps. could be said to be due to the fact that they were in an older age group. Therefore, they had completed the stage of family procreation. When we glance at the educational level of these doctors, 76% of G.Ps. had only an MBBS degree, while 16.00% had a diploma along with

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Table 2 The Number of Children and Professional Situation G.P.

P.P.

C.P.

No. Children

No.

%

No.

%

No.

%

No. children

6

24

−

−

−

−

9

36

9

36

−

−

2–3

1 only

10

40

7

28

21

84

4 and above

−

−

3

12

4

16

Not married

−

−

6

24

−

−

Total

25

100

25

100

25

100

the basic degree, and 8.00% had a foreign degree along with their MBBS. Among the P. Ps. 56.00% had an M.D. degree, 8.00% had foreign degree along with an M.D. and only 36.00% had an MBBS degree. (They were all appearing for a higher degree examination). All consultants had M.D. degree and 20.00% had foreign degree along with their M.D.

Occupational Rewards The type of work and hours of practice were dependent on the degree. It was found that among G.Ps. 52% had their own private practice, while 24% had an attachment to a factory along with the practice and another 24% had the added advantage of the E.S.I.S. Registration practice. The paid physicians were all working in hospitals as employees and did not pursue any private practice. The consultants (72.00%) were honoraries in some general hospital, and devoted their full time to practice. Besides this attachment to a general hospital, 14.00% had attachments to other hospitals and another 14% had attachments to factories also. The amenities that are considered important for medical practice and some luxuries for recreation were found to be available to the consultants in the greatest numbers and minimum to the paid physicians. Thus all the consultants had telephones, cars, scooters, 76% own consulting rooms, houses and television sets. Of the paid physicians, on the other hand, 32% had a telephone, 24% had a car, 76% had a scooter, 32% had their own house and 44% a television. Among G.Ps. 68% had a telephone, scooter, a house and a television, while 40% of the

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Table 3 Total Income of the Physicians per Month (as Declared in Their Income-Tax Returns) G.P. Total Income Per Month

P.P.

C.P.

No.

%

No.

%

No.

%

Below Rs. 1000, but more than Rs. 800/-

8

32

12

48

−

−

Rs. 1,000–1,500

4

16

6

24

−

−

Rs. 1,501–2,000

3

12

5

20

−

−

Rs. 2,001–3,000

6

24

2

8

−

−

Rs. 3,001–4,000

4

16

−

−

−

−

Rs. 4,001–5,000

−

−

−

−

2

8

Rs. 10,000 only

−

−

−

−

3

12

Rs. 10,001–15,000

−

−

−

−

2

8

Rs. 15,001–20,000

−

−

−

−

3

12

Rs. 20,001–30,000

−

−

−

−

8

32

Rs. 30,001–40,000

−

−

−

−

5

20

Rs. 40,001–50,000

−

−

−

−

2

8

25

100

25

100

25

100

G.Ps. also had a car. These amenities are directly related to the income of these groups. Table 3 gives the income of the respondents. It is seen therefrom that the income picture makes it clear that the consultants earn the maximum income amongst professionals, who practice medicine. It may be pointed out in this connection that education and income are not correlated in the case of P.Ps. because many a time the P.Ps. earn less money than the G.Ps. who are less qualified.

Total Output of Work When we look at the professional data we find that all these doctors work from 6 to 14 hours a day. Table 4 gives the number of hours of work done by the doctors. This work ratio is to a great extent in proportion to the number of patients handled and income earned by these physicians. This

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Table 4 Hours of Work Put in by the Physicians G.P. Hours of Work Per Day

P.P.

C.P.

No.

%

No.

%

No.

%

2

8

−

−

−

−

6 to 8 hours

13

52

9

36

3

12

9 to 10 hours

8

32

16

64

10

40

Less than 5 hours

11 to 12 hours

2

8

−

−

6

24

13 to 14 hours

−

−

−

−

4

16

15 hours a day

−

−

−

−

2

8

Total

25

100

25

100

25

100

incidentally is also in keeping with the number of places these doctors work. We find that 52% of the G.Ps. work in only one place, that is, their own clinic while 48% work in two places. All the P.Ps. work in one place only as they are not allowed to work elsewhere and they receive a compensation in the form of a non-practicing allowance. The consultants on the other hand work at minimum two places. As many as 60% of our sample said they worked in two places, but 20% worked in three places and 20% worked in four or more places. The number of patients examined per day were also in direct ratio to the number of hours devoted to work and the place of work. Thus a greater number of patients were examined by those physicians who went to more than one place of duty. When we look at Table 5 this position is fairly clear. Incidentally those physicians, who said that they worked for 15 hours a day and attended 4 or more than 4 places of work, spent on an average with each patient 6 minutes i.e., 10 patients an hour. Thus the time devoted to each patient is less. No doubt that Merton (1976) while remarking on the ambivalence of physicians, feels that the physicians must be emotionally detached in their attitude towards patients thus keeping “emotions on ice” and not becoming overtly identified with patients. But Merton also says that they must avoid becoming callous through excessive detachment and should have compassionate concern for the patient. This little contact time, has put to rest another theory of self image put forward by Merton (1976: 67–69) who felt that physicians must provide

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Table 5 Number of Patients Examined per Day G.P.

P.P.

C.P.

No.

%

No.

%

No.

%

10 to 20

2

8

3

12

−

−

21 to 30

4

16

13

52

−

−

31 to 40

−

−

7

28

−

−

Number of Patients

41 to 50

13

52

2

8

−

−

51 to 60

−

−

−

−

2

8

61 to 70

4

16

−

−

−

−

71 to 80

2

8

−

−

9

36

81 to 90

−

−

−

−

−

−

91 to 100

−

−

−

−

9

36

About 150

−

−

−

−

5

20

25

100

25

100

25

100

Total

adequate and unhurried medical care for each patient—but they should not allow any patient to usurp so much of their limited time as to have this at the expense of other patients. No doubt, the C.Ps. are in no way spending more time with the patients, to dislodge the Mertonian theory of self image. On the other hand, they have no time for unhurried medical care for each patient.

Inter-personal Relations This would bring us to the focal point of physician-patient interaction. We find that a greater number of G.Ps. (68%) know all their patients very well, 16% of G.Ps. said they know 70% to 80% of their patients personally. Approximately half the patients were known to 8% of the G.Ps. and only 8% of G.Ps. said that they knew very few of their patients well. The emphasis here was on a more personal relationship. As on many occasions a physician becomes a confidant, it is to be expected that he knows the financial conditions, family composition and the emotional state of the patient. The patient and his family have

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the deepest emotional involvements in what the physician can and cannot do, and in a way his diagnosis and prognosis will define the situation for the patients. The doctor himself carries the responsibility for the outcome and cannot help but be exposed to important emotional strains by these facts. Similar considerations apply to physician’s need of access to confidential information about his patients’ private life. For reasons among which their place in the system of expressive symbolism is prominent, many facts, which are relevant to people’s problems of health fall into the realm of the private or confidential, about which people are unwilling to talk to an ordinary friend or acquaintance. These problems may concern the privacies of intimate personal relationships, particularly those with sexual partners. This situation inevitably involves the physicians in the psychologically significant private affairs of the patient. For this very reason, a G.P. was known as a family physician. On the other hand all the consultants said that they know only a very few of their patients well. The paid physicians (72%) said that they knew 70% to 80% of their patients while 28% felt that they knew only a few patients well. The consultants felt they had no time to ‘cultivate’ social rapport with the patients. The P.Ps, came in contact with patients as ‘ill human beings’ and did not attend to the same patient every time. This is essentially because an increasing proportion of medical practice is now taking place within the context of some organization. To a large extent this is necessitated by the technological development of medicine itself, above all the need for technical facilities beyond the reach of the individual practitioner, and the fact that treating the same case often involves the complex cooperation of several different kinds of physicians as well as of auxiliary personnel. This greatly alters the relation of the physician to the rest of the instrumental complex. He tends to be relieved of much responsibility and hence necessarily of freedom, in relation to his patients other than that in his technical role. Thus the total image that emerges, is that of the G.P. being more aware of social interaction with the patient than the other two groups. With this in view, we will examine the data collected in response to questions aimed to elicit information about doctor-patient social contact. Of the G.Ps. 48% said that patients were now family friends. Further 40% of G.Ps. said none of the patients were friends of the family and 12% said that very few of the patients were on friendly terms with their families. Amongst the P.Ps. 88% said a few of their patients were family friends, the rest (12%) said a few patients were now known

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to their families. The consultants (44%) declared that a limited number of patients were family friends while a greater number of consultants (56%) said none of their patients were friends. A uniform pattern was observed regarding visit of these doctors to their patients on a social footing. Among G.Ps. 40%, among P.Ps. 80% and 92% of C.Ps. said they do not visit patients at their home socially. The main reason given was that such familiarity bred contempt in the sense that the authority of the doctors stood in the danger of being reduced and patients took advantage of such a friendship. Another factor was the lack of time and lack of interest to develop friendship with the patients and their families. Thus we find that even where both professional and non-professional aspects of the relationship of the physicians to the same persons are possible, there is a definite tendency to segregate the two aspects. When we analyse the data a characteristic picture emerges, that is: (1) Total output of work: number of places of work: financial reward, are all proportionate to each other. (2) The role of the physician centres in his responsibility for the welfare of patient in the sense of facilitating his recovery from illness to the best of his ability. In meeting his responsibility, he is expected to acquire and use high technical competence in ‘medical science’ and the techniques based upon it. (3) The G.P. knows his patients best and has more person-to-person contact with the ‘ill’ human being. He also devotes more time to his patients. (4) The P.P. has a more mechanical approach to the patient as in the setting in which he works, personal identity is not given much importance. Further, he is not totally responsible for the patient as he is safeguarded by the bureaucratic machinery of the institution wherein he works. Yet the P.P. has access to most sophisticated equipment and can avail himself of the most modern methods of healing. But the P.Ps. treat a disease as a case and not as a human being. Thus once a particular individual is cured of a specific illness, he is discharged. This is despite the fact that the individual in question may continue to be afflicted by one or more dormant diseases, for no comprehensive care of the individual is assured by institutions where these P.Ps work.

The P.Ps. have no doubt one very great advantage, that of examining and acquainting themselves with a number of rare conditions and implications to the virtual exclusion of commonest problems.

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Personal Need Gratification We now consider a very important factor in the whole set up of medical practice—the one of job satisfaction. It is indeed true that a happy worker is a willing worker. Therefore, this factor of personal need gratification begins with one’s qualification. When assessed, it revealed that all the consultants (100%) said that they were completely satisfied with their academic achievements. On the other hand 30% G.P.s. and 64% P.Ps. were found to be satisfied with their qualifications, while 24% G.Ps. and 36% P.Ps. were dissatisfied. The reason given for their dissatisfication was the aspiration of a higher qualification in their chosen field. There were 36% G.Ps. who said they were in doubt whether or not they were satisfied with their present qualifications in medicine. Naturally, the choice of a job and satisfaction in it go hand in hand. We found that 32% G.Ps., 100% P.Ps. and 72% C.Ps. had chosen their present jobs on a priority basis. This choice being their ‘first preference’, they were totally satisfied with the work they did. There were 36% G.Ps., who were not too happy with the pattern of work they had chosen, as they had to stifle their desire for higher education. Thus we found, 8% G.Ps. said that private practice was forced on them by retiring parents. Another, 8% had no choice as the burden of heavy family responsibilities made them set up practice soon after graduation and 8% of G.Ps., who were older said it was the fashion of the day to set up practice. They further testified that “all this specialization was a new fangled idea”. There was no specific response from 8% G.Ps. If as high as 36% G.Ps. were dissatisfied with their work, they were asked if given the opportunity would they like to change it? There were 75% of the dissatisfied G.Ps., who said they could not change now and restart their further studies since they would not be able to meet the financial burden, while 25% said that it was not too late to change. Of the P.Ps., though all were satisfied with their chosen field, 44% said that they would definitely like to branch out as consultants and begin private practice. Though this was their cherished desire, some could not put it into practice because of two factors, (1) Economic and (2) Psychological. The economic factors concerned the heavy investment and doubtful returns of private practice. Psychologically, they were afraid of facing failure, social censure and total dissipation of professional ethics. In a hospital setting, an individual does not have to take

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total responsibility of any patient, which he would be obliged to do in case of private practice. Job satisfaction and lack of role conflict invariably create a healthy atmosphere. This may be a reason for recruiting more individuals in the profession. Thus it is believed that medical practitioners encourage and welcome their siblings and offsprings to enter the same profession. We found this was true in the case of all consultants, 56% P.Ps. and 24% G.Ps., while 16% G.Ps. emphatically said ‘No’ to such a proposition. Further, 44% P.Ps. and 16% G.Ps. said that the choice was not theirs, but that of their children and so at this stage they could not commit themselves. About 34% G.Ps. said they were in two minds and could not say what they wanted their siblings and children to do. Finally, the question—would you encourage your children or relatives to take up a practice like yours?—produced the following response. Of the G.Ps. only 8%, of P.Ps. 24% and 80% of C.Ps. said ‘Yes’, while 60% G.Ps., 32% P.Ps. and 20% C.Ps. said ‘No’. A further 32% G.Ps. and 44% P.Ps. said “We cannot say what we would like our children to do.” The various reasons advanced, by those who said ‘No’ amounted to—‘Would like them to specialise and start consulting practice.’

The Functional Significance of Medical Practice Parsons (1952) has pointed out that ‘The analysis of this problem may be centred about the pattern variables and the particular combination of their values which characterizes the “professional” pattern in our society, namely achievement, universalism, functional specificity, affective neutrality and collective orientation in that order.” The most fundamental basis for the necessity of a universalistic achievement lies in the fact that modern medical practice is the application of scientific knowledge by technically competent, trained personnel. Therefore, a physician’s role is not particularistically ascribed. The universalism of the medical role has, however, also another type of functional significance. In the light of this consideration it is clear that there is a strong pressure to assimilate the physician to the nexus of personal relationships in which patient is placed quite apart from the specific technical content of the job he is called upon to perform. In so far as his role can be defined in unequivocally universalistic terms,

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this serves as a protection against such assimilation, because personal friendships, love relationships and family relationships are overwhelmingly particularistic. This data gives a bird’s eye view of the total work pattern of physicians. Before we conclude, we can sum up by saying that the role of the medical practitioner belongs to the general class of ‘professional’ roles, a subclass of the larger group of occupational roles.

Conclusion We can draw some clear conclusions from this exploratory study: (a) The general practitioners (G.P.) combine physical cure along with the psychological and emotional care of their patients. He is thus a doctor to whom patients go oftener and consider a family friend too. On the whole the monetary gains of G.P.s are limited and yet the number of hours of work are considerably longer than in other professions. The general physician can always refer difficult cases to the hospital or send them to consultants. (b) Paid physicians even though have less monetary gains are compensated by curing patients, who have abnormal complications. They have at their command good paramedical service, and excellent equipment, which the other two categories lack. Without incurring the social responsibility of failure, these P.Ps. can achieve job satisfaction. (c) Usually the consultants get patients with a case history from G.Ps. or government hospitals. So they start treatment sometime in the middle of a sickness. They also utilize the services of technicians and other paramedical facilities but the time they can utilize for examining the patients is too little. So they cannot give much emotional and psychological satisfaction along with the physical cure. The rewards offered by society in terms of money and prestige are the maximum in this category.

When we consider the time spent per patient by doctors in relation to the patients’ illness and the doctors’ rewards, the two seem to be negatively related. The specialist, that is the consultant spends the minimum time with his patient. All the same, his reward is the highest. For this very reason the level of need gratification and interpersonal relationship of consultants (C.Ps.) is the highest. The C.Ps have a very positive approach to their work and not only like it but feel that their children should also follow in their footsteps.

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On the other hand, the P.Ps. are not all that satisfied with their occupation. They either want to set up their own private practice or want their children to be independent professionally. We feel that this attitude is essentially linked up with the monetary benefits of the doctors. Occupational hazards as such seem to make or mar the career of a professional and yet none of the three categories of doctors have felt the need to stress on this part of their professional life. As mentioned earlier the maximum degree of interaction between the physician and patient is between the G.P. and his patient and on a lesser degree between the C.P., P.P. and their patients. Now coming to the important aspect of attaining affective neutrality in their interaction with the patients we find that in the Indian context the expert physicians (C.P.) have dragged affective neutrality to such an extent that they spare only 5 to 6 minutes on an average for diagonising an ailment and have no time for the total ‘human-being’. The P.Ps. are also able to attain affective neutrality due to rota duty. This enables them to see new patients oftener than is possible in the case of a G.P. The G.Ps. on a lesser degree than the P.Ps, and C.Ps. can achieve some neutrality. All the same, all the three categories of physicians can perform their roles without considerable emotional involvement. Finally we can say that each type of practice has its own silver lining and the rewards are generally much more than in any other profession. Besides, doctors are the most respected persons in society, getting a great deal of importance and weilding a great deal of influence. The doctors in turn on the whole get psychological satisfaction while curing the sick, which could be much more than perceived in other jobs.

References Deodhar, N. D. and Adranwala, J. K. (Ed.) 1971. Basic Preventive and Social Medicine G. Y. Rane Prakashan. Friedson, E. 1972. Profession of Medicine: A Study of Sociology of Applied Knowledge. New York: Dodd Mead. Henderson, L. J. 1935. “Physicians and patient as a social system”. New England Journal of Medicine, 212, 819–832. Merton, Robert K. 1976. Sociological Ambivalence and Other Essays. New York: The Free Press. Morehead, M. A., Donaldson R. S. and Burt, R. R. 1964. A Study of the Quality of Hospital Care, Seen by a Sample of Teamster Family Members in New York City. New York: Columbia University School of Public Health and Administrative Medicine.

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Parsons, Talcott 1952. The Social System. London: Tavistock Publications. Peterson, O. L., Andrews, L. P., Spain, R. S. and Greenberg, B. G. 1956. An Analytic Study of North Carolina Practice 1953–64. Ewanston Illinois: Association of American Medical Colleges. Roemer and Friedman H. E. 1977. Doctors in Hospital (As sighted by Rhee-Sango). Rhee Sang 1977. “Relative importance of physicians personal and situational characteristics for the quality of patient care”. Journal of Health and Social Behaviour, 18(1), 10–15. Weswager, L. 1952. “The measurement of the job satisfaction of professional nurses”. Research Studies of the State College of Washington, 20, 45–55.

