MARK NICHTER

NEGOTIATION THERAPY

OF THE ILLNESS

EXPERIENCE:

AYURVEDIC OF

AND THE PSYCHOSOCIAL ILLNESS

DIMENSION

ABSTRACT. The negotiation of the illness experience by ayurvedic vaidya and South Kanarese patients suffering from specific sources of psychosocial distress is examined in light of the cultural patterning of illness and communication within the clinical context. The negotiation process is initiated by the posing of rhetorical questions about somatic and affective states and structured by a conceptual framework which relegates such states to humoral interrelationships. By establishing a humoral explanatory model for an illness episode or affective state which takes into account environmental and constitutional factors over which one has little control, responsibility is mollified and dialogue about personal problems eased. A comparison of the interaction between ayurvedic practitioners and patients and astrologers and clients is made in this regard. The socially integrative and adaptive consequences of ayurvedic therapy is considered vis ~ visa portrayal of a popular vaidya's therapy for a number of illnesses associated with the somatization of psychosocial stress.

In India, considerable latitude exists in the interpretation o f the illness experience. The doctrine o f multiple causality applies to a majority o f illnesses in such a way that multiple etiological factors alone, or in concert, are thought capable of causing an illness and/or complicating the course o f an illness. Often as important as the identification o f primary etiological factors manifesting an illness is consideration o f contributing factors which draw attention to one's state of vulnerability, prior to or during illness. Consequently, the occasion of illness affords a time of introspection b y a patient and family; a time to consider illness as a sign o f an individual's or group's vulnerability as well as a set o f symptoms indicative of physiological imbalance. Given that illness may be interpreted as a sign of vulnerability in the domains of social space one inhabits, as well as a state o f imbalance or uncontrol, illness provides a fertile idiom for the expression of anxiety about the integrity o f relationships within these social domains as well as affective disorders; states of uncontrolled or imbalanced emotions weighed on a cultural scale. In a previous paper (Nichter 1977), the context o f which was a consideration o f the expression of distress by South Kanarese Havik Brahmin women, I examined illness as an idiom in which symptoms are symbolic as well as somatic constructs. The somatic complaints o f weakness, dizziness, indigestion/loss o f appetite, menstrual irregularity, heat, and loss of semen/dhatu 1 were discussed in relation to their symbolic significance; the potential for these symptoms when belabored to draw attention to a general loss o f well being, feelings o f

Culture, Medicine andPsycfiiatry 5 (1981) 5-24. 0165-005X/81/0051-0005 $02.00. Copyright 1981 by D. Reidel Publishing Co., Dordrecht, Holland, and Boston, U.S.A.

MARK NICHTER

vulnerability, social distance and conflicts involving self worth. It was suggested that a preoccupation with the somatic substituted for and displaced distress generated by inter- and intra- personal problems. The affinity existing between the body and mind as well as the body and society was seen to facilitate the expression of feelings about social relationships and affective states through reference to physiological processes. In this paper, I wish to focus attention on the negotiation of the illness experience by ayurvedic practitioners, vaidya, and patients suffering from specific sources of psychosocial distress. Discussion of the process of negotiation will entail a consideration of the cultural patterning of symptoms and communication within a particular clinical context. Within this context, I will examine the semantic framework a vaidya imposes on symptoms providing a strategy for action which is at once disease oriented yet responsive to illness, as a situational concomitant. In this light, I will examine the socially adaptive consequences of ayurvedic therapy: coping strategies supported, caring responses initiated and psychosocial problems mitigated. It is emphasized that while socially adaptive aspects of ayurvedic therapy will be the focus of attention, I do not wish to minimize maladaptive aspects which also occur. This topic is, however, beyond the scope of the paper. NEGOTIATING THE ILLNESS EXPERIENCE When a patient initially consults a vaidya for diagnosis as well as medicine) he volunteers relatively little information about his overall state of health. Such behavior was not only observed in the clinical setting but corroborated by a survey. During interviews with a sample of 50 rural, low to middle class, multicaste families in South Kanara, only 32% of informants noted that it was necessary or indeed appropriate to initially tell all of one's symptoms to a vaidya. 3 The consensus of opinion was that a few symptoms should be told to a vaidya and that the practitioner should through his powers of observation, appropriate questioning, intuition (power of the hand), and technical skills reveal the underlying nature of the patient's ill health. Appropriate questioning referred to the asking of specific questions about essential body processes as a follow-up to somatic complaints identified by a practitioner. In a majority of cases involving systemic malaise as opposed to acute pain, 4 topical wounds, skin lesions, etc., a vaidya takes the initiative in directing dialogue. After hearing a patient's general complaints such as weakness, bloodlessness, pain in the body, "heat", the vaidya conducts a topographical diagnosis of the patient's anatomy observing the skin, hair, eyes, tongue, etc., for signs and symptoms indicative of both the patient's constitution and general state of health. Based upon observations and his knowledge about humoral predominance

