Popular Perceptions of Medicine: A

South Indian Case Study

Mark Nichter

INTRODUCTION
In this chapter, I explore popular perceptions of medicine in South
Kanara District, Karnataka State, India.1 My initial vantage point
will be that of a rural semi-literate villager who has access to the
rapidly expanding pool of practitioners and medicines available in
crossroads towns.2 These resources have become increasingly
accessible since the mid-1970s due to improved transportation
facilities and rising wages for agricultural labor and the beedi
(cigarette) home industry. I focus attention on the most common
ways medicines are thought of and spoken about within rural
South Kanara.
Before considering local perceptions of medicine, it is important
to correct a misleading stereotype of popular health culture in
rural India commonly found in the anthropological literature of
the 196070s.3 Specifically, the portrayal of the rural villager as
thinking within an yurvedic cognitive framework will be
questioned. A brief description of a town health care arena, as
seen through the eyes of our representative villager, will be
presented as a means of highlighting the eclectic practice of
medicine in India and the mix (masala) of medicines produced and
available to the public. My description is meant to complement
observations made by Charles Leslie (1975).
Leslie astutely described the widespread eclectic use of
indigenous and allopathic (biomedical) medicine by cosmopolitan
practitioners in India. He aptly characterized the villager seeking
medical assistance as more con cerned with questions of cost,
time, and empathy than type of therapy system.4 While my
observations largely concur with those of Leslie, his description of
therapy choice requires some elaboration. I argue in the next
chapter that two different patterns of health care seeking
associated with market and pre-capitalist values coexist in India.

206 ANTHROPOLOGY AND INTERNATIONAL HEALTH

One is aimed at securing good medicines at a reasonable cost; the

other is characterized by the seeking of a practitioner who has the
power of the hand to heal a particular patient.5 In the present
chapter, I argue that the type of therapy system to which a
practitioner is affiliated often matters less to patients than the
form and qualities of medicines he dispenses. I document how
medicine appropriateness is evaluated both in terms of illness and
patient characteristics. The afflicteds relative strength, age,
previous experience with medicine, and special disposition (e.g.,
pregnancy) all influence perceptions of medicine suitability.
YURVEDA AND POPULAR HEALTH CULTURE
In many ways a discussion of the relationship between the
yurvedic system of medicine and South Kanarese popular health
culture is similar to the discussion about the Brahmanization of
the South Kanarese pantheon (Nichter 1977). I will exploit this
comparison while noting that yurvedic and Brahmanic world
views are closely aligned philosophically (Zimmerman 1987). The
South Kanarese pantheon is composed of numerous indigenous
Tuluva deities (bhta), as well as pan-Indian gods, just as the
popular health sector is composed of numerous folk healers and a
few influential yurvedic pundits (a majority of whom are
Brahmans or Keralites steeped in Brahmanic tradition). Just as
Brahman priests have over the years encompassed Tuluva deities
within a distinctly Brahmanic cosmology and organizational
structure, so yurvedic pundits have encompassed folk health
notions and practices within a highly elaborate and
accommodative yurvedic conceptual system.
It is important to note that while Brahmanic tenets about
hierarchy and order in the cosmos and yurvedic statements about
humors and illness are accepted as authoritative, the actual
impact of both Brahmanization and yurveda on local Tuluva
culture has been limited. The principles of yurveda are publicly
acknowledged as eternal truths, yet the lay persons
comprehension of yurveda is limited to a few names of illnesses
and medicines.6 yurvedic terms have taken on local significance.
For the typical villager, an understanding of yurvedas
centralmost principle of body humors (tridhtu/trida) is limited
to a notion of dha as troubles. Within yurveda, humors (e.g.,
vta, pitta, and kapha) index essential bodily processes associated
with universal principles manifest in myriad forms.7 Like the
terms liver and pressure introduced by cosmopolitan
physicians, the names of humors have become objectified and