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6 The System of Hope: The Constitution of Identity in Medical Institutions Roma Chatterji

I

n this paper I discuss three monographs that deal with medical institutions in the Netherlands. Two of these, Vie Nursing Home: Field of Study by H. ten Have and Disturbance and its Processing in Nursing Homes by J.C. van der Wulp, are studies of nursing homes for old people suffering from chronic and terminal diseases and are written by nursing home doctors who have used methods culled from sociology. The third is a study of a cancer research institute, conducted by a team of psychologists and sociologists at the invitation of the institute itself. However, the report on the investigations of the team was not well-received by the institute and was withdrawn from circulation soon after it was published in 1978 with the title, Dealing with Despair in a Cancer Hospital1 by A. van Dantzig and A. de Swaan, two members of the research team. There are two questions to which I wish to address myself. The first is why should doctors actively involved in medical practice choose to write sociological accounts of institutions in which they work, and the second is why did the book on the cancer hospital receive such a negative response from within the institution while books on nursing homes were not only received with enthusiasm but were also helpful in giving focus to the discussion on nursing home identity in the Netherlands.2 I argue that answers to both these questions must be sought from

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within the institutions themselves—their self-perception and modes of organization. For the authors, these works are not merely ethnographic monographs but are also efforts at understanding problems posed by invalidity, suffering and death for medical institutions themselves as well as for the society at large. They are critical of the way in which these problems are handled by the institutions but they are equally critical of the increasing professionalization of care in Dutch society which leads to the diminution of personal responsibility and initiative in the management of such problems. Thus, de Swaan, in a later work, refers to the ‘total medical regime’ through which society entrusts all matters pertaining to disease and death to professionals. The overarching medical network ties the sick person to a complicated and extensive therapeutic apparatus which removes all sense of personal agency (de Swaan 1990). However, in this paper the focus will be on the institutions themselves—the nursing home and the cancer research institute. The authors’ main concern is with a particular model of organization, ‘the medical model’, which allows for the creation of a work routine whose legitimacy is sought to be based on medical knowledge or on therapeutic requirements. Goffman’s work on total institutions (1961) has had a major influence on the critical understanding of medical institutions in the Netherlands. It has helped to articulate the relationship between the institution and society. For Goffman this relationship is examined in terms of a series of oppositions between everyday life in a total institution and life in the wider society. Thus, the spatial barriers that separate the three spheres of life—sleep, work and play—in the wider society (Western society, that is) are broken down in the total institution. Batch-living in the total institution is contrasted to family life in society. Batches perform routinized activities under a supervisory authority. These activities are brought under a single rational plan to fulfil the aims of the institution. In society at large, a distinction is made between the public domain of work and the private familial domain. The totalizing influence of the institution breaks down this distinction. The official goals of the institution become rationalizations for trivial rules which regulate the daily life of inmates. All aspects of the inmates’ behaviour tend to be interpreted in terms of the official goals. Thus, for example, a prisoner by definition becomes a criminal by virtue of the fact that he

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is an inmate of a prison. In medical establishments, similarly, patients’ behaviour is often explained by disease categories. The strength of Goffman’s work lies in its ability to demonstrate how the total institution is not merely a bureaucratic organization, but also a social institution and in this sense embodies a particular morality. Ten Have (1979) uses this aspect of Goffman’s work as his point of departure and distinguishes between two aspects of the nursing home: the organizational and the institutional aspects. For him the organization is a social group defined by certain goals.3 The individuals in the organization interact to achieve these goals. They may have the freedom to choose the methods by which the goals are best achieved, but they have no freedom in the choice of particular goals. These are considered to be a priori.4 He defines the institution as being a complex of normative modes of action. There is always a tension between these two aspects. Ideally the institutional aspect should encompass the organizational one, but there is always a danger that the organizational aspect can become reified, serving as an end in itself rather than as a means for attaining institutional goals. For ten Have there must be a reflexive relationship between these two aspects. The nursing home as an institution occupies a moral space in society and must articulate its self-critique in terms of this reflexive relationship.

The Medical Institution: The Cancer Hospital The Dutch Cancer Institute was established in 1914 to promote research and treatment of cancer. At that time, the medical establishment was still caught between conflicting ideologies. On the one hand, the new approach to disease that emphasized research and experimentation had been gaining ground since the middle of the 19th century, and on the other, remnants of the ‘charity-based’ approach towards sickness were still present. This was characterized as ‘fatalistic’ and ‘pessimistic’ by the new approach. Hospitals were no longer thought to be places where poor people went to die, but were to become centres of knowledge where teaching, research and treatment could be combined. The cancer hospital grew out of this ideology and shared the same proselytizing zeal towards the disease. The emphasis was on technology and greater specialization. ‘Specialization demanded particular aids and services: a laboratory, operation theatre and also an X-ray room, and so on. The patient had to

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come to the instruments. . . . The doctor slowly became the dominant figure in the hospital.’5 The cancer hospital established its identity in opposition to the religious tradition of charitable care. There were to be no wards for terminal patients. Only those patients for whom ‘something meaningful’ could be done were to be admitted. As van Dantzig and de Swaan show, ‘something meaningful’ in the context of this institution generally refers to the somatic aspect of sickness that can be handled aggressively by means of sophisticated medical technology. The other aspects of the disease, its impact on the sick person as well as the traumas resulting from the medical treatment itself, are thought to be of secondary importance and are taken into consideration only if they interfere with the course of treatment.

The Nursing Home As hospitals became in creasingly specialized and technologically sophisticated, there arose the need for another kind of institution that could take care of the cases that could no longer fit into the organizational framework of the specialized hospital. After the Second World War it was the nursing home that grew into an institution that could accommodate chronic cases that did not require specialized medical treatment, but rather, intensive nursing care. However, over the years the nursing home has changed from being a second order hospital to an institution that has a specialization of its own—a ‘medicine of care’ called continuous, long-term, systematic and multidisciplinary care (CLSM). To understand the identity of the nursing home and its ideology of care which it has developed in opposition to the ideology of cure of the hospital, one has to turn to its history. In the Netherlands the rise of the nursing home is associated with the growth of medical and paramedical disciplines like geriatrics and revalidation after the Second World War. Revalidation was able to achieve the status of a scientific discipline when societies involved in the War were faced with the necessity of putting thousands of disabled soldiers back into the production process. This had an influence on the treatment of patients suffering from chronic diseases. Chronic patients in medical institutions were now kept out of bed as far as possible and were made to follow a routine that would reflect that of normal everyday life as far as possible within the requirements of medical treatment.

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Nursing home medicine6 in the Netherlands is involved chiefly with the specialization, geriatrics. Geriatrics was carved out as a special field of medical knowledge when it was found that the structure of the aging body and brain showed significant differences from that found in the normal adult population. It was argued that specialized knowledge was required to diagnose diseases among old people because symptoms manifested themselves very differently. Further, the incidence of chronic diseases rose sharply with increasing age and these were again manifested as multiple pathologies involving both the body and the mind and thus required a holistic approach. For greater clarity let us conceptualize the difference in the treatment offered in the hospital and in the nursing home in terms of two alternative models of disease and its treatment. One model would conceive of the disease as having a particular pattern that is revealed in a restricted time span. The disease first shows itself in symptoms which are not necessarily intelligible to the sufferer, but which allow the specialist to make a diagnosis and to suggest a course of treatment. We may call this the acute/cure paradigm in which treatment is supposed to lead to cure. The patient is considered to be a passive entity and the disease is treated purely as a somatic manifestation—that is, as a biological pathology. The second is the chronic/care paradigm. The treatment of chronic disease involves its management rather than cure and must take into account factors other than biological ones. Since this involves an extended time span, the patient’s biography and his psycho-social environment must also be considered. It must be reiterated that these two models do not necessarily conform to the empirical description of particular diseases. They are important, however, because they serve to orient representations that the medical institution may have of itself and the diseases that it deals with. This can best be illustrated by taking the example of specific diseases, for example cancer and Alzheimer’s disease. Their suitability for discussion here is determined by the fact that they fall within the purview of the institutions being discussed. The nursing home, as an institution specializing in gerontological problems, has developed techniques for the ‘treatment’ of forms of senile dementia like Alzheimer’s disease, while the cancer hospital, as is suggested by the name itself, is a research institute for the investigation and treatment of cancers of various forms. Alzheimer’s disease has no clear-cut etiology or diagnosis, it is usually recognized from the symptoms. These are radical personality changes,

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short- and long-term memory deficits, aphasia, apraxia and agnosia.7 All the symptoms are manifested gradually over an extended period of time and it is usually difficult to recognize these symptoms in their pathological form in the early stages of the disease. In fact, as we shall see, the distinction between normal senescence and pathological senescence remains problematic in gerontology. Recent research into the structure of the aging brain has shown that the brains of persons suffering from Alzheimer’s disease have a preponderance of senile plaques composed of cellular debris and an amyloid substance (a glycoprotein resembling starch), as well as neurofibrillary tangles. It is not clear, however, whether the accumulation of this abnormal substance is a cause or an effect of the disease. Also, symptoms such as these are usually discovered during post-mortem operations and have no relevance to its treatment or management. Alzheimer’s disease is a chronic and terminal disease. It cannot be seen as the direct result of morphological and biochemical changes occurring in the brain and the central nervous system. The relationship between so-called pathological behaviour and changes in the central nervous system is mediated by the social environment and must be understood in terms of the total profile of the person’s life. Cancer is also a chronic and terminal disease. It has multiple causation and there are multiple pathologies associated with it. Its status is ambivalent because some forms of cancer are curable while others are not. However, unlike Alzheimer’s disease, it can be controlled and is amenable to palliative intervention. The cancer hospital represents itself primarily as a research institute, and not one for the care of cancer patients. It operates within the acute/cure paradigm of medicine. The lives of patients who come to it for treatment are structured around elaborate investigative procedures which are supposed to plot the etiology of the disease, its diagnosis, prognosis and eventual cure. However, as van Dantzig and de Swaan point out, the model of treatment that is supposed to eventually lead to cure is really based on the hope of cure. Anxieties about the very real possibilities of death are kept hidden by a ‘system of hope’ in which both staff members and patients participate. The nursing home also receives cancer patients, but mostly in the terminal phases of the disease when they can no longer be accommodated within the system of hope generated by the acute/cure paradigm institutions like the cancer hospital. The nursing home operates within the chronic/care paradigm of medicine. It is recognized that cancer

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patients admitted to it are likely to die. Here it is treated like a terminal rather than a curable disease. As far as Alzheimer’s disease is concerned, an opposition does not emerge between the two models of medicine at the level of institutional practice since there is no treatment for this disease. Patients are admitted to institutions operating within the chronic/care paradigm. However, there is a distinction in the way it is viewed in the research laboratory and the hospital or nursing home. Research into the causes of Alzheimer’s disease has led to the isolation of a protein which may be significant in the formation of the senile plaques and neurofibrillary tangles which are the iconic markers of this disease. But this is still very distant from the tentative diagnosis based on the doctor’s observation of the patient’s behaviour and the hetero-anamnesis8 collected from the members of the patient’s family (see Chatterji 1993). It must be remembered that investigative procedures like the CAT scan are not usually performed to establish a diagnosis. The brain of the patient afflicted with Alzheimer’s disease is only accessible after death—for purposes of research not treatment.

The Medical Model In all the works that are under consideration here, it is the medical model that is supposed to have given rise to the bureaucratic organization of the institution. Also, the critique that emerges from these works is addressed to the medical model rather than to the institutions concerned. Hence, we must now try to outline its basic features. To begin with, in the medical model the sick person’s life is organized in terms of a disease trajectory. His role in managing his own life decreases as the doctors and nurses take over agency in its planning. The illness process is broken up between many specializations which in turn requires a particular mode of organization in which the relationship between different aspects of the illness can be managed. For instance, the social worker is in charge of the interface between the patient’s social world and his world in the institution. She organizes the admission and discharge processes, sets the medical insurance procedure in motion and even gives advice to the family members on the correct selection of clothes and other personal possessions for the patient. The nurses take over once the patient is admitted to the ward. They take care of his or

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her physical well-being while the pastor and recreational therapist take care of his or her spiritual and emotional life. The various paramedical disciplines are organized hierarchically under the medical disciplines. This is so even in the nursing home which emphasizes the team-care approach with the focus on the individual patient as a whole which includes the disease picture and its influence on his or her personality. Even here, the doctor is the final authority in the decision-making process around the patient. Also, it is only the doctor who has complete access to information concerning the patient under the Medical Secrecy Act. This applies to areas of the patient’s life that do not necessarily pertain to his illness directly. For instance, the family may make certain items of information concerning the patient’s private life available to the doctor, to give him a ‘complete’ picture of the patient’s personality which may be important for the diagnosis of diseases associated with senile dementia. Information of this kind is usually kept in the patient’s medical file which only the doctor in charge is authorized to view. Besides this, the language of medicine itself operates as a veil or as a technique of affect management to conceal the true condition of the patient from him. In the Netherlands, the patient has the right to information regarding his condition, including access to his case file. However, the technical language in which the account of his medical condition is articulated does not allow the patient true access to knowledge of his condition. Van Dantzig and de Swaan give an example of the way in which patients, desperately searching for clues that will give an indication of their condition, may misread perfectly neutral signs. Thus, one patient in the cancer hospital thought that the symbols that signify gender on the case sheet actually referred to the gravity and progression of the illness—d’meant that the person whose name followed the symbol was getting better and meant that the person was deteriorating. But the staff and patients also operate in a double bind; the patients may not really want to face the truth of their condition and the doctors or nurses may not be ready to face the impact of such truth-telling on the patients’ emotional equilibrium. This results, therefore, in a kind or ‘affect management’ in which both the staff and patients engage in an exchange of half-truths so that a ‘system of hope’ is created and maintained. The process of treatment breaks up the course of the illness into phases, each marked by a series of investigative procedures, so that the prognosis is deferred to the outcome of the next test. In this way the hope for cure can be maintained. De Swaan (1990) shows how the organization

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of investigation and treatment structures the experience of being sick into a course consisting of a series of episodes of hope, disappointment and ever-renewed expectation. In this way it removes agency from the patient because he or she is no longer in control of the meaning generated by the illness experience. In fact the experience of illness has been taken over to constitute part of the definition of disease. Similarly, the daily routine in the ward which tends to regiment the patient’s life into standardized patterns of activity can also be rationalized on the grounds of medical requirement. For example, the requirements of hygiene could be used to account for the sparse furnishings in the wards, and so on.

Institutional Responses to the Three Monographs We are now in the position to address ourselves to the two questions posed in the introduction: first, why do medical personnel feel the need to write sociological monographs about their workplaces, and second, why were the responses of the two types of institutions to these studies so different. Perhaps some tentative answers can be found if we can identify the particular experiences that led these authors to articulate the fundamental questions they have been concerned with in their works. The introduction to Disturbance and its Processing in Nursing Homes (van der Wulp 1986) offers an illustration. He narrates a personal experience with a patient—a woman with uraemia—who died. Nothing in her condition led him to expect her death. He could not understand it until one of the nurses told him that she had wanted to die. Both ten Have and van der Wulp turn to sociology to help them create spaces to listen to the voices of their patients. They both feel that their patients have more to tell them about their illnesses than the specialists care to know, and the space offered by medical discourse is not adequate to understand this. Contrast this with the experience of the researchers who wrote the report on the cancer research institute. Van Dantzig and de Swaan (1978) have discussed the conditions under which the study was undertaken. Van Dantzig was first asked to act as psychiatric consultant by the doctors of the cancer institute to advise them on deviant patients. He refused because he felt that these patients could only be understood in terms of their total hospital experience, which would include their

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interactions with other patients and the hospital organization itself. These patients who had been defined as problem cases by the hospital would have problems that were shared by many people in their condition—problems around the anxiety caused by the disease and the very real possibility of death. Van Dantzig thought that it would be more meaningful to investigate the hospital community, to see whether there were special problems that were experienced by certain deviant patients alone, or whether these problems were more general and could be located in the organization of the hospital community and the strategies that were devised to manage death anxiety. Finally, a project was devised to study coping strategies and affect management in the hospital. Even though the hospital staff cooperated with the research team during the course of the investigation, the authors feel that the goals of the research project were never fully understood or accepted. There were no objections to particular facts as they had been portrayed in the report, but rather, to the general picture that was considered to be one-sided and extremely negative in tone. It was also felt that there was no mention of the spiritual care that is institutionalized in all medical establishments through pastors and social workers. The report had shown that the very real possibility of death is kept hidden under a surface calm. Patients are appreciative of the care they receive. They are aware that they are in a premier institute and are in a position to receive the best treatment that is available in Europe. Yet, they are caught in a double bind. They live in a world of hope and anxiety at the same time. This anxiety is not addressed. Rather, it is pushed away. The rationalization given is that it is not good for therapeutic treatment for such emotions to be aired. Both staff and patients collude to create this system of hope. The central paradox lay in the fact that the report was received as personal criticism by the hospital staff, when the intention of the researchers was to provide a general critique of the medical structure and of its relationship to society. Van Dantzig and de Swaan feel that the principal objectors to their work were the senior officials who have participated in the technological reorganization of medicine in the Netherlands. They see the hospital organization as an instrument of their intentions, which is the growth of medical knowledge leading to the control of adversity brought about by disease, and assume that if these intentions are not realized it is either due to the inefficient organization of the hospital or is a criticism of their intentions. Therefore, staff members led by senior

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officials did not recognize the critical representation of the hospital as their reality. ‘Those who have adjusted to the system of hope cannot see it for what it is’ (1978: 19). This is the damning conclusion of the authors. If the portrait of the hospital that emerged in the external observers’ report sharply differed from the perception of the staff members of the hospital, leading to the negative reception accorded to the report by the latter, in the case of the nursing home the insiders themselves tried to view their workplace from an external point of view: ten Have says that in his experience as a doctor he found that old people had more to tell him than he had to tell them. Therefore, he chose to study old people in the nursing home context in terms of their worlds and their life situations, using a method that is ‘natural’, that is, the phenomenological method.9 He uses the categories of ‘time’, ‘space’ and ‘person’ to delineate different life worlds the spheres of meaningfulness of the two major groups in the nursing home. Of course the method he designates as ‘natural’ is not at all natural from the perspective of his own discipline (medicine) which would define the experiences of these people in terms of disease categories. Ten Have chooses to create ‘mini ethnographies’ (to use Kleinman’s phrase), to listen to their ‘illness experiences’, to what is significant for them in their life worlds, and thereby he constitutes the doctor not as an expert but rather as a ‘moral witness’ or a listener (Kleinman 1988). The conclusion he arrives at is a negative one. One of the official goals of the nursing home is to provide an optimal life milieu for persons who cannot live in society, and the patients themselves are appreciative of the care they receive; yet the problems emerging from their life situations—some of them inherent in being old and sick, others arising from the process of institutionalization—are not understood by the staff members. Ten Have’s work provided an impetus for self-reflection in the nursing home world. Since then there have been efforts to create structures that are more open-ended and receptive to criticism and to institutionalize a more personalized care system. Thus, individual nursing homes have been encouraged to organize committees to receive complaints from patients and their families, to hold ward discussions between nurses and patients, and to try and structure the care and treatment around the requirements and wishes of individual patients (Chatterji et al. 1991). There have also been several follow-up studies of which van der Wulp’s is one of the more systematic. He follows, broadly, ten Have’s concern but tries to systematize the relationship between different spheres of

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significance, specifically that between the patients’ lives before they fell ill and their present situation in the nursing home. The relations are characterized either by conflict or equilibrium and by an experience of disjunction between the past and the present. The three major areas in which this disjunction is perceived is in terms of the body (health vs. sickness), mental status (autonomy vs. dependence) and social state (home vs. the institution). Van der Wulp suggests that institutions should structure their work routine so as to be able to handle these disjunctions therapeutically. What is it about the institutional structure of the nursing home that allows it this reflexivity? To answer this question we shall have to return to the discussion on the two models of disease—the acute/cure versus the chronic/care model. They involve different perceptions of normalcy and health. The nursing home’s residents are mainly elderly people. The structures of the aging body and brain are supposed to be different from those of the normal adult population. Most old people are thought to be suffering from some chronic problems even if these are insignificant and do not cause major impairment. The standard of normalcy for the elderly population must take the presence of some pathology into account. Rather than using terms like ‘normal’ and ‘pathological’, geriatricians prefer to talk in terms of ‘function’ and ‘disfunction’ (Sunier 1986). The individual organism (the elderly person in this case) is defined in terms of his environment which is conceived as being composed of other beings as well. The individual is in a functional relationship with his environment as long as he or she is able to respond to it meaningfully. There is a relationship of equilibrium or ‘homeostasis’ between the two. In this perspective illness is defined as a break in homeostasis between the individual and his environment. Normalcy refers to the restoration of this homeostasis rather than to an average norm. However, the elderly individual may lose his or her ability to adapt to the environment which may then be experienced as threatening. If the individual is to survive, the environment will have to be adapted to meet his or her needs. The nursing home defines the elderly sick person in terms of a support structure. This includes not merely the family and neighbourhood but also professional care services, including ambulatory medical care. When this support structure breaks down the nursing home steps in to provide a supportive environment in which the sick person can lead a

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‘normal’ life within the parameters allowed to him or her by his or her illness. However, the nursing home is perceived as an end stadium by the wider society, a place for people who are incurably sick, a house of death. There is thus an ambiguity in the identity of the nursing home. The fact that it offers a medicine of care means that there is greater sensitivity to the emotional problems that accompany sickness and disability. But at the same time there is a confrontation with the brute fact of death and with the incurability of chronic disease which can be perceived as threatening, especially as the nursing home has also developed from the medical model which is based on what van Dantzig and de Swaan call a ‘system of hope’—the possibility of cure. The ambiguity at the heart of the nursing home’s representation of itself makes it more open to critical reflection. Nursing home medicine is a marginal discipline. It is not invested with the kind of legitimacy or prestige associated with a research institute like the cancer hospital. It is therefore also more open to other languages and to more distancing representations of itself. However, there is something to be said about a critique that comes from within as opposed to one formulated by outsiders. At the time that ten Have’s work was published there was already an incipient body of critical writing available on subjects like chronic illness and pain (see Leering 1967). Ten Have helped to locate this discussion within the organization of the nursing home. As opposed to this, the cancer hospital was not prepared for the portrait that had been painted of itself. We have already discussed the institutional structures which make this response cognizable. Over and above this we must examine the nature of the representation which may also be relevant in understanding the hospital’s response to the report. The critics of the report felt that there was a greater sensitivity to and a more willing reception of the emotional demands of patients in the cancer hospital than had been portrayed in the report. The researchers pointed out that this was at an informal, interpersonal level and was not an institutionalized part of the work process. The critics found it difficult to empathize with a generalized overview of hospital structure that was, however, based on the detailed observation of one particular case. The paradox of the method adopted by the researches lay in the fact that the monograph was built up of concrete examples of interactions between particular individuals which, however, can only be understood within a generalized critique of the organizational structure of the hospital.

