by Sudhir Kakar
Here, we are neither concerned with a psychological understanding of Ramnath’s symptoms nor with the tracing of their genesis in his life history. Our purpose is to understand Ramnath’s ailments and his efforts toward the restoration of well-being, against the background of his predominantly Hindu cultural tradition. In other words, the aim is to essay a cultural analysis rather than a psychoanalysis of Ramnath’s condition, which will help us understand the nature of health and illness in the Indian setting.
At first glance, Ramnath’s cognitive space in matters of illness and well-being seems incredibly cluttered. Gods and spirits, community and family, food and drink, personal habits and character, all seem to be involved in the maintenance of health. Yet these and other factors such as biological infection, social pollution and cosmic displeasure, all of which Indians would also acknowledge as causes of ill health, only point to the recognition of a person’s simultaneous existence in many different orders of being. To use Western categories, from the first birth cry to the last breath, an individual exists equally in a soma, a psyche and a polis; in other words, a person is simultaneously a body, the self and a social being. Ramnath’s experience of his illness may appear alien to non-Indians only because of the fact that the body, the self and the polis do not possess fixed, immutable meanings across cultures. The concept of the body and the understanding of its processes are not quite the same in India as they are in the West. The self—the Hindu ‘subtle body’—is not primarily a psychological category in India, though it does include something of the Western ‘psyche’. Similarly, for most traditional Indians, the polis consists not only of living members of the family and community, but of ancestral spirits, other spirit helpers, and—for the Hindus—the familiar gods and goddesses who populate the Indian cosmos.
Subjectively, then, an Indian is inclined to believe that his or her illness can reflect a disturbance in any one of the orders of being, whereas the symptoms may be manifested in the other orders. If a treatment, say in the bodily order, fails, one is quite prepared to reassign the cause of illness to a different order and undergo its particular curing regimen—without losing regard for other methods of treatment.
The involvement of all orders of being in health and illness also means that an Indian is generally inclined to seek more than one cause for illness in especially intractable cases. An Indian tends to view these causes as complementary rather than exclusive and arranges them in a particular order by identifying an immediate cause as well as peripheral and remote ones. The causes are arranged in concentric circles, with the outer circle including all the inner ones. To continue with our example, Ramnath, in concordance with Ayurvedic theory, which provides the governing paradigm for the explanation of physiological processes in traditional, Hindu India, may identify his arthritic pain as the result of a disequilibrium—what Ayurveda would call an imbalance of doshas. He would see it, say, as an excess of vayu or ‘wind’, which needs to be brought back in the right balance through diet, drugs and external applications. The disequilibrium may be felt to be compounded by personal conduct—bad thoughts, habits—which, in turn, demand changes at the level of the self. The fact that the disease persists or is manifested with a stubborn intensity may be linked with his astrologically ‘bad times’, requiring palliative measures, such as a puja. The astrological ‘fault’ will probably be further traced back to the bad karma of a previous birth about which, finally, nothing can be done—except, perhaps, the cultivation of a stoic endurance with the help of meditative practices.
Like most Hindus, Ramnath’s image of his body and bodily processes, in which he would locate the first circle of any illness, is still governed by the precepts of Ayurveda, of which he may or may not be fully aware. Ayurveda is more than a traditional system of medicine. Ayurveda comprises the Indian notions of the constituents of the person and the nature of the body’s connection with the psyche, the polis, the natural environment and the cosmos. These ideas constitute a cultural prism through which men and women in India have traditionally viewed the person and his or her state of well-being. As the Sri Lankan anthropologist Gananath Obeyesekere has remarked, ‘Without some awareness of the theory of Ayurveda medicine it is not possible for us to understand much of what goes on in the minds of men in the South Asian world.’2
THE BODY IN HEALTH AND ILLNESS IN AYURVEDA
Ayurveda is not unique in its intimate connection with the culture and society from which it springs. Medical theories, opinions and practices in any society tell us as much about social beliefs as about the art and science of healing. For instance, expensive medical procedures after the disease has run its course, or keeping alive a person in a coma with no hope of recovery, tell us something about the high value placed on technology in addressing problems that do not have a solution, the importance of the individual vis-à-vis the community (especially if the procedures have been financially ruinous for the family), the mechanistic conceptualization of the body, and so forth. In contrast to Western medicine, which is now global, Ayurveda has been less a mirror of society’s cultural belief system than one of its chief architects. Its contribution to the shaping of Indian consciousness derives from its monopoly of the theory and practice of healing for scores of centuries till the nineteenth century, when this monopoly was challenged by Western medicine.