NEGOTIATION OF THE ILLNESS EXPERIENCE

in respect to age and the seasons, the vaidya speculates on possible humors which are vitiated. Once a few symptoms are ascertained, rhetorical questions focus on additional symptoms in a stereotyped manner. For example, if a patient deemed to have a rata, wind dominant constitution (indicated by signs such as dry rough skin and hair, a lean body, etc.), complains of symptoms linked to an aggravation of wind - joint pain, for example - a vaidya will then ask if the patient does not also have less sleep, an intolerance to cold, a desire for unctuous and hot foods, a fondness for the tastes sweet and salt, and an attraction to heat. s The flow of symptoms suggested stems from a vaidya's training where lists of adjunct symptoms are committed to memory along with associated and oft times poetic references to seasonal-humoral relationships and materia medica offering appropriate compensation to aggravated or depleted humors (Zimmerman 1978, 1980). The suggesting of additional somatic complaints intertwined with the asking of questions about body processes - hunger, digestion, sleep, elimination, etc., is viewed by patients as indicative of the vaidya's interest in restoring health as well as his interest in curing an illness. Diffuse and unreported somatic complaints experienced in the recent past are anticipated by the vaidya and recalled by the patient, unfolding an implicit explanatory model of the present illness negotiated between the vaidya and the patient. 6 The model is most often either a truncated version of the practitioner's own explanatory 'disease' model or a model which he creates for the patient in terms of what he presumes the patient's frame of reference will accomodate. In the latter case we fred extensive use of metaphor and the hot-cold idiom exploited by the practitioner. An explanatory model is not necessarily speUed out but inferred from references to hot-cold, metaphoric expression, or by the very structure of therapy, prescribed dietary behavior, etc. Generally, a patient and attending family members do not question a vaidya about his explanatory model of an illness episode once an illness has been named, nor does a practitioner offer theoretical explanation when a case is fairly straightforward; that is, when the response of a patient is either ambivalent or passively accepting. 7 A local illness category is either named or inferred while the vaidya's ayurvedic disease category based on his humoral diagnosis may never be mentioned. Here, either patient and practitioner assume that their ideas about the identity and etiology of the illness are congruent or a patient is sufficently impressed by the statute of the vaidya that explanation seems superfluous and the practitioner's power of the hand is the critical factor. Concern in such cases, if displayed, usually takes the form of questions concerning therapy, e.g., the repetition of instructions and conditions of taking medication and most importantly, questions pertaining to prescribed and restricted foods to be taken with

MARK NICHTER

the medication. Here the patient relegates concern to a semantic domain which is closer to home - to his everyday understanding of internal transformation through diet. In general, the greater number of questions asked about therapy, the greater the patient's anxiety about an ailment. In cases of illness which have not responded favorably to a variety of previous therapies, indigenous as well as cosmopolitan, patients are more concerned and curious about the nature of an illness and why a cure has been so difficult to obtain. At this juncture, disease is not the only major issue. Concern is shown about the patient's overall state of health, for in most cases, the disease involved is not that uncommon and many patients have been cured by the therapies they themselves have already undertaken. At this point, explanation becomes a more important part of the cure and patient's seek out vaidya with reputations as pandit; specialists within the ayurvedic sector who receive the referrals of less learned vaidya. The explanatory model of an illness episode advanced to patients by such pandits is, in most cases, only partially understood by a patient but congruent to his reasoning. Illnesses involving affective disorders and strategic use of the sick role often end up with a visitation to a pandit. In such cases, communication with a patient entails considerable tact and f'messe, because the expectation level of the family is high while the morale of the patient may be low due to past transactions with practitioners and inappropriate therapy that fail to support or provide a patient with an effective coping strategy. It is here that the symbolic dimension of illness and a recognition of the somatization of psychosocial distress become so important. As has been noted elsewhere (Carstairs 1957; Nichter 1977; Obeyesekere 1976) the belaboring of symptoms such as semen loss, leukorrhea, ammenorrhea, and dysmenorrhea, associates symbolic connotations with specific psychosocial problems. This is recognized to varying degrees by traditional practitioners confronted by numerous cases of such complaints. Ayurvedic pandits whom I investigated impressed me as recognizing that concordance exists between the somatic, social, and interpersonal problems of their patients. They were aware that they were at once faced with rectifying a patient's underlying humoral imbalance (the disease) as well as providing for, or paying credence to, coping strategies which reduced immediate sources of distress facilitating a cure or the management of an illness through efforts undertaken to enhance health. Before discussing coping strategies in relation to ayurvedic therapy, however, let us first consider how a pandit dialogues with a patient whom he suspects has come to him with symptoms concomitant with or precipitated by a psychosocial problem; a problem which the patient wishes to communicate but cannot comfortably make explicit outside a clinical context where his liminal experience is cushioned and responsibility, guilt, or shame mitigated. As a means of preparing the stage for a discussion of this play between patient and vaidya, may Ipose as

NEGOTIATION OF THE ILLNESS EXPERIENCE

analogous (for our purposes) the interaction between an astrologer and client in a similar circumstance - a play perhaps more readily seen in relation to the stellar macrocosm than the body microcosm. An astrological consultation focuses attention on man in relation to the universe. A consultation alters a client's everyday conception of self as he is made more aware of influences from beyond the sphere of normal comprehension; influences that are accepted as real but about which little is actually known. By being made aware of the complexities of the universe through the eyes of the astrologer, a client gains a degree of freedom from the responsibility of his own acts; he is able to talk about these acts no longer having to bear full responsibility for them. During an astrological enquiry, computation of stellar coordinates is undertaken, but this is only part of the astrologer's role. An astrologer considers the position of planets and stars as signs; as indications of general phenomena. The astrologer must then use his intuition to uncover the relevant factors underlying or effecting a particular event. What this means is that the astrologer uses a dialogue about the position of heavenly bodies to indirectly probe other states of affairs which could not otherwise be discussed overtly. This is not to say that he does not rely on his calculations, but to say that he uses his calculations and techniques of divination, such as the tossing of cowrie shells, to orientate discussions involving social relationships and implicit personal feelings; grounding them, so to speak, in the stars. By continually referring to the effects that various planets and stars have on a person or place, an astrologer encourages his clients to somewhat objectify their situation thereby facilitating easier discussions of problems. Moreover, projecting psychosocial problems onto a celestial stage makes possible the revaluation of sources of distress and emotion-laden events such that an abreactive experience may occur providing some temporary relief from distress. An example may illustrate this point. I once observed a despondent mother of a runaway son of a matrilineal caste consult an astrologer and inquire about the well being of her son and whether he would return to the family. The son was an only brother to three unmarried sisters - all of marriageble age - in a household which had lost much of its land as a result of land reform. Nevertheless, his family was attempting to keep up its prestige; a position which required the giving of relatively large dowries. The boy, who was 25, had been under considerable social pressure. Hopes that the family would be able to secure for him a 'coveted' bank job fell through when he failed his college examinations twice. Later, a marriage proposal was considered between the boy and a girl of a former tenant family (the girl's brother had secured a government job) which was attempting to raise its status through investing wealth (a large dowry) in a prestigious marriage alliance. The youth in question had not favored the marriage