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There was also a more specific objection to the report. The hospital staff felt that there was an insufficient description of pastoral work. According to the observation of the researchers this sphere of activity did not really provide a means for subverting the organizational structure, but only provided solace at the individual level. However, this does remain a lacuna in their work. Van Dantzig and de Swaan are aware of the fact that they were not sufficiently self-conscious about their own subjective orientation. They feel that an empathetic approach and greater sensitivity towards affectivity is part of their training as psychotherapists and psychologically-oriented sociologists. They are willing to admit that the ‘system of hope’ may be the only mode of care available in the medical context. They see their critique of the medical institution as being part of a larger critique of the professionalization of care in society in which experiences of suffering and death have been removed from the familial domain and placed within the regime of experts. There is, however, a problem with the mode in which the ethnography is presented. To use a distancing, third-person generalized style is not necessarily the most sensitive mode in which to represent private experiences of suffering. The authors’ style tends to remove agency from the persons undergoing these experiences. Their voices are not heard. The authors’ voice stands above them, purportedly objective but easily interpreted as negative and judgemental. Ten Have and van der Wulp in contrast use a dialogical mode which gives primacy to the voices of their patients. They turn to the social sciences not to provide a distance but to be able to come closer to the experiences of their patients.

Conclusion The authors of these works would like to see more openness in medical institutions and a more personalized approach to medicine in which the patient is central not merely in terms of his or her disease but in terms of his/her whole life experience. They would like to see medical personnel not as mere technicians for the treatment of the body but also as spiritual advisors and sympathetic witnesses to the patient’s suffering. In recent years most institutions have switched over to the teamcare model in which an individualized care programme is constructed for each patient. What happens in practice is that the patient is broken

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up between the various so-called specializations, including that of pastoral care which becomes just another service present in medical institutions. This does not mean that there are no cases of interpersonal bonding between staff members and patients and no informal attempts at affect management. Van Dantzig and de Swaan (1978) dismiss all such relationships precisely because they are not part of the institutional structure. They feel that the bureaucratic organization of work prevents emotional relations from being articulated. However, my own work in a nursing home in the Netherlands has shown that it is precisely through the work routine that inexpressible sentiments may be articulated. Nurses express their bonding with patients by taking care of their bodies. Verbal communication may not be the most significant form of communication for persons with debilitating illnesses. It is interesting to note that all the authors rely on verbal communication for their research. If they had been more sensitive to non-verbal communication they would have realized that it is characterized by a tentativeness that cannot be structured in the manner in which the work routine can be bureaucratically structured. The ideal that stands behind the critiques of these authors must be understood in terms of the moral value that the medical institution has in this society. The model on which it bases its own identity is that of the community. The ideal approach to problems associated with suffering, illness and death are modelled on those that are supposed to be found in the community. At the same time their critique of the professionalization of Dutch society shows that they are aware that this ideal community may be illusory. The danger of even greater professionalization and regulation of the individual personality that may be inherent in the changes that van Dantzig and de Swaan would like to see, are not explored. It may be pertinent to end here with Goffman who believed that the individual personality could only be articulated in the cracks of bureaucratic organizations.

Notes 1. I am grateful lo Professor B.S. Baviskar for encouragement in the writing of this paper. The Dutch titles of the books are as follows: Ha Verpleeghuis: Veld van Onderzoek by H. ten Have; Verstoring en Verwerking in Verpleeghuizen by J.C. van der Wulp; and Omgaan met Angst in Een Kankerziekenhuis by A. van Dantzig and A. de Swaan. The works of both ten Have and van der Wulp were written originally as dissertations for Ph.D. degrees in sociology. However, both are directors of nursing homes in the

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Netherlands. Van Dantzig is a psychiatrist and de Swaan is a sociologist. All three works are written in Dutch. I have tried to substitute English terms for the Dutch originals as far as possible for the convenience of English-speaking readers. 2. Ten Have’s book was published in 1979, a year after the book on the cancer hospital by van Dantzig and de Swaan. Van der Wulp’s book, published in 1986 and dealing with many of the same questions that had been raised by ten Have, is an indication of the ongoing discussion around these problems in the Netherlands. 3. According to the Webster’s Dictionary (third new international edition, unabridged), an organization refers to a group that has a constant membership, a body of officers, a purpose and usually a set of regulations. 4. Ten Have does not acknowledge Weber’s influence in his formulation even though it seems evident to us here. 5. Quotation in van Dantzig and de Swaan (1978) from A. Querido ‘Gedachten over de evolutie van het ziekenhuis’, De Gide, 136, 9/10 1973, pp. 619–28 (my translation). 6. Van der Wulp (1986) characterizes the treatment offered in nursing homes as ‘nursing home medicine’. He also makes a distinction between the acute/cure and chronic/care paradigms in medicine. 7. Apraxia is a disorder of the cerebral cortex resulting in the patient’s inability to organize his movements. Aphasia is caused by a disease in the dominant hemisphere of the brain, (i.e., in the left hemisphere of a right-handed person’s brain). It causes a language disorder affecting the generation of speech and its understanding. Agnosia is caused by a disorder of the association areas in the parietal lobes of the brain, whereby the patient cannot interpret sensations correctly although the sense organs and nerves conducting sensation to the brain are functioning normally (Harrison 1986). 8. A hetero-anamnesis is an account of the patient’s biography and past behaviour which may throw light on his/her present condition. 9. The phenomenological perspective takes as its fundamental unit the individual human being and his/her experiences of the world. These experiences are studied in terms of overlapping structures of intentions. It tries to describe the individual’s subjective orientation to the world.

References Chatterji, R., V. Das, S. Dutta-Chaudhury, R. Pradhan and K.W. Van der Veen. 1991. The Welfare State from the Outside: Aging, Social Structure and Professional Care in the Netherlands: Indo-Dutch Program for Alternatives in Development. Chatterji, R. 1993. An Ethnography of Dementia. A Case Study of One Psycho-Geriatric Patient. Paper presented at the Sociological Research Colloquium, Department of Sociology, Delhi School of Economics. De Swaan, A. 1990. The Management of Normality. Critical Essays in Health and Welfare. London: Routledge. Goffman, E. 1961. Asylums. Essays on the Social Situation of Mental Patients and Other Inmates. Harmondsworth: Penguin. Harrison, L.M. 1986. The Pocket Medical Dictionary. Delhi: C.B.S. Publishers.

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Kleinman, A. 1988. Illness Narratives. Suffering, Healing and the Human Condition. Basic Books: New York. Leering, C. 1967. ‘Vragen naar Zinvolle en Zinloze Invaliditeit bij (oude) Mensen. Beschowingen naar aanleiding van een aspect in het werk van Samuel Beckett, Gawein: Tijdschrift voor Psychologie. XVI(6). Sunier, A. 1986. Body and Mind in Old Age and Decay. Assen: Van Gorcum. Ten Have, H. 1979. Het Verpleeghuis: Veld Van Onderzoek. Deventer: Van Logum Slaterus. Van Dantzig, A. and A. de Swaan. 1978. Omgaan met Angst in Een Kankerziekenhuis. Utrecht: Het Spectrum. Van der Wulp, J.C. 1986. Verstoring en Verwerking in Verpleeghuizen: Belevingswereld en Conflicten van hen die hun Verdere Leven in een Verpleeghuis Doorbregen. Nijkerk: Intro.

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7 Voice of Illness and Voice of Medicine in Doctor-Patient Interaction Mathew George

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edical care achieves its salience through the processes of diagnosis, treatment, and follow-up. These are usually accomplished by the active group-effort of doctors, patients, and other paramedical staff through health institutions. The roles played by doctors and patients become pivotal in the process of medical care. The role played by the patient cannot be seen merely as a recipient of medical care but as that of a partner in the total effort at curing the disease, as it is the patient (or her/his relatives) who first identifies the problem and seeks treatment. This becomes a necessary condition for the recovery of illness through medical care. Besides, the whole process of medical care that transforms a lay category of illness to a medical category of disease is facilitated through these interactions. In other words, doctorpatient interaction can provide an expert and a lay interpretation of the same event, which, in turn, reveals the context and the reasons for these interpretations. The present paper is an attempt to show various voices in doctor-patient interactions in a clinic and thereby explaining these interactions as outcomes of the socialisation of actors involved.

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Understanding Doctor-Patient Interaction The interaction between doctors and patients becomes cardinal not only in the process of medical care, but also within the institution of medicine. It is through this interaction the basic components of medical care like diagnosis, prognosis, and therapeutics get accomplished. Additionally, this interaction can be seen as part of the whole process of medical care where both the actors are influenced by the changing medical knowledge. There are several approaches through which the interaction between doctors and patients can be examined. A brief overview of some of them will be attempted here thereby situating the approaches used for the present study in its context. Scholars have attributed a passive role to patients, thereby expecting them to co-operate with the doctor in the process of medical care (Seal 1971). These studies mostly examine the gaps in the knowledge and understanding of patients about medicine with a view to rectify them by the process of socialisation of the patients to medical values and beliefs (medicalisation). Talcott Parsons’ ‘sick role’ (1951) has been one of the dominant as well as influential approaches among sociologists which resulted in the acceptance of the physician’s expertise in tackling illness as the key for doctor-patient interaction. This not only problematises illness but also considers bureaucracy in hospital as a feature manifested through doctor-patient interaction (see Mechanic 1976; Tuckett 1976). In all these, patients were not given sufficient attention, as the major role attributed to them was to help the physician in their maximum possible capacity in the collection of information about illness for rendering better care. Moreover, from a professional perspective, another stream of studies examined the temperament, attitude, and behaviour of doctors and patients and tried to link them to the socio-economic class of the respective actors, thereby showing conflict between them (see Friedson 1970/2001; Advani 1980). Besides, scholars have also examined the changing nature of role structures and behaviours among professionals and semi-professionals within a bureaucratic setting and linked these to the social characteristics of the actors (Oommen 1978). Taking into consideration the varied roles played by doctors and patients, four models have been developed to understand the physicianpatient relationship, namely, paternalistic, informative, interpretative, and deliberative models (Emanuel and Emanuel 1992). As the term

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indicates, the paternalistic model assumes that the physician is an expert, similar to a priest, who knows what is best for the patient, who, in turn, will be thankful for such help. The informative model, also known as scientific engineering, is the process of translation of patient’s values into facts through the mediation of the physician, the expert. The interpretative model, similar to that of a counsellor, helps the patient understand her/his priorities, thereby helping her/him in decision-making. The deliberative model proposes the possibility of negotiation where the physician, through dialogue, enables the patient to look at available options that aid final action. In all these approaches, the upper hand and expertise of the physician and the capability attributed to medicine are obvious. The rise of the consumerist perspective, which considers medical care as a commodity and the right of the patient as that of a consumer, further attempts to empower the patient where the patient is expected to assert her/his needs and make her/him aware of the possible options. This could not go very far due to the patients’ inability to enter into the expertise of medical knowledge, which plays an important role in the process of medical care decision-making. For H. Waitzkin (1979), this is only an outcome of a professional hegemony embedded in medicine prevalent in any society, whose intensity is greater in a capitalist society, which is capable of exerting social control that ultimately gets precipitated through the doctor-patient interaction. The realisation of uncertainty within medicine (Fox 1957, 2000) has resulted in an approach that questions acceptance of physician’s expertise in tackling illness. Here, diagnosis is seen as a practical approach that does not seek to pursue beyond the stage that predicts therapy and a theoretical approach that seeks to refine diagnosis to the limits of the possible (Mccormick 1979). Furthermore, the reasons people consult doctors are not always for diagnosis and treatment of disease, but also for getting reassurance about the meaning of symptoms, help with the problems of living, certification of sickness, and prevention of disease (ibid.). In this context, it will be farcical to understand doctorpatient interaction merely as a dyadic relationship. Instead, a contextual analysis that situates doctors, as the representation of the prevalent medical fraternity and patients, depending on the social strata to which one belongs, along with the prevalent cultural practices reflected in the type of health institutions, needs to be attempted (see Atkinson 1995; Good and Good 2000).

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This can be a means for analysing how larger social and cultural processes are made relevant to the experience of patients, suggesting that clinical conversations are a form of traffic not only among doctors and patients, but also among diverse local and global sites that produce biomedical knowledge, therapeutic technologies, and the scientific imaginary (Good and Good 2000). That is, consultation is the forum through which biomedical theory and scientific assumptions meet lay expressions of the experience of illness. In the encounter, the personal, social, and psychological contexts of sickness that are brought by the patient are translated by the physician into terms that are intelligible in biomedicine. This is accomplished here by analysing doctor-patient interaction in its totality using narrative analysis whose basic assumptions and techniques is discussed in the following section.

Doctor-Patient Interaction as Narrative The suitability of narrative analysis in clinical encounters is dealt by C. Mattingly: ‘Narrative plays a central role in clinical work not only as a retrospective account of past events but as a form healers and patients actively seek to impose upon clinical time’ (1994: 811). This becomes clear as (illness) narratives are extensively used to understand patients’ representations and experiences of illness and to provide a temporal frame (clinical time) for therapeutic events. When the doctor-patient interaction is seen as a narrative, the scope of analysis widens, as it can be a tool to situate the physician and the patient in their socio-cultural milieu and a means of communication, whose further analysis provides the meaning given by both the actors to a common event, namely, illness. This is because narrative can be studied as a mode of discourse—as text or as performance: ‘Narrative is used when we want to understand concrete events that require relating an inner world of desire and motive to an outer world of observable actions and states of affairs’ (Mattingly and Garro 1994: 771). Narrative thus makes it possible to understand not only the past experiences, but through that the present understanding of that experience and the future options perceived within the given socio-cultural context. As narrative is about experiences, it is through stories that narratives are produced where stories themselves are outcomes of experiences of the actors within their respective context (socialisation). The linkages between narrative and life stories have been dealt extensively by

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many scholars (see Frank 1995; Mattingly and Garro 2000). It is this narrative or life story that is further analysed by the researcher as a text based on her/his socio-cultural milieu. The position of the researcher here is more of a ‘passive’ participant observer (Spradley 1980: 59–60), as the researcher neither has the first-hand experience of the illness patient suffers nor the expertise of the physician with which the illness gets interpreted as disease. Thus, by taking the position of a bystander (witness), it is possible that the researcher would have internalised the problems of the patient better possibly due to greater familiarity with the patient and her/his context. Besides, not having the expertise of the doctor limits a complete understanding of the physician’s point of view. This would result in being more of a patient-centric perspective in the analysis. Thus, the model in which experience leading to narrative, narrative to text, and text further reshaping the experience is in itself inadequate, as the role of socialisation of the actors and the researcher in the formation of narrative and the text is not addressed. This inadequacy is tackled by introducing the concept of institutions at each juncture, that is, during translation of experience to narrative, narrative to text, and text further reshaping the experience. The concept of institutions used for this study is based on Jamie A. Saris’ work about a schizophrenic patient (1995).

Institutions in Narrative Saris (ibid.) addresses the above problem by elaborating narrative, or, in his terminology, ‘the conditions of narrative production’. The translation of experience to narrative and narrative to text, according to Saris, is shaped by the institutions that are prevalent in each social context. The concept of institutions he puts forth encompasses the prevalent socio-cultural milieu. He defines institutions ‘as bundles of technologies, narrative styles, modes of discourse, and as importantly, erasures and silences. Culturally and historically situated subjects produce and reproduce these knowledge, practices and silences as a condition of being within the orbit of the institution (ibid.: 42). Saris elaborates institutions as helping to constitute stories as well as being sites of narrative productions, thereby problematising the relationship between experience and the development of the story about that experience (narrative) in such a way as to focus the analyst’s attention

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on the specific circumstances of the social field in which narratives are developed and deployed. Moreover, narratives as text would ensure a thick description that would show a better picture of the social context in which the narrative is embedded (ibid.). Unlike clock time or serial time, that follows one after the other, narratives follow narrative time where the time itself is dependent on the events explained with a beginning, middle, and end (plots). Mattingly (1994) has used the concept of narrative time and emplotment in the analysis of clinical interactions. For her, emplotment involves ‘making a configuration in time, creating a whole out of a succession of events (plots) (ibid.: 812). She elaborates that narrativity and, particularly, the work to create a plot out of a succession of actions, is of direct concern to the actor in the midst of action. Narrative analysis used in clinical interactions generates sufficient space for adequate understanding of the actors’ (doctors’ and patients’) perspective about the illness and their future plans for the same. According to Mattingly, A narrative analysis offers a way to examine clinical life as a series of existential negotiations between clinicians and patients, ones that concern the meaning of illness, the place of therapy within an unfolding illness story, and the meaning of a life which must be remade in the face of serious illness (1994: 821).

It is this perspective of narrative—a narrative that is shaped by the institutions—that is used to analyze the doctor-patient interaction in the context of fever care rendered by allopathic health facilities in Kerala.

Voices of Interaction In order to contextualise the doctor-patient interaction deploying narrative analysis, E.G. Mishler’s concept of voice (2005: 320) is used. Mishler argues that Voice represents a particular assumption about the relationship between appearance, reality, and language or, more generally, a ‘voice’ represents a specific normative order. Some discourses are closed and continually reaffirm a single normative order; others are open and include different voices, one of which may interrupt another thus leading to the possibility of a new ‘order’ (ibid.).

Thus, it has to be understood that the idea of voice does not equate with a speaker. One speaker may articulate more than one voice; different

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speakers may share the same voice. Different voices distinguish contrasting orientations to the world and to the moral order as each voice realises a particular relationship between the speaker and the world. For Mishler (ibid.: 321), in clinical interaction, two different voices representing different normative orders can be identified: the voice of medicine and the voice of the life-world. He argues that, in the medical interview, the former dominates the latter. Occasionally, in this interview, the patient articulates the voice of life-world (based on her/his personal experiences and pre-occupations), but that gets overlooked by the voice of medicine. The whole clinical interaction then is seen as a struggle for dominance, the voice of life-world occasionally interrupting the voice of medicine (ibid.). The above approach of voice situates the clinical interaction as a dynamic one where the power of the patient is also acknowledged by locating both the patient and the doctor within their socio-cultural context. Similarly, based on the narrative of a person diagnosed with schizophrenia, Saris (1995) shows how, at several junctures, the institutions of medicine and their categories lack insight in understanding and tackling the problems faced by the person due to the illness. He also shows how the institutionalised authority of professional expertise reflected in the power to name silences and erases other experiences and knowledge. The above approaches, based on discourse analysis, portray doctor-patient interaction as an everyday activity of human beings whose meaning becomes obvious on contextual analysis.

