Contesting Healing Power and Knowledge: Health care in Kerala’s Plural Medical System

Abstract: The instrumentality of biomedicine in colonial empire has been the subject of many discussions. Western medicine or biomedicine was introduced in Travancore during the reign of GowriLaxmi Bhai in 1811 when the British resident was very powerful. Of all the three major systems of medicine in Kerala, western medicine was the first to receive state patronage – even prior to the indigenous medical system of Ayurveda. Over the years biomedicine has developed rapidly to become the dominant medical system in Kerala. In the changing context of decentralised and localised development initiatives in Kerala, it is professed to salvage and resurrect sustainable local knowledge and resources. Therefore it is necessary to take a closer, critical and self-reflexive re-look at our health education, licensing practices of health care providers and drug policies with a historical appreciation.

Keywords: Kerala medical system, Travancore medical practitioner, Ayurveda, Homeopathy, biomedicine, pharmaceutical companies, surgery and obstestrics, administration of medicine

Subaltern historians like David Arnold (1989) have drawn our attention to ‘the way in which colonial doctors and imperial medicine shaped the interaction between the rulers and the ruled’. This instrumentality of biomedicine in colonial empire has been much discussed (Muraleedharan 1991; Mac Leod and Lewis 1988; Harrison 1990; Klein 1980). Western medicine or biomedicine was introduced into Travancore during the reign of Gowri Laxmi Bhai in 1811 when the British resident was very powerful. Of all the three major systems of medicine in Kerala, Western medicine was the first to receive state patronage even prior to the indigenous medical system of Ayurveda. Over the years, biomedicine has developed rapidly to become the dominant medical system in Kerala. State patronage was a major instrumental factor for biomedicine’s dominance.

Biomedicine’s entry into Travancore was made easier by two factors: the smallpox epidemics that ravaged India in the early 19th century and the revision of the Treaty of Permanent Alliance between Travancore and the British, a turning point in Travancore history. The epidemic, largely mystified with legends about the small pox goddess was treated in the religious realm causing great number of fatalities while at the same time, the Treaty of Permanent Alliance gave the East India Company the power to interfere in the internal administration of Travancore. The small pox vaccination units thus were introduced into Travancore. As people showed signs of alarm, the members of the royal family got themselves vaccinated (Pillai 1940). Then it was made compulsory for government officials, inmates of prisons etc. (Travancore Administrative Report 1927-28). Shortly after this, the proliferation of biomedical institutions was initiated in Travancore. The first hospital was opened in the state in 1817 and a Durbar Physician, a European, was appointed. Within a decade, there were 27 hospitals, 30 dispensaries and 12 grant-in-aid institutions (TAR 1927-28). In 1928, the government requested the Rockefeller Foundation in America to depute one of their representatives to the State to advise the government in organising a public health department on modern lines. The Foundation acceded and appointed a personnel to take up public health work in Travancore (TAR 1934). With the Rockefeller involvement, British imperialism and American medical imperialism joined hands in shaping Travancore’s health care. Western knowledge was introduced as scientific truth and its technology as superior and progressive. Largely due to state patronage and imperialist interventions, by the time India attained independence in 1947, the number of government medical institutions had reached 143 and a Committee of Experts had been appointed to formulate a scheme for starting a Medical College in Travancore.

The move towards an organised plural medical system took place when Ayurveda received state recognition. It was only in 1875, more than half-a century after the opening of a hospital for western medicine that an Ayurvedic physician was appointed to Government Service in a biomedical hospital. It was also after a full century since the establishment of the first biomedical hospital that the first Ayurveda hospital was opened. Under imperialist interventions, status difference for different systems of medicine was constructed by a differential allocation of resources to different systems of medicine. State policies in both education and the registration of medical practitioners also created hierarchies within the medical system. Besides the major hierarchy with the dominance of biomedicine, within each system of medicine itself hierarchies were constructed.1 When there was a scarcity of doctors who received formal education in Medical Colleges, either in India or abroad, people in Government Service were trained to practice medicine. When Medical Colleges began producing “Qualified doctors”, the other category of practitioners who were until then qualified to practice, ceased to be qualified.2 The early beginnings of private practice in biomedicine also occurred during the British period in Travancore. From the year 1886-87, private medical institutions were being awarded grants, thereby laying the foundation of the state organised private sector in medicine.3