POPULAR PERCEPTIONS OF MEDICINE 207

synonymous with symptom complexes. In other words, the names

of bodily processes in yurveda and bodily organs and measures
of body function in biomedicine have been reduced to illnesses.
In some cases, yurvedic and biomedical terms are used
interchangeably to mark conditions perceived in folk terms. For
example, an excess of pitta (often translated into English as bile) is
used to describe someone who is high strung and easy to anger.
Over the last decade the term BP (blood pressure) has been used
in a similar fashion, especially when the person in question is an
older man who shouts when angered.8 Pitta is not perceived as a
humor which serves a valuable function within the body and BP is
not associated with the heart. Both constitute disorders
associated with overheat in the body and a hydraulic model of
ethnophysiology.
Three points may be made about yurveda which have
widespread generalizability in rural India. First, the response to
illness by the non-Brahman lay population does not reflect an
yurvedic approach to health care despite the fact that yurveda
and folk medicine share points of commonality, e.g., a concern
about hot-cold, a hydraulic model of the body, concern about the
blood and digestion, etc. I do not mean to belittle the impact of
yurveda on popular health culture by this statement anymore
than I would want to disregard Brahmanic elements of local
Tuluva ritual. What I wish to emphasize is that discrete yurvedic
practices and medicines, and not a systematic yurvedic model of
health and pathology, influence popular health care behavior.
A second point is that the practice of orthodox yurveda
represented in classical texts is not presently, nor has it been in
recent history, a popular form of therapy available to the masses.
Systematic yurvedic treatment is not affordable for most people,
is often time consuming, and requires lifestyle changes few people
are in a position to make.9 The notion that systematic yurvedic
therapy, based upon yurvedic diagnostic principles, is readily
available and inexpensive in village India is unfounded. This myth
is propagated by surveys which classify all herbal practitioners as
practitioners of yurvedic medicine, confounding herbal medicines
with yurveda. This is misleading.
A third and related point is that the system of yurveda as
presented in texts and espoused by authoritative pundits is not
understood by most folk herbal practitioners. An increasing
number of practitioners administering yurvedic medicines gain
their knowledge about these medicines from commercial medicine
catalogues provided to them by yurvedic medicine companies.
Many of these catalogues intermix yurvedic and biomedical

208 ANTHROPOLOGY AND INTERNATIONAL HEALTH

terminology in an attempt to scientize yurveda while

simultaneously emphasizing yurvedas long, glorious, and sacred
tradition. To accomplish this, biomedical disease syndromes are
encompassed within a humoral conceptual framework. A mixing
of metaphors occurs. Popular health culture in India is a
bricolage, an assemblage of eclectic conceptual and material
resources.
MASALA MEDICINE IN THE HEALTH BAZAAR
Let us imagine that our representative villagerwho we will call
Ramatravels to a nearby town to obtain health care for fever and
weakness after exploiting more accessible sources of aid from a
local herbalist and shopkeeper who stocks a few patent
medicines. Numerous small clinics and medical shops are found
in most fair sized towns in South Kanara. Rama strolls past a few.
As he looks into each shop, he pays little attention to the
qualifications boldly written or scribbled under the names of each
practitioner. This is hardly surprising given the proliferation of
abbreviations displayed on signboards. Abbreviations for licenses
from regional and foreign medical schools as well as integrated
medicine courses of allopathy and yurveda (from different states
at different points in time) are intermixed with initials designating
homeopathic correspondence courses, the possession of university
certificates (in some cases, certificates of attendance not
completion!), foreign training or residence, and membership in
little known and often bogus professional societies.10
Rather than look at qualifications, Rama focuses his attention
on the types of medicines and paraphernalia exhibited in medical
shops. It is not possible for him to distinguish the type of therapy
system to which a practitioner is affiliated by looking at the
medicines and paraphernalia displayed in these shops, however.
Many institutionally trained, as well as non-institutionally
trained, registered medical practitioners (RMP) engage in an
eclectic form of therapy which draws from all existing therapy
systems. Their shops display hypodermic sets and stethoscopes as
well as hand labelled bottles of yurvedic tonics, tins of metallic
oxides, and a few vials of homeopathic pills. The offices of recent
graduates of yurvedic and homeopathic colleges commonly
display stethoscopes as well as a carefully laid out stock of
commercial yurvedic/homeopathic medicines bottled and
packaged in much the same way as allopathic medicine. In most of
their clinics, a syringe and a collection of allopathic and yurvedic
injectables (indistinguishable to the villager) are also conspicuous.