Voice(s) of Medicine The above perspective is, however, limited, as it dichotomises the clinical encounter to only two voices, where the voice of medicine is seen as homogeneous. P. Atkinson (1995: 130–42), in his study among haematologists, shows how, within medicine, different voices are articulated and how they can be in conflict with each other. This he elaborates by analysing a situation in a haematology laboratory where the ‘voice of experience’ of a senior physician contradicts the ‘voice of textbook medicine’ of a student in a teaching hospital. This Atkinson views as a feature of medical work that can occur in any setting influencing medical practice. Furthermore, he explains that voice of medicine constitutes the voice of experience and voice of science. The voice of experience comprises accumulated experiences and a biographical warrant for knowledge and

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opinion. By voice of science, he means an articulation of knowledge warranted by an appeal to research, namely, published scientific papers as well as textual knowledge. Haematology laboratory is a place where the core of medical work is accomplished and is, therefore, considered as more ‘scientific’ in its proceedings. If contradictory voices are heard in such a setting, it is possible that heterogeneous and even contradictory voices can be heard in a doctor-patient interaction. Based on Atkinson’s and Mishler’s insights on clinical encounter, I would like to argue that it is the voice of illness that can be heard along with the voice of medicine. This obviously would be based on the past experiences, perceptions, and worldview (life-world). In a medicalised society, it is possible that the voice of illness itself will be medicalised thereby articulating a medicalised voice of illness. Thus, there can be different voices that are in constant interaction in doctor-patient interaction: the voice of experience and the voice of science, together constituting the voice of medicine (Atkinson 1995), and the medicalised voice of illness and life-world voice of illness (Mishler 2005) together constituting the voice of illness. Thus, for the analysis of doctor-patient interaction in fever care in Kerala, the following model will be used, as there can be voices of illness and voices of medicine: the voice of illness would be divided into life-world voice of illness and medicalised voice of illness, and the voice of medicine would be divided into voice of science and voice of experience. Most of these voices get articulated in a clinical interaction. An analysis of these voices will be carried out, as they have a bearing not only on the prevalent discourse, but also on the process of medical care. The above voices in themselves should not be seen as all-encompassing; there can be several other voices which may not fit into any of the above categories. Moreover, the dynamics of these various voices depend on the context of interaction and the actors involved.

The Study The Context In the state of Kerala, until the mid-1980s, fever, as a broad category, included viral fevers, common cold, runny nose, and similar other infections. Later, during the late-1990s, by the increased reporting of the number of cases of rat fever (leptospirosis), dengue fever, and viral fever, a threat about fevers was generated and the distinction between

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the types of fever became difficult. From 2002, every year during postmonsoon season, fever as a broad category has been taking its toll. It is at this juncture that the health minister of Kerala declared, in May 2004, the starting of ‘fever clinics’ in all district and taluk hospitals and major community health centres in the state. These clinics were expected to function as a separate division in the existing outpatient departments (The Hindu, Thiruvananthapuram, 25 May 2004). As in any other context, it is possible that the meaning attached to ‘fever’ could be different for different people. It was found that fevers could be a symptom for clinicians and a state of ill-health for those affected, whereas for public health experts, it appeared to be an epidemic. Discussion with public health experts revealed that they had come to view the problem of fever as an epidemic. In fact, ‘fever clinics’ were set up by the health ministry as a response to the crisis of ‘fever’. It is interesting to note how the concept of ‘epidemic’ gets constructed/negotiated during a crisis, as in the case of dengue fever in Delhi (see Addlakha 2001) and cholera in Kolkata (see Ghosh and Coutinho 2000). Fever talk, as mentioned before, implies the varied understandings about the illness, fever. This is based on the premise that the understanding and perception about fevers is determined by the discourses about disease and illness, health services, and so on, which is further determined by the various discourses on medicine prevalent in the society. Different groups, namely, those affected, clinicians, public health professionals, and so on will see illness/disease differently. This is obvious from the fact that, for each, the nature of interaction with the illness is varied and it influences their understanding of it and, therefore, their response to it. For individuals, whose lives are delimited by a combination of physical and social constraints and potentialities, there can be diverse perceptions of illness. For example, working and housing conditions and dietary habits and health customs impact on the health of working-class people as imperatively as physical entities such as viruses, genes, or environmental pollutants (Yardley 1997: 14).

The Data The present paper is based on a larger study (George 2007) on the various facets of the problem of fever in Kerala of which ethnography of biomedical clinics was one component. The data for the study was collected during January–June 2005. All the respective authorities were

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informed about the study and necessary permissions were obtained. Consent from those patients and physicians who were part of the study were also ensured. The major tool to understand the culture of fever care was participant observation: the procedures involved in fever care were observed closely and the events of medical care were recorded (ethnography of the clinic) from the health facilities. Several semi-structured interviews were carried out as clarifications from doctors, patients, and other actors involved in the events. Moreover, the doctor-patient interaction during clinical encounter was recorded for a few cases on the spot giving due consideration to the context of interaction. This was later used as a text for analysing doctor-patient interactions and was subjected to narrative analysis (Czarniawska 2004). The process of clinical decision-making and the response of the patient were examined within the context and their respective influence on the outcome of fever care were analysed. Above all, follow up of each cases identified from the health facilities was done using household survey. The data was collected in the local language (Malayalam) and was translated into English keeping in mind the original twists, turns, and the context. In the first stage of data analysis followed the holistic-content approach (see Leiblick et al. 1998). Later, for each case, John Heritage’s approach of identifying institutions in interactions (2004) was used. Although institutions were identified almost ‘everywhere’ in the interactions, they became obvious from the turns, sequences, lexical choices, and more importantly, epistemological and other forms of asymmetry (ibid.)

The Setting The description of health facilities is inevitable at this juncture, as making explicit the field setting is the only way by which credibility of anthropological studies can be established (Sanjek 1990). Broadly, there are two functions involved in these hospitals: the administrative function and the medical function. The former comprises the process of registration leading to the making of a case record, which remains as the identity of those who seek care, and collection of cash as the price of the care rendered. The latter comprises the diagnosis accomplished through physical examination, history taking, laboratory investigations, and so on along with therapeutics. This function constituting the medical work will form my major focus.

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The procedures for consultation is such that the doctor and the patient interact with each other the first time and, based on the patient’s explanation, the doctor records the details of the illness in a particular format in the case record. Subsequently, the patient is subjected to physical examination and laboratory investigations, as the case may be, and thereafter asked to meet the doctor with the results of the tests and investigations. The doctor then prescribes medicines for a short period and asks the patient to come for a follow-up, if required. The extent of physical examination carried out, laboratory investigations prescribed, and prescription of medicine all depend on each case that calls for an analysis, taking into consideration the context as it is influenced by a range of factors.

Voice of Illness Jincy Joseph, a 17-year-old girl studying in class XI, went to a practitioner in the hospital accompanied by her mother and a neighbour. She belongs to a middle-class family; her brother, working in the military service, is the major source of income for the family. Her parents are educated till the tenth standard and they run a small pettikada (a small shop-like structure where lemon juice, sweets, soda, chewing items, cigarettes, etc. are sold). The hospital they went to was a private hospital having over 300 beds with emergency and laboratory facilities, including biochemical tests. It has specialisations in general medicine, paediatrics, ENT (ear, nose, and throat), ophthalmology, orthopaedic, skin and VD (venereal diseases), and others. The physician she consulted completed his medical degree from one of the leading medical colleges in the country and holds a masters degree in general medicine. He has been practising since 1972 and has been the physician in this hospital for the last eight years. The patient along with her mother and neighbour entered the consulting room after completing the registration procedure of the hospital. The interaction1 between the doctor and the patient (in Malayalam) proceeded as follows: 1D: What is your illness? P: Fever, severe pain in the legs. 1MoP:  Severe weakness and headache. 2D: Was there swelling [in English]?

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2MoP:  She is very weak and, at times, there is swelling on the side of the feet. Sometimes there is difficulty in breathing and back pain. Especially after coming back from the school . . . she has to walk long distance . . . she is very tired. 3D: Is it hereditary? 3MoP: No. 4D:  Show your tongue, open your mouth. Is there recurrent throat pain or any other illness? P: Ahh!! No.

The doctor physically examined the patient’s mouth, abdomen (by pressing), and with the stethoscope. He then prescribed ECG (electrocardiograph) and routine blood and urine tests. 4MoP: What is the disease, doctor? 5D:  I need to see whether it is the initial stages of arthritis [in English].Anyway let me have a look at the test results.

The doctor then asked the patient to come on the next day. On the second day, the doctor, after checking the laboratory test results said: lab test results are normal and the illness could be due to excess strain due to travelling. Medicines for swelling and weakness are written.

As the consultation ends, the patient collected the medicines from the pharmacy and left the hospital for home. A perusal of the medical case record showed that neither diagnosis nor symptoms were recorded. All the laboratory test results were within the normal ranges. During the follow-up of the patient at her home, a month later, it was found that she continued to suffer from the illness. Moreover, it was discovered that, before going to the above hospital, steam inhalation had been done at home and thereafter she had been taken to a small clinic near her home for consultation; the doctor at the clinic had prescribed a tonic (a kind of syrup usually taken to resist weakness and enhance health). This clinic, run by a qualified allopathic doctor, had no facility for inpatient care, but had basic laboratory facilities. During my conversation with the mother about the illness of her daughter, she said that [her daughter] complains of weakness everyday and invariably goes to sleep as soon as she comes home from school. She is not able to study properly. She doesn’t help

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Voice of Illness and Voice of Medicine in Doctor-Patient Interaction 107 me in any household work. She is very lazy and she complains of weakness . . . as the illness was not subsiding and news of epidemic diseases made us think that the illness could be serious we decided to do a complete check-up in the highly-reputed private hospital.

During the clinical interaction, it was obvious that the problem of weakness of the girl was not addressed adequately. Instead, the fact that the search for symptoms by the physician dominated the interaction was revealed by his question (2D). It has to be noted that, despite the expression of the problem by the mother (2MoP) based on her experience of her daughter’s suffering, it got sidelined by the subsequent direct question of the physician (3D) on heredity. Thereafter, the physical examination portrays how the voice of medicine dominates the lifeworld voice of illness during the clinical interaction. It appears that the major purpose of the physician’s consultation was to collect information regarding medically acceptable illnesses. In other words, the patient’s mother presents the illness from the viewpoint of the abnormality of social body (Taussig 1980) by highlighting her daughter’s problem as the inability to perform daily chores like travelling to school, studying her lessons, and helping in household work (2MoP). The physician, on the other hand, first inquires about heredity to find some lead (3D) on the abnormality of biological body (ibid.) reflected in the physical examination of the patient (4D) and the prescription of laboratory investigations (5D) for diagnosis. This leads to one-sided interaction: the patient becomes a mere object in the process of therapeutic care. The doctor’s use of the English terms swelling and arthritis, despite there being popular Malayalam equivalents like neeru and vaatham, shows the intense urge of the physician to fit the patient’s complaints (that are lay problems) into textual medical categories. In other words, this was the moment at which the translation of a lay category into medical category, be it a symptom like ‘swelling’ or a suspected disease, namely, ‘arthritis’ occurred. The above case also shows the management of uncertainty during clinical interactions when a valid diagnosis or symptoms are not identified. Despite this, medicines were prescribed. This is evident as, in the initial stage, the doctor expected the possibility of a hereditary factor (3D); next, before the laboratory test, he suggested the possibility of arthritis (5D); and he then concluded with observations about swelling and weakness, which was at the symptom level and devoid of any

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final disease diagnosis. In his study of haematologists, Atkinson (1995: 113–17) shows how uncertainty has become an important characteristic of contemporary biomedicine. He elaborates the relevance of close examination of the process of everyday medical work: It is necessary to pay rather close attention to how uncertainty or certainty is actually conveyed in the course of everyday medical work. . . . There is need for detailed examination of how medical practitioners, students, scientists and others express and discuss their information how they voice their opinion and how they claim particular warrants for the knowledge and interpretations they endorse (ibid.: 17).

He points to the need to examine and understand the context of uncertainty or certainty and how these are accomplished in everyday medical work. The implications of the outcome have more to do with the question of the relation between knowledge and power. Rene C. Fox (2000) examines how doctors, as part of their medical training, get socialised to manage uncertainties at various levels of medical care, thereby internalising this ability as an achieved quality of the art.

Medicalised Voice and Voice(s) of Medicine Ramachandran, a 31-year-old married man, a commerce graduate working in a private finance company went to a private hospital (the same as Jincy Joseph) with complaints of fever and body-pain. He belongs to a middle-class extended family comprising his parents, two younger brothers, and a younger sister. The physician he consulted was around 36 years of age, with a masters degree in general medicine. This physician has been practising for eight years of which seven years have been in the present hospital. The doctor-patient interaction during consultation proceeded as follows: 1D: Uh, what is the problem? 1P: Fever and body-pain. 2D: For how many days? 2P: Around two-three days. 3D: Was there vomiting present? 3P: No, there are rashes on the body. 4D:  Take off your shirt and turn back [Ramachandran’s body was full of rashes].

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The doctor carried out investigation using a stethoscope; he later examined the patient’s mouth using a tongue depressant. 4P: [While examination was going on] I have been taking medicine for jaundice. My serum bilirubin was tested from a nearby lab and the value was 1.1. 5D: Have you heard of measles? 5P: No. 6D:  It is a viral infection [in English] and the typical clinical symptoms [in English] are shown. 7D: Getting admitted, aren’t you? 6P: Yes.

The patient got admitted, and routine blood tests were carried out. The platelet count was tested everyday until the third day when the patient was discharged from the hospital. At the time of discharge, medicine was prescribed for one more week. The patient was relieved of the illness only after ten days from the day of discharge. As per the medical record, the diagnosis was ‘Measles with URTI [upper respiratory tract infection]’. On talking to the physician about fever care later, especially on the need for laboratory tests in diagnosis, he opined that ‘All fever except viral fever need basic laboratory parameter support’. He clarified, when asked about the platelet count and its relevance, that ‘Unless and until platelet count becomes normal we cannot discharge a patient’. During  follow up at the patient’s residence, the patient commented about the illness: . . . as there was discoloration in urine together with body pain and rashes in the body, I checked serum bilirubin from a nearby lab and as the value was higher than the normal, I went to the hospital.

In the above interaction, after the initial problem-identification session, the urge of the physician for the medically relevant information becomes clear, as it sidelined the patient’s doubt (4P) about jaundice. The way the physician ensures/justifies his findings to himself is visible in his use of expressions like ‘viral infection’ and ‘typical clinical symptoms’ in English (6D). These are the textual terms that shape the physician’s thought style or clinical mentality. It appears that, in a society where English is neither the mother tongue nor the common language, the use of English terminology in clinical interaction has to be seen as the point

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at which the translation2 of clinical presentations (patent’s illness) to textual knowledge (medical categories) occurs. The moment the patient felt that the examination was over and before the doctor reaches a conclusion, the patient submits his analysis about the illness, by pointing to the fact that he is taking medicine for jaundice and his blood test shows an abnormal value (4P). Here, the fact that the patient associates serum bilirubin and its raised value to jaundice, which is logically possible, is a way of expressing his illness in medical terms. In other words this is the medicalised voice of illness that can be heard in many clinical interactions. These medicalised voices may or may not be relevant to the physician as contextual factors determine whether to associate rise in serum bilirubin to jaundice. The response of the physician may be either acceptance or rejection. In the above case, it is clear that the physician rejected the medicalised voice of the patient and supplanted it with authoritative voice of medicine—a voice of medicine in which the clinical diagnosis overrules the laboratory values of serum bilirubin, the latter provided by the patient’s medicalised voice of illness. This is despite the fact that the physician is dependent more on laboratory tests for clinical diagnosis and for fever care as reflected in the physician’s response to the need for laboratory tests (platelet count) in fever care. The prevalence of dengue fever in the area might have possibly influenced the doctor to suspect the case as an instance of dengue fever, as reflected in his advice for admission and checking platelet count everyday till discharge from the hospital. This is because in cases of measles rarely are the patients admitted and their platelet count taken. In other words, the above case also shows how, during epidemics, threat and medicalisation influence each other forming a vicious circle that aggravates the process of medicalisation. This medicalised voice of illness has to be seen as an outcome of the patients’ past experiences with illness and the western medical system, resulting in a state which R. Crawford calls ‘healthism and medicalisation of everyday life’ (1980). He argues that Past therapeutic experiences and notions derived from diffused medical idea as well as reinforcing ideological premises of the society acquired by other means pre-structure the encounter (therapeutic). The client (patient) is already, in a sense ‘professionalised’. In other words, persons being helped take on as their own some of their helpers’ theorised assumptions and explanations (ibid.: 373).

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In the above case, it is the medicalised voice of illness that was heard. This goes well with the argument that the patient’s context offers a ‘professionalised’ outlook about her/his illness and everyday life. A similar but different phenomenon that occurs during clinical interaction is the genesis of new categories; this is shown in the following case.

Therapeutic Interaction: A Site of Knowledge Production Saritha, a 21-year-old woman went to a Community Health Centre complaining fever, headache, and weakness. Her father accompanied her. She belongs to a lower-income-group and hails from an extended family. Her parents are daily-wage labourers, and there are two elder brothers, of which the eldest is married and has two children. Saritha occasionally works in the cashew factory depending on the availability of job. The Community Health Centre does not have regular laboratory test facilities; these tests have to be carried out at private laboratories situated on the premises. As there is overcrowding at the Centre, the duration of interaction was too short. The physician was a 52-year-old man. He has a basic medical degree with specialisation in child health; he has been practising for 25 years. The interaction between the doctor and the patient proceeded as follows: 1D: What is the matter? 1P: Fever, headache and weakness in hands and feet. 2D: For how long? 2P: One week. Everybody in the house has this. 3D: Vishapani (poisonous fever) is there, could be that, it is better to get admitted.

The patient got admitted after getting the laboratory tests done. After four days, she was discharged with medicines prescribed for one more week. According to the doctor, the illness was ‘viral fever’. This case shows how, during doctor-patient interaction, certain kinds of information get internalised by the patient and how such information later forms a new category for the public. This was clear from what the patient said at her home during the follow-up visit: The illness was vishapani. This is not like earlier ones. There is something poisonous that enters the body. That is why this is very severe.

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The doctor’s version about this illness makes the picture complete: . . . it is just viral fever. Since the patients won’t understand it if we say ‘viral’ it is convenient if we use ‘visham’ (poison) instead of viral as the virus when it enters the body becomes poisonous.

The fact that this was indeed a physician-created category, created ostensibly for patients who may not understand, was borne out by a number of other patients using the same category of vishapani to express their illness. One of the patients, who himself considered his illness as vishapani, when asked about it, responded by saying: . . . last time I came with symptoms of fever and body pain then the doctor said that this is vishapani—a new type of fever with severe symptoms.

It is obvious that the context of doctor-patient interaction becomes a site of knowledge production, a knowledge that can determine the patient’s understanding of and behaviour during illness.

Conclusion This paper has been an attempt to show how doctor-patient interaction takes place in a clinical setting as part of fever care. The duration of interactions was very short and in local health institutions in which clinical interaction is minimal. The three cases describe clinical interaction in an Indian setting and how these interactions are outcomes of the socialisation of the actors involved. The clinical interaction is not merely the two-way communication desired for exchange of information; it is the product of the networks through which those actors involved are communicating. In other words, the interaction is the outcome of the socialisation of doctors and patients in their respective contexts. This is similar to the notion of thought style used by Fleck in the case of physicians (cited in de Camargo 2002) and life-worlds in the case of patients (Mishler 2005). It is in this context that the interactions between doctor and patient become the interaction of various voices, where voices themselves are representations of illness from various realms. L.J. Kirmayer deals with the real complexity of this interaction when he says that Doctor and patient are attempting to communicate, but their conversation is heavily constrained by the demands of the situation and their efforts to

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Voice of Illness and Voice of Medicine in Doctor-Patient Interaction 113 present an appropriate face to each other. Each speaks from a different position, which includes awareness of both the interactional context and its relationship to larger social spheres. Each speaks with the voice of the self but invokes the voice of others (2000: 169).

