Mishra and Nambiar International Journal for Equity in Health (2018) 17:175 https://doi.org/10.1186/s12939-018-0890-1

RESEARCH Open Access On the unraveling of ‘revitalization of local health traditions’ in : an ethnographic inquiry Arima Mishra1* and Devaki Nambiar2

Abstract Background: India has recently renewed emphasis on non-allopathic systems of medicine as a means to address the health needs of its populace. Earlier in 2002, its national health policy had sought to ‘revitalize’ community- based health knowledge and practices – jointly christened ‘local health traditions’. Yet policy texts remain silent on the actual means by which ‘revitalization of local health traditions’ should take place. Our research sought to understand the policy lessons of and for revitalization of local health traditions in the three Southern Indian states through an ethnographic inquiry in 2014–2016. Methods: Our inquiry included a narrative synthesis of policy texts tracing the history of governance processes and mechanisms pertaining to traditional medicine, including local health traditions, linking this to the activities of non- governmental organizations (NGOs) and networks involved in “revitalization”. Through in-depth interviews, observations and case studies, we sought to understand the life worlds of local health tradition practitioners and what revitalization meant to them. Our method revealed that beyond a purely academic inquiry, we needed an (inter)action that would give greater voice to these perspectives and views leading to hosting an interactive dialogue among practitioners, NGO representatives, academics, and government officials. Results: Our ethnographic inquiry unraveled the problematic of a litotic approach to local health traditions as those which are non- institutionalized, non-certified, non-documented; assuming the state to be the only source of power and legitimacy. Revitalization discussions were restricted (and often misled) by such an approach. Local health practitioners and others directed us to interesting possibilities of revitalization either through participatory modes of documentation of traditional health knowledge, strengthening existing collective forums for formal social recognition, and building pedagogical institutions that promote experiential learning. Conclusion: Were we not enabled by ethnography as a method that changes its shape apace with emerging findings, we would have not been able to comprehensively answer our questions. This is critical because not only wasthisalreadyamarginalizedareaofinquiry,butwithany other method we risked reinforcing inequities by imposing epistemological and other hierarchies on our participants– whom we would argue were partners - in arriving at our conclusions. Keywords: Local health traditions, Revitalization, Ethnography, India, Legitimacy, Inequities, Documentation

* Correspondence: [email protected] 1School of Development, Azim Premji University, , India Full list of author information is available at the end of the article

© The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Mishra and Nambiar International Journal for Equity in Health (2018) 17:175 Page 2 of 12

Background launch of International Day a year later, India sig- naled an emphasis on non-allopathic systems of medi- “I believe that the strong calls we are hearing for a cine as a means to address the health needs of Indians renewal of primary health care create an ideal as well as the global community. Along with several opportunity to revisit the place of traditional medicine, measures to strengthen traditional systems of medicine to take a positive look at its many contributions to through research, training and practice, the recent 2017 health care that is equitable, accessible, affordable, and National Health Policy additionally calls for developing people-centred (Director General, World Health mechanisms for certification of “prior knowledge of Organisation [WHO] at the Congress on Traditional traditional community health care providers and en- Medicine, 2008, Beijing, China)” [1]. gaging them in the conservation and generation of the raw materials required, as well as creating opportunities On the heels of this announcement by the former for enhancing their skills” [9]. (See Table 1 for a sum- Director General of the WHO and subsequent Beijing dec- mary of the policy developments on traditional systems laration on traditional medicine [2], the 2009 World Health of medicine since 2002 onwards). Assembly called for the upgrading of the WHO’sfirsttrad- In our view, the significance of these policy devel- itional medicine strategy (2002–2005) to support member opments is two-fold. First, the potential of AYUSH in states in “harnessing the potential contribution of Trad- achieving national health goals and thus its integra- itional Medicine to health, wellness and people-centred tion in the national health system, has received health care; and promoting the safe and effective use of sharper attention. Second, ‘non-systems’ of medicine Traditional Medicine by regulating, researching and inte- or community based health knowledge and practices, grating Traditional Medicine products, practitioners and have found space in the state policy documents where practice into health systems, where appropriate” [3]. This they are acknowledged as having potential to contrib- culminated in the launch of the WHO’s next Traditional ute to strengthening primary health care. This recog- Medicine Strategy (2014–2023) in the year 2013. nition marks the coinage of the term ‘local health India’s policy prescriptions in this domain over the traditions’. Such traditions are defined as the undocu- past two decades have followed this arc of global trends. mented knowledge (or folk health traditions) pos- In 2002, the first ever national policy on Indian Systems sessed by birth attendants (dais), bone setters, herbal of Medicine and was passed. This policy healers, poison specialists etc. [10]. candidly acknowledged the long neglect of state support The recognition of local health traditions in policy docu- for traditional systems of medicine including household ments is an important development in the history of and community based health knowledge and practices. health governance in India. In the organization of India’s Thus, along with the traditional systems of medicine like health systems, traditions (such as folk medicine, indigen- , Siddha, and Homeopathy, this policy, for the ous healing) have had no clear legitimate place. Except for first time, recognized the contribution of folk medicine/ sporadic attempts at involving the providers of commu- community health knowledge and practices. The nity based health knowledge and practice in community National Rural Health Mission (NRHM), the flagship development programs through appropriate (re)training program of the (later rechristened [11, 12], these traditions could not conform to centralized the (NHM)), offered a major state governance instruments of professionalization, boost to the spirit of strengthening traditional systems of licensing, certification and standardization [13–15]. Yet, medicine including folk medicine through concrete pro- local health traditions have continued to be practiced grammatic strategies starting in 2005. It proposed the among communities in different parts of India even at the twin strategy of mainstreaming traditional systems of margins of the state [13, 16–20]. A recent study showed medicine namely AYUSH (Ayurveda, Yoga & Naturop- that more than 80% of households in 14 out of 18 Indian athy, Unani, Siddha, Sowa Rigpa, and Homeopathy) and states studied, reportedly utilized some form of local revitalizing Local Health Traditions (LHT) as part of its health tradition to treat episodes of minor illnesses overall mandate to strengthen the Indian public health (in the 3 months preceding the survey), in addition to system in rural areas. Policy discussions in India occur- its use in preventive and promotive health [21]. Select ring around the time of the strategy’s revision, have non-governmental and grassroots organizations (NGOs) called for, among other measures, documentation, valid- and networks have contributed to nurturing such tradi- ation and promotion of home and community based tions with varying degrees of success [22–24]. knowledge and practices including tribal medicine [4–7]. The state’s recent turn towards such community based In 2014, the AYUSH division in the Ministry of Health health traditions, at least in policy pronouncements, is and Family Welfare got its own ministry and the connected to its plans for reorientation of health care National AYUSH Mission was launched [8]. With the delivery in meeting the national goal of universal access Mishra and Nambiar International Journal for Equity in Health (2018) 17:175 Page 3 of 12