POPULAR PERCEPTIONS OF MEDICINE 209

Some clinics are manned by both practitioners of allopathic and

yurvedic medicine. As Leslie (1975) has noted, many of these joint
clinics are managed by two generation practitioner families
adapting to the competitive medical market.
Let us imagine that while passing by the office of an MBBS
(biomedically qualified) doctor, Rama sees a stock of allopathic
medicines displayed alongside several patent yurvedic medicines
having English names. If Rama could read English, he would find
the labels of these patent medicines replete with the language of
biomedical science. The same medicines are on display in the
chemist shops located in the town. Passing by the most popular
chemist shop, Rama remembers a request made to him by his
postpartum wife. He inquires about the availability of a popular
yurvedic tonic (aristha) his wife once took, but which he does not
see on the shop shelves. Three other commercial brands of the
aristha are available from a Kerala based company, a company
from South Kanara, and another from Bombay. He is asked a
brand preference. While thinking about which bottle to purchase,
Rama observes other customers. Some present chits to the
attendant of the shop and appear to be selecting only a few of the
medicines prescribed once they find out costs. Other customers do
not have chits and directly ask for medicines by name, while a few
customers present symptoms to the attendant and ask for his
recommendations.
Rama chooses a familiar brand and continues on his way,
anxious to consult a doctor before he misses the last bus home.
He passes by the busy Primary Health Center (PHC) with its long
line of patients and proceeds to the small clinic of a practitioner
he has heard is inexpensive. The medicines and paraphernalia in
this practitioners clinic are eclectic (masala)mixed to both taste
and pocket. Rama presents his symptoms: headache and
weakness; lack of appetite and a bitter taste in his mouth;
burning sensation, cracked lips and feet (indicating too much heat
in the body); and intermittent fever. The symptoms are noted by
the doctor but he does not ask follow-up questions or physically
examine Rama. Rama asks for an injection and receives a B
complex injection in addition to two types of pillsone white and
one yellow. He pays 8 rupees, a days wages in 1978, about what
he expected to pay.
How might Rama have obtained the name of this practitioner
and why did he consult him when there are seven other private
practitioners located in the same town? Let us suppose that before
his trip to the town, he asked friends and relatives about the type
of treatment given by various practitioners. What types of

210 ANTHROPOLOGY AND INTERNATIONAL HEALTH

description might he receive? When listening to numerous such

descriptions, I found that comments were commonly made about
both the general cost of a practitioners treatment and his healing
capacity, described as power of the hand. Power of the hand
attributions were generally noted in the context of an illness story
involving a serious illness which at least one practitioner had been
unable to cure. In some cases, a practitioner was spoken of as
having a special ability to heal particular illnesses or age groups
while in other cases power of the hand attributions were of a
more general nature.
The most frequent comments made about a practitioner involve
the kind of medicine he dispenses. Occasionally the kind of
medical paraphernalia he owns is also noted. Practitioners are
described in relation to the forms of medicine they tend to give for
particular ailments, e.g., single injection, double injection
(distilled water and a vial of medicine), injection-powered pills
(capsules), or tonics for a particular type of ailment. In the
mid-1970s villagers also spoke of practitioners in terms of the type
of stethoscope (dekree) which they possessed. German, English,
and Indian stethoscopes were credited with having varying
capacities to locate illness.11 By the mid-1980s such descriptions
were waning. On the increase were descriptions of the medical
tests practitioners administered or ordered from small local labs
recently established in the town.
Other descriptions of practitioners which Rama might hear from
friends portray practitioners as agents of pharmaceutical firms,
distributing particular brands of medicine. In the 1970s some
villagers described going to a practitioner in the town as going to
the company.12 This term reflected the impression that it was
the brand of medicine which a practitioner stocked which cured,
not the practitioner himself. When the medicine administered by a
practitioner was not deemed efficacious, the strength and
compatibility of the medicine for the patient was questioned more
often than the skill of the practitioner. A prevalent idea was that
given a set of symptoms, medicine found to be useful for one
person might not be effective for another because of differences in
body constitution, life style, or previous medicine-taking history.13
Perceptions of medicine compatibility depend in part on what
patients expect to happen after consuming a medicine and when
they expect symptoms to abate. For example, investigations of 150
children experiencing acute episodes of diarrhea, respiratory
infections and fever revealed that the average length of time a
child was administered medication was three days. Commonly,
two to three days of medicine were given to the child following a