It has to be noted that the study was conducted in Kerala where recurrent epidemics and deaths due to various kinds of fevers were reported since the mid-1990s. The media reports and several control programmes initiated in the state generated a pervasive feeling of threat among the public about fevers. In Jincy Joseph’s case, it is clear that the problem the patient put forth is a social one: the patient and her mother tried to present the problem in terms of the patient’s inability to perform everyday life activities. On the contrary, the doctor keenly searches for medically-valid findings that have physiological explanation. Two different notions about the same event are in fact the reflection of each of their lived experience and the respective role they perform. The doctor’s aim is to settle the issue by a diagnostic and prescriptive act, whereas the patient’s purpose is to seek relief. Here, I would like to refer to the concept of institution advanced by Saris (1995) mentioned earlier. In the three cases, the manifestation of institutions is varied. In the first case, the threat about fever was the guiding force in the patient’s understanding of her illness as reflected in her response towards treatment-seeking. In the second case, the patient articulated the medicalised voice of illness, showing the patient’s dependence on western medicine in general and medical technology in particular, that ultimately reached a state of communicating illness in a language close to medicine. This de Camargo describes as ‘how lay people rely on expert systems in every day life, meaning the myriad of technologies that we interact with on a daily basis without really having a firm grasp on how they work’ (2002: 830). The institutions with which the patient engages—the health institutions, the dominant discourse about fever in the society, one’s own experience with illness—play an important role in the patient’s understanding of health, illness, and cure. This is obvious in the third case, where new category/knowledge (for instance, vishapani) is produced in a clinical setting which is part of neither medical knowledge nor lay knowledge. It is not possible to draw a general pattern from these interactions, but the meaning of illness/disease and, therefore, the outcome of medical care will be determined depending on the institutions prevalent in which clinical interactions occur and the actors involved.

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Notes I am indebted to my guides Dr Alpana D. Sagar, for her valuable inputs emanating from her expertise as a physician and a public health professional, and Dr Harish Naraindas, for his sociological inputs, especially on narrative analysis. I sincerely thank the anonymous referee for meticulously going through two drafts of this article and offering invaluable comments for its improvement. 1. Their interaction is denoted as follows: D—doctor (physician); P—patient; MoP— mother of the patient. The number indicates the order of interaction. 2. It is noteworthy that only few English terms are used during the whole clinical interaction. The medium of medical education being English, it is possible that physicians have internalised medical categories and terminology in English and are not concerned with translating them into Malayalam for the benefit of the patients or their relatives.

References Addlakha, R. 2001. ‘State legitimacy and social suffering in a modern epidemic: A case study of dengue haemorrhagic fever in Delhi’, Contributions to Indian sociology, 35 (2): 151–79. Advani, M. 1980. Doctor patient relationship in Indian hospitals. Jaipur: Sanghi Prakashan. Atkinson, P. 1995. Medical talk and medical work: The liturgy of the clinic. London: Sage Publications. Crawford, R. 1980. ‘Healthism and medicalisation of everyday life’, International journal of health services, 10 (3): 365–88. Czarniawska, B. 2004. Narratives in social science research. London: Sage Publications. Emanuel, J.E. and L.L. Emanuel. 1992. ‘Four models of the physician-patient relationship’, Journal of American Medical Association, 27 (16): 2221–26. de Camargo, K. Rochel. 2002. ‘The thought style of physicians: Strategies for keeping up with medical knowledge’, Social studies of science, 32 (5–6): 827–55. Fox, Rene C. 1957. ‘Training for uncertainty’, in R.K. Merton, G. Reader and P.L. Kendall (eds.): The student physician (207–41). Harvard: Harvard University Press. ———. 2000. ‘Medical uncertainty revisited’, in L.A. Gary, Ray Fitzpatrick and Susan C. Scrimshaw (eds.): Handbook of social studies in health and medicine (409–25). London: Sage Publications. Frank, Arthur. 1995. The wounded storyteller: Body, illness and ethics. Chicago: University of Chicago Press. Friedson, E. 1970/2001. ‘The profession of medicine’, in M. Purdy and D. Banks (eds.): The sociology and politics of health: A reader (130–34). London: Routledge. George, Mathew. 2007. Interpreting fever talk and fever care in Kerala’s socio-cultural context. PhD Thesis, Centre of Social Medicine and Community Health, School of Social Sciences, Jawaharlal Nehru University, New Delhi. Ghosh, I. and L. Coutinho. 2000. ‘An ethnography of cholera in Calcutta’, Economic and political weekly, 35 (8–9): 684–96.

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Voice of Illness and Voice of Medicine in Doctor-Patient Interaction 115 Good, B.J. and M.D. Good. 2000. ‘Clinical narratives and the contemporary doctor-patient relationships’, in G. Albrecht, R. Fitzpatrick and S. Schrimshaw (eds.): Handbook of social studies in health and medicine (243–58). London: Sage Publications. Heritage, John. 2004. ‘Conversation analysis and institutional talk: Analysing data’, in David Silverman (ed.): Qualitative research: Theory, method and practice (2nd edition) (161–82). London: Sage Publications. Kirmayer, L.J. 2000. ‘Broken narratives: Clinical encounters and the poetics of illness experience’, in M. Cheryl and C.G. Linda (eds.): Narrative and the cultural construction of illness and healing (153–80). Berkeley, CA: University of California Press. Leiblick, A.; R. Tuval-Mashaich and T. Zilber. 1998. Narrative research: Reading, analysis, and interpretation. Thousand Oaks: Sage Publications. Mattingly, C. 1994. ‘The concept of therapeutic “emplotment” ’, Social science & medcine, 38 (6): 811–22. Mattingly, C. and L.C. Garro. 1994. ‘Introduction: Narrative representations of illness and healing’, Social science & medicine, 38 (6): 771–74. ———. 2000. ‘Narrative as construct and construction’, in M. Cheryl and C.G. Linda (eds.): Narrative and the cultural construction of illness and healing (1–49). Berkeley, CA: University of California Press. Mccormick, James. 1979. The doctor: Father figure or plumber. London: Croom Helm. Mechanic, D. 1976. The growth of bureaucratic medicine: An inquiry into the dynamics of patient behaviour and the organisation of medical care. New York: John Wiley and Sons. Mishler, E.G. 2005. ‘The struggle between the voice of medicine and the voice of lifeworld’, in Peter Conrad (ed.): The sociology of health and illness: Critical perspectives (7th edition) (7–19). New York: Worth Publishers. Oommen, T.K. 1978. Doctors and nurses: A study in organisational role structure. New Delhi: McMillan. Parsons, T. 1951. The social system. London: Routledge and Kegan Paul. Sanjek, R. 1990. ‘On ethnographic validity’, in R. Sanjek (ed.): Fieldnotes: The makings of anthropology (385–418). Ithaca and London: Cornell University Press. Saris, J.A. 1995. ‘Telling stories: Life histories, illness narratives and institutional landscapes’, Culture, medicine and psychiatry, 19 (1): 39–72. Seal, S.C. 1971. An introduction to hospital-patient relationship. Kolkata: Nababharat Publishers. Spradley, J.P. 1980. Participant observation. Belmont, CA: Wadsworth/Thomson Learning. Taussig, M. 1980. ‘Reification and the consciousness of the patient’, Social science & medicine, 14B (1): 3–13. Tuckett, David. 1976. ‘Doctors and patients’, in David Tuckett (ed.): An introduction to medical sociology (190–224). London: Tavistock. Waitzkin, H. 1979. ‘Medicine, superstructure and micropolitics’, Social science & medicine, 13A (6), 601–09. Yardley, Lucy. 1997. ‘Introducing material-discursive approaches to health and illness’, in Lucy Yardley (ed.): Material discourses of health and illness (1–24). London: Routledge.

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8 Narratives of Sickness and Suffering: A Study of Malaria in South Gujarat Purendra Prasad

T

he Latin word disease literally means the absence of ease, which is defined as a bio-pathological process that affects the organism. As Karl Popper (1972: 106) says, for the clinician, disease is experienced as present in the body. For the sufferer, however, the body is not simply a physical object or physiological state; it is an essential part of the self. Thus, disease is considered as a medical view of ill health, whereas illness is a much broader phenomenon than disease (see Young 1982; Turner 1987; Kidel 1988; Good 1994; Boyd 2000). Illness refers to the individual’s subjective awareness of the disorder. This awareness is articulated primarily through language. While the ‘disease model’ argues based on the mind-body dualism,1 the ‘illness model’ questions this reductionist theory. However, both disease and illness models take the individual as their object. Moreover, the illness model is interested in the issue of medical efficacy,2 that is, augmenting clinical medicine by way of enhancing patient education, remedying problems of non-compliance, and challenging maladaptive course of treatment. On the contrary, the social relations or sickness model questions both the biomedical model of disease as being equivalent to sickness and the explanatory model of disease as being equivalent to illness. Neither

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of these models explains the sociological background and context of sickness. Accordingly, physicians tend to think of non-health as disease; psychologists, as illness; and sociologists, as sickness (see Twaddle and Hessler 1987). Allan Young defines the concept of sickness comprehensively as follows: . . . the process through which worrisome behaviour and biological signs, particularly ones originating in disease, are given socially recognisable meanings, that is, they are made into symptoms and socially significant outcomes. Every culture has rules for translating signs into symptoms, for linking symptomatologies to aetiologies and interventions, and for using the evidence provided by interventions to conform translations and legitimise outcomes. The path a person follows from translation to socially significant outcome constitutes his/ her sickness (1982: 270).

This definition gives primacy to the social relations that produce the forms and distribution of sickness in society and recognises the wider social context. According to Young, therefore, the task is not simply to demystify knowledge but to critically examine the social conditions of knowledge production. The sickness model is interested in medical productivity and not efficacy alone, that is, identifying the direct and indirect impacts of particular clinical practices and perspectives on the levels of morbidity and mortality of the population at large (Ibid.: 279). Historically speaking, after the Renaissance, medicine has been characterised by a shift from person-oriented to object-oriented cosmology. Hence, it is always individuals who become sick, rather than social, economic or environmental factors which causes them to be so. As such, disease became more important than the sick person. Hence, while it is important to understand the conceptual differentiation between ‘disease’, ‘illness’ and ‘sickness’, it is also necessary to recognise that these concepts are no more than analytical categories. This is because, in the real world, it is difficult to separate the biomedical perception, the selfperception and the social perception. As long as there is this clarity of thought, it does not matter whether ‘disease’, ‘illness’ or ‘sickness’ is used to define suffering. The sociological understanding of suffering is that the patient is not an abstract being, but of a certain age, sex, caste, class and nation, and that he/she has internalised a specific historical experience from childhood to adulthood.

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A critical medical social science forcefully poses the question of when illness or sickness representations are actually misrepresentations which serve the interests of those in power, be they colonial powers, elites within a society, dominant economic arrangements, the medical profession, or empowered men. Critical analysis investigates both the mystification of the social origins of disease wrought by technical terminology and metaphors diffused throughout medical language, and the ‘social conditions of knowledge production’ (Ibid.: 277). Moreover, several factors have contributed to critical re-examination of biomedical or disease model by the medical world itself for the past two decades. The factors as pointed out by Leon Eisenberg include intolerable costs (either to individuals or to governments), inaccessibility of medical care because of poor distribution by locality and specialty, and dissatisfaction with the ‘quality’ of the medical encounter when it takes place, etc. (cited in Lock 1989). Within this conceptual framework, this paper attempts to understand sickness through a study of malaria in India. Sickness identification and prolongation of sickness (longer duration of sickness) are major concerns for policy makers. However, the whole discourse of preventive and curative models fixes the blame on the individuals and prescribes several health-education and behaviour-change programmes as remedies, instead of understanding and addressing the social conditions of disease production. Pursuing this line of argument, a few pertinent questions are raised in order to understand the recurring human suffering due to malaria and subsequent interventions. The narratives3 are explored in terms of semantics in the local context. What are the specific human factors that social scientific research highlights or undermines as the processes in the identification of malaria, its causes and subsequent treatment patterns?

Malaria in India: An Historical Assessment It is estimated that malaria affects 300–500 million people and results in more than one million deaths per year worldwide (McCarthy et al. 2000). The UNO statistics reveal that, aside AIDS, malaria is the only other disease that has been steadily spreading in the 1980s and 1990s. In India, there were 2,019,066 reported incidences of malaria and 946 malarial deaths in the year 2000. According to WHO estimates, the

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numbers exceed well over the reported cases, and that the actual numbers are around 15 million and 20,000 respectively (see http://www. who.org). The overall malaria situation in India remained unchanged until the 1940s, prior to the introduction of Dichlorodiphenyltrichloroethane (DDT). DDT was first imported into India for military purposes. In 1945, following the first major large-scale trial of DDT application along the Tennessee River (USA), it was made available to the Bombay Malaria Organisation in September 1945 for field trials in the rural areas of Dharwar and Kanara districts (now in the State of Karnataka). This had proved to be remarkably successful in the project areas (cited in Kamat 2000). Based on these results, the Government of India had launched the National Malaria Control Programme (NMCP) in 1953 with the support of WHO, USAID and the Rockefeller Foundation, during which time there was an estimated annual incidence of 75 million cases of malaria and annual incidence of 80,000 deaths. Within five years of the launching of NMCP, the incidence of malaria had drastically dropped from 75 million cases to 2 million cases. With the exuberant confidence over its success achieved in malaria control, the government renamed NMCP as NMEP (National Malaria Eradication Programme) in 1958, and implemented it as one of the vertical programmes in the country. By the year 1964, it was claimed that malaria was eradicated from 88 percent of the area and the remaining 12 percent could have been contained if the supply of DDT was maintained as scheduled.4 It has been pointed out that, starting with the shortages of DDT and malaria larvicidal oil, inadequate infrastructure in general and health services in particular hampered surveillance and vigilance. Inadequate staff in health centres and technical problems contributed to the rise in malarial cases (Sharma and Mehrotra 1986; Wessen 1986). Some studies fixed the blame on the movement of population (particularly rural migrant labour due to distress conditions), increased waterintensive cropping, labour habitats near construction sites and mining areas, delayed or piecemeal financial sanction to NMEP in certain states, and diverting basic health workers for other health programmes (see Rajagopalan et al. 1986). The annual number of cases rose again to over half a million in 1970. The Government of India acknowledged the gravity of the situation and abandoned the eradication strategy in favour of a strategy known as Modified Plan of Operation (MPO) (implemented in 1977)

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which emphasised control and containment (Sharma and Mehrotra 1986). In fact, since 1979, the incidence of malaria has shown no marked change in India and that the incidence of plasmodium falciparum has increased from 20 percent in 1965 to 50 percent in 2000 (Sharma 2003: 514). By the year 2000, when the situation was diagnosed as beyond control (leave alone eradication), the Government of India changed its nomenclature from NMEP to NAMP (National AntiMalaria Programme).5 Again in December 2003, NAMP was changed to VBDCP (Vector Borne Disease Control Programme). This shift from NMCP to NMEP to NAMP to VBDCP reflected not only a shift in the approach to the problem, but also the way it undermined the role of human beings in creating new epidemiological trends. This also brings to the fore the intensity of the communities’ suffering and high incidence of mortality and morbidity due to malaria, more particularly plasmodium falciparum.6 In a nutshell, India continues to experience malaria epidemic in different parts of the country every year. The gravity of the problem is emphasised by the fact that the Government of India has identified several districts in each state as ‘malaria endemic regions’ and decided as a policy to treat all febrile illnesses with anti-malarials as part of presumptive treatment. This, however, showed how bodies are being viewed or attended to in suppressing the apparent symptoms rather than addressing the persons, communities and their suffering in context. As Robert H. Black has argued: How often one reads or hears that malaria eradication failed because the vectors became resistant to insecticides and the parasites resistant to chloroquine. This is a nice ‘scientific explanation’ that appeals to hard scientists whereas the main reasons for failure have to be sought in the soft sciences—human behaviour, politics, economics . . . (cited in Wessen 1986: iii).

Malaria: The Processes of Prognosis It is recognised that, since malaria is a moving target, the control approaches/programmes to control it must constantly adapt to the changing patterns of epidemiology over the times (Shivlal et al. 1998). Recognising the high incidence and the changing epidemiological pattern of malaria, the NAMP issued directives and guidelines by which

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district health administration should predict and detect local malaria epidemics to initiate adequate control measures. However, the district health administration was provided neither the authority nor the competence to adapt to the locally acceptable methods of detection and treatment. Given the iniquitous social structure, caste hierarchy and economic disparities, on the one hand, and the high incidence of malaria and its geographical spread, on the other, it has not been possible to provide facilities for clinical diagnosis of malaria for majority of the affected persons. Moreover, technically it has been acknowledged that there are difficulties in developing a clinical definition of malaria, because of the wide variety of symptoms that occur as well as the increase in asymptomatic cases (for example, either severe headache or knee pain as in Surat district) in different parts of the country. Thus, to a large extent, malaria is being diagnosed based on physician’s experience (particularly of those in private practice). Majority (68 percent) of the affected persons consult private practitioners, who would normally not recommend clinical diagnosis because of its high cost (Prasad 2000). Furthermore, where local governments commissioned active surveillance during epidemics, it revealed a large number of undetected malarial cases. In a study on malaria epidemic in Mumbai, Vinay Kamat reports that ‘surveillance system actually picked up those fever and malaria cases that would have been left undiagnosed, untreated or most likely to be treated by a private practitioner’ (2000: 146). The prognosis of malaria, starting from collection of blood slides, efficient screening, appropriate skills of lab technicians, scheduled delivery of reports to the affected persons, follow-up of treatment, reputation of government run health centres, non-specified treatment provided by unregulated private sector etc., is quite complex. For instance, in order to detect malaria epidemics, the NAMP directs district health administration to find out if the increase in fever-rate reaches one-third or more of new OPD cases in dispensaries, primary health centres or hospitals during the current month; or rely on field-staff communication about the increase in fever cases. However, neither is the field-staff communication reliable nor do most sick persons visit the government-run health centres, thus resulting in a large number of undetected malaria cases in rural India. Our study (see Infra) revealed that most (78 percent) of the affected persons were labelled by the doctor as having malaria without

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any clinical test. This brings into focus how sickness is identified and labelled, and subsequently treated. In this context, people’s expression or articulation of sickness is a significant factor in terms of prognosis. People use various analogies and metaphors to describe and explain sickness. The terms used by laypersons to explain sickness often do not coincide with those used in the biomedical parlance and, hence, the scope for misunderstanding between sufferers and healthcare providers. At times, both may be using the same term for indicating different things and, at others, both use different terms to mean the same thing. For instance, when people say they are affected with ‘malaria’,7 they may not mean the same thing as medical professionals do, though both use the same word.8 It may be noted that less than one-third of the respondents indicated ‘malaria’ as one of the three most serious sicknesses in their village. However, placing malaria in the matrix of serious ailments has two main limitations. First, ‘seriousness’ has to be defined and, secondly, not all those who have reported knowledge about malaria necessarily mean it as ‘clinical malaria’. Several research studies have pointed out that a key step in studying treatment-seeking with respect to malaria is to identify local disease categories or illness terms that correspond to malaria (see McCombie 1994; Hausman 2000) and then devise appropriate policies and interventions.