Table 1 Timeline of policy developments on traditional systems of medicine (since 2002) Year Policy developments Key feature pertaining to traditional systems of medicine 2002 National Policy on Indian Systems of Medicine Acknowledged long neglect of traditional systems of medicine; revitalization of folk and Homeopathy medicine mentioned for the first time 2005 National Rural Health Mission Suggested mainstreaming of AYUSH and revitalizing local health traditions as part of strengthening primary health care 2014 Separate ministry of AYUSH formed To ensure optimal development and propagation of AYUSH systems of health care including LHT Launch of National AYUSH Mission 2015 Launch of International Yoga Day Promotion of yoga towards holistic health and wellbeing 2017 National Health Policy Access to assured AYUSH services and support for documentation, validation and promotion of LHT to health. The revitalization agenda in the NRHM was the ‘what’ and ‘how’ of the revitalization of the local health located within government’s overall promotion of com- traditions to inform policy development and implementa- prehensive primary health care, that sought greater com- tion [30–32]. munity ownership of health, in line with reviving the Our research was conceived as an opportunity to spirit of Alma Ata declaration. This fit with other com- understand the (silences around) policy lessons of and munity–based measures being implemented, like recruit- for revitalization of local health traditions in the three ment of a village level health activist, village level Southern Indian states of Kerala, Karnataka, and planning committees, community monitoring, and more Tamil Nadu in 2014–2016. This paper discusses the [25, 26]. Revitalization of the NRHM, as part of a findings on such policy lessons and elucidates how an process to reach the goal of universal health care, also ethnographic inquiry enabled us to arrive at these occurred within an Indian health context of persistent findings. health inequity, growing double burden of diseases and high out of pocket expenditure [27, 28]. Methods We find that the policy intent to revitalize local health Overview of the ethnographic research process traditions is critical and laudable, yet major policy texts do Our research relied on an ethnographic inquiry that not elaborate on how these could be revitalized. In the broadly defines ethnography as “combining research twin mainstreaming-revitalization strategy of the NRHM design, field work and various methods of inquiry to as well as in subsequent AYUSH mission document, there produce historically, politically and personally situated are detailed guidelines on how AYUSH can be main- accounts, descriptions, interpretations and representa- streamed and strengthened. However, both these docu- tions of human lives” [33]. Following this definition and ments are silent on the actual means by which the work of other medical anthropologists, we wish to ‘revitalization of local health traditions’ is/ought to occur. highlight three critical features of an ethnographic An analysis of the NRHM’s strategies on the status of inquiry that we incorporated into our research process. AYUSH and LHTs shows that while different states have First, it interrogates the framing of the ‘problem’ itself, innovated and translated the NRHM intent in main- situating it in the historical, political and societal con- streaming AYUSH, very few states had much that is sub- texts [34–37]. It is thus “attentive to the processes, stantial regarding revitalization of LHTs for effective structures and power relations that constitute the field integration into the formal health systems delivery [29]. in which a policy is both constructed and negotiated” This first ever evaluation report of the NRHM twin strat- [38]. Second, considering the complexity of social real- egy of mainstreaming-revitalization, noted that “Local ity, ethnography commits itself to be responsive to Health Traditions, which have been ignored by most state multiple perspectives and their lived realities. The third plans, need to be incorporated within a conceptualization underscores critical reflexivity as an integral component of the health care system so that they can be appropriately of ethnographic inquiry. It is hence necessarily mindful supported by state planning. They are autonomous forms of self and others (researcher’s own positionality and of self-care and the initiation points of locally accessible that of the research participants), of interpretations of primary health care that can be promoted through a few diverse (often contested) viewpoints, and research simple activities by the rural health service system” process that is ‘emergent, spontaneous and dialogical’ [29:08]. Research has further been undertaken to assess [34]. (See Table 3). the effectiveness and/or map the processes of mainstream- Our methodology – comprised of various methods (see ing of AYUSH, elucidating appropriate policy recommen- Table 2) - was decidedly iterative and dynamic as distin- dations for their strengthening but no study has unpacked guished from typical “one-time” qualitative research Mishra and Nambiar International Journal for Equity in Health (2018) 17:175 Page 4 of 12