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MARK NICHTER

alliance but was placed in a predicament because his eldest sister, now 28 years old, needed part of the dowry he would receive for her own marriage (as her dowry). In the end, the boy joined thousands of other rural youths who flee family pressures to seek a new life in cosmopolitan cities. What impressed me about the case was that once the astrologer associated the influence of Saturn, Shani, with the turn of events in the boy's life and defined the duration of Saturn's negative period of influence, the mother was greatly relieved. More importantly, she proceeded to note other problems and conflicts in the boy's life as if negotiating with the astrologer a revised version of personal history in which the boy's school problems, fights in the family, inability to see marriage in a positive light, and recent bouts of illness were also caused or in some way aggravated by Saturn. The astrologer responded by becoming more detailed in his analysis, mentioning in addition to Saturn, Rahu, another planet associated with malevolence. As he proceeded, the expression on the woman's face markedly changed from one of acute distress to that of interest and relief. Later, I learned that the woman's husband had feared that mata 'sorcery' had been performed against his son. Identification of malevolent stellar influences apparently offset this suspicion, at least for the moment. At the end of the consultation the astrologer recommended that a nava graha shanti homa - a ritual appeasing all nine planets, be performed to mitigate family difficulties. Without going into the intricacies of the case, we may note that a coping strategy was negotiated between astrologer and client wherein the causes of a problem were identified, delineated in time and associated with sources of responsibility beyond the family's control. Moreover, socially acceptable explanations for the youth's inappropriate actions were provided, an alternative explanatory model (sorcery) was superseded by an explanatory model emphasizing stellar influences and a plan of action - ritualintervention - was provided. Let us now turn to the vaidya. Vaidya subtly discuss with their patients sensitive issues relating to family interrelationships and personal problems by referring to humoral imbalances much the same way as astrologers refer to stars and planets. As in the case of the astrologer, an important part of the vaidya's therapy is making explicit hidden emotions and displacing responsibility. We will see that instead of stars and planets, reference to the body constitution, humors (tridosha), states of hot/cold, diet, season, etc., serve as the vaidya's critical points of reference. Just as the astrologer uses reference to the macrocosm as a means of altering a client's (or his family's) consciousness, so a vaidya uses reference to the body microcosm. When a patient consults a vaidya, or for that matter an astrologer, he is scrutinized carefully by the specialist. The client's caste, social status (marriage, widowhood), class, vocation, as well as the kinship relations of those accom-

NEGOTIATION OF THE ILLNESS EXPERIENCE

11

panying a client (often revealed during introductions) and visible signs of magical protective devices (talismans) are keenly observed. Such information provides a backdrop against which a client's responses are viewed; a backdrop against which points of information take form as constellations of interrelated factors to the specialist with an experienced eye and sensitivity to common patterns of social problems. For example, if the client is a young married woman, by ascertaining her caste and who has accompanied her to the consultation a specialist is afforded several clues as to the probable dynamics occuring within her household. In South Kanara, castes are both matrilineal and patrilineal. A married woman of a matrilineal caste accompanied at a consultation by her mother and/or brother would not suggest possible marital difficulties to the extent that it might if the woman was of a patrilineal caste. Information elicited on residence might further shed light on a client's marital situation and probable sources of social stress without the vaidya directly probing the subject. Subsequent responses to the vaidya's subtle questions would take on considerably different meaning depending on the kinship and residence pattern of the family in question. While asking rhetorical questions, traditional specialists take careful note of the body language of their clients and family members attending a consultation. In cases where vague complaints are ambivalently volunteered a vaidya tries to focus attention on particular symptoms as a means of initiating dialogue. A common pattern which I observed in cases suspected by vaidya to have an important psychosocial dimension was for vaidya to suggest or question patients about the presence of symptoms they have learned through experience are anxiety laden, associated with psychosocial distress and belabored by patients who tend to exploit the sick role as a means of withdrawing from unsatisfactory, frustrating, or over-demanding social relationships. Such symptoms are used to bait patients while vaidya watch for verbal and non-verbal responses. For example, confronted with a young Brahmin widow's complaint of tale tirigutade, head spinning, a vaidya might start out by questioning the woman about weakness and backache (ubiquitous complaints) and then ask about menstrual difficulties. If no response is evoked from the latter he might suggest bili hogutade, white going, an indirect way of denoting leukorrhea, an ailment having cultural significance linked to the loss of dhatu. If these symptoms fail to evoke a response, a vaidya may move to the digestive process and metaphorically cast his nets, after suggesting, for example, that the palor or coating of a patient's tongue denotes loss of appetite. When a significant response is noted, the humoral framework is applied to the symptoms responded to and an illness is named accordingly. Attention next shifts from vitiated humors to disruption in routine behavior patterns, emotional dispositions and social circumstances effecting the patient's state of well being.

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MARK NICHTER

During such discussions reference is constantly made to the relationships between humors, a patient's body constitution and the environment, providing a framework for discussion, s To draw a reluctant patient into a discussion, a vaidya may exploit pulse reading, declaring that through the pulse he can feel that one has a particular problem which is latent if not manifest. Let us move from a general discussion to a consideration of how the therapy of a popular vaidya ascribed the status of pandit assists in mollifying psychosocial problems of his patients and the initiation of positive caring responses from family members. I will briefly describe the pandit, illustrate by way of a case study the manner in which he negotiates a sensitive but fairly straightforward case of illness having psychosocial overtones, and then consider some examples of how his therapy is supportive of coping strategies which mitigate or ease immediate sources of social distress. Before doing so, however, I wish to emphasize that while this pandit employs an ayurvedic approach to the treatment of patients he has an individual style which is not generalizable to all vaidya. This style is at once conservative in appearance yet highly individualistic and influenced by the vaidya's gregarious personality and knowledge of the contemporary world. From my observation of several other vaidya in South Kanara, I would judge him more socially aware and innovative than most vaidya, but I would certainly not present this awareness as extraordinary .9 He is well respected by peers and the treatment he prescribes is quite in keeping with ayurvedic doctrine. His outgoing nature and curiosity do, however, make him a bit of a character within his own culture. Ganapathy belongs to a Havik Brahmin family renowned for ayurveda in South Kanara. As the younger brother of two practicing vaidya in the same household, he was not initially encouraged to make a career of medicine and became the manager of his family's arecanut gardens. After several years of struggling with routine agricultural operations, Ganapathy became restless and began searching for a new identity. He became interested in hathayoga, tantra, and the study of religious texts. He also began traveling in search of a guru. Ganapathy's two eider brothers, both eminent vaidya who now lived in separate households, became concerned about Ganapathy's wanderings and persuaded him to study ayurveda. Ganapathy eventually consented and soon became obsessed with ayurveda as a means of understanding Hindu custom, law, and ritual as well as illness. He found the role of vaidya well suited to his personality for he enjoyed meeting and talking to a wide cross section of people. The role was congenial to his wife for her father was a vaidya. She served as Ganapathy's compounder and assistant when examining female patients and conversing with them about personal problems. Among women she was highly respected as a mother of ten children and the capable manager of a busy household, the portico of which is Ganapathy's consulting room.