Not that Ayurveda remained in a mythically pure state till the colonial period. There have always been local deviations from the canonical texts, reflecting the influence of folk medical practices and, from the thirteenth century onwards, the impact of Islamic Unani medicine. Western, allopathic medicine, however, could not be easily accommodated in the Ayurvedic paradigm. Its challenge gave rise to modern Ayurveda, professionalized and institutionalized on the model of Western medicine and concerned with providing ‘scientific’ evidence for the efficacy of its healing methods and medicines. In recent decades, there has been a commercialization and standardization of Ayurvedic therapy, especially in its drugs for an urban middle class, and a transnational Ayurveda has emerged, one that has adapted parts of the traditional system, mainly pleasurable herbal oil massages and dietary advice, for an international clientele.
These modern developments go against the essence of classical Ayurveda and are vigorously resisted by some of the more traditional doctors. For them the storehouse of true knowledge is located in a remote golden past and only the ancient texts can be regarded as true teachers of this art and science of healing. It is precisely Ayurveda’s ‘unchanging’ character, with the weight and authority of the past behind it, which testifies to its ‘truth’ and gives Ayurveda its legitimacy in Indian eyes. For Ayurvedic doctors, changing Western theories of disease—from disease as a consequence of faulty distribution of bodily fluids to the theory of autointoxication, from the concept of focal infection to the bacterial and viral origins of diseases—are then a search for the truth that Ayurveda has already discovered. The application of the standard criteria of science (for example, experimentation, falsification, quantification, concepts of proof other than authority) are thus irrelevant to Ayurveda since it operates with a model of a person quite different from one that underlies Western medicine.
The cornerstone of the Ayurvedic system are the pancha-bhuta—earth, fire, wind, water and ether—the ‘five root forms of matter’, the basic constitutive elements of the universe. Under certain favourable conditions, these elements become organized in the form of living creatures. These living creatures constantly absorb the five elements contained in environmental matter (nutrition), which is transformed by the fires in the body into a fine portion and into refuse, the three main forms of the latter being faeces, urine and sweat. Successive transformations of the fine portion of food produce the seven physiological elements (dhatus) of the essence (rasa) of food—blood, flesh, bone, fat, marrow, semen, as well as the substances constituting the sense organs, body joints, ligaments, etc.—and the three doshas—kapha, pitta and vata. Since the Ayurvedic theory of illness and
its cure hinges on the three doshas—translated variously as ‘humours’ (akin to the four Greek humours), ‘metabolic principles’, ‘mind/body types’, ‘energy types’ and ‘irreducible body principles’—we need to understand them better.
When food first begins to be digested, a foamy kapha appears. When the food is half digested and passes into the intestine, a liquid substance called pitta appears. When the remnants of food reach the large intestine and begin to dry up, vata appears. Here’s a simplified idea of how these three doshas are conceived of in Ayurveda:
Kapha is the controller of growth. It supplies moisture to all body parts and maintains the immune system. In mental rather than physiological terms (remember the basic identity of body and mind in Ayurveda), kapha is associated with love and compassion when in balance and with insecurity and envy when out of balance.
Pitta governs the metabolic system. Mentally, in balance, it promotes intelligence and general satisfaction with life. Out of balance, it leads to outbreaks of rage.
Vata regulates body functions associated with breathing, circulation of blood and beating of the heart. It promotes creativity when in balance and causes anxiety and insomnia when out of balance.
Each human being has all the three doshas, although one or the other may predominate, making a person a kapha, pitta or vata type. The division of human beings into ‘doshic’ types is a testimony to Ayurveda’s belief that, ultimately, medicine has to be completely attuned to the individual’s body-mind make up, and its various categorizations are merely attempts to come as close to the uniqueness of the sick person as humanly possible.