Table 2 Summary of methods Method Sample and field procedure a) narrative synthesis of policies 22 policy documents at the national level as well as key international policies that were contemporaneous to or are reflected in the terms and concepts used in national policies. b) stakeholder landscaping Visits to and interactions with organisations and agencies in all three states, both referred to and indicated in publicly available policy documents on LHT, and as nominated by those interviewed c) key informant interviews with Interviews carried out with 18 NGO representatives involved with the revitalisation agenda as indicated in policy NGO staff documents or as referred by prior key informants d) observations Participant observations in meetings of 6 national, regional, and state-level healers associations and conclaves, as well as 5 scientific conferences, seminars and meetings e) focus group discussions 3 discussions with convenience samples of healers at aforementioned conclaves to discuss what they do, why they attend these meetings and what they feel ought to be done to improve their situation f) in depth interviews Interviews carried out with 51 healers and 15 of their patients, 20 government representatives of AYUSH department as well as AYUSH research councils at the state level, 15 academicians/researchers involved with documentation efforts or broader research/writing/advocacy on LHT in the popular media or academic literature g) interactive dialogue 1.5 day long interaction involving 36 of the aforementioned stakeholders in a direct conversation with each other on themes emanating from earlier fieldwork, i.e. a) documentation, b) linkages between LHT and AYUSH, c) recognition and legitimacy and d) ways forward for research, advocacy and policy. h) case studies of healers Repeated interviews carried out to develop case studies of 10 (6 menn and 4 women) healers to more deeply understand their experience in light of themes emerging from the dialogue. Care was taken to ensure diversity in gender, years of experience and representation of both those present and absent from dialogue methods. Our research also drew a distinction, as indicated relationsaswellasbeingperformativeand“multi-vocal” by Nichter, between “qualitative research” involving one [39]. It embodied the latter, as Table 3 explains. time interviews, surveys, or focus groups, and ethnographic In seeking to operationalize such an inquiry, our re- research that examines behavior and knowledge production search began with interrogating the notions of as context sensitive and subject to contingencies and power ‘revitalization,’ and ‘local health traditions’–seeking to

Table 3 Summary of methods applied, findings generated and progression through methods.

Note: white boxes describe findings, dark gray boxes describe gaps in findings or emerging findings filled/deepened through additional methods applied subsequently Source: Authors Mishra and Nambiar International Journal for Equity in Health (2018) 17:175 Page 5 of 12