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13

Ganapathy was trained in diagnosis through an apprenticeship with one of his brothers. He inherited copious notes on family medicines and became a diligent student of classical texts on ayurveda as well as commentaries written in Sanskrit, Malay~am, Kanna.da, and Hindi. His ability to use parables as well as classical verses from ayurvedic texts is noteworthy as is the collection of texts which he refers to in true scholarly fashion during consultations. When patients arrive at Ganapathy's house, they take a seat on the veranda. In front of them is a desk upon which Ganapathy keeps a few ayurvedic texts in Sanskrit, red, white, and black wooden rods symbolizing the three humors, tridosha, and a plate of arecanut and betel leaf for chewing. If Ganapathy is performing his routine rituals, patients wait and chew arecanut, betel leaf and lime. If they arrive when Ganapathy is not busy, they sit, chew arecanut and listen while Ganapathy lectures to them about ayurveda. In any event, a consultation with Ganapathy is time consuming. A visit to Ganapathy is also costly for he charges a Rs. 15 initial consultancy fee in addition to the cost of medicines. Unsurprisingly, most of his clientelle have tried home remedies (herbs, 34%; herbs or diet, 87%) the therapy of other indigenous practitioners (any, 90%; only an ayurvedic vaiclya 34%) or cosmopolitan practitioners (any, 82%; chemist, 6%; Public Health Center, 14%; private, 62%) having lesser consultation fees. Ganapathy is particularly renowned for the treatment of women's complaints (47% of all adult clients), a family specialty. Although he resides in an interior village, at least 50% of his patients come from cities and towns within the district and 74% are literate. Ganapathy carefully examines patients and spends a considerable amount of time talking to them. If a female patient is too shy to speak about matters possibly pertaining to her sexuality while her husband or father is present, Ganapathy accompanied by his wife will call her privately into a room reserved for diagnosis. Aside from a battery of routine questions, Ganapathy engages in pulse reading. Moreover, while taking a patient's history, he subtly inquires about previous consultations with astrologers, offerings to patron deities, and suspicions of witchcraft sorcery, if a patient mentions a visit to an exorcist. Ganapathy acknowledges and pays credence to a patient's beliefs and lays emphasis on faith as an important aspect of the curing process. He maintains good relationships with other traditional specialists and it is not uncommon for him to receive a patient who produces a slip of paper written by an astrologer denoting humoral imbalance as well as a commentary on the patient's stellar coordinates. A case study may provide an introduction into the way in which Ganapathy negotiates a sensitive but fairly straightforward case.

Background:
A 25 year old unmarried woman of the toddy tapping Billava caste arrived for a consultation accompanied by her mother. From her appearance, it was obvious that she was engaged

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MARK NICHTER

in the beedie (cigarette) home industry and she was dressed (by South Kanara standards) in a fashionable saree (showku).

Complaints volunteered by the woman: weakness, backpain (ubiquitous among beedie rollers). Complaints volunteered by the woman's mother: poor sleep, lack of interest in her work, loss of appetite. Prior consultations: It was revealed during the consultation that the woman had already attended a private cosmopolitan practitioner who had given her red pills and a B~2 injection (the chit had been retained), an ayurvedic compounder who had given her a 16-day supply of a tonic and a local exorcist who had given her a talisman. Her condition had not improved. Negotiation of illness identity: Ganapathy questioned the patient about her urine, asking the frequence per day, color, smell, and whether she needed to urinate at night - a 'calling' contrary to routine practice. The latter question was answered affirmatively, no unusual color or smell was noted, but it was noted that urination was more frequent than normal and scanty. Next Ganapathy asked if the patient was suffering from white discharge. This was denied and the patient displayed signs of embarrasment. She was next asked if she felt itchiness in the genital region. This was answered in the affirmative. Ganapathy then felt her pulse and revealed, after graphically illustrating the movement of the pulse between the pulse points of the three humors, that her dhatu was leaking into her urine. Next, Ganapathy's wife took her inside for a physical examination and she reported privately to Ganapathy that the woman had white discharge, a point he later reported to the patient on the basis of his analysis of a urine sample. Ganapathy played up to the patient, noting that she was attractive and of marriageable age and that it was important for her in preparation for marriage to gain weight and build up herdhatu. To this, the patient displayed minor embarrasement. Prescribed Treatment: The patient was prescribed: (a) medicine for increasing weight, (b) medicine for increasing dhatu, (c) a blood purifier, (d) a special diet, and (e) cooling oil to place on her head at night to induce sleep. Advice: Ganapathy advised her not to scratch her genital area with her hand but, if necessary, to rub herself with a towel, to use smoke therapy for her genital region, i.e., to stand over a pot of smoking herbs as a purification technique. Comments to researcher by vaidya after consultation: The patient is of age where marriage weighs heavily on her mind. She is engaging in masturbation. This has caused a loss of dhatu and her symptoms. Follow-up on patient by researcher: Members of the patient's family have been delaying an intensive search for a marriage alliance because the girl is making good wages as a beedie roller. The family is living at subsistence level with an additional burden o f 4 children from a married daughter who is ill and has returned to the home. The patient assists in the support of the household but is attempting to save money for her own dowry. This causes a conflict which is suppressed. To placate the girl, her family encouraged her to purchase a flashy saree, face powder, and a necklace. They associate her illness with dhatu loss, less blood, and overheat.