Dominance of a particular dosha, though, is not disequilibrium. The three doshas play a supporting role in the body as long as they are in proper proportion and hence in balance. However, if a dosha becomes agitated and assumes abnormal proportions due to predisposing causes (which can range from wrong diet to environmental factors such as the weather, from psychological factors such as stress arising from disturbed family relationships to immoral conduct) it acts on the dhatus, the seven physiological elements of the body, producing disease. It is the task of the vaid, the Ayurvedic doctor, to re-establish the disturbed dosha balance, primarily through diet and drugs but also through oil massages and prescriptions relating to proper conduct and behaviour.
A VISIT TO THE AYURVEDIC DOCTOR
To get a picture of Ayurveda in action and how its healers operate, let us describe Ramnath’s (fictional) visit to a vaid for consultations. Guruji is a traditional Ayurvedic doctor who has a clinic on the ground floor of his two-storey house in the Sita Ram bazaar of old Delhi. Dressed in a white kurta and loose khadi pyjamas, a white turban wrapped around his head, Guruji is a sixty-year-old man with humorous eyes that belie the strictness of his manner. It is apparent that he is a man accustomed to commanding respect and deference.
Ramnath climbs up the three steps to the clinic and walks to Guruji’s seat in the corner of the room, its floor covered with a thin white cotton mattress. The doctor is sitting cross-legged on the mattress, his back reclining against a thick round cushion pushed up against the wall. As Guruji watches Ramnath’s nervous bird-like movements and looks at his thin frame, he is already speculating on Ramnath’s doshic type—a vata perhaps? After Ramnath has described his physical complaint of arthritis in the right elbow and wrist, Guruji begins to gently question him. Does the pain get worse in any particular season or location? Any family history of the same ailment? Does the pain increase or decrease after taking any particular food?
Once the detailed history has been taken, which has given the doctor preliminary information on the predisposing causes, early indications, the symptoms and full extent of the disease, it is now time for a physical examination which will not only determine Ramnath’s doshic profile but also indicate which of the doshas has got out of proportion to the others and what is the stage of the disease. Guruji is a firm believer in traditional wisdom and is particularly diligent in going through all the required steps. He begins with an overall physical examination recording his impressions of Ramnath’s build, hair, nails, the colour and texture of his skin, the colour and sensitivity of parts of his tongue, the colour and consistency of his stool and urine (Ramnath has thoughtfully brought the samples along). Close questioning of Ramnath’s habits, sleep and dreams follows as Guruji notes the characteristics of his patient’s speech. All this—the tattva pariksha—is in service of determining Ramnath’s basic mental make-up, whether he is of a sattvic temperament—calm, quiet and intelligent—or whether he is an active rajasic type—sensual and prone to impatience—or whether he is tamasic—lazy, dull and mentally unsteady. Ramnath is also closely questioned on his food preferences. A sattvic type likes sweet and agreeable tasting food, a rajasic type is partial to spicy, sour and bitter foods, and stale or half-cooked food devoid of its natural juices is the preferred tamasic fare. Ramnath answers all the questions and tells Guruji about his recurring fearfulness and bouts of forgetfulness.
Since food is of signal importance in the Ayurvedic scheme of things, questions on digestion now follow, the information collated with the results of the stool examination. The predominance of pitta makes for a fast digestion, of kapha for a slow one, while in the vata mode digestion can be either fast or slow. Ramnath admits to indigestion and a decreased appetite.
Now comes the most important part of the physical examination, the naadi pariksha, which roughly translates as ‘examining the pulse’, though naadi stands for both a nerve and an artery. According to Guruji, a good doctor can see the image of every important organ of the body reflected in the beat, movement and temperature of the naadi, a skill which like dancing or music can only be acquired through personal instruction by a good teacher combined with systematic practice. Although there are twenty-four clear naadis worthy of examination, the most frequently examined are the radial artery in the right wrist followed by the naadis in the fingers and the thumb. Except in cases of emergency, the examination must be conducted in the morning—hence Guruji’s morning consultancy hours. This is due to the belief that the beat of the naadi is in its pure state in the morning after the night’s rest; in the afternoon because of heat and in the evening because of the day’s accumulated tensions, the natural beat of the pulse is likely to be contaminated.