understand the history and politics shaping both. We on opportunities and challenges in revitalization of local thus asked four questions: health traditions. We then sought to understand the life worlds of vai- 1) ‘How are ‘local health traditions’ constituted in the dyas (what local health tradition practitioners are called), policy frameworks and in their everyday practices? seeking to understand what revitalization meant to them 2) What does revitalization entail? in the context of their everyday practice. This happened 3) What is the role of the state in relation to non-state over multiple interactions and observations of their actors including NGOs, community of healers in practice including accompanying them to the forest, vil- revitalization? lage health camps, preparation of the medicines in their 4) What are the specific experiences with revitalization homes and/or dispensaries. Our methodology allowed us of local health traditions including identifying to follow events, people and places – thus observing the opportunities and challenges across multiple Siddha Marma conference in Kanyakumari in Tamil perspectives – governmental agencies and Nadu with 300 healers to the Government and departments, NGOs and the community of healers non-government organizations that led us to healers themselves (whose knowledge is sought to be already working on documenting their knowledge. We revitalized)? conducted FGDs with healers in these collective forums. Many months into fieldwork, our method revealed These questions required that our tools elicit perspec- that beyond a purely academic inquiry, we needed an tives and experiences of policy makers, officials in (inter)action that would bring these different perspec- NGOs, government departments as well as the healers tives together. This was important for three reasons. across multiple sites across the three states in southern First, beyond just presenting different perspectives on India including Kerala, Karnataka and Tamil Nadu (see revitalization of local health traditions, our research Table 2). We chose these states because of our prior sought to provide a space for diverse perspectives to co- knowledge of policies, institutions and practices related alesce and dialogue with each other to see whether a to local health traditions. shared understanding of revitalization would/could emerge. Second, we were mindful of the need to give ad- equate voices to the vaidyas – their worldviews, know- Data collection process ledge frames and their experiences in their own We began with a narrative synthesis of national level language- on whose behalf revitalization debates and dis- health policy documents (health policies and reports of cussions were being held everywhere. Third, we wanted committees and task forces set up specifically on trad- to validate the direction of our enquiry. On itional medicine, N = 22)) seeking to understand the tax- 20-21January 2016, we hosted one and a half days inter- onomies and contexts of the rationale for revitalization active ‘dialogue’ among traditional healers/vaidyas, NGO starting with the first National Policy on Indian Systems representatives, academics, and government officials. of Medicine and Homoeopathy and the notion of The dialogue brought multiple perspectives, actors and revitalization of ‘local health traditions’ was made experiences alive when key issues around recognition explicit. and legitimacy, documentation and future directions of Following from this policy analysis, we mapped NGOs local health traditions were debated and discussed. It and their networks working in the area of traditional also placed us as potential catalysts in a shared journey medicine and local health traditions in the three states of advocating for meaningful revitalization. This was evi- where our fieldwork was situated. We carried out mul- dent in a wrapping up session in this dialogue on ‘The tiple interviews with key informants in these organiza- Way forward’ where expectations and responsibilities tions, observed their activities (documentation, relevant on/for different actions on revitalization were spelt out meetings) in the field sites and analyzed the for us. organizational documents (eg: methodology for docu- This turning point in our research allowed both pres- mentation of local health traditions, outcomes of docu- entation and sharpening of our analysis. It gave direction mentation in the form of books, CDs, pamphlets, to additional interviews and observations, specifically to protocol for certification of healers, internal evaluation explore the dimensions of gender and ethnicity (tribal/ reports of organization’s efforts in revitalization) shared non-tribal healers). It also led us to follow up on docu- with us. Our interactions then extended to representa- mentation process by select healers and to understand tives of government departments and institutions specif- further the scope of associations and networks in ically Department of Environment and Forests, AYUSH, revitalization, as some of these were highlighted during government research councils on traditional medicine, the dialogue. We developed ten case studies of healers and state Bio-diversity Boards to elicit their perspectives with different expertise, gender and nature of training by Mishra and Nambiar International Journal for Equity in Health (2018) 17:175 Page 6 of 12