In Ayurveda, until professionalisation began in the twentieth century, the Gurukula pattern-the residential pattern-was the most prevalent form of education in Kerala. By professionalisation is meant specialization, social courses, bureaucratic organisation of medical work dominated by physicians and centered in hospitals, state responsibility for organising or supervising medical services, with the distribution of authority throughout the system enforced by state powers to license and regulate all forms of medical practice. (Leslie 1976:319-20). In 1886-87, the first Ayurveda school was opened in Travancore as a private undertaking of a reputed Ayurvedic practitioner. After two years of its existence, the state took over the school and a Department of Indigenous Medicine was established. By the time the government integrated examinations and syllabi throughout the state in 1943-44, there were many titles and degrees offered in Ayurveda, like vaidyasastri, vaidyakalanidhi, ayurvedaacharya, aryavaidyan and so on. These courses were discontinued and in their place was introduced a Diploma in Ayurvedic Medicine (D.A.M). Only in the sole Ayurveda College in the state (Thiruvananthapuram) the degree course-Bachelor of Ayurvedic Medicine (B.A.M)- was introduced.

The licensing of medical practitioners created additional hierarchies within the system. The Travancore Medical Practitioners Act enacted in 1943, “to regulate the qualifications and to provide for the registration of practitioners of various systems of medicine…” (Travancore Medical Practitioner’s Act M.E 1119:50-51) distinguished between “medical practice” and “medical work” and between “qualified practitioner” and “recognised practitioner”.4 The Travancore Medical Council was established to carry out the provisions of the Act. The Act also defined “Systems of Medicine.” It “means and includes the systems of Allopathy including Dentistry, Ayurveda, Siddha, Unani Tibi and Homeopathy whether supplemented or not by such modern advances as the council may from time to time have recognised.” Thus hierarchies of practitioners belonging to various systems of medicine came about and many practitioners were relegated to the category “illegal” or “fake” practitioners.

When the states of Travancore and Cochin were amalgamated and the Travancore-Cochin State came into being, the Travancore Medical Practitioners Act was replaced by the Travancore-Cochin Medical Practitioners Act of 1953. This was replaced by the Kerala Medical Practitioners Act of 1974. Both these also allowed the registration of practitioners who were not “qualified” but when the Act of 1953 allowed registration for those who have been practicing for a period of five years, the Act of 1974 increased it to ten years. Also practitioners who had no formal qualifications in surgery and obstetrics were prohibited from practicing them. The State was slowly weeding out “unqualified practitioners” as it was increasingly producing more “qualified practitioners.”

Ayurvedic education also followed the structuring that professionalisation demanded. An All-India syllabus for Ayurveda was introduced in the place of the Under the new degree course-the Bachelor of Ayurvedic Medicine and Surgery (B.A.M&S.) biomedical surgery training was imparted to the students of Ayurveda instead of the ancient Ayurveda surgery techniques of Salakya. Later a postgraduate course of Ayurvedic Medicine and Surgery was also introduced.

In the highly hierarchised plural medical system, not all Ayurvedic practitioners in Kerala have the same qualifications or titles.5 Differences in titles, degrees, training, reputation, charisma-all of these contributed to an ambivalent but unmistakable hierarchy of Ayurvedic practitioners in Kerala, causing also ambiguous identities among practitioners. As it is, even in the pre-professionalised system, there were diverse practices, some following Charaka Samhita, others following Susrutha Samhitha, still others following Ashtanga Hridayam or Ashtanga Samgraham. Consequently, there were regional variations as well.

In countering biomedicine’s hegemony, Ayurveda found an ally in Homeopathy. Although originated in Germany and introduced into Travancore in 1906 by a private practitioner and received recognition in 1928 in the Travancore Legislative Council with the support of non-official members of the Council, Homeopathy came to be established as a major medical system in Kerala. Government Homeopathic institutions did not come into existence until 1958- more than a decade after independence. However, Homeopathy was received as in indigenous system in opposition to biomedicine’s “preeminence.”6 The elaborate case-taking and the intimate practitioner-patient relationship are shared by both Ayurveda and Homeopathy which determine treatment for each individual patient.