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15

We may use this case study as a base for discussing the social consequences of Ganapathy's therapy in providing or enhancing coping strategies for patients which reduce psychosocial stress. In the above case, we see that Ganapathy's therapy: (1) brings attention to bear on the issue of marriage through a discussion focusing on the preparation of the patient for marriage through therapy; (2) reduces the patient's immediate distress by providing a plan of action; (3) focuses the attention of the family onto the general well being of the patient by involving members of the family in the preparation of time consuming medicines and special meals. This social participation aspect of ayurvedic treatment serves to socialize instead of alienate the illness experience; (4) mitigates latent guilt or sense of responsibility within the family for not arranging a marriage - a consideration which has increased now that the patient is ill and less desirable for marriage; (5) relieves anxiety on the part of the patient that she has in some way spoiled her body or become less of a person through masturbation or dhatu loss - fears related to a perception of self worth. Let us consider the social ramifications of Ganapathy's therapy in a series of cases related to prevalent psychosocial problems. We may begin by elaborating on the type of case cited above. Ganapathy is frequented by an increasing number of young unmarried men and women who complain of semen loss, menstrual disorders, leukorrhea, general malaise and lethargy. 1 As has been mentioned elsewhere (Nichter 1977; Obeyesekere 1976) the rise in incidence in these disorders is related to the rising marriage age and increased exposure via the media to romance. Many young adults are anxious about marriage or riddled with guilt or shame for having engaged in masturbation; guilt perhaps being more common among cosmopolitan men than women or rural men where shame is more prominent. Some of the young associate masturbation with the fact that they can no longer control their romantic thoughts or desires; they report an inability to concentrate (students) and ambivalence to work. In such cases, Ganapathy reestablishes a patient's sense of self worth by a medicinal rite de passage which is at once instrumental and symbolic. Ganapathy reduces guilt and transforms the patient by a therapy where emphasis is on purification and control. Ayurvedic medicine is given to undo the harm caused by masturbation (if the subject is directly discussed), replenish the dhatu supply, calm (cool) the mind, restore a perceived loss in mental capacity and purify the blood. Dietary regulations enhance therapy. After a course o f treatment has been completed, the patient is told (convinced) that his/her full capacity of dhatu and vigor has been normalized. On occasion, Ganapathy will overtly take the role of counselor and speak to the parents on the relationship between health and marriage. I noted three separate occasions when Ganapathy subtly suggested to parents that a daughter or son be married in the near future for health's sake. Ganapathy also is consulted by many married women who have not yet

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become pregnant or who have miscarried in the first trimester of pregnancy. It is common for such women to complain of painful or irregular menses. Their concern about their menstrual cycle facilitates a coping strategy which focuses attention on a natural disorder which may be rectified by therapy, displacing fears that they are cursed or barren like some distant relative. Ganapathy supports this coping strategy and in fact suggests that menses is not "perfect" when a childless woman consults him but does not overtly mention menstrual difficulties. Ganapathy's therapy focuses on the menstrual cycle - regularity, flow, and color. This medication is accompanied by a course of blood purifying medicine to reinstate the purity of the woman's blood, dhatu producing medicine to increase strength and vitality, and medicines to increase her fertility which are structured by homeopathic logic and the doctrine of correspondence. 11 During the course of treatment, which may last some months, attention is focused upon enhancing a patient's purity, humoral balance, and allignment with the power of fertility. A patient receives new hope as well as a coping strategy - a plan of action and an explanation for her failure to become pregnant in a household where a mother4n4aw may relentlessly bemoan each menstruation. Women who are particularly anxious about pregnancy or who have a history of habitual miscarriage are referred by Ganapathy to cosmopolitan practitioners for the performance of a dilation and curation (D & C) procedure as an adjunct part of his therapeutic strategy. Ganapathy and, for that matter, most educated laypeople, view a D & C performed on a non-pregnant woman not as a procedure for infertility testing (determination of the consistency of endometrial maturation relative to time in cycle) but rather one which increases fertility by purifying the womb (garbha kosha). This perception of the D & C procedure has made it popular among the middle class who periodically have it performed, making for a booming business in private nursing homes. Two points may be noted here. First and most obvious is that undergoing such a procedure increases the wife's hope for and expectations of pregnancy, reducing stress on her part at least temporarily. Secondly, a husband who takes his wife to see Ganapathy and pays for her to undergo an expensive D & C demonstrates his concern and support while reducing his own guilt. 12 or sense of responsibility. The more attention focused on his wife's physical condition, the more infertility is seen as her problem. Ganapathy noted to me that in his experience, when a couple consulted him for infertility, a feeling was evident that the wife needed more extensive, expensive, and powerful medicines. The attention focused on the wife may therefore be seen as providing the husband with a coping strategy. Ganapathy is also consulted by patients (mostly Brahmin) who complain of semen loss, menstrual disorders or white discharge as a means of expressing anxiety due to unsatisfactory or frustrating sexual relationships. Ganapathy's