following each for a period of a week to ten days. This weaving with the findings of the narratives synthesis, re- allowed a deeper understanding of what local health tra- ports of observations of events, detailed proceedings of ditions constituted, modes of acquisition of knowledge, the interactive dialogue as well as secondary literature. family repositories, interactions with patients, the evolv- Four analysis meetings, spanning two days each, were ing nature of the knowledge and practice, perceived held. During these meetings, the entire research team challenges to the continuation of such practice, as well discussed and finalized the findings of the study. Glean- suggested possibilities of revitalization. ing the experiences, interpretations, models and lessons Data were collected over a period of eighteen months of revitalization across states, led us to a more nuanced by the research team from January 2015 to June 2016. understanding of what revitalization means, what it en- The two authors were the primary investigators. Three tails, and what roles are played by various stakeholders senior research associates, proficient in English and local in revitalization, definition, and practice of LHT. languages in these three states (Kannada, Tamil and Ma- layalam) and familiar with this thematic domain were in- Results volved in data collection along with the two authors. We This paper focuses on the shared findings across sites in interviewed senior government officials, representatives relation to our research questions. of NGOs and academics. The research associates had prior training and experience in doing qualitative health LHT in national policy frameworks and in everyday systems research. They were supervised by the two au- practices thors, who are trained in anthropology and are experi- Originally drawn from the Greek word litotes means enced in ethnography methods. Apart from getting a simple. It also means an understatement in which an af- weekly update on each of the field sites (shared with the firmative is expressed as the negative of the contrary authors by each of the research associates) there was a [40]. Our ethnographic inquiry unraveled an important monthly skype meeting among the research team. This and hidden reality of health care in India- revealing the meeting discussed the progress, key insights and reflec- problematic of a litotic approach to local health tradi- tions on the processes of data collection and analysis, for tions as those which are non- institutionalized, non-certi- all the three field sites during the entire data collection fied, non-documented. Such a litotic reference emanates and analysis phase. Interview guides were prepared col- from the power of the state to define legitimacy of a sys- laboratively by the research team following the narrative tem of medicine (and hence its inclusion in the national synthesis and the mapping of organizations exercise, health systems) through standardized governance instru- which had helped us identifying key stakeholders and an ments of training, certification, registration and licens- overall thrust of their work. These guides evolved the- ing. Our narrative synthesis showed how the matically and were modified, as we did the interviews, to organization of health services in post-independence speak to the different category of participants (govern- context created a hierarchy of legitimacy with biomedi- ment, NGO representatives, academics, healers),. Each cine at the top, followed by six Indian systems of medi- interview was transcribed and translated into English cine (later renamed as AYUSH in 2005), with soon after the data collection, and was discussed be- ‘non-systems’ of medicine like local health traditions tween the research associate and the authors. Key (earlier known as folk medicine/indigenous healing) as themes of each interview were noted on the transcript, the ‘residua’ that fell outside the purview of the state. for discussion during the monthly meeting. The recent coinage and turn to local health traditions (since 2002), continues to refer to these as undocu- Data analysis mented, non-certified and non-institutionalized forms of Data were analyzed concurrently, as they were collected knowledge and practice (as those that are not through a process of open coding and thematic analysis. non-allopathy and non-AUSH). The Government as well This concurrent analysis allowed, where necessary, for as the non-government organizations, we spoke to, follow up interviews to better understand and situate the largely subscribed to such a view, manifest in their data. Specific attention was given to the process of local revitalization strategies. usage and context of the terms for local health tradi- Vaidyas/Healers, on the other hand, drew our atten- tions, legitimacy/recognition that repeatedly emerged as tion to what local health traditions are, through the the themes of discussion. Transcripts of interviews with constitution of its knowledge base and practice. Local each category of respondents (healers, Government rep- health traditions, as the healers explained, are learned resentatives, NGOs and their networks, academic/re- and practiced through rigorous modes of knowledge searchers) were arranged and analyzed separately for acquisition and transmission. Our study focused each state and then across states. This was followed by largely on healers with specialized knowledge (Vaidya juxtaposition of these perspectives across categories title is referred to healers with specialized knowledge Mishra and Nambiar International Journal for Equity in Health (2018) 17:175 Page 7 of 12

only). Yet, the healers and key informants in the Documentation as revitalisation of LHT non-government organizations involved in The predominant approach to revitalization whether revitalization, noted that certain local health know- sanctioned by the state or preferred by NGOs with fund- ledge was embedded within households and employed ing from a variety of sources, was documentation [41]. in everyday life in curative, preventive and promotive The policy texts, we analyzed, cited various rationales care. Specialized LHT knowledge, as explained to us for documentation including preservation due to threat by our participants, called for everyday practice of a of erosion of such knowledge (due to the apprenticeship different sort. For a specialized LHT healer, practice mode of transmission and the perceived lack of interests comprises everyday observations, doing and learning among the younger generations towards such mode of that includes knowledge about plants, their growth, learning), promotion of best practices among the com- modes of plucking and replenishment, preparation of munity for preventive and promotive care through docu- medicines and their dispensation along with other mentation and validation, potential for drug discovery as lifestyle modifications. These experiential modes of well as protection from probable commercial exploit- learning necessarily involve extensive use of senses in- ation of such knowledge. Our study found that several cluding smell, taste, touch of different plants and documentation efforts were underway by AYUSH insti- their therapeutic properties. Healers pointed towards tutions, NGOs, university departments (botany, forestry, the composite nature of such knowledge that goes be- pharmacy among others) and research collectives. While yond medicine or treatment, linking local ecology to mapping these documentation exercises, our research nutrition and wellness in preventive and promotive focused on interrogating the ‘who, what and how’ in health and even spiritual balance. The modes of documentation, to assess the viability of documentation learning and practicing entails specific qualities in- as a mode of revitalization. Healers trained in family cluding sincerity, commitment, perseverance and pas- lineage, who were highly successful in their practice and sion for such knowledge and practice. Such qualities had a large clientele, were not entirely convinced about are highlighted as important constituents of local the narrative of the threat of extinction of such know- health traditions that have a service (seva) orientation ledge and the urgent imperative to document. No one distinguishing itself from a health care model that is seriously contested the need to document local health driven by profit. Family lineage (parampara), as the knowledge. Yet, those healers involved in documentation site for a rigorous mode of learning and practicing, shared concern about the lack of clarity of objectives of becomes an important marker of legitimacy for local documentation; the ethnobotanical/ethno-medicinal na- health traditions. ture of documentation assuming local health traditions Our study also revealed that LHT – far from being a to be about alone; as well as reducing unified category – as projected in the policy texts and knowledge holders/practitioners to mere informants in implied in the revitalization strategies of the organiza- documentation surveys. tions we spoke to, represent a multiverse of healing ex- Healers participating in the dialogue and in our inter- periences, expectations (from the state), modalities of views ubiquitously felt that they were themselves were revitalization (across gender, and types (tribal/non-tribal) important – and neglected - stakeholders in the of healers), modes of acquisition of knowledge (para- documentation: mparika or traditional vaidyas and non-paramparika vaidyas including nattu or local vaidyas), and properties Those who practice the knowledge need to be of healing expertise. Further, in different states, emphasis involved in documentation. How can someone who was placed on different dimensions of LHT in connec- does not know the context and has never practiced tion with practice. For example, in Kerala LHT practi- the knowledge even understand what it is all about tioners were referred to as paramparika nattu vaidyas and document? (IDI_HEL_21_KA). (traditional indigenous healers) emphasizing the lineage mode of transmission of knowledge and practice, while Documentation of local health knowledge cannot be in Tamil Nadu, they are identified as siddha vaidyas everybody’s business. Someone who is sincere, (practitioner of ) seeking to draw atten- dedicated and who has a respect and passion for such tion to the primordial nature of this practice to the insti- knowledge can and should document. It should not tutionalized siddha medicine. In Karnataka, this meant go into the hands of those with selfish motives paramparika vaidyas (traditional healers) or gram vai- (IDI_HEL_11_KE). days (village healers). These terms of reference are im- portant as these draw attention to the legitimacy This concern is related to what is being documented accruing from family lineage, local community distin- which indeed delimits the scope of LHT in the form of guishing itself from . registers of plants and remedies. Healers stated that Mishra and Nambiar International Journal for Equity in Health (2018) 17:175 Page 8 of 12