Methodology The data for this study was part of a larger multi-disciplinary research project sponsored by the Government of India (involving entomologists, epidemiologists, social scientists and health policy makers) with the aim to develop a strategy for malaria control and prevention. The study was conducted over a period of five years (1995–2000) in Surat district in Gujarat. During this project period, three interventions— Insecticide Treated Mosquito Nets (ITMN), Indoor Residual Spray (IRS), and Early Detection and Prompt Treatment (EDPT)—were tested out in forty-two villages in each zone (coastal, plains and hilly)9 covering altogether 126 villages. Social science component in the larger project had three major objectives: (i) to carry out fieldwork through participant observation method and collect data on perceptions of illness and health, particularly on beliefs and practices surrounding treatment of fever; (ii) to prepare

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reports setting out the findings of the field work and discussing the implications for introducing modern scientific knowledge about the transmission and treatment of malaria to the local population studied; and (iii) to advise on the setting up of training programmes for health workers in rural areas and health promotion and training programmes in urban areas incorporating research gathered during field work. Accordingly, we selected three villages, one intervention village each from three different ecological zones—Karanj in the coastal, Sathvav in the plains and Khogalgam in the hilly zones—for intensive study. These villages were chosen primarily keeping in mind the needs of interventions proposed by the MCRP. The research team comprising one principal investigator and one research assistant spent about six months in each village. Participant observation was used to understand people’s perceptions on diseases in general and malaria in particular. Tools of data collection included unstructured interviews, group discussions, case studies and discussion with key informants. After one year, two more villages in each zone were subjected to intensive study for further clarity. The findings of these nine villages were validated through a structured questionnaire in eleven villages in each zone, thus covering 976 households (15% of the total households) in thirty-three villages. Similar methodology was used in ‘non-intervention villages’ (1,704 households) in order to compare the findings of ‘intervention villages’ (see Lobo et al. 1998 and 2000).

‘Lay’ Perceptions of Malaria: View from the Field Health was something that one ‘possesses’ normally in the course of life, whereas sickness can be avoided by eating appropriate food as per the season, by good action, by warding off evil, and by propitiating the appropriate deities. There are different types of sickness, one associated with physical body (rising temperature, injury through accidents, etc.), the cause of which is perceived as internal; and the other, with non-physical activities (bad actions, fevers due to external agents, etc.), the cause of which is external. It is important to understand this overall attitude before various concepts and perceptions about sickness and treatment are discussed from the field data. In Surat district, bimari and mandgi are the local terms used for sickness. If a person is sick for short duration,10 he/she denotes it as

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bimari, while it becomes mandgi if it is for a longer duration. Bimari includes cold, cough, fever, diarrhoea, etc., while mandgi includes jaundice, malaria, typhoid, etc. The term rog is used to indicate chronic sickness like TB, cancer, asthma, paralysis, arthritis, skin diseases, etc. The main criteria used to indicate rog was ‘continuous attention’ required; sicknesses that cannot be easily cured; and fatality, economic cost and abnormal time it demands. The duration of sickness also, in fact, distinguishes these three concepts of sickness—bimari, mandgi and rog. Malaria11 is bimari for some, while it is mandgi for others, depending upon their perceived sickness, intensity of pain, frequency of sickness etc. The reference group is always their own family members or kin group who were affected with intense sickness. In the instance of malaria, another common term used by the communities to describe their sickness was tav in Gujarati and jora in tribal (Gamits) dialects meaning fever. The words tav and jora originate from the Sanskrit words tapa and jwara meaning fever. The symptoms of tav were further elaborated as body temperature, internal heat/pain in the body (kadtar tav/dukhavo), ‘steam comes out from the body’ (sharir dhagu dhagu thaye), uneasiness (jeev ukalat); acute ‘tearing’ pain in limbs (hath pag fatva made), loosening of the body (sharir dhilu dhilu lage); severe headache (mathu fati jatu hoi tem bahuj dukhava lage) etc. Ashakti was another term used to describe their sickness, implying their condition of sickness rather than a label for the sickness. These terms or narratives not only indicated physical abnormalities but also social problems or complications in day-to-day life. Furthermore, the biomedical term ‘malaria’ is being understood in a varied sense in the study area. The word tav (fever) opens the window for understanding specific pain affliction and suffering expressed through different semantics. If a person said he/she was afflicted with zeri (poison) tav, it may indicate the intensity of fever in terms of high temperature, pain, etc. or that somebody with envy/jealousy may have performed witchcraft on him/her. Similarly, communities use the words simple malaria (sado malaria) and poisonous malaria (zeri malaria). Sado malaria, to a large extent, indicated physical pain, whereas zeri malaria meant several things—like malaria afflictions due to bad intentions or punishment for some wrongdoing etc. The local medical practitioners use the terms zeri tav and zeri malaria to refer to plasmodium falciparum and other tavs to refer to plasmodium vivex. However, it may not be possible to make these simplistic distinctions in terms of semantics used

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without understanding the complex situation the people are describing. This was quite evident, say for instance, about their knowledge of malaria. Even in the non-trial12 villages, the study revealed that 97 percent of the 1,704 households claimed to know malaria. However, only three-fourth of those who claimed to know malaria could describe the cause (that is, the malaria-mosquito link) and symptoms of malaria as per the generally accepted clinical knowledge. Similarly, there were varied semantics used which indicated specific pain in terms of frequency, body sites, cause, seasons etc. Frequency: Fevers related with frequency of occurrence like alternate day fever (antario tav or ekantario tav), fever occurring in turns on the same day (varino tav, varkiliya jora), fever occurring daily (rojiyo tav), fever occurring fortnightly (mudati tav), fever occurring every fourth day (chouthiyo tav). Fevers/pain on body sites: Few respondents described stomach pain (petmadukhavano tav, khad jora), saying ‘I felt something was moving in my stomach, I felt like vomiting; also had slight cold and fever’. Other descriptions included pain in the head (ardha mathanu tav, adhiheeno jora), fever due to ache in the waist (kamar dukhavano tav); fever resulting from cold and shivering (thadiyo tav, kapro tav, kapro jora), fever from cold (sardino tav), fever from cough, (khansino tav); fever with shivering (hihee jora, also thandino tav), body feels torn apart, knee pain, feeling a compulsion to hold the limbs together and desire for sleeping (tutino tav). Haddino tav is the fever in the bones followed by a feeling of lethargy. Fevers linked to causes: like tiredness (thakno tav), big and small rashes (fullino tav, chandano tav, pikhala jora), hot winds (loono tav, garmiwalo tav), and bad air (bura pavan)—which referred to unnatural forces (baharni asar). Season: Fevers occurring in different seasons—monsoon, winter and summer—were indicated by barasati tav, thandino tav and garmino tav. Across the district, different social groups used various semantics for expressing similar pain/suffering. For instance, antario tav was used in multi-caste villages in the coastal zone; varino tav, in the plains (both tribe and caste villages); and varkiliya jora, in the tribal hilly zone. Similarly, some fevers have different names even within the same village, like antario tav, which is same as ekantario tav (fever that comes on alternate days). Another example is zeri tav (poisonous fever) and magazno tav (cerebral fever) which are used synonymously.

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Fluidity of tav: As far as the consequences of fevers are concerned, there are some fevers which turn into more serious diseases/sickness. For instance, zino tav (simple fever), followed by an uneasy feeling in the stomach, resulting in moto tav (intense fever). This intense fever causes rise in the proportion of blood in the body and may lead to malaria (biomedical term) or jaundice or paralysis. The extent to which these local disease categories represent true malaria is variable. In principle, broad terms that can be translated as ‘fever’ should incorporate most cases of malaria, though they include other diseases as well. For instance, certain other terms like uthal pathal (upsets), gabhraman (fear), peeda (pain), ashakti (weakness or fragility), bechani (uneasiness), kam karvanu man na thai (lethargy) and khavanu man nathi lage (loss of appetite) were expressions used along with tav (fever) to describe their suffering/symptoms. These semantics, emanating from their bodily experiences, to describe their pain and sickness have no meaning in a different context. Moreover, these semantics, expressed to indicate their pain in terms of ‘sickness in itself ’ and ‘symptoms’, do not get acceptance because the words used neither coincide with the biomedical term malaria nor the sequence of ‘signs’. The cases described below narrate the complexity of the sickness situation and treatment patterns. Case 1 Dhansukhbhai Gamit, an agricultural labourer aged 32 years, who lived in the village Kosambiya, had fever. When he felt sick, he did not even disclose this to his family members for the first two days, and it was also the period when sugarcanecutting operation was at its peak. When it became unbearable, he revealed it to his family members and on the advice of his grandfather (who has knowledge on herbs/roots, that is, jadimudi), Dhansukhbhai consumed crushed juice of neem bark for two days. When the fever did not subside, he went to Dr Kiritbhai, a private doctor in Valod, at a distance of 4 km from the village. When the doctor enquired and asked to narrate the symptoms, he revealed saying that he had sado tav (simple fever) and ashakti (weakness), that he was not able to eat and often felt thirsty, and that he did not feel like working. The doctor did not tell him what he was suffering from, but he gave antibiotics and paracetamols for three days along with an injection. After two days, when the temperature got aggravated, he went to Dr Pawar in Valod, another private doctor. On enquiry, he revealed the same symptoms, but emphasised on weakness, for which Dr  Pawar asked

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him to take an injection, and prescribed paracetamols and multivitamin tablets. Within a day, the situation became worse, and he was forced to get admitted in a government-run community health centre. The blood-slide examination revealed that he was suffering from malaria, and was treated accordingly. Upon interviewing, both the private practitioners said that it was not possible for them to send large number of poor sick persons for blood-slide examination, which is expensive in private laboratories. They also feared that the poor sick would never return to them for consultation because of the expensive treatment. When Dhansukhbhai Gamit was asked as to why he had not consulted the government-run health centre at first instance, he and his family members expressed apprehensions about the treatment available there. They also wanted to consult private doctors to recover quickly so that he did not lose wages, as he is the main breadwinner.

Case 2 Savitaben Rathod, aged 35 years, is an agricultural labourer, who also works as ‘helper’ in domestic work in Timberva village. When she was not well, she waited for a day and bought four tablets from a local shop (ganchi ni dukan) and consumed them in the next two days. On the fourth day, as the symptoms persisted, she consulted Dr Chandubhai, a private doctor at Mohini, which is 2 km from the village. When the doctor enquired about the symptoms, Savitaben said that she had fever (tav) along with limb ache (hath pakh phate), fear (gabhraman) and weakness (ashakti lage). On hearing the symptoms, he gave an injection and prescribed tablets for two days symptomatically. She was curious to know about the diagnosis, but the doctor did not say anything. She consulted the doctor thrice, every alternate day, that is, for five days, and took three injections but took the tablets only for the first two days. Her perception was that if she takes more tablets, the body gets hot; hence, she did not consume all the tablets, though she spent Rs 20 for each visit to the doctor. The doctor advised her to take ‘cold food’ (particularly milk), but she did not, as her family could not afford it. The body temperature was reduced, but her back pain, cough, fear and weakness persisted. After three days, she became seriously unwell and all the symptoms along with the fever aggravated. She went to another private doctor, who immediately asked her to get admitted in Sardar Trust Hospital, but when they approached, it was beyond their ability to bear the cost of treatment. She was taken to a government hospital and was diagnosed as having malaria and treated for the same. (Case 2: Contd.)

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(Case 2: Contd.) In this case, discussion with the private doctor revealed that the symptoms described by her did not indicate malaria. Savitaben went on expressing fear and weakness as major symptoms because of the huge indebtedness they had ended up due to crop loss in the previous year as well as the unanticipated death of a milch cow, which provided significant income to meet household expenses on day-to-day basis.

These two cases revealed the anxiety with which both the sufferers and healthcare providers are negotiating sickness situations. The method of identification of sickness becomes much more problematic because the affected persons are narrating the sickness in its specificity, whereas the healthcare providers are looking for clinical translation of symptoms into signs without taking into account the social circumstances. Byron Good (1977) showed through his study in Iran that ‘heart distress’ was used sometimes to name an illness, sometimes as a symptom, sometimes as a cause of other illnesses. Heart distress in Iran’s context meant worry about poverty, nerve distress, sadness, anxiety, anger—all of these can be caused or exacerbated by living in poverty. Similarly, in the explanation of ‘sinking heart’ (kamjori) by the Punjabis living in Bradford, IngaBritt Krause (1989) says that, illness complex was conceptualised as a set of physical signs, emotional sensations, and feelings and social circumstances which once triggered off tend to be perpetuated and experienced again and again. Narrating similar usage of semantics of pain, Judy Pugh (1991) remarks that pain behaviour in India incorporates a range of styles appropriate for specific categories of persons, situations and types of pain. Thus, the medical way of thinking focuses exclusively on physical abnormalities ignoring the sufferer and her/his attributes as human persons.

Two Perceptions of Malaria: A Sociological Analysis My purpose here is neither to come up with an inventory of local illness semantics nor justify it, but to highlight two contrasting worldviews, where each group is operating in its own frame of reference and hence

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unable to negotiate sickness situations. As Sanjyot Pai (2003) points out, the physician and the patient experience sickness in significantly different ways. Therefore, sickness, in effect, represents two distinct realities rather than representing a shared ‘reality’ between them. A shared world of meaning between the healthcare providers and healthcare receivers largely does not exist. Despite their limited economic, political and social resources, including access to education, health and affordability to modern medical practitioners, communities have enormous trust in and expectations of the modern system of medicine. One could find communities grappling with their own sickness- and suffering-narratives, as they are unable to reach out to the realm of modern institutions and its practitioners. Instead of understanding the struggle and transition of the communities to negotiate space for quality life, one finds a major discourse emanating from both medical and non-medical domains undermining people’s ability to comprehend sickness situations. Consequently, biomedical as well as social scientific literature to some extent advocates providing health education in order to set free the communities from their ignorance. Technically speaking, surveillance, detection and prompt treatment are considered as crucial factors in not only reducing large number of malaria cases, but also in preventing potential community carriers of parasites (Hausman 2000). As policy makers also admit, only when communities participate in large numbers in the anti-malarial programmes designed by the government, the detection of cases is possible. With the lead role provided by international funding agencies in advancing the rhetoric of ‘community participation’ in all the development programmes, NMEP or NAMP in India can hardly be an exception to it. There is little evidence if one were to examine healthcare policies and its implementation to find locally acceptable methods of identification of malaria. In other words, community perceptions and the ways and means of negotiating suffering, whether it is malaria or any other disease situation, has never been uncovered. The recurrent incidence of malaria and other fevers initiate a process of rationalisation of what comes to be constituted as ‘endemic’. The underlying reasons for the failure or non-compliance by the malaria-affected persons need to be understood, rather than letting loose a victim-blaming process. The commonest forms of evading social responsibility is to identify ‘certain group character’—‘defaulter’, in

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the case of Tuberculosis; ‘non-compliant’, in the case of malaria; and ‘uncooperative’, in the case of leprosy. In addition, specified group of people—migrants, rural women, illiterates, etc.—have been identified as community carriers of malaria parasite. Several studies have pointed out that the prominent social response that emerges during epidemics is the shifting of responsibility and blame to the other (see Ghosh and Coutinho 2000; Prasad 2000). On the one hand, sufferers, particularly women and the aged, have hardly any option but to resort to available healing processes within the community (elders of the family/kin, traditional healers—herbalists, faith healers, etc); on the other hand, treatment providers and health administrators blame the people in terms of their beliefs, superstitions and value systems.

Linear Causation by Major Cause Similar to sickness identification, causes of sickness also indicate differential pattern between medical and lay narratives. However, a deeper understanding of these narratives reveals that persons with sickness and their families are confronted with several sickness dichotomies prior to their response to sickness. Apart from mosquitoes as a cause of malaria, getting drenched in rain, physical work for long hours, exhaustion, tiredness, working under hot sun, bad air, bad weather, baharniasar,13 eating certain types of food like cucumber, custard apple, stale food, etc. are some of the ‘causes’ of malaria/local fevers as revealed in this study. A young person (a tribal Chodry, who is educated up to primary level and holds a private job) with fever said ‘since last week the weather was moist due to rain. Hence, there was shivering, blocked nose, body ache and headache, which all culminated into tav gripping me. Later the doctor told me that it is malaria’. In another case, a tribal male (aged 32 years) described how his fever began. After completing his weeding work in the field, as he was returning home, he felt chakkar (giddiness) on the way. His body started paining and he began feeling cold. By the time he reached his home, he was gripped by the fever. It began to rise further. He said, some fevers/ malaria are accidental/coincidental after getting tired or exhausted working under the sun, or due to bura pavan (bad air).

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The causes of malaria narrated in all the study villages are very dissimilar. Some of the causes are sheer coincidental such as getting wet in the rain. However, the communities’ perceptions on the causes of malaria could be classified thus: physical work (hard work), bio-chemical (change in water), supernatural (sorcery), psychological (tension), seasonal (getting wet in rain), contagious (close contact with malaria patients), loss of crop or any misfortune (anxiety) etc. In this multiple causative logic, one major dichotomy that arises is between natural (kudrath) and unnatural (baharni) causes of malaria. This dichotomy is crucial or a liminal phase of sickness. One starts introspecting her/his own life-world and social events that take place during that particular period of sickness. In their multi-causal analysis, baharni asar as a cause cannot be ruled out in any sickness. However, medical aetiology denotes mosquitoes as the only causative factor and dismisses other factors as having no relevance in the process of treatment. This not only widens the critical gap between groups of sickness sufferers and healthcare providers, but also results in the under-diagnosis of malaria cases evident in the study area. Naming a specific cause for a disease is not sufficient. It is essential to find a pattern of events that makes the patient to become vulnerable to specific causes of disease(s). It is also reported that most deaths due to malaria remained unreported in different parts of India (see Rana and Johnson 2003). Apart from causing mortality, malaria gravely weakens many of its affected persons, making them susceptible to other life-threatening illnesses such as pneumonia, anaemia, or dysentery. As Watts Sheldon (1999) notes, in addition to its role as a killer and weakener, malaria was an element in that vicious circle which makes the poor malarious and the malarious poor. In fact, a single set of signs can designate more than one sickness and social forces help determine which group of people get which sicknesses. As Vijay Kumar Yadavendu points out, ‘The taking of a purely medical history individuates the patient; however, the disease or injury from which the patient is suffering, is received as part of a collective experience in a particular historical, cultural and social setting. These latter circumstances are as much a part of the cause, and should be part of the treatment as purely medical facts’ (2001: 2787). This is also ironic since the problems of ill health and disease in the Third World countries is entirely of a different order, located in hunger, poverty and infection, all of which have social bases.

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Interventions and Specific Groups Anti-malarial programmes also need to identify specific groups and devise appropriate interventions rather than offer generalised services. A special focus is required for all the tribal communities across the country, as malaria takes a high toll on these communities. Although tribal communities account for 8 percent of the total Indian population, it contributes to 30 percent of the total reported cases of malaria and 50 percent of malarial deaths (ICMR 2004). Similarly, other specific groups, such as women, children and the aged, need to be focused. For instance, though research indicates that, in terms of prevalence and incidences of malaria, men outnumber women in the country (approximately 1.39 to 1), women disproportionately bear the economic burden of disease and illness. When members of the family fall ill, there is labour substitution to maintain the income and functions of the family unit; and the burden of labour substitution tends to fall disproportionately on women. Maternal health is also critical for infant health. Malaria is the leading cause of anaemia and low birth-weight babies. Thus, malaria is also a cause of infant mortality and threatens life-long morbidity. Malaria prevention among children also needs to be a priority since it is one of the leading causes of mortality and morbidity for children under the age of five. Migrants form another category of people that requires a great deal of attention. In South Gujarat, there is surveillance on migrants. For instance, in Surat city, migrants need to seek special permission from the municipal authorities both before and after arrival into the city, as the migrants are the suspected carriers of protozoa. However, the surveillance is restricted to identifying actual malaria cases and sending back the malaria affected migrants to their respective home states, rather than to providing treatment. Instead of targeting the migrants, they need to be provided with special facilities in accessing health services. As provisions of public health infrastructure in terms of access to healthcare, safe drinking water and sanitation have collapsed, the migrants, rural poor and urban poor are increasingly becoming vulnerable to the malarial fevers. In addition to this, caste issue continues to plague the malaria control programme and health system in general. In rural areas, the continuing stigma of untouchability remains painfully obvious and detrimental to the health and livelihood of the lower castes. Additionally, the

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impoverished state of many of these castes only compounds this problem of access and capabilities. Ill health is not a problem by itself, it is rather a symptom of deeper socioeconomic injustice. As Sheila Zubrigg (2001) avers, ill health can be interpreted as a form of institutionalised violence in society.