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therapy is directed towards both marriage partners. His therapy orients the couple to help each other reach a new state of health and corporate awareness. Ganapathy puts the couple on a strict diet, gives them rasayana - rejuvenation medicines and prohibits them from sexual contact for a stipulated number of days, a period of reduced stress and an opportunity to break away from maladaptive interpersonal patterns supporting illness behavior. He tells the couple that their sexual difficulties have in part been caused or accentuated by humoral imbalance and in this way minimizes personal responsibility for the problem. Ganapathy's therapy requires that humoral imbalances be normalized and over the course of treatment gradually prepares the couple for sexual reunion. Each partner has an allotted task to perform. A wife must prepare special foods and medicine while her husband performs ritual duties which emphasize joint expectations. Such duties may include going on pilgrimage or offering rituals to deities concerned with progeny, sexual strength, or ideals of marital life. Other cases exist where a patient complaining of semen loss, leukorrhea, chronic weakness or dysmenorrhea wishes to withdraw from sexual encounters entirely, a3 Ganapathy is faced with treating a patient who does not want to relinquish symptoms and desires a long term sick role as a coping strategy. Such patients are disinterested, but ambivalently sit through Ganapathy's pep talks about restoring sexual vigor or his lectures on the duties of husband and wife. On one occasion, I observed Ganapathy give one such patient, a woman complaining of dysmenorrhea, medicine for this complaint as well as an aphrodisiac medicine containing a mild intoxicant. When Ganapathy's medication failed to give anything but temporary relief for the patient's dysmenorrhea, he sustained the patient's sick role by continuing to prescribe medicine for the symptoms which she reported. In his case, illness became an important source of refuge for the patient in avoiding marital duties! Ganapathy blamed the case on an inappropriate matching of horoscopes leading to a mismarriage. He rationalized to me that perhaps sexual union of the two would lead to an unhealthy child, so it was just as well her sickness made sexual union ill advised. He suggested that the best thing that the husband could do was seek a second wife. On occasion, a woman is brought to be examined by Ganapathy ten days to a few weeks after delivery, usually by a mother or husband who reports that she is talking nonsense, acting irrationally, scolding elders, and not listening to what others say; cultural symptoms which might be compared to those of postpartum depression or psychosis in the West. In some instances, relatives are afraid that the woman has gone mad, h u c h u , or that she has been possessed by a lowly spirit. 14 Ganapathy identifies such women as suffering from an illness known as sutaka vayu, literally 'pollution wind' (Nichter 1979), and ascribes the cause to
-

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impure blood which has been retained after delivery as well as cold air entering into the womb after delivery, a time of great vulnerability and temperature change, is He prescribes bitter tasting blood purifiers and heat treatment, asking the patient to return when possible every few days until the illness recedes. Ganapathy's diagnosis and therapy provide the patient with a coping strategy; an illness identity which explains and gives meaning to abnormal behavior so that the patient is dissociated from culturally inappropriate action. 16 Such an identity provides an alternative to being labelled "possessed" which would require exorcism of a spirit at a time of emotional vulnerability, weakness, and ritual impurity. Interestingly, women prone to experiencing sutaka vayu are recognized by Ganapathy as being women who have a history of complaining about menstrual difficulties. This association could be related to nutritional or hormonal factors. It might also be related to the fact that women who seek treatment for menstrual problems sometimes do so because of major psychosocial stress and these women would be more prone to suffer from a syndrome akin to post partum depression or psychosis. Ganapathy receives a number of children's cases associated with malnutrition, usually extended breastfeeding compounded by delayed weaning. Occasionally, he receives a case where a breastfeeding mother expresses latent feelings of responsibility over the ill health of her child linked to her following of traditional dietary restrictions. Such cases usually involved long term diarrhea, gaseousness, green feces, lack of appetite, or irritability. Feelings of responsibility are related to a perception of the child as an extension of the mother expressed through the ideology that a mother's diet affects the quantity and quality of breastmilk and thus the child's health. Some mothers exhibit anxiety that their breastmilk is indigestible or poisonous, visha halu. Ganapathy performs for women exhibiting anxiety over the purity of their breastmilk a test to determine if the milk is poisonous. Breastmilk is expressed and a small quantity is fed to red ants to see if after tasting it they perish. If a woman's breastmilk passes the ant test, Ganapathy gives her medicine to be administered orally to the child, medicine to increase the mother's dhatu and quantity of breastmilk, and moreover, medicine to be consumed by the mother to be passed on to the child through her breastmilk. This reaffirms the mother's sense of self worth, and involves her directly in the curing of the child. If a mother's breastmilk fails the ant test, breastfeeding is temporarily discontinued, although Ganapathy instructs the mother to express breastmilk, thereby removing toxins from the breast while at the same time continuing secretion. The mother is given tasks which involve her as much as possible with the well being of her child, e.g., preparation of decoctions as well as the application of medicinal oils to the child's body. Moreover, as the treatment progresses and a mother's breastmilk is gradually thought to become pure, faith is reestablished

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in the inherent goodness of the mother's milk by using it in the cure of the child; at first externally and then internally. At first she is advised to rub breastmilk on the child's head to cool it or on the child's eyelids to reduce redness and burning sensation. Leukorrhea is also linked indirectly to insufficient or weak breastmilk. The quality of breastmilk is related to a woman's supply of dhatu. Leukorrhea is associated with a loss of dhatu. Ganapathy therefore subtly inquires of this ailment. He sometimes finds himself confronted by a woman who wishes treatment but who does not want to openly admit her problem lest other family members (particularly a critical mother or sister4n4aw) place blame on her for the child's ill health. In such cases, Ganapathy refers to the problem indirectly and offers the patient treatment for the ailment without specifically identifying it. To do this, he gives dhatu producing medicines as well as medicines which he notes rather vaguely will correct "women's complaints". Ganapathy is consulted by elderly patients, particularly widows, maintaining a certain degree of ambivalence toward life; patients who on follow-up investigation were found to live in families where they had reason to feel that they were neglected or unappreciated. Common complaints reported include dizziness, weakness, and digestive problems, fairly ubiquitous but at the same time symbolically relevant symptoms. As I have noted (Nichter 1977) dizziness is a symptom which denotes physical as well as psychosocial imbalance, weakness denotes vulnerability, and digestive problems are associated with social distance and breaks in the internal flow of family relationships symbolized by a shared digestive as well as commensality cycle. Ganapathy offers such patients considerable attention and moreover places their children or grandchildren in greater physical contact with them. Not only are special medicines and foods to be prepared but Ganapathy lays emphasis on older patients receiving routine oil massages. This places the patient in "touch" as well as in mind. If a member of his own caste, Ganapathy offers the patient emotional satisfaction by referring to the prestige of the family which reflects on a patient. A final example of a type of case which Ganapathy receives, although less commonly, is worth highlighting because it illustrates the role played by a vaidya when confronted bY a patient suffering from a psychosocial problem for which he cannot single handedly negotiate a coping strategy, but must refer to another specialist for complementary therapy. The complaint involved is a symptom set characteristic of duodendal ulcer; a complaint reported as particularly high in South India (Kouwenaar 1971). While a number of factors probably contribute to the high incidence of this complaint, including diet (excessive chillies), it is suggested that cultural factors are significantly involved in the focusing of stress on the digestive process. These factors include the central importance given to digestion in respect to indigenous notions of physiology and the symbolic