LHT needed to be documented as community based such a broader strategy or intent. While some had the health knowledge and not only by botanic properties or clear intent of discovering new drug formulation, for nosology of disease. There was an uneasy tension others, documentation aimed at active promotion of between LHT across these forms. On the one hand, doc- such knowledge for strengthening primary health care, umenting LHT was typically done in a format capturing yet some others found the documentation exercise itself the immediate and tangible forms of knowledge in terms to be a process of social legitimation of such knowledge. of products and preparation drawing from methodolo- Each of these objectives demands different methodo- gies employed by AYUSH-focused institutes and NGOs. logical process, involvement of actors and outputs. Aspects that sometimes got excluded or ignored were Healers we spoke to specifically raised concern about workship and invocation of the God of forest (Vana the lack of clarity of objectives and outcomes. The debta) is as important as preparation and dispensation objective of drug discovery for potential commercial of herbs. In this view, the forest, as the source of healing purpose, and promotion of primary health care through properties (medicinal herbs) was sacred, as collection of community ownership of health, are contrasting objec- plants was integral to conservation and replenishment in tives. We came across three specific models of docu- LHT practice. There were elaborate rules about modes, mentation that hold promise for a more inclusive timing, techniques of collection of herbs and their prep- process, in the spirit of NRHM. These were explained to aration, which the healers shared with us in general us by key informants from the organizations who devel- terms that they felt were integral to understanding, oped these models. According to them, these models acquiring and recording knowledge. The rules pertain to relied on a bottom up approach with the local commu- detailed dietary and other lifestyle prescriptions that they nity and healers playing an important role in establishing perceived as critical to the process of healing. The the first tier of legitimacy of knowledge, healer and healers therefore contested the narrow and confining practice based on experiences of the community. The vision of documentation. Documentation with a focus models involve documentation through the healers, in on medicinal plants (in terms of botanical names, med- conversations with practitioners of institutionalized ical usage and application to ailments) was but a first medicine (eg: Ayurveda) [42, 43]. Additionally, the dia- step that should not be exclusive of the social context of logue drew attention to other documentation efforts that the use of LHT knowledge. adopted the methodological approaches of active listen- Participants felt that documentation must be linked to ing and cooperative inquiry. Such attempts sought to practice; without which it may lead to mere museumiza- enter into the world views of traditional midwives or tion of knowledge (stored in libraries and filing cabinets) barefoot gynecologists, while recording their knowledge –having the opposite effect of “revitalization.” Officials and elements of practice [22, 23]. The latter two models spearheading such documentation effort conveyed to us did not seek out to ‘document’ as such, instead they somewhat wistfully: were more in the spirit of reviving and strengthening community based health knowledge and practice, in We have collected local knowledge on health and order to promote community ownership of health. The medicine but we do not know what to do with this. emphasis in these models of documentation is on the Several files of such knowledge are stored in the methodological process which relied on a dialogical ap- cabinet quite safely. Perhaps now they need to be proach. These documentation efforts while capturing the validated? (IDI_GOV_03_KA). strengths of such traditions also pointed out areas where each tradition would need to be improved or strength- Others including NGO representatives took things a ened. As the discussion in the dialogue made it appar- step further with a view shared by all the healers we ent, a key challenge in documentation of LHT has been spoke to as well: to capture the strengths of such knowledge in a language that is legible to more mainstream, systems-based med- Documentation has real meaning when this ical knowledge and practice. [knowledge contained in the documentation] is actively promoted in the community. Thus, without Roles and possibilities for revitalization of LHT the practice of such knowledge, mere documentation While the state officials in our study were a bit cautious will have limited purpose (IDI_NGO_07_KE). in terms of the specific role of the state in revitalization of the local health traditions, NGOs representatives pre- Most documentation efforts lacked a larger strategy or ferred that the state act as a facilitator of ongoing efforts intent on what the process would lead to. Further, since rather than attempting to mold LHT in the line of the myriad of documentation efforts had multiple objec- bio-medicine or institutional systems of traditional tives, it would be difficult to have them cohere under medicine. Healers and representatives of select grassroot Mishra and Nambiar International Journal for Equity in Health (2018) 17:175 Page 9 of 12