Discussion It is evident from the study that an analysis of disease/health that isolates the individual from her/his social environment not only fails to identify sickness as well as address contributing and causative factors, but implicitly accedes to the continuation of power arrangements in social relations. The problem identified with description or narration of local illness categories is its failure to link these categories to the larger systems of domination that often influence or even generate them (Farmer 1988). It is the state and civil society groups, which lacked commitment to provide basic needs, particularly public health facilities and ‘education’,14 to the rural communities for the last five decades, which created a huge gap between healthcare providers and receivers. Instead of empathising with the struggling communities and their suffering, one finds ‘victim-blaming’ as a predominant agenda taken up by the healthcare bureaucracy and policy makers. State and civil society groups, which failed to create conditions for self-realisation of individual capabilities, do not hesitate to put the blame on the dependency syndrome of the people. The findings from the malaria-affected persons revealed that communities have lot more expectations from the modern medical institutions, which are not able to live up to the aspirations of the larger masses. Hence, understanding sickness from the ‘sufferers’ point of view holds the key to any intervention in the area of tropical diseases. As Arthur Kleinman et al. rightly observe: Social suffering brings into a single space an assemblage of human problems that have their origins and consequences in the devastating injuries that social force can inflict on human experience. Social suffering results from what political, economic and institutional power does to people and reciprocally, from how these forms of power themselves influence responses to social problems (2001: ix).

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People have given fifty different local names for fever. It will be useful to put these fevers into categories of malaria and malaria-like fevers, so that policy makers do not miss out the malaria cases just because they do not use the same nomenclature for an illness. Aetiology, however, cannot be different. There may be hundred reasons for getting fever, but malaria is transmitted through mosquitoes. Sometimes when people describe malaria and malaria-like fever as baharni asar and its aetiology as an evil force (through dakan) in the form of an insect, what it means is the same. This is simply because the biomedical scientists view it as a parasite, while communities view it as an insect; it is only a difference in language. Given the intense suffering due to malaria, V.P. Sharma (2003: 514) boldly suggests that higher levels of funding, cooperation, effective health and malaria education, though necessary and important, offer only a part of the solution to malaria. These approaches fail to address the greater socioeconomic concerns that, if corrected, would revolutionise health in the country. There should be access to medical services for anyone in medical need (Daniel 1985). However, specific non-medical features of individuals—their caste, gender, and politicoeconomic location—actually determine whether or not they have access to healthcare.

Notes This is a revised version of the paper ‘Conceptualising Health: A Study of Malaria in Gujajrat’ presented at the seminar on ‘Health and Society: Issues and Concerns’ organised by the Department of Sociology, Goa University on 5–6 March 2003. I am thankful to the organisers of the Seminar for the invitation. I am grateful to the anonymous referee for her/ his useful comments and suggestions that helped me revise the paper substantively. 1. Rene Descartes provided a highly influential conceptualisation of the mind/body/ senses relationship. His formula ‘cogito, ergo sum’ (‘I think, therefore I am’) was linked at one level to a complete devaluation of all the body’s senses. Such an approach exposes the western philosophy’s inability to deal comprehensively or consistently with the human body (cf. Mellor and Shilling 1997: 6). 2. Medicine may be efficacious; it may nevertheless have little or no positive effect, as is evident in the case of tropical and other diseases in India. 3. Narratives are not individual accounts, but collective social accounts of the struggling communities. 4. The factors that contributed to the short supply of DDT were the outbreaks of hostilities with Pakistan and a breakdown in production at the Alwayne factory.

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5. This change in nomenclature was effected due to the advice by the World Bank as part of the Enhanced Malaria Control Project (EMCP) in fifteen states in India. 6. Plasmodium falciparum (PF) is more severe and complicated compared with Plasmodium vivex (PV) that was common in India till 1980s. 7. Malaria is a parasitic disease spread by the bite of Anopheles mosquito which is active between dusk and dawn. Malarial symptoms can occur eight days after an infected bite. The principal symptoms are fever, malaise, headache, chills and sweats, but it can present itself as a respiratory or gastrointestinal illness, too. 8. The research projects and intervention programmes on malaria implemented by the government through different funding agencies also influenced people to largely adapt the biomedical or English terms whether they mean same thing or not. 9. The geographical zones of Surat district are also socio-cultural zones. Hilly zone, a dry region was inhabited by the tribes (Chodrys and Gamits); caste groups (Koli Patels, Ahirs, Desai, Kaduva Patidars, Prajapatis, Chamars, Parmars and Halpatis) were predominant in the irrigated coastal zone; and the plains zone (both dry and irrigated) comprised villages inhabited by both castes and tribes. Surat district was chosen for trial research not only because of its malaria endemicity, but also due to its geographical and socio-cultural spread, so that generalisations made from the trial zones would have broader relevance for the entire country. 10. ‘Short-’ and ‘long-duration’ are relatively used, as what is short or long depends on the type of sickness, its conceived ranking in the family and community, age of the person affected, the circumstances under which the sickness occurs, etc. Broadly, short duration may be one to five days, and long duration may be three days and more. 11. Wherever the biomedical term malaria is used, it also includes local fevers which may or may not correspond to malaria. 12. Non-trial areas were those villages where there was no intervention by the Malaria Control Research Project. Three interventions (namely, ITMNs, IRS, and EDPT) in trial areas required scores of official visits, distribution of material things, and external dissemination of information on malaria, which largely influenced people’s ideas about malaria. 13. Baharnisar meaning malevolent social relations which go beyond witchcraft and sorcery. Both intentional and unintentional acts of ‘abnormal’ persons, ancestors, or unnatural forces may strike a person to make her/him sick. It is observed that beliefs about different forms of malevolent social relations are prevalent in all societies and tribals are no exception. Furthermore, modern health services have been well accepted by the tribals and they are craving for efficient delivery of these services. 14. Here, education does not mean adult literacy or health education/awareness, but formal education.

References Boyd, Kenneth M. 2000. ‘Disease, illness, sickness, health, healing and wholeness: Exploring some elusive concepts’, Journal of medical ethics: Medical humanities, 26 (1): 9–17. Daniel, Normal. 1985. Just health care. Cambridge: Cambridge University Press.

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Farmer, Paul 1988. ‘Bad blood, spoiled milk: Bodily fluids as moral boundaries in rural Haiti’, American ethnologies, 15 (1): 62–83. Ghosh, Ishita and Lester Coutinho. 2000. ‘Normalcy and crisis in time of cholera: An ethnography of cholera in Calcutta’, Economic and political weekly, 35 (8 & 9): 684–96. Good, Byron. 1977. ‘The heart of what’s the matter: The semantics of illness network in Iran’, Culture, medicine, psychiatry, 1: 25–58. ———. 1994. Medicine, rationality and experience. Cambridge: Cambridge University Press. Hausman, Susan. 2000. Community understanding of malaria and treatment seeking behaviour in a holo endemic area of South Eastern Tanzania. Switzerland: Switzerland Institute of Tropical Medicine (unpublished thesis). Kamat, Vinay. 2000. ‘Resurgence of malaria in Bombay (Mumbai) in the 1990s: A historical perspective’, Parasitologia, 42: 135–48. Kidel, Mark. 1988. ‘Illness and meaning’, in Mark Kidel and Susan Rowe (ed.): The meanings of illness (1–19). London: Routledge. Kleinman, Arthur; Veena Das and Margaret Lock. 2001. Social suffering. New Delhi: Oxford University Press. Krause, Inga-Britt. 1989. ‘Sinking heart: A Punjabi communication of distress’, Social science and medicine, 29 (4): 563–75. Lobo, Lancy; Purendra Prasad, Babasaheb Kazi. 1998. Ethnography of malaria in Surat district—VI report. Surat: CSS (mimeo). Lobo, Lancy; Purendra Prasad, Babasaheb Kazi and D.C. Sah. 2000. Ethnography of malaria in Surat district—Composite report. Surat: CSS (mimeo). Lock, Margaret. 1989. East Asian medicine in urban Japan. Berkeley, California: California University Press. McCarthy, F. Desmond; Holger Wolf, and Yi Wu. 2000. ‘Malaria and growth’ (Policy research working paper). Washington D.C: Public Economics, World Bank Development Research Group. McCombie, S.C. 1994. Treatment seeking for malaria: A review and suggestions for future research. UNDP/World Bank/WHO Special Programme for Research and Training in Tropical Diseases. Mellor, Philip and Chris Shilling. 1997. Reforming the body: Religion, community and modernity. London: Sage Publications. Pai, Sanjyot. 2003. ‘Illness: Philosophical perspectives’. Paper presented at a Seminar on ‘Health and society: Issues and concerns’, organised by the Department of Sociology, Goa University on 5–6 March. Popper, Karl. 1972. Objective knowledge: An evolutionary approach. Oxford: Clarendon Press. Prasad, Purendra. 2000. ‘Health care access and marginalised social spaces: Leptospirosis in South Gujarat’, Economic and political weekly, 35 (41): 3688–94. Pugh, Judy. 1991. ‘The semantics of pain in Indian culture and medicine’, Culture, medicine and psychiatry, 15 (2): 19–43. Rajagopalan, P.K.; P. Jambulingam, S. Sabesan, K. Krishnamoorthy, S. Rajendran, K.  Gunasekaran and N. Pradeep Kumar. 1986. ‘Population movement and malaria persistence in Rameswaram island’, Social science and medicine, 22 (8): 879–86. Rana, Kumar and Liby T. Johnson. 2003. ‘Hot-tempered “cold fever”: Illness and impoverishment among adivasis in Jharkhand’, Economic and political weekly, 38 (15): 1451–55.

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Sharma V.P. 2003. ‘Malaria and poverty in India’, Current science, 84 (4): 514. Sharma V.P. and K.N. Mehrotra. 1986. ‘Malaria resurgence in India: A critical study’, Social science and medicine, 22 (8): 835–45. Sheldon, Watts. 1999. ‘British development policies and malaria in India 1897-c.1929’, Past and present, 165: 141–81. Shivlal, G.P.; Dhillon Singh, R.L. Yadav and R.M. Sundaram. 1998. Operational manual for prediction, detection, prevention and control of malaria epidemics. New Delhi: NMEP, Directorate General of Health Services, Ministry of Health and Family Welfare. Turner, Bryan S. 1987. Medical power and social knowledge. London: Sage Publications. Twaddle, A.C. and R.M. Hessler. 1987. A sociology of health. New York: McMillan. Yadavendu, Vijay Kumar. 2001. ‘Social construction of health: Changing paradigms’, Economic and political weekly, 36 (29): 2784–95. Young, Allan. 1982. ‘The anthropologies of illness and sickness’, Annual review of anthropology, 11: 257–85. Wessen, F. Albert. 1986. ‘Introduction: Resurgent malaria and the social sciences’, Social science and medicine, 22 (8): iii–iv. Zubrigg, Sheila 2001. ‘Rethinking public health: Food, hunger and mortality decline in South Asian history’, in Imrana Qadeer, Kasturi Sen and K.R. Nayar (eds.): Public health and the poverty of reforms (174–97). New Delhi: Sage Publications.

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9 Caste Variations in Reproductive Health Status of Women: A Study of Three Eastern States Papia Raj and Aditya Raj

Introduction

I

n India, caste plays a major role in the life of her people, influencing their socioeconomic activities, and in turn regulating their health status. S.N.M. Kopparty (1991) shows the variation in the utilisation of health resources among different caste groups and its impact on their health status. Similarly, Thomas Matthai (1996) states that, because of differential literacy rate and economic status between the scheduled castes and non-scheduled castes, there is also a difference in their health status. In caste-based Indian society, women of the lower castes are the worst hit, as they suffer from double discrimination: First, in the patriarchal society women are discriminated against men, as they have to bear the burden of household work demanding much time and energy without adequate compensatory diet. And second, a lower-caste woman, owing to her poor socioeconomic status, also experiences social deprivation. Both these factors are detrimental to the health status of women, especially their reproductive health. Given that caste is important in the life of an individual, in this paper we examine the caste variations in the reproductive health of women.

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There are as yet no studies on the reproductive health status among different caste groups. The National Family Health Survey (NFHS)-1 (1992–93) gives us an opportunity to conduct such a study, as it has compiled data on caste (International Institute of Population Sciences 1994). Though a second round of NFHS also collected similar data in 1997–98 (International Institute of Population Sciences 2000), we have not considered that data in this study for two reasons: First, when the NFHS-2 was conducted, the state of Bihar had been divided into Bihar and Jharkhand. And second, since the NFHS is a sample survey, and not a longitudinal survey, comparing the two sets of data would not throw much light on the actual situation.

Reproductive Health in India Women and child health received a major impetus after the International Conference on Population and Development (ICPD) in Cairo (1994), which recommended that the participant countries should implement unified programmes for Reproductive and Child Health (RCH), as it was considered essential to human welfare and development. In the ICPD, reproductive health was defined as the state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity, in all matters relating to the reproductive system and to its functions and processes (ICPD Programme of Action, paragraph 7.2). India, being a signatory to the ICPD, strongly supports the Programme of Action and, since the 1990s, the Government of India has introduced the RCH Approach. This approach includes the ability (of couples) to reproduce and regulate their fertility. Women can go through pregnancy and childbirth safely, the outcome of pregnancy is successful as for maternal and infant survival and well-being, and couples can have sexual relations free of fear of pregnancy and of contracting diseases. Indian women, by and large, have a poor reproductive health status, as is evident from the NFHS data. For assessing the reproductive health of a woman, the NFHS-1 incorporated the following variables: antenatal care (ANC), immunisation of pregnant women, institutional deliveries, and assistance at delivery. Proper ANC is crucial for the good health of both mother and child. NFHS-1 data show that, among all the women who have given any live birth in the four years preceding the survey, only 62.3 percent of mothers have received various types of ANC services. All pregnant women are expected to receive doses of

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Figure 1: Schematic Framework for Analysing the Influence of Caste on Reproductive Health of Women

tetanus toxoid vaccine to be protected against tetanus. Two or more doses of this vaccine during pregnancy were received by only 53.8 percent of all mothers. The situation is not much different as for the coverage for iron and folic acid tablets, which forms a prophylaxis against nutritionally induced anaemia among pregnant women. According to the NFHS-1, only 50.5 percent of women had this coverage. Another important thrust of maternal health services is the encouragement of institutional deliveries attended by trained health professionals to ensure better health for the mother and the child. The proportion of institutional births (25.6 percent) is very low in India. Both international and national organisations, such as the World Health Organisation (WHO), United Nations Population Fund (UNFPA), Population Association International (PAI) and Population Foundation of India (PFI), have attempted to measure the reproductive health of women with the help of certain sets of indicators. The most recent index of reproductive health has been computed by PAI (2001). It puts India in moderate rank, with a score of 44.8 on a scale ranging from 0 to 100. However, despite government programmes and intervention, the reproductive health status of women in India presents a sorry scenario, mainly because of the socioeconomic forces that influence reproductive health. Caste is one social institution in India whose impact on

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the life of her people cannot be exaggerated. To understand the influence of caste on reproductive health of women a schematic framework is developed. From Figure 1 it follows that caste influences socioeconomic variables that include educational status, work status and standard of living. These variables, in turn, have an impact on knowledge and utilisation of contraception and reproductive health care services, ultimately affecting the reproductive health of women.

The Study The study area is restricted to the eastern region of India, comprising the states of Bihar (that is, former Bihar, including Jharkhand), Orissa and West Bengal. Obviously, the caste structure is not uniform across the country, and there are significant regional variations. We use a modified version of H.H. Risley’s (1881) classification (see Appendix 1) as his survey was undertaken when the geographical area comprising these three states was administratively united. In these three states the caste structure is more or less similar due to their historical moorings. Moreover, the authors’ acquaintance with the area facilitated better understanding of the behaviour of various caste groups. The three main objectives of the study are: 1. To analyse the variations in the reproductive health status of currently married women belonging to different caste groups in the states of Bihar, Orissa and West Bengal. 2. To compute a Reproductive Health Index (RHI), for the various castes in these three states. 3. To examine the influence of social and economic factors on the reproductive health of women, with special reference to their caste membership.

The data used in this study were obtained from the NFHS-1 (1992–93) conducted between April 1992 and September 1993. The Survey covered more than 89,000 ever-married women in the age-group 13–49 in twenty-four states and the union territory of Delhi; it was, thus, the largest of its kind in the subcontinent. It provides national- and statelevel estimates of fertility, infant and child mortality, family planning and maternal and child health. In this study, we have drawn data from the following sections of the Women’s Questionnaire used in the Survey:

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the respondent’s background, reproduction, contraception, pregnancy and breast feeding, husband’s background, and women’s work. For analysis, only those women who have given any live birth during the four years preceding the survey (1988–91) are considered, and only the recent birth is taken into account. Since the main purpose of the study is to analyse the impact of caste on reproductive health, only the Hindu women falling in this category are considered. The reproductive health indicators used in the present study are as follows: contraceptive usage (any method), birth order, birth interval, antenatal care (any type), status of immunisation of women during pregnancy (doses of Tetanus toxoid vaccination), obtaining iron and folic acid tablets, place of delivery, assistance during delivery, weight of the child at birth.1

Caste Variations in Reproductive Health Indicators Table 1 presents caste variations in the reproductive health indicators. ‘Use of contraceptives’ is an important indicator of reproductive health. In Bihar, only 55.7 percent of the couples use contraceptives, and there exist castewise variations: among the High Caste 73 percent of the couples use contraceptives, followed by the Highest Caste (62.2 percent). The rural-urban difference in contraceptive use is large, and it is more so in case of the upper castes and the Intermediate Caste. The high ruralurban disparity among the upper castes is because, unlike in urban areas, in rural areas there are some taboos attached to the use of contraceptives, and these taboos are more observed by the upper castes. Also, in rural areas, the joint family system is still prevalent among the upper castes, which are land-owning communities. The joint family norms regulate the reproductive behaviour of the couples and hence affect the use of contraceptives. In urban areas, due to the prevalence of nuclear households, even among the upper castes such controls do not operate and the couples are relatively free to exercise their reproductive choices. In the case of the lower castes that are generally engaged in agricultural labour, the joint family system does not exist even in rural areas. Hence, their reproductive behaviour does not change much with place of residence. Apart from this, the upper castes have a higher literacy rate in urban areas as compared with the lower castes, and this increases their * Due to archaic nature of the articles some tables in this chapter are not available and could not be reproduced.