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importance of digestion as a marker of corporate identity. Members of a group derive their identity in part from a shared food pool as well as a shared digestive cycle. Disruptions of the digestive process may be perceived as disruptions in the social group. The symptoms of kai visha, hand poison, include indigestion an hour or so after eating a meal, burning sensation and a feeling that there is a ball in the stomach. Vomiting relieves the pain temporarily and this is interpreted as poisons being ejected from the stomach. The symptoms noted are almost identical to an illness locally known as gulrna, ball, and an ayurvedic disorder ama both of which are associated with improper diet or digestive capacity. As I have noted (Nichter 1977), most cases of kai visha in South Kanara are associated with families on the brink of partition or wishing to partition but existing as a unit because of lack of possible alternatives. When ill, if a person suspects that kai visha is being administered secretly by a household member he generally will not accuse a person openly. A patient often frequents an ayurvedic practitioner with these complaints, for vaidya are ascribed expertise in treating gulma. The patient then takes a course of medicine and vocally expresses that either no relief is experienced or that relief is only temporary. In my conversations with Ganapathy, it became apparent that he was aware that kai visha was associated with inter-family conflict; after all, who is close enough to the hearth to place poison in the food on a regular basis? In two cases, when Ganapathy encountered a case involving symptoms typical of gulma or kai visha, he subtly questioned the patient not only about his physical symptoms but the number of members in the household, the amount of land tilled, etc. It was my impression that he was trying to get a feel for possible sources of strife leading to a latent suspicion of poisoning. Ganapathy treated both patients for manifest symptoms with 16 to 30 days of medicine during which time the patient was to visit him two to three times. Medicines prescribed included an emetic as well as blood purifiers and digestive aides. In one case, a patient did not return after the second visit, in the other the patient reported only a temporary lessening of symptoms. Ganapathy told the latter patient that while his medication could reduce symptoms the cause of the trouble, dosha, must be divined. The patient was asked to seek the consultation of an astrologer. Initially, no astrologer was mentioned by name, but Ganapathy mentioned that a renowned astrologer resided some ten miles away. In a follow-up of the case to the astrologer, who incidently maintains a referral relationship with Ganapathy, the specialist tossed cowrie shells as a divination procedure and decreed the patient suffering from kai visha. He furthermore suggested that the culprit was a female member of the client's household but not his lineage, e.g., an affine and most likely a brother's wife, inasmuch as the client hailed from a joint family of Brahmin patrilineal caste. The patient

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was not told the exact name or relationship of the culprit but was told to think of a name of anyone that he suspected. With a toss of the shells, his suspicion was confirmed. Next, the client was directed to go to an exorcist for protection against additional attacks by enemies, to continue taking the medication of the vaidya and to eat a special diet prepared by his wife in which busma, sacred ash from a ritual fire, was to be placed - an act which effectively created a partition at the hearth, this being a prelude to a future partition in the household. In this case, referral by the vaidya justifies and legitimates a client's visit to a diviner which supports an implicit suspicion of kai visha. It must be kept in mind that within a joint family where suppressed conflict exists, a visit to an astrologer and exoricst, which otherwise might be suspect, is facilitated by the vaidya's referral. Here the vaidya is one member of a chain of specialists who negotiates a coping strategy. One final point in conclusion. Ganapathy's practice is in an interior ~_llage and many of his patients travel a considerable distance to see him. As has been noted, more than half of his patients are from towns or a city which is 50 miles, two to three hours travel time, away. A visit to Ganapathy's village house is troublesome but the journey heightens anticipation and expectations. The journey may be viewed as part of the process of healing itself; an expression of concern by a family for a patient as well as a symbolic act involving the traveling from a cosmopolitan world of modernity and change to a more traditional world. We might characterize this as a mental journey from the world ofgessellschaft and the cosmopolitan medical reality where cure is the foremost concern, to the world ofgemeinschaft and the reality of the traditional medical sector where healing is the focus of attention. This is a journey from a clinical context where a disease is identified and where medicine is in actuality the doctor (the medicine cures) mediated by a practitioner 17, to a clinical setting where the pandit is involved in the negotiation of illness as a somatic as well as symbolic construct and establishing a patient's sense of balance, control, self worth and positive health as well as cure. Through the pandit's efforts to establish order and balance 'within', the patient is afforded strategies for coping with the world 'without' concordant with an altered or envigorated sense of identity and milieu interieur.

Department of Psychiatry University of Hawaii School of Medicine

ACKNOWLEDGEMENTS Fieldwork upon which this paper is based was conducted in South Kanara District, Karnataka State between 1974-76 and 1978-79. I gratefully acknowledge support for the latter

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period of fieldwork by a senior fellowship from the Indo-U.S. Subcommission on Education and Culture and express my appreciation to the Department of Community Psychiatry, National Institute of Mental Health, Bangalore, for their affiliation during both fieldwork experiences. Thanks go to Arthur Kleinman for comments on a companion paper (Nichter 1977) leading to the conception of the present paper. Special thanks go to Mimi Nichter who assisted in the interviewing of women patients described in the text and for her valuable insights into the world of women. NOTES