POPULAR PERCEPTIONS OF MEDICINE 211

consultation to a doctor. If symptoms persisted, a new medicine

was sought and if symptoms abated, parents often did not return
to the doctor to acquire additional medicine even though they
were asked to do so. If symptoms persisted, it was more likely that
the childs caretaker would consult another practitioner than
report back to the first practitioner.
To summarize, rural South Indian villagers explore their options
within expanding health care arenas. When searching for
treatment of acute complaints, they are attentive to the cost of
therapy, practitioner availability (waiting time as well as times
available), and practitioner reputation irrespective of the type of
therapy system or training course to which they are formally
affiliated.14 A trial and error approach to the seeking of treatment
is common. Given this environment, many practitioners feel
compelled to adapt their practice of medicine to client demands.
Client demands often take the form of illness and age specific
preferences for forms of medicine associated with ideas about
medicine habituation, compatibility, and power.
HABITUATION (ABHYSA, AUCITYA)
That plant is a good medicine for fever; it was used by my
father. I do not use it. I have taken many injections. Herbal
medicine does not take to my body, (excerpt from field
notes)
The concept of habituation (abhysa) is a counterpart to the
concept of body constitution (
). One is born with a
subject to the characteristics of age and humoral predominance.
One achieves abhysa. In the words of one villager:
Some people are born with the capacity to gain weight easily,
others eat but gain little. This is due to their
. Ones
health, their age, or the seasons may influence their digestive
power, but they always have this capacity to gain weight
easily. It is their
. Abhysa requires adjusting, the way
a rice eater may adjust to be able to digest wheat after some
time. As a parboiled rice eater, I cannot eat wheat, it is
heating to my body and I become constipated. Even polished
rice causes me to have digestive problems. But to one with
abhysa to these grains they are not heating, but the best of
foods.

212 ANTHROPOLOGY AND INTERNATIONAL HEALTH

An analogy was drawn by another informant between the concepts

of constitution: habituation, and fate: karma.
Nontransformable
Transformable
baraha
: karma
unqualified fate, what one is
the fruit of ones actions,
obligations,
responsibilities,
what one has
: abhysa
ones constitution
what one becomes through
experience and habituation
An appreciation of abhysa is important for an understanding of
medicine-taking behavior. It is common to hear villagers
describing that a medicine has not been effective because they
have no abhysa for that kind of medicine. This comment is made
of both cosmopolitan and traditional herbal medicine. During a
health behavior survey in 1974, I asked 100 adults stratified by
caste and class whether they thought herbal medicine (folk as well
as yurvedic) was as effective as it had been 20 years ago. Over
90% of informants answered that herbal medicine was less
effective. Several reasons were given for this phenomena including
changes in diet, the decreased potency of medicinal plants due to
chemical fertilizers, and increased tea drinking. The most
frequently mentioned reason, however, was the increased use of
English (allopathic) medicine.
According to local reasoning, in order for the body to take to a
new food or type of medicine, it must first adjust to its
properties.15 For this reason, mothers feed young children minute
quantities of food prior to weaning so that the child will become
accustomed to the food. In the case of medicine, a young child
regularly receives herbal medicines to promote health and prevent
a number of culturally defined illnesses. Cosmopolitan medicine is
generally not administered to a child until an illness crisis
occurs.16 Cosmopolitan medicines are thought to be too powerful
for a young childs body to be able to accommodate. Moreover, it is
thought that they interfere with a childs capacity to take to the
herbal medicines used in the home for preventive as well as
curative purposes. Children are gradually introduced to
cosmopolitan medicine during an illness crisis wherein it is
deemed prudent to manage serious symptoms by English
medicine. Over time, it is thought that frequent consumption of
English medicine causes the user to lose their habituation to

POPULAR PERCEPTIONS OF MEDICINE 213

herbal medicine and gain habituation to cosmopolitan medicine.