By the time of India’s independence, the crystallization of state organised health care in Kerala came about under two broad sectors: Government and Private. Both these sectors have practitioners and institutions belonging to the three major systems of medicine-biomedicine, ayurveda and homeopathy. Other systems like Unani and Siddha exist only in the private sector, along with a variety of traditional practices as well as religious practices, herbal and home remedies.7 Conflicts between practitioners and systems of medicine came about under the state organisation as hierarchies were created and many hitherto practitioners became illegitimate practitioners.

Under the nationalist phase, there was revival of Ayurveda. Homeopathy and Siddha also survived along with Ayurveda as indigenous systems in opposition to the well introduced, imperial biomedicine.

The biomedical systems’ superiority had to come from the demonstrated efficacy and advertised superiority of its medicinal products or its technology. During the nationalist phase in India, many multinational pharmaceutical companies came to India. The professional contest between the medical systems in India overlapped with and was strengthened by the political contest between the “crown” and the “colonised.” In this contest, the pharmaceutical products emerged as very powerful. Pharmaceutical products medicine as a commodity separated power and knowledge from the biomedical system and its practitioners and brought them to the market place with multitudinous meanings and forms, offering options to people. As a result, when many practitioners of other systems began using biomedical pharmaceutical products to their advantage, biomedical system’s power centered around greater use of surgery. Surgery as an object of contest in the Kerala medical scene should thus be understood in relation to the Commodification of health.

Students in Homeopathy and Ayurvedic Colleges began receiving training in Surgery and Obstetrics in the District biomedical hospitals in Kerala from 1960 and 1984 respectively. The State’s justification for this decision was that an All-India syllabus was being followed for both Ayurveda and Homeopathy and that the respective professional councils at the national level had decided that surgery training was essential for Ayurveda and Homeopathy education. Supporters of the biomedical system alleged that the decision was to circumvent section 32 of the Kerala Medical Practitioner’s Act of 1974– the section that prohibited the practice of surgery and obstetrics by those registered practitioners. The Kerala Medical Practitioners Act of 1988 proposed to incorporate the provision for surgery-obstetrics training to Ayurveda and Homeopathy students. This attempt to legitimize the training which was already being given sparked severe opposition in biomedical circles. The Indian Medical Council, the national level professional organizations of the biomedical practitioners vehemently opposed the move. The government decided to set up surgery theatres in Ayurveda and Homeopathy Colleges and opened surgical units in Thiruvananthapuram Ayurveda College and Calicut Homeopathy College where students of Ayurveda and Homeopathy in the respective localities were to receive training in surgery. However, due to opposition from their professional organizations, surgeons refused to give training in these theatres. Following this the government tried to reserve two seats for Post-graduate surgery course for tutors in Ayurveda and Homeo Colleges in the State. This also received much opposition. The Kerala health sector was more or less paralysed during a forty-nine day long agitation in 1990 at the end of which the government discarded the seat reservation move. However, the surgery training for Ayurveda and Homeopathy students in Thiruvananthapuram was imparted in Thiruvananthapuram Ayurveda College and for those in Calicut, in the Calicut Homeopathy College. It was left to the three national medical organizations to arrive at a joint agreement about the nature of the surgery training, the center of such training, teaching staff and other details. During the agitation period, there was a lot of mudslinging between the two sides: biomedical system vs. the systems of Ayurveda and Homoeopathy. Not only practitioners of the systems of medicine but also the concerned public, politicians, literary figures and people from different walks of life engaged in public debate through various media. In these debates, the harmful side effects of biomedical products, and the unethical practices of biomedical practitioners, such as over-prescription of drugs, the lack of their social responsibility, and unwanted medication and surgery were emphasised by the opponents of the biomedical system. The supporters of the biomedical system pointed out the unethical and dangerous practices of Homeopathic and Ayurvedic practitioners’ use of biomedical pharmaceutical products, the use of these products by unqualified practitioners and the like. The cumulative effect was the general confusion on the part of the public regarding the social responsibility and ethics of practitioners of all systems of medicine. This too contributed to self-medication or greater reliance on pharmaceutical products-biomedical or Ayurvedic without prescription from any practitioner.