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awareness about the various family-planning methods, thus influencing the use of contraceptives. Orissa also presents a similar situation where 59.9 percent of the couples presently use contraceptives. The highest proportion of contraceptive use is among the High Caste (79.2 percent), followed by the Highest Caste (72.5 percent), while less than 60 percent of the couples among the Intermediate, Lowest and Low Castes use contraceptives. Striking differences are also noticed between rural and urban areas in the use of contraceptives. In West Bengal, 66 percent of the couples use contraceptives, and, unlike in Bihar and Orissa, there is not much caste variation. In fact, the proportion of couples using contraceptives is the same for the High Caste and the Low Caste (that is, 69 percent). There is also not much rural-urban difference among these caste groups. In West Bengal, the marginal difference in the use of contraceptives by various castes is due to the caste structure being not as rigid as in Bihar and Orissa. One reason for this is that the reform movements in Bengal had liberalised the caste system. Moreover, the relatively higher literacy rate in rural areas of West Bengal has fostered a more liberal outlook, which positively influences the reproductive behaviour. The higher the birth order of a child, the more adverse the effect it has on the reproductive health of the mother, as it means repeated number of pregnancies. In Bihar, 38.6 percent of the live births are higher order births, that is, birth order of equal to or more than four. With a higher proportion of their members using contraceptives, the upper castes have low proportions of high order births. The rural-urban difference in birth order among the caste groups is high, except for the Lowest and the Intermediate castes. This is obviously the result of the prevalence of joint family system in rural areas which encourages couples to have more number of children. Moreover, in rural areas, where the standard of living is not very high and the economy is labourbased, children are viewed as an economic asset, and more so among the lower castes, who are also generally the low income-groups. On the other hand, in urban areas, the cost of bringing up a child is relatively high. This also is responsible for the differential birth order between the rural and urban areas. In Orissa, 30.7 percent of the births are of higher order; a large difference in birth order is noticed among the various castes in this state. As in Bihar, the proportion of higher order births is much less in urban areas and irrespective of caste affiliation. In West Bengal, all the castes

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have fairly small proportion of higher order births, ranging between 20 percent (Highest Caste) and 31.9 percent (Lowest Caste). Since there is not much variation in the pattern of contraceptive use between the rural and urban areas in West Bengal, it gets reflected in the birth-order pattern. Apart from birth order, it is also the interval between two births that has a bearing on the reproductive health of a woman. A little over 39 percent of all live births in Bihar have a birth interval of more than or equal to twenty-four months, without much caste variation. In Orissa, 56.9 percent of the live births have a birth interval of equal to or more than twenty-four months. The proportion of births with a higher interval is almost 60 percent among the lower castes, while it is only 48 percent among the upper castes. Since, in West Bengal, only 25 percent of the births are of higher order, and among the lower order births 32 percent are of first order, the proportion of births with large intervals is quite low (45.1 percent). This applies to all castes. Antenatal care (ANC) is one of the four most important pillars of safe motherhood along with family planning, safe delivery and essential obstetric care (WHO 1996). In the study region, there is a large difference in the proportion of women receiving ANC: it is only 40.8 percent in Bihar, while it is 79.8 percent in West Bengal. In Bihar, the proportion of lower-caste women receiving ANC is much less (35.5 percent) compared with their upper-caste counterparts (68.1 percent). This difference is accentuated in rural areas, where only 34.3 percent of the women receive any type of ANC, either visited by a health worker or going to a clinic. However, the position of the Lowest Caste does not improve much with place of residence: it is 34.1 percent in rural areas and 46.2 percent in urban areas. Lack of accessibility to ANC services is a major cause for this. Accessibility refers to both physical accessibility (in terms of distance travelled) and accessibility in terms of cost incurred to avail such services. Long distance and inadequate public transportation facility are common constraints to health-care utilisation, and this is more so in rural areas (Thaddeus and Maine 1994). This applies to rural Bihar too, where the availability of medical facilities does not meet the requirements of the people, and the transport infrastructure is underdeveloped. Also, in the rural areas of the states under study, the residential pattern follows caste hierarchy: the houses of the upper castes are located in the centre of the village, and those of the other castes are located farther

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away from them according to their ritual and occupational status. As a result, the lower castes are usually settled on the periphery of the village. Moreover, in Bihar, as is well known, the family-planning programme is not a success story, and the health workers visiting homes is also rare. Also, as elsewhere in rural India, land continues to be the most important source of income, and the upper castes are usually the landowning communities (Chakravarti 2001). This contributes to the improvement in the standard of living of the upper castes in rural areas. The lower castes, on the other hand, are also down in the hierarchy as for their economic status and they cannot afford the transport-cost for availing the ANC services if they are located at a far off place. Even the private clinics, due to their exorbitant charges, are out of their reach. All these lead to a drop in the percentage of lower-caste women receiving ANC. On the contrary, in urban areas, physical inaccessibility is not a problem, as there are many clinics and the transport system is also better. Moreover, urban areas are free from caste-based settlement patterns, which fact too acts facilitates lower-caste women receiving ANC. Lower standard of living and lack of knowledge among the urban lower castes may be responsible for less proportion of their women availing ANC. Similar caste variations are noticed in Orissa, too. Among the upper castes more than 80 percent receive ANC, while among the lower castes the figure is below 70 percent. The ANC coverage is higher in West Bengal, without much rural (77.8 percent) and urban (87.6 percent) differentiation. There is also not much caste variation in availing the ANC services. Apart from the ANC services, a birth attended by skilled health professionals assures safe delivery and reduces risk to the life of the mother and the child. In Bihar, skilled health professionals attend only 23.4 percent of the births. The situation is grimmer for the lower castes, as less than 20 percent of their births are assisted by skilled health professionals. Only among the High Caste a majority (53.4 percent) of the births are assisted by skilled health professionals. Rural areas are worse off, as the figure for no caste exceeds 40 percent. This is due to the traditional outlook prevalent in rural societies, where most of the births still take place at home and are assisted by dais (traditional midwives) who are not very skilled and follow traditional practices, some of which are unhygienic. Even in urban areas, the situation is not satisfactory for the lower castes: skilled health professionals assist only 37.2 percent of the births among the Lowest Caste, but the corresponding percentage is 80.3

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for the High Caste. It is perhaps the inaccessibility due to high cost that influences this variation in urban areas. The government hospitals lack adequate infrastructures in terms of both equipment and personnel, while the poor lower-caste people cannot afford the services of private hospitals. In Orissa too, skilled health professionals assist a very low proportion of (28 percent) births, and a large caste variation is noticed. The upper castes have higher proportion of births assisted by skilled professionals (51 percent). Skilled assistance at delivery is also not very satisfactory in West Bengal (41.6 percent), and caste variations exist: 60 percent of the births among the High Caste are assisted by skilled professionals, in contrast to 26.1 percent, among the Lowest Caste. To summarise, the caste differences are the highest in Bihar, followed by Orissa and West Bengal. In all the three states, the upper castes are in a better position in comparison with the lower castes. The Intermediate Caste shares more characteristics of the lower castes than that of the upper castes. The place of residence has a great influence on the reproductive health status of women as is evident from the striking rural-urban differences in all the states for all the reproductive health indicators, with urban areas presenting a better picture.

Reproductive Health Index For a comprehensive understanding of caste differences in reproductive health status of women, based on the above discussed indicators, a Reproductive Health Index (RHI) has been computed for the various caste groups (see Appendix 2). The range of this index varies between ‘0’ and ‘5’. The higher the value of the index, the better the reproductive health status of the women. Based on the mean value of the index, women are grouped under two broad categories of reproductive health status: High RHI and Low RHI. In Bihar, as most of the reproductive health indicators for women are poor, only 39.1 percent of them show High RHI (see Table 2a). Caste variation is also large: 64.4 percent of the High Caste women have High RHI, and only 36.5 percent of the Lowest Caste women have High RHI. Though in urban areas 65.3 percent of women have High RHI, this percentage drops to 33 in rural areas.

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Table 2a Caste-Group and RHI—Bihar, 1992–93 Low RHI (%)

High RHI (%)

Caste Groups

Rural

Urban

Combined

Rural

Urban

Combined

Highest

57.65

34.15

52.70

42.35

65.85

47.30

High

50.00

11.48

35.58

50.00

88.52

64.42

Intermediate

70.43

35.25

64.36

29.57

64.75

35.64

Low

74.09

34.85

68.68

25.91

65.15

31.32

Lowest

65.92

52.56

63.51

34.08

47.44

36.49

Total

66.97

34.72

60.89

33.03

65.28

39.10

Table 2b Caste-Group and RHI—Orissa, 1992–93 Low RHI (%)

High RHI (%)

Caste Groups

Rural

Urban

Combined

Rural

Urban

Combined

Highest

31.67

7.14

21.57

68.33

92.86

78.43

High

33.33

6.98

22.64

66.67

93.02

77.36

Intermediate

44.17

29.17

40.29

55.83

70.83

59.71

Low

54.82

29.03

48.65

45.18

70.97

51.35

Lowest

53.95

36.92

50.00

46.05

63.08

50.00

Total

49.36

25.14

42.83

50.64

74.86

57.17

The proportion of women having High RHI is 57.2 percent in Orissa (see Table 2b), with the upper castes holding a much higher position in comparison with the lower castes. Orissa has a sharp rural-urban difference as regards reproductive health status of women. Irrespective of the place of residence, the upper castes have better index in Orissa. The reproductive health status of women in West Bengal is the best as compared with that of Bihar and Orissa: 67.4 percent of women in this state have High RHI (see Table 2c). The difference among the highest (Highest Caste = 77 percent) and the lowest values (Lowest Caste = 58 percent) is only 19 percentage points.

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148Papia Raj and Aditya Raj Table 2c Caste-Group and RHI—West Bengal, 1992–93 Low RHI (%)

High RHI (%)

Caste Groups

Rural

Urban

Combined

Rural

Urban

Combined

Highest

29.0

12.1

23.0

71.0

87.9

77.0

High

34.4

6.9

25.6

65.6

93.1

74.4

Intermediate

35.2

21.6

32.6

64.8

78.4

67.4

Low

34.4

25.0

33.1

65.6

75.0

66.9

Lowest

42.1

41.1

42.0

57.9

58.1

58.0

Total

35.9

20.2

32.6

64.1

79.8

67.4

Correlation among Predictor Variables A correlation matrix has been constructed to understand the relationship among the predictor variables. For correlation, education of women has been re-coded as ‘0 = illiterate’ and ‘1 = literate’, and husband’s occupation has been coded as ‘0 = agriculture and other primary activities’ and ‘1 = others’. The other codes remain unchanged. The results of correlation are presented statewise. Only those results for which the ‘r’ value is more than 0.2 and that are statistically significant are discussed here. But, to highlight the influence of caste, all correlation results that are statistically significant against caste are discussed.

Bihar The correlation matrix for predictor variables for Bihar is presented in Table 3a. Age of the woman and experience of child-loss has a positive correlation (r = 0.27). It means that experience of child-loss is higher for women of older age-groups as compared with women of younger age-group. Caste also shows a negative correlation with child-loss (r = −0.07), as more women among the lower castes experience child-loss. This is because of the low literacy rate among the lower castes coupled with lower standard of living, hindering awareness of and accessibility to medical facilities.

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Caste and place of residence are positively correlated (r = 0.07), which means that upper caste women usually live in urban areas. Place of residence has a positive correlation with education of women (r = 0.32). As expected, women in urban areas are more literate than those in rural areas. The negative correlation between work status of the woman and place of residence (r = −0.20) suggests that women in rural areas are engaged in work. In rural areas, due to the agrarian economy, which is labour intensive, even the womenfolk join hands with the male members of the family in the field, and this raises the work-participation rate among rural women. Since most of the men are engaged in agriculture in rural areas, there exists a positive correlation between place of residence and occupation of the husband (r = 0.34). Exposure to the mass media has a positive correlation with place of residence (r = 0.34), that is, women in urban areas are relatively better exposed to the mass media than those in rural areas. There is a positive correlation between caste and the following variables: education of the woman (r = 0.23), husband’s occupation (r = 0.14) and exposure to the mass media (r = 0.14). These correlations indicate that the literate women are from the upper castes and their husbands are engaged mainly in non-primary activities. These women are also better exposed to the mass media. Work status of the woman and caste are negatively correlated (r = −0.16). Education of the woman is negatively correlated with her work status (r = −0.27), but is positively correlated with husband’s occupation (r = 0.35). It follows from the results that illiterate women are generally working and their husbands are engaged in either agriculture or other primary activities. Exposure to the mass media (r = 0.49) and spousal communication (r = 0.22) show a positive correlation with education of the woman, as exposure to the mass media is high among literate women and this increases communication among the couples. A negative correlation is observed between work status of the woman and husband’s occupation (r = −0.22), which means that if husbands are engaged in agriculture or other primary activities then the work-participation rate among their wives is also high. Such a situation is perhaps explained by the labour-intensive nature of primary activities, and the family being the main source of labour for them. Work status of the woman is negatively correlated with exposure to the mass media (r = −0.24) because more of the working women are settled in

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rural areas, where exposure to the mass media is limited, especially so in Bihar, where electricity supply is yet to reach all villages and the electronic media are noticeably absent. Also, owing to the low literacy rate, the print media is not widespread either. For those women whose husbands are engaged in agriculture there is less exposure to the mass media (r = 0.33).

Orissa Table 3b presents the correlation coefficients for predictor variables in Orissa. It is seen that age of the woman has a positive correlation with experience of child-loss (r = 0.24), suggesting that, as in Bihar, the experience of child-loss for women in older age-groups is higher. There is a positive correlation between caste and place of residence (r = 0.12). Place of residence also has a positive correlation with husband’s occupation (r = 0.32) and exposure to mass media (r = 0.23). Thus, women in urban areas, with their husbands mainly engaged in non-agricultural activities, are also better exposed to the mass media. Caste has a positive correlation with education of the woman (r = 0.26), as in Bihar, indicating that more women of lower castes are illiterate than those of upper castes. A negative correlation, though small, is observed between caste and work status of the woman (r = −0.07). As a corollary, we find a positive correlation between caste and husband’s occupation (r = 0.22), showing that lower-caste males are engaged in agricultural activities. Moreover, there is a positive correlation between caste and exposure to the mass media (r = 0.21). Hence, increasing status along the caste hierarchy leads to a decrease in exposure to the mass media. Education of the woman shows a positive correlation with husband’s occupation (r = 0.35) and exposure to the mass media (r = 0.43): husbands of literate women pursue mainly non-primary occupations, and these women are more exposed to the mass media. Husband’s occupation, however, has a positive correlation with exposure to the mass media (r = 0.28). This shows that women are better exposed to the mass media if their husbands are not engaged in agriculture or other primary activities. A positive correlation is also noticed between exposure to the mass media and spousal communication (r = 0.22), that is, spousal communication increases with an increase in exposure to the mass media.

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West Bengal Table 3c presents the correlation coefficients for predictor variables in West Bengal. Age of the woman shows a positive correlation with experience of child-loss (r = 0.24), like in Bihar and Orissa. In West Bengal, caste and child-loss are negatively correlated (r = −0.08), indicating that experience of child-loss is common among lower-caste women. A positive correlation between place of residence and husband’s occupation (r = 0.36) means that in rural areas males are involved in agriculture or other primary activities. In urban areas women are better exposed to the mass media, and this is also evident from the positive correlation between these two variables (r = 0.21).

Multivariate Analysis The logistic regression analysis (see Table 4) represents the influence of demographic and socioeconomic conditions on RHI. The results for the eastern region of India show that all the predictor variables affect the reproductive health of women, as the odds-ratio is statistically significant. When other variables are controlled, caste is observed to be an important variable influencing reproductive health of women: High Caste women are 1.8 times more likely to have High RHI as compared with the lower-caste women. This is because the upper-caste women enjoy better socioeconomic status that influences their reproductive choices and reproductive behaviour, there-by improving their reproductive health. Age of the woman has an inverse relation with reproductive health: with an increase in age there is a decrease in the reproductive health status of women. Even experience of child-loss influences RHI. Women who have experienced child-loss are 39 percent less likely to have High RHI. Women’s educational level and exposure to the mass media are important variables that exert a positive influence on reproductive health. Women exposed to the mass media are more informed and aware about various measures that affect reproductive health. However, women who have not discussed children with their husbands are less likely to have High RHI. Place of residence and husband’s occupation are two other variables influencing RHI positively. The likelihood of High RHI is more among women who are settled in urban areas. Similarly, women whose husbands are not engaged in agriculture are more likely to have High

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RHI. On the other hand, work status of the woman shows an inverse relation with her reproductive health status. This is mainly because of the nature of women’s job, which is mainly agricultural labour.

Discussion This study highlights the impact of caste on reproductive health of women in the eastern states of Bihar, Orissa and West Bengal. It does not emphasise the overall status of the health-care system in these three states, as we are more concerned with the determinants of reproductive health of women at the individual level than with providing a generalised scenario. The study helps us to understand how even personal decisions like reproductive behaviour and reproductive choices are largely influenced by caste. One important finding of the study is that there persists an intra-regional difference in reproductive health status of women. In the eastern region of India, caste differences in reproductive health are most pronounced in Bihar, while it is least so in West Bengal. This is mainly because the caste system in its rigid form is more a characteristic of the less developed state of Bihar, where caste and class are almost synonymous (Chakravarti 2001). The economic differences among the caste groups widen the social inequalities among them. It is observed that poor educational status among women is an important reason for their poor reproductive health. The educational status of the woman is not free from her caste membership. In Bihar, according to the 1991 Census, literacy rate among the scheduled caste females is only 5.5 percent. During the colonial period the upper castes gained access to modern western education. The trend persists without much change in the educational status across the various castes. According to the 1931 Census, literacy rate was much higher among the Kayastha, Namasudra, Mahishya and Brahman caste groups, which constitute the upper castes; it was quite low among the Agarwals and Doms, who are the intermediate and lower castes. This implies that policies should be so framed that emphasis is placed on education, especially among the lower castes in rural areas, as caste variations are much higher in there. Apart from trying to diversify the economy and provide better educational facilities, a major task for policy makers is to ensure that policies on reproductive and child health focus on campaigning the utilities of availing maternal care services and encouraging institutional deliveries

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assisted by professional health workers. It is observed that there prevails socioeconomic differences among the caste groups and this is one among various causes for inequality in their reproductive health status. Thus, different campaigning approaches should be adopted to reach different sections of the society to make the campaign more effective. Moreover, health workers should more regularly visit areas that comprise mainly of lower castes, who are deprived of access to formal maternal care due to reasons discussed earlier. Also, more auxiliary nurse and midwives should be trained so that births are assisted by skilled personnel. This study leaves many gaps for future investigation. The caste classification considered in this study could be disaggregated for a detailed understanding of the influence of caste on the reproductive health of women. Our analysis is based on the individual level; the reproductive health status of various castes could also be studied at the district and state levels.

Note 1. In the present study the status of immunisation of women is not included in the RHI as it shows a strong positive correlation with ANC utilisation (Table not included). Women who avail ANC services usually receive two or more doses of tetanus toxoid injections. Similarly, iron and folic acid tablets also show a strong positive correlation with ANC, and hence it is also not included in the RHI. Since assistance at delivery is more important to determine the reproductive health status of women, in the RHI it is considered leaving out the place of delivery. Weight of the child at birth could not be included in the analysis as more than 70 percent of the children were not weighed at birth in the states covered by the study.

Appendix 1: Caste Classification

Caste Classification (Risley 1881)

Caste Classification (Based on Ritual Status) Used in the Study

1. Brahman

Highest Caste

2. Baidyas, Kayasthas and Kshatriyas, and also Rajputs

High Caste

3. Clean Sudra: Gandhabanik, Karmakar, Kansari, Kumar, Kuri, Madhunapit, Modak, Malakar, Napit, Sadgope, Sakhari, Tamil, Tanti, Tili, and Teli also Karan, Kustha and Raju of Midnapur, Khan of Rangpur and Sudra of East Bengal

Intermediate Caste

(Continued )

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154Papia Raj and Aditya Raj (Continued ) Caste Classification (Based on Ritual Status) Used in the Study

Caste Classification (Risley 1881) 4. Clean castes with degraded Brahman: Chasi Kaivarta, Mahishya and Goala

Low Caste

5. Caste lower than group >4 = whose water is not taken by Brahman: Sarak of Manbhum, Swarnakar, Sunri, Subarnabanik and Sutradhar 6. Low caste who abstain from eating beef, pork and fowl: Bagdi, Barua, Bhaskar, Chain, Chasa, Dhoba, Doai, Gauran, Hajang, Jaliakaibarta, Kalu, Kan, Kapali, Kptl, Malo and Jualo, Mech, Namasudra, Chandal, Palia, Patri, Pod, Paro, Rajbanshi, Koch, Sukli, Tipura and Tipra etc. (This group includes most of the nonAryan race and castes.)

Lowest Caste

7. Unclean feeders: Not served by Brahman, Dhoba or Napit: Bauri, Chamar, Dom, Hari, Bhuimali, Kaora, Konai, Kora, Lodha, Mal, Muchi, Sialgir

Appendix 2: Reproductive Health Index Variable

Score

1. Contraceptive usage

Presently using contraceptives = 1 Not using contraceptives = 0

2. Birth order of the last child

Low birth order (