When this happens, herbal medicine is thought to be less
effective.
Using allopathic medicine is not without a cost. Many villagers
think that English medicine offers a quick cure, but harms ones
body and undermines ones health over time. This concern is
expressed in different ways. Some people speak of English
medicine as heating while others say its continued use leads to
bloodlessness and weakness. One literate informant drew the
following analogy between chemical urea fertilizer and English
medicine:17
English medicine and urea are both powerful, heating, and
harmful after some years of use. But, they are popular.
Urea makes crops green over night and increases yield until
one day you find that the earth is hot, acidic, and useless.
Injections are like that too. You take them and feel better
quickly, but later your body turns weak. The agricultural
extension officer tells us to balance urea with potash and
other chemicals and that this will prevent the soil from
becoming hot. The doctor tells us to eat good food, drink milk,
and take tonic and we will not have side effects from the
injections he gives us. But this is not how we live. We dont
drink milk or take tonic daily, nor do we use fertilizer the way
they tell us. Such things are costly and we have other
needs.
There is a second meaning conveyed by the comment that the use
of English medicine leads to weakness. Developing an abhysa to
English medicine, entails entering into a dependency (dasya)
relationship. The words of one yurvedic practitioner (vaidya)
capture the sentiment of many villagers:
Allopathic medicines are like eyeglasses. They allow you to
see but once you put them on your eyes they do not improve.
Your eyes become dim with continual use of glasses and you
come to depend on glasses more and more. Eyeglasses are
not bad. They are a good crutch, but if one does not need a
crutch this may be a bad thing. One leans on the crutch and
does not strengthen the leg, one wears the glasses and does
not strengthen the eyes, one takes medicines and does not
strengthen the body. To become dependent on the medicine
bottle makes the company strong, but the body remains
weak.

214 ANTHROPOLOGY AND INTERNATIONAL HEALTH

An increasing number of villagers have come to question the longterm utility of English medicines, especially fixes which appear to
require continual or repeated use. In some cases this is because
only symptomatic treatment is being offered to them, not a cure. A
rural doctor with an MBBS degree, the son of an yurvedic
vaidya, presented the following illustrative case to me during one
of my visits to his clinic.
People are losing faith in English medicines even though they
are using them more. See that patient who just visited my
clinic? She came in with a painful skin eruption on her
hands. She showed me an ointment she has been using given
to her by a doctor in town. She used it for two weeks and got
relief, but then the problems returned just as they were
before. She used it again with the same results. Here is the
chit she left behind. It is for a steroid cream. The doctor in
town did not inquire as to the cause of her problem. It is
because she washes vessels (pots and pans) daily with
tamarind which irritates her skin especially in the cold
season. Would a town doctor ask such things about a patients
life? No, he sells instant relief and collects a fee and spoils
the good name of biomedicine. The woman requested me to
give her yurvedic treatment knowing that my father was a
vaidya.
People may return to using herbal medicine for several reasons.
Patients who have an ailment which cosmopolitan medicine has
failed to cure may consume blood purifiers, purgatives and
diuretics to cleanse the body and prepare themselves for herbal
treatment. Other people seek herbal medicine which will enhance
their bodys ability to respond to English medicine after they have
noticed a decline in the response of the allopathic medicines they
have been taking for a chronic illness. Some people think it is
harmful to take English medicine every day and so suspend
treatment temporarily until symptoms flare up, while others
approach vaidya for medicines to improve the bodys ability to
digest English medicines. During the course of an interview in
1990, a popular rural vaidya made a comment which extended
the analogical reasoning of the informant cited earlier who drew a
comparison between chemical fertilizer and modern medicines:
You have been coming here for 20 years. Have you not seen
that over the last few years people are becoming more
interested in natural fertilizers such as neem cakes? They

POPULAR PERCEPTIONS OF MEDICINE 215

have learned a lesson from using chemical fertilizers every

year. For a few years the crop yield improves with chemical
fertilizers, then after some time it declines. Why? Because the
soil has become
(hot). People notice that there are no
worms in the field. They can also taste the difference in the
rice they grow. With chemical fertilizers the crop is more, but
taste is less. Just as people talk of the land becoming
from fertilizers, they talk of the body becoming
from
English medicines. Just as the soil becomes weak, digestion
becomes weak. Just as the soil becomes unsuitable for
worms, the stomach becomes so
that it is unsuitable for
the worms that aid in digestion. Some people are switching
back to natural fertilizers and some are switching back to
yurvedic medicines. Many people, however, use fertilizers
and English medicines for a time and then switch to using
natural fertilizers and yurvedic medicines for a whilethe
way agricultural officers tell us to shift between crops. But in
my opinion this is harmful for the body. Some people want to
use both medicines at the same time. Did you observe my
last patient? She came to me and said, I have taken so much
English medicine that my body can digest nothing, not even
the medicine the doctor at the hospital says I must take. The
effect of this medicines becomes less and less. Please give me
herbal medicines to help my body digest food and the doctors
medicine.
Metamedical reasons also underlie the use of yurvedic
medicines. Some people seek realignment with yurvedic medicine
as a means of an identity reconstruction which entails the
embodiment of Hindu values (Nichter 1981). Among this group
are the elderly preparing for a good death, as well as those in
Hindu revivalist groups who champion yurveda for political
as well as personal purposes. The taking of yurvedic medicines
constitutes a means of affirming a moral identity. Others consume
traditional medicine for reasons described by Farquhar (1994a)
with reference to the Chinese. Consumption of such medicine
provides a satisfying, empowering remedy for the pressures of
modernization (see Chapter 9) as well as an evocative, sensuous
experience analogous to the eating of culturally marked foods
which trigger a cascade of memories and associations.