While pharmaceutical products separated the knowledge of drugs from biomedical practitioners and knowledge of surgery was extended to Ayurveda and Homeopathy, more and more laboratory tests, x-rays, ultra-sonic, scanning devices and other such technologies for diagnosis became popular in the biomedical system, giving greater scientific credence to biomedical diagnosis. Biomedical treatment was also becoming increasingly high-tech. Increased use of technology in diagnosis was justified by most biomedical practitioners with reference to the Consumer Protection Act passed by the Indian Parliament in 1986.8

In the backdrop of the complex dynamics of Kerala’s plural medical system discussed hitherto, this paper will now highlight certain practices in the health care segment easily accessible to the Kanikkar, a scheduled tribe population in Kerala. For the purpose of this study, only a section of the Kanikkar or the Kani living in some forest settlements have been selected. In order to provide anonymity to informants, the exact location of the study area is not being specified here.

The Kanikkar once had many communal curing rites, but with the compulsory settlement of the hill tribes and the consequent social re-structuring, many Kani settlements now do not have a Plathi (Kani ritual specialist) or a Moottukani (Kani Headman) and their communal rituals are now an infrequent affair. Moreover, with the forest take-over by the Government, many forest herbs have become inaccessible and traditional curing with forest herbs are not always practical for the Kanikkar, especially when Ayurvedic companies have taken license for collecting forest herbs and even employ tribal people to collect them. Under the changed circumstances, Kanikkar have to rely on external health care options, but those options easily accessible to them are very few.

In the village closest to the forest area, there are no government hospitals or dispensary; all their options in the village are in the private sector: one homeopathic practitioner, one ayurvedic practitioner and another practitioner who allegedly practices bio-medicine without any formal qualifications and a private hospital. The Kanikkar avoid the private hospital unless hospitalisation becomes a necessity because of the high expenditure involved in this choice. Of the three private practitioners in the village, the Ayurvedic vaidyan has no license but belongs to a family of ayurvedic practitioners. In the hierarchy of professionalised Ayurveda, this vaidyan who has no formal qualification or registration would be very low in the rungs. However, Ayurveda is reputed for successful treatment in arthritic complaints, aches and pains of the body, injuries, fractures and sprains due to falls and accidents, and in diseases like chicken pox, measles and jaundice, as well as pre-natal and post-natal care. Therefore, at some stage in their health quest, the Kanikkar as well as other villagers resort to Ayurveda and this vaidyan is assured of a clientele. Therefore, he is not involved in competition with other practitioners and we do not find him crossing over to biomedicine in his treatment.

However, the same cannot be said of the other two private practitioners in the village. The person alleged to be practicing biomedicine without any formal qualifications refused me an interview saying that he was a sick man and had no practice. My informants claimed that he never stopped treating them. They have heard that he was a “fake” doctor, but they trusted his healing powers, especially where children’s diseases were concerned. Many of the Kanikkar said that this practitioner was very kind and allowed them to pay his fees later if they were short of money. One informant went to the extent of saying: “It doesn’t matter whether he gave water or medicine, he has kaipunayam and we trust him.”

Personal charisma and kaipunyam are two important characteristics attributed by many in Kerala for the success of a practitioner. The concept of kaipunyam referred to by the Kanikkar is the same as kaiguna or “power of hand” referred to by Nichter and Nordstrom (1989). It refers to the gift of healing attributed to practitioners. A practitioner should be compassionate, kind and dedicated in order to possess this gift. A practitioner may have kaiguna for one illness, but not for another; he may have it for an illness, but may not have it for a specific patient even for that illness. Thus, the concept of “power of hand” in essence, symbolizes a good practitioner-patient relationship in a specific illness context. The association of the Kanikkar to this allegedly “fake” practitioner who has kaipunyam goes a long way back to a time when there was no other medical practitioner in the village. In this practitioner, the “charm of medicine” and the “power of hand” coexist. Lack of formal qualification has apparently not created any difference to his clientele that consists mostly of tribal children.

The other private practitioner– a homeopath– believed that biomedical pharmaceutical products were more advanced in providing product information and that these products were easier to procure. He often received biomedical and Ayurvedic pharmaceutical products from the medical representatives who visit him. This has enabled him to be very eclectic in his practice of medicine. This homeopath believed that for fever above 100 degree centigrade, antibiotics should be given and that if fever persists, an “over dose” of antibiotics for a long duration should be given. He also believed in giving ampicillin, tetracycline, gentamycin, erythromycin, etc. in injection when fever is very high. Most of his information about biomedical pharmaceutical products came from medical representatives; every month three or four of them visited him and gave free samples, according to him. He also admits to using “satisfaction globules” for “placebo effect.” According to him, “for chronic diseases, homeopathy medicine can be given only with a gap of two months in between the first and second doses. So, for patient satisfaction, the globules with no medicine will have to be given. It is generally found very effective. In English medicine, B-complex injection, multivitamin tablets, iron tablets etc. are generally used for placebo effect.” This homeopath allowed me to see a copy of a medical journal published by the Indian Medical Council. On several of the pages, there were red tick marks on selected medical products. Upon inquiry, he admitted that he was prescribing them to his patients.