The disturbance of a dosha is the minimum information a doctor gets from examining the pulse. An increase in vata makes the pulse unsteady, like the ‘slithering of a snake’; an increase in pitta is reflected in a ‘froglike hopping’; while an increase in kapha makes the pulse slow and steady ‘like the gait of a hen’. There are different combinations of beat and movement of the naadi—the pulse signatures for various diseases, affected organs and emotional states, which a competent Ayurvedic doctor is supposed to be able to read. Moreover, in case of long-standing illness, a really good doctor is believed capable of predicting the time of a patient’s death within a specified number of days, even hours, from the state of the naadi.
At last, Guruji is ready to make his diagnosis and prescribe the required treatment according to Ayurveda’s concise dictum, ‘Purify, pacify and remove the cause’. His diagnosis for Ramnath’s disease is chronic ama vata, which he quietly explains to his puzzled patient. Ama is a toxic by-product of indigestion which is carried by an increased vata to kapha-dominated areas of the body like the joints, stomach and brain. Due to the imbalance of doshas, the ama becomes sticky and begins to block vital channels that nourish the body. Guruji’s line of treatment is to increase the digestive fire to stop the production of ama, expel the already formed ama, reduce the inflammation of the joints and rejuvenate the affected joints at the wrist and elbow.
He prescribes two herbal drugs for increasing digestion and two drugs combining herbs and mineral compounds for reducing the inflammation of and rejuvenating the joints. He stands up and disappears into a room at the back which serves as his pharmacy and reappears after a while with a fortnight’s supply of the drugs, each d
ose of each medicine wrapped separately in a piece of old newspaper. He cannot understand how people can take recourse to Ayurvedic drugs manufactured by pharmaceutical companies and sold over the counter in drug stores. These have a fixed-dose combination of herbs, plants and minerals whereas the whole basis of Ayurveda is to prescribe a drug individually according to the patient and the conditions of his life.3
Guruji is especially careful about the drugs containing mineral compounds. For although these drugs are easily available over the counter—millions of Indians, especially the urban middle class, use Ayurvedic preparations—he believes they can be dangerous in the absence of any quality controls and information on the methods of their manufacture. It is a myth, believed by most Indians, that Ayurvedic drugs are completely safe and have no harmful side effects. ‘If a drug is effective, it is also dangerous,’ he says, and quotes from memory from the Carakasamhita, the founding text of Ayurveda: ‘A potent poison also becomes the best drug on proper administration. On the contrary, even the best drug becomes a potent poison if used badly.’
To get symptomatic relief from the pain in the joints, Guruji recommends that Ramnath have bi-weekly massages with sesame or mustard oil. Besides a cryptic ‘Reduce worry and anxiety’ and the more concrete ‘Avoid late nights and afternoon naps’, ‘Always use hot water to bathe and drink’ and ‘Be very careful to have regular bowel movements’, Guruji’s advice in the area of personal conduct ends with ‘Do not control any natural urge’, giving Ramnath permission to belch or fart in public.
Guruji’s most detailed prescriptions, though, are in the area of diet. ‘Avoid curds, milk, jaggery and constipating foods,’ he tells Ramnath, not needing to spell out the latter which he assumes every Indian is familiar with from childhood. ‘Consume chana dal, ginger, bitter gourd and drumsticks,’ he continues. The ‘juice of carrots, beet root and cucumber mixed together is recommended. Fruits like oranges, grapes and papaya are to be preferred. Soak half a teaspoon of garlic pods overnight in buttermilk, grind them into a paste in the morning and take it with a half a teaspoon of warm water on an empty stomach every day. Your spices of choice in cooking should be coriander and cumin.’ We should note that in Ayurveda’s striving to be a person-rather than disease-centered medicine, the prohibition of forbidden foods is not couched in terms of ‘This and this is bad for all persons’ but a more relative ‘This is bad for certain kinds of persons, especially in a certain season.’