organizations pointed out the limitation of documenta- set of deeper questions about the policy on local health tion as the only or main model of revitalization as well traditions and their revitalization, that focus more as the danger of a state-led mode of regulating providers. squarely on the lived experience of policy and on its They pointed towards three possibilities of community operationalisation. Ethnographic inquiry is well posi- based revitalization, which envisioned a central role for tioned to allow asking of awkward questions and to the state, not as merely regulator but also as a facilitator. approach core policy concepts with some criticality [34– The first possibility presented by community based 37]. We sought to unpack the meanings, contexts and revitalization was the strengthening of the already exist- interpretations of ‘local health traditions’ and their ing healers’ collectives and associations which bring to- ‘revitalization’, both of which find mention only in very gether healers through conclaves and meetings recent policy texts. We found in our interviews, that nei- providing a platform for exchange of knowledge, identify ther LHT nor revitalization are self-evident categories. potential for further research as well as acting as a Understanding the time, context and processes that have self-regulating body. In Tamil Nadu, such collectives brought about an otherwise marginal body of knowledge have played an important role in continuing education to the forefront through the coinage of local health tra- and training of younger generation of healers, introdu- ditions was important as no research on local health tra- cing a community health curriculum in formal institu- ditions can afford to be oblivious to the power tions and building repositories of family based asymmetry in which such traditions are nested. knowledge. In the state of Kerala, such collectives have The term of reference for LHT in state policy docu- sought to garner legitimacy through commendations for ments in litote as non-documented, non-system etc. sig- senior healers with long standing service to the commu- nified a kind of power asymmetry. It also assumed a role nity as well as evolving collaborative research with med- for revitalization through particular and preset forms of ical institutions. In Karnataka, healers’ associations have documentation, certification and institutionalization. organized health camps, and experimented with introdu- Our fieldwork revealed that the deployment of litotes in cing certificate courses through experiential mode of identifying local health traditions in fact simplifies a learning. complex plurality of practices and persons. Revitalization The second possibility, strongly indicated by healers, is discussions were restricted (and often misled) by such a that pedagogical institutions could promote experience documentation-centric approach, which did not yield an based learning through close mentoring for such know- understanding of what the strengths (and limitations) of ledge to be passed on to the next generations. For them, these traditions are. We were able to explore concrete such mode of transmission of knowledge and practice is possibilities (as well as specific challenges) of much more sustainable than documentation. Members revitalization, by approaching LHT to understand what of the Healers’ Association actively deliberated on this these traditions stand for, what the modes of knowledge possibility in their meetings and conclaves that we acquisition and transfer were, how these are practiced, attended. Models of gurukula based education do exist and what the sources of legitimacy are. Using this ap- and in their view, offered promise. proach we privileged the perspectives of its practitioners. The third possibility was documentation where healers Prior research has found that language and categories were partners in the production and use of knowledge. in international development, for example, traditional Contrary to the commonly held notion that local health medicine, traditional birth attendants, as is discussed in traditions are undocumented, several family based gen- the context of Nepal, efface local understanding and erational healers showed us the documentation of their contextual translations of such categories [14]. In this knowledge and practice in regional languages and dia- context, the language of “traditional medicine”, and lects that are used for their everyday practice. They also “traditional birth attendant” were cast as retrogressive in shared that these documents evolve with new know- international development discourse serving on the one ledge, emerging health ailments and practice and hence hand to make development institutions the locus of au- are not static or closed. They raised the issue that docu- thoritative knowledge and on the other, completely de- mentation needs to speak to different kinds of audiences, valuing local forms of knowledge [14]. In such a context, including the community, the healers, and the institu- a development program that is meant to empower local tionalized systems of medicine. communities only reinforces power asymmetry through the rejection of certain words and taxonomies. Local Discussion health traditions as a unifying category that brought to- Ethnography, is increasingly being seen as an important gether diverse set of practices though may have a signifi- methodological lens in health policy and systems re- cance in its visibility vis a vis the allopathic systems of search [38, 44–47]. Our study showed why a critical medicine and AYUSH in the policy frameworks, had no ethnographic stance was important to be able to ask a meaning on the ground, beyond the policy texts. LHT Mishra and Nambiar International Journal for Equity in Health (2018) 17:175 Page 10 of 12