During my next visit to this homeopath, I took with me some lists of drugs: essential drugs compiled by the W.H.O. (1983), drugs banned in other countries, drugs banned in the countries of their origin, and various combination drugs the use of which were reported to have produced serious health hazards.9 The homeopath tick marked more than twenty products in my various lists. Among them were Nectarine Tonic (banned in Canada, U.S.A. U.K, and a host of other countries), drugs like Baralgan, Novalgin, Avil Expectorant and Periactin (forbidden in the country where they were originally manufactured either because of fatal contra-indications or because of lack of medicinal value), drugs like Dexabutazone, Reducin, Esgypyrin, Novalgin and Analgin (reported to cause agranulocytosis, a disease which causes reduction of red blood corpuscles), Enterostrep (a combination of chloramphenicol and streptomycin, suspected to cause weakening of optic nerves), Mexaform and Mexogyl (containing clioquinol which causes a fatal disease known as SMON/SubAcute- Myelo_Optic Neuropathy). It should be noted that drugs containing Clioquinol have been banned in most developing countries, but in India there is only a conditional ban on clioquinol. Accordingly, the drug cannot be used for any disease other than dysentery and amoebiasis. But as Clioquinol is intended for use mostly in the treatment of these diseases, even this conditional ban is meaningless. The deadly drug introduced into the international market in 1934 had raised serious suspicions about its hazardous side effects, the very next year itself. But, it took a lengthy court battle in the Tokyo High Court and nearly four long decades before the manufacturing pharmaceutical company would admit that SMON was caused by its drug. At the end of the court battle in Tokyo, the Company apologised to SMON patients.10 Following the admission of the company, all developed countries banned Clioquinol in 1978, but the company continued to manufacture the drug and market it to third world countries, including India. Many of these drugs are available in the village near the Kanikkar settlements and the homeopath prescribes them. As these drugs are for dysentery and amoebiasis, common health problems among the Kanikkar, there are serious concerns that need to be addressed. Drug pushing into the third world has been widely discussed (Silverman, Lee, and Lydecker 1982: Melrose 1982: Singh 1985). India has been no exception to this dimension of capitalism. Newer and newer products have flooded the Indian market, accompanied or preceded by claims and counter-claims about the superiority of each competing product. Medicine as a commodity becomes a powerful symbol and plays into asymmetrical power relations in detaching knowledge of cure from one system of medicine and vesting it in another, or in depriving a practitioner of medicine of that knowledge and empowering a person who has no formal education in medicine.

Today in India, even biomedical practitioners have to depend on the information supplied by pharmaceutical companies. Naturally, the power of these companies is enormous. Two biomedical journals– Monthly Index of Medical Speciality (MIMS), and Current Index of Medical Speciality (CIMS) are the major sources that provide biomedical registered practitioners with official information in new products in the market. Although these journals are intended for biomedical practitioners, they are also available to anyone who subscribes to these journals or has access to libraries that subscribe to them. These journals depend largely on advertisements from the pharmaceutical companies. The companies advertise in popular media as well. So the power of medicine as commodity does not rest with biomedical practitioners as their monopoly. In the village under study, out of the three private practitioners, two were using this power to entice their patients.

Knowledge is often an instrument of hegemony, but it can also be counter hegemonic and democratising. In the context of health commodification in India and the emergent power of western pharmaceutical products, the counter-processes are visible not only in the use of biomedical pharmaceutical products by indigenous practitioners but also in the phenomenon of “self-medication” by the populace, as previous studies have shown (Greenhalgh 1987). In the case of the Kanikkar under study, self-medication has been limited, but more than 90% of them used pharmaceutical products without a doctor’s prescription. There is a great reliance on the medical store and in the pharmacist in the absence of good practitioner-patient relationships, except in the case of one practitioner whose qualification is suspect, and when practitioners not qualified in biomedicine prescribe biomedical pharmaceutical products.