216 ANTHROPOLOGY AND INTERNATIONAL HEALTH

POWER
Comments about a medicines power are common whenever
therapy is discussed. Villagers consider medicine in relation to
both its inherent power and their ability to accommodate to this
power. Powerful medicine is desired by those whose body can
stand the shock associated with it. A medicines shock effect is
considered carefully when the afflicted is weak, when a chronic
illness demands long-term treatment, or if a person is
experiencing a heightened state of vulnerability such as during
pregnancy or postpartum. Shock is also an important health
concern influencing health care decisions involving infants and
children rendered weak by multiple or long-term illness. This
concern is also heightened during monsoon season, a time
associated with blood impurity and poor digestive capacity.
As a category, English medicines are spoken of as powerful yet
dangerous. Let us consider what the concept powerful means to
the villager. Conceptually, power is regarded as unstable,
vacillating, and requiring control, a factor evident in ritual healing
as well as in the worship of deities (Nichter 1977). While English
medicine is praised for its fast action, it is commonly spoken about
as having uncontrolled side effects. yurvedic medicine, on the
other hand, is referred to as safe, and as establishing control and
balance in the body. yurveda is typically spoken of as causing
no side effects. This statement needs to be understood in relation
to what it connotes as well as denotes.
Gleaning my notes on these two general categories of medicines,
a set of oppositions emerged which was complementary to
oppositions drawn between classes of local and Brahmanic deities
particularly by Brahman informants. Rash, blood demanding
deities of local bhta possession cults and cool Brahmanic gods
receiving vegetarian offerings are contrasted. The set of
oppositions which emerged during a discussion with one of my
key vaidya informants are presented below:18
Local bhta deities
Uncontrolled power/desire
Immediate action, often rash
Requires blood sacrifices
English/cosmopolitan medicine
Heating of the body
Reduces blood

:
:
:
:
:
:
:

Brahmanic deities
Controlled power/balance
Ultimate justice over time
Vegetarian offerings
yurveda/herbal medicine
Balances body humors
Produces/enhances blood

POPULAR PERCEPTIONS OF MEDICINE 217

English medicine is commonly referred to as heating and

yurvedic medicine as neutral (sama), although individual
medicines within each system are recognized as having heating
and cooling properties.19 The term heating is multivocal. Its
meaning varies by context and indexes concepts related to
strength, control, speed, and affect on the blood. Saying that
English medicines are heating is, in one sense, a statement about
the speed at which they act. It also indexes associations with
uncontrolled activity and heightened danger. The term sama when
applied as a general descriptor of yurvedic medicine expresses
balanced action and the concept of control. Stating that English
medicine is heating also infers something about its perceived
affect on the blood. The notion exists that heating the blood
causes it to evaporate. In Tulu, the expression used to explain this
process is netter ajune. Ajune is a verb used to describe water
evaporating from a boiling rice pot. Since digestive capacity is
related to the quantity of blood and to ones general strength, the
statement that English medicine is heating conveys a sense that
one is at risk to general symptoms of malaise as well as symptoms
such as burning skin, rashes, and burning urine. All of these
symptoms are associated with excess heat in the body.
Some villagers frequent yurvedic vaidya or folk herbalists weeks
or even months after taking English medicine for decoctions to
cool the body and replenish blood which has been evaporated by
excess heat in the body. Herbal medicine is taken as a complement
to English medicine to restore the integrity of body processes
which powerful medicines have disrupted. The notion that
powerful medicine disrupts body processes and causes weakness
is one reason why English medicine is not favored for the very
young or old. It is not necessarily neglect or inexperience which
leads villagers to use English medicine sparingly for infants or the
elderly. Hesitation to use powerful medicines may index
concern.20
Perceptions of a medicines properties and power influences the
innovative ways people use it. Medicines administered for one
purpose are sometimes used for other purposes on the basis of
assumptions about how they affect the body.21 For example,
menses is thought to be a state of overheat in the bodylike a
rice pot boiling over. When a woman suffers from amenorrhea
(lack of menses) a cosmopolitan practitioner or chemist shop
attendant may offer her a hormone booster such as E.P.Forte to
induce her period. The popular interpretation of the drugs action
is that it causes the blood to heat up such that the wind inside
the body pushes the blood outward. Accordingly, a popular belief