existed in these three states as plural categories with health traditions (seeing from the perspectives of the varying internal logics and relationships based on local practitioners of such traditions) to understand its frames of reference as well as symbolic, political and strengths, scope and challenges in revitalization. It also pragmatic connotations. It is therefore somewhat arbi- uncovered that documentation as a mode of trary to assume a single policy treatment or frame for revitalization can be made more meaningful through a these traditions. Programs of revitalization will likely dialogical process. Our inquiry further led to identifying only succeed if they are designed in cognizance of such the less obvious possibilities of revitalization (beyond specificities. documentation). These included strengthening healers’ One of the biggest tensions expressed in our data, associations and collectives and reviving pedagogical in- emerged from the fact that votaries and practitioners stitutions (in the style of the older Gurukul system) to of LHTs were concerned with practice whereas the nurture experience based learning. Evidence in others state logic has been to categorize by system, resulting contexts demonstrates the potential of healers’ associa- in the grouping of diverse LHTs into the single cat- tions to not merely accrue social recognition to healers egory of non-system. This results in a single, but also to contribute to strengthening the practice of homogenous category being created that may not only such traditions in the provision of primary health care be inapplicable for the diversity of practices repre- [50]. If the revitalization mandate seeks to strengthen sented, but also poses a larger threat to the very community ownership of health (as enunciated in the agenda of revitalization. Our research findings rein- NRHM policy), it is important to carefully nurture com- forced how critical it is to understand local interpre- munity based institutions like the healers’ collectives. tations and contextual usages of terms and categories and to be sensitive to the threats posed by imposing Conclusion and homogenizing categories [14, 34, 48]. Recent policy developments promoting the role of Considering the complexity of policy processes, cap- non-allopathic systems of medicine, specifically local turing multiple perspectives and experiences is central health traditions, in strengthening primary health care to the field of HPSR. An ethnographic inquiry allows have been significant. This is critical considering India’s one to draw out these different perspectives across dif- current race towards achieving health for all. Our policy ferent sites and locales of power. It also allows for the analysis began to reveal which policy measures could creation of a dialogue or confrontation between these achieve such objectives, but not how. Our ethnographic perspectives and spaces through which a ‘deeper under- inquiry revealed that far from a linear translation of pol- standing of the larger picture becomes possible’ [34, 37]. icy measure, a critical, reflexive methodological engage- Our study provided an interactive dialogue space, where ment could unpack the meaning, contexts and these perspectives and experiences on revitalization of interpretations of revitalization of local health traditions local health traditions debated, clarified and coalesced, to break the silence (in policy documents) on the spe- drawing and redrawing power hierarchy among the cific ways to operationalize the policy intent. Were we stakeholders. This dialogue began to question the linear- not enabled by ethnography as a method that changes ity and certainty of the policy prescription on its shape apace with emerging findings, we would have revitalization of local health traditions (through docu- not been able to as comprehensively answer our ques- mentation, validation and promotion and/or certification tions about the policy lessons for revitalization of local of healers) and brought to the fore tensions and chal- health traditions. This is critical because not only was lenges in going about revitalization and identifying the this already a marginalized area of inquiry in health re- role of different stakeholders. In the acknowledgment of search, but with any other method we risked reinforcing and confrontation with these tensions, deeper conversa- inequities by imposing epistemological and other hier- tions arose about who, what and how, of effective and archies on our participants– whom we would argue were meaningful modes of documentation. Future conversa- partners - in arriving at our conclusions. tions need to consider different kinds of documentation - family repositories of healers as well as those that sys- Abbreviations AYUSH: AyurvedaYogaUnaniSiddhaHomeopathy; FGD : Focus Group tematically record such knowledge and practice through Discussion; LHT: Local health traditions; NGO: Non-Governmental participatory methodologies. This is an area that calls for Organization; NRHM: National Rural Health Mission; WHO: World Health more collaborative and trans-disciplinary thinking, Organization rather than the siloes or vertical approaches in use thus Acknowledgements far [23, 49]. We are grateful to our Research team including Lakshmi Priya, Steffy Priyadharshini, Our critical ethnographic inquiry was sensitive to the Sarika Kadam, Pooja, V and Praveen Lal. We also acknowledge the inputs to field work by Rajeev BR and Maya Annie Elias. This work has gained from the insights hidden, invisible spaces as well as the visible. It uncov- and cooperation of local/traditional healers, organizations and their representatives ered the need for reorienting the lens to approach local in these three states. Mishra and Nambiar International Journal for Equity in Health (2018) 17:175 Page 11 of 12

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