The pharmacist, like the private practitioners, get knowledge about the products from the companies’ representatives. The patient does not have to be present before the pharmacist for diagnosis or choice-making. Anyone can go and explain the problem and get medicines. This “prescription” is also negotiable, depending on the price of the products and the money the patient can spare at that time. When competing products flood the market, choices galore. In approaching the pharmacist, the Kanikkar were getting rid of the intermediary– the doctor. The healing power is with the product, not the practitioner. As Vander Geest and Whyte (1990) have suggested, the charm of medicine as a liberating substance, liberates people from social relationships. For the Kanikkar when their traditional social relationships were extraneously tampered with, in the changed practitioner-patient relationships under the plural medical system, they have found the “charm of medicine” through the pharmacist who, they believe, will refer them to a hospital if hospitalisationis required for further clinical investigations, i.e. for technological diagnosis, or for surgical procedures.

The hegemonic power of biomedicine during the colonial period which was thus, sought to be entrenched through formal medical education and the practice of licensing of medical practitioners and the resultant professionalisation was contested in the decolonising phase through the very same practices in the “indigenous sector” of medicine. However, in the ensuing commodification of health, which in one sense was counter-hegemonic and democratising through “self-medication” and “liberation” from practitioners, use of biomedical pharmaceutical products by practitioners of other systems of medicine, etc. hegemonic powers have been vested on multinational pharmaceutical companies, and to a lesser extent, on their medical representatives, and the pharmacists. In a fastly changing country with onslaughts of globalisation and liberalization, this hegemony of pharmaceutical companies which make competing and contradictory claims regarding the efficacy of various products and confuse practitioners as well as patients, is a matter of serious concern, especially in the context of drug pushing to the “third world.” When formal medical education alone does not equip medical practitioners to keep up with up-to-date knowledge of pharmaceutical products, doctor-patient relationship and ethics of the medical profession in any system of medicine become crucial factors in gaining public trust as well as patient compliance and in countering “health commodification.” In rural and hilly areas, where government health care facilities are found wanting, negative aspects of health commodification are very glaring, but poorly recognised. During the colonial period when medicine was an instrument of colonialism, there was systematic weeding of indigenous health care knowledge; under nationalism, professionalising tendencies of modernisation continued to displace these disparate knowledge of unorganised and powerless populace despite the fact that dominant organised system could not cater to all their needs to satisfaction. In the post-colonial era too, we have failed to recognize that several health care practices and practitioners became “illegitimate” and “fake” even when many people considered them providers of essential and effective health care. In the rural heath care sector, when these practitioners continue to provide health care, mostly to marginalised people surreptitiously, many registered, legitimate practitioners follow practices which are far from legitimate with no circumspection or guilt. In a changing context of decentralised and localised “development” initiatives in Kerala, we profess to salvage and resurrect sustainable local knowledge and resources. Can we then afford not to take a closer, critical, and self-reflexive re-look at our health education, licensing practices of health care providers, and our drug policies with a historical appreciation?

1. In the colonial period, in Travancore there seems to have existed a hierarchy of European doctors and Native doctors, a hierarchy of European-educated and Indian-educated Native Doctors, “Licentiates” of Madras University and “Apothecaries” who graduated from Madras Medical College. In 1889, arrangements were made for forming a class of Compounders.

2. The Travancore Manual has recorded that in 1869, the Durbar Physician proposed a scheme “for the better education of the subordinates to fit them for the better discharge of their duties especially for the more responsible duties attaching to the charge of outstation hospitals then recently sanctioned. It provided for the education of the subordinates already in the service and those who might subsequently enter it, by starting a series of regular lectures in the various branches of medical art and science… The scheme was sanctioned and the medical school was opened in the beginning of 1045 M.E. (1869-70)” (Aiya 1906).

3. In 1898-99, a Medical School was opened for the training of hospital assistants. The objective of the Medical School was “not to supply the men required for the medical service of the State, but also bring into parts of the country which are not within easy reach of the State institutions” (Aiya 1906:540).