1. Dhatu is a term commonly translated as semen. Dhatu, however, is more than a source
of vitality and virility. It is a substance associated with the regulation of body processes, the control of heat, enduring strength, and a positive source of health. On this point see also Obeyesekere (1976). The paper focuses on vaidya who are respected for their broad knowledge ofayurvedic diagnosis, therapy, and verse; practitioners who offer inclusive diagnosis of the patient's overall state of health and not just an illness. Such vaidya may be distinguished from the many herbal practitioners and dispensers of ayurvedic medicines subsumed under the rubric vaidya but who are treated more as compounders or specialists in the treatment of specific types of illnesses. Incidentally, only 22% of these informants deemed it necessary to initially volunteer all of one's symptoms to cosmopolitan practitioners. Discomfort is tolerated remarkably well and often not initially revealed in a clinical setting while pain is displayed openly and referred to directly. An exception is the displaying of pain during childbirth. The example is simplistic for it involves a patient manifesting an illness which he is predisposed to vis fi vis his constitution. More complex cases would involve illness where the factors of age, season, diet, and vocation might clash in the humoral equation. My use of the term 'explanatory model' derives from the work of Kleinman (1977, 1980) and refers to the reasoning applied by laymen and professionals to explain a particular illness episode - not illness in general. Kleinman (1980: 93) has characterized interaction with Chinese style practitioners in Taiwan's health sector in much the same way as I have ayurvedic vaidya. He later notes that perhaps elite health professionals are socialized to provide technical information to patients as opposed to meaningful explanations. My observation of vaidya tend to support this point primarily among those who have received institutional training. Traditional vaidya tend to legitimate their therapy by reference to Sanskritic verse. Ayurvedic verse lends itself to popular metaphoric explanation drawing upon ecology as a model. The concept of constitution, prakr,ti, and the way it is used by vaidya to denote a propensity to particular types of humoral imbalances, is in keeping with Balint's discussion (1957: 256) of the idea of a 'basic fault.' Balint describes this idea as serving to link external and internal causal theory. Ganapathy's awareness of the psychosocial aspect of illness and his interest in the social context of his patients is not unique although many conservative vaidya strictly treat patients for dosha imbalances, viewing psychological problems and emotional states as predicated by such imbalances. In a previous paper (Nichter 1977) I describe another vaidya's (Gopal) recognition of the use of the illness idiom for the communication of distress. Gopal was aware that leukorrhea and menstrual complaints were often belabored by patients as a means of communicating distress and negotiating sick roles. Ganapathy observed that the number of patients frequenting him with latent anxiety about masturbation or semen loss was highest among educated but unmarried males.

2.

3. 4.

5.

6.

7.

8.

9.

10.

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11.

12.

13.

14. 15.

16.

17.

This observation was corroborated by a survey of clients purchasing rejuvenation and sex vigor drugs at ayurvedic stores in two towns and a city. Alignment with sources of fertility and development is a pervasive feature of Hindu ritual endeavor. For example, in an important South Kanarese ritual, known as kural kutunni (rice tying ceremony), leaves from plants used in essential agricultural operations and milky plants associated with prosperity and bounty are placed in contact with new rice stalks, a symbol of development and sustenance. Bundles of the forementioned are tied to tools and placed over thresholds points of transition and transformation as a means of providing appropriate orientation. Likewise many fertility medicines are structured vis ~ vis the doctrine of signatures to enhance and orientate life force toward fertility. For example, Fieus religiosa (ashvata tree), a milky tree, is an important fertility medicine as well as being worhipped as a source of fertility by women who circumambulate the tree. Shrines to cobra, naga, another source of fertility, are often located at the base of these trees. Among the lay population, infertility is spoken about in reference to women not men. However, an unspoken recognition does exist, particularly among middle class educated males, that men may be sterile. From my discussions with informants, however, it appeared that infertility in women was commonly viewed as hereditary, but among men was viewed more as an ailment which could be corrected rather than a constitutional or hereditary deficiency. Balint (1957: 259) discusses the use of illness as a means of withdrawing from unsatisfactory or frustrating relationships citing dysmenorrhea as a recognized dispensation used in the West to avoid marital duties. During this time of impurity, sutaka, women are not possessed by ancestor spirits or patron buta spirits but only wild malevolent spirits requiring exorcism. The post-delivery stage is a time of openness as well as internal temperature change. Women during pregnancy exist in a heated state while after delivery they are in a cool state, one reason for prescribed hot bathing and heating medicines. Byron Good (1977) in his semantic network analysis of illness categories in Iran points out that popular illness categories facilitate alternative health care options. For other examples of this in South Asia see Nichter (1979) and Waxler (1974). For a further discussion of medicine as the agent of cure as opposed to the practitioner see CasseU (1970: 63).

REFERENCES Balint, M. 1957 The Doctor, His Patient, and the Illness. New York: International Universities Press. Carstairs, M. G. 1957 The Twice Born. London: Hogarth Press. Cassell, E. J. 1970 In Sickness and in Health. Commentary, June edition, 59-66. Good, B. 1977 The Heart of What's the Matter: The Semantics of Illness in Iran. Culture, Medicine, and Psychiatry 1 : 25-58. Kleinman, A. 1977 Comparisons of Practitioner-patient Interactions in Taiwan: The Cultural Construction of Clinical Reality. In A. Klelnman et al. (eds.); Culture and Healing in Asian Societies: Anthropological, Psychiatric, and Public Health Studies. Cambridge, Mass.: Schenkman Publishing. 1980 Patients and Healersln the Context of Culture: An Exploration of the Borderland

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between Anthropology, Medicine, and Psychiatry. Berkeley: University of California Press. Kouwenaar, W. P. 1971 Epidemiological and Sociocultural Factors in the Etiology of Duodenal Ulcer. Advances in Psychosomatic Medicine 6 : 1 2 1 - 5 1 . Nichter, M. 1977 Idioms of Distress: Expression of Anxiety and Psychosocial Conflict among Havik Brahmin Women. Paper presented to the British Medical Anthropology Society Conference on "Women, Illness, and Stereotypes", June 1977, School of African and Asian Studies, Sussex University. Publication forthcoming. 1979 The language of illness in South Kanara. Anthropos 74: 181-201. Obeyesekere, G. 1976 The Impact of Ayurvedic Ideas on the Culture and Individual in Sri Lanka. In C. Leslie (ed.): Asian Medical Systems: A Comparative Study. Berkeley: University of California Press. Waxier, N. E. 1974 Culture and Mental Illness: A Social Labeling Perspective. J. Nerv. and Ment. Dis. 159: 379-395. Zimmerman, F. 1978 From Classical Texts to Learned Practice: Methodological Remarks on the Study of Indian Medicine. Soc. Sci. and Med. 12: 97-103. t980 Rtu-s~tyma: The Seasonal Cycle and the Principle of Appropriateness. Soc. Sci. and Med. 14B: 99-106.