218 ANTHROPOLOGY AND INTERNATIONAL HEALTH

is that if two tablets are powerful enough to induce menses, then

a double or triple dose will heat the body enough to induce an
abortion.22 In the mid-197080s a flourishing trade existed in
hormone boosters in town chemist shops.23 Chloroquine tablets,
also perceived to be very heating, were reportedly used as an
abortive as well.
Perceptions of the power of a medicine are related to both dose
and medicine form. Tablets are generally perceived to be weaker
doses of medication than injections or capsules (injectionpowered pills). Capsules are stronger than pills but weaker than
injections. A notion exists that a single injection is a weaker dose
of medication than a double injectiona term referring to a test
dose and an injection, or an injection where the villager observes a
vial of distilled water being mixed with a vial of medicine powder.
Perceptions of the power of medicine affect medicine selfregulation and supplementation. Some people try to enhance the
power of recommended doses of medication. If one tablet does not
yield satisfactory results, two or three tablets are taken
simultaneously. If a single injection is given for an ailment for
which a friend has received a double injection, another practitioner
may be seen for an additional injection without mention being
made of prior treatment.24
Going to a practitioner is a learning experience for the villager.
The villager listens, watches, and interprets what transpires at the
clinic in terms of preexisting knowledge as well as subjective
reasoning. For example, acts associated with the administration of
English medicine may be interpreted as increasing the power of the
medicine. In 1976 I questioned informants about the heating (e.g.,
boiling) of needles before an injection. Some villagers perceived
this act not as a sterilization procedure, but a method to increase
the power of the medicine and the speed at which it traveled
through the body.
Conventional knowledge is reproduced at times of illness, but
new impressions are also formed. The perceived action of
medicines causes villagers to extend and in some cases reinterpret
notions of how bodily processes work. For example, according to
notions of ethnophysiology in South Kanara, many channels
(narambu) run throughout the body. When talking to villagers
about narambu, I found explanations about the structure of
narambu networks directly related to experiences with medicine.
Some informants told me that narambu were all connected. When
I asked how they knew this I was told that an injection might be
given in the left arm despite the location of the illness in the body.
It was reasoned that the medicine must travel through all the

POPULAR PERCEPTIONS OF MEDICINE 219

narambu to get to the location where it was required. Unlike herbal

medicine, an injection did not go to the stomach first. Experiences
with medicine expand explanatory models of physiology and
health.
DIET AND MEDICINE
Disease is a hunger, food a medicine for that hunger. (
proverb)
Since South Indian culture has an elaborate food classification
system (Nichter 1986), dietary advice is an expected part of a
consultation with a practitioner. One of the few questions asked of
a doctor during a consultation is what types of food should and
should not be consumed. Responses to this question are
interpreted both in relation to the qualities of the illness and the
type of medication administered or prescribed. A villager (such as
person discussed at the beginning of this chapter) enters a
consultation having a number of ideas about which foods should
be generally restricted during illness. He expects the practitioner
to offer more specific advice related to special attributes of this
illness, the patients body constitution, and the medicine
administered.
Foods are thought to enhance and facilitate the action of
medicines as well as to provide a means of balancing the extreme
qualities of medicines. For example, most impoverished villagers in
South Kanara drink milk only during times of illness and when
taking medicines. Traditionally, yurveda has placed great
importance on milk, buttermilk and ghee both in the preparation
of medicines and as a vehicle (
) to assist a medicine take
to the body. Milk is thought of as enhancing the medicines
action. When recommended by a cosmopolitan practitioner,
however, milk is perceived to play a different role. Milk is thought
to reduce and control the heating side effects of English medicine,
particularly when injections are received. Villagers interpret the
nutritional advice of doctors to mean that the medicine they are
taking is so very heating that they require milk as a
counterbalancing