4. “Medical practice” was defined as “the practice of the healing art for human ailments of any sort by any measures such as administration of medicines by any channel, natural or artificial, surgical procedure with or without cutting and obstetric measures.” “Medical work” was defined as “the practice of the healing art for human ailments of any sort by any measures by administration of medicines by natural channels.” Attendance at delivery without the use of instruments is medical work whereas bone setting is medical work only if no surgical procedure like cutting is involved and when fracture is simple. “Registered Practitioner” was one whose name was entered in the register of practitioners and “qualified practitioner” was one who possessed the recognised qualification as per Sec. 19 of the Act. (Travancore Medical Practitioners Act 1119:50-51).

5. When Kerala came into being as a conglomeration of Travancore-Cochin and Malabar, the diversities among Ayurvedic practitioners became more complex. In Shornur, an Ayurvedic Association by name KeraliyaAryavaidyaSamajam established a school in 1946. Initially, this school followed Gurukula system and issued certificates but later, a degree course recognised by Madras Government known as Vaidyapadan was offered. Similarly, two Sanskrit colleges in Pattambi and Thrippunithura were producing practitioners with the titles Vaidyabhushanam and Ayurveda Siromani.

6. According to Eliot Friedson (1970), the major characteristics of the profession of medicine is its pre-eminence, pre-eminence not of prestige, but of expert authority, or of authoritative and definitive expert knowledge.

7. Travancore Administrative Report shows that twenty Siddha practitioners had applied for registration but not one of them received registration, the reason for which is not made clear.

8. Consumer Protection Act envisages a most simplified form of redressal of the consumers’ grievances. A complaint can be submitted in plain paper in the complainant’s own language and hand writing, with no court fees or legal paper. The question whether patients are consumers was raised in the cases. The Consumer Protection Council held that the patients pay for the services of the doctor and was therefore, a consumer. This definition took away the govt. practitioners from the ambit of the Act.

9. A book by a biomedical doctor entitled “Banned Drugs, Ought-to-be Banned Drugs, and Essential Drugs” (Ekbal 1986) helped me prepare these lists.

10. A detailed history of clioquinol is provided in Ekbal 1986). In 1935, Argentinean doctors reported the drug’s hazardous side effects on the nervous system. In 1960, in Sweden and in England, veterinarians reported that the drug caused epilepsy in dogs, and consequently, its use on animals was banned, but its use on human beings continued. By 1965, 450 cases of SMON were reported from Japan. In five years, the number is reported to have risen to 11000. Dr. Ole Hanson who started a court battle in the Tokyo High Court to ban the drug cautioned that the drug would cause blindness. In 1973, reports started pouring in from England, Australia, and Switzerland about nervous disorders caused by the drug, but the company insisted that it was virus-caused. Finally, in 1976 the company conceded in the Tokyo High Court that SMON was caused by its drug and apologised in these words: “In view of the fact that medical products manufactured and sold by us have been responsible for the occurrence of this tragedy in Japan, we extend our apologies, frankly and without reservation, to the plaintiffs and their families.” (Ekbal 1986:132)

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Ekbal, B. NirodhichaMarunnukal, NirodhikkendaMarunnukal, AvasyaMarunnukal. (In Malayalam) Thiruvananthapuram: Social Scientist Press, 1986.

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Greenhalgh, Trisha. “Drug Prescription and Self-medication India: An Exploratory Survey”. Social Science and Medicine. 25.3.1987: 307-318.

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Melrose, D. Bitter Pills. London:Oxfam, 1982. Muraleedharan, V.R. “Malady in Madras: The Colonial Government’s Response to Malaria in the Early Twentieth Century,” D. Kumar (ed.) Science and Empire, Essays in Indian Perspective (1700-1947) Delhi: n.p.1991.101-14.

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————. The Travancore Administrative Report, 1927-28.

————. The Travancore Administrative Report, 1934.

————. The Travancore Medical Practitioners Act, 1119 M.E.

————. The Travancore-Cochin Medical Practitioner’s Act, 1953.

————. Kerala Medical Practitioners Act, 1974.

————. Kerala Medical Practitioners Act, 1988.

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 Is Reader at the Department of Anthropology at the Kannur University, Kerala. Her Ph.D is in Social Anthropology from York University, Canada. She is the recipient of the Commonwealth Scholarship (1990 – 95) and Tina and Morris Wagner Fellowship (1981- 83).

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Is Reader at the Department of Anthropology at the Kannur University, Kerala. Her Ph.D is in Social Anthropology from York University, Canada. She is the recipient of the Commonwealth Scholarship (1990 – 95) and Tina and Morris Wagner Fellowship (1981- 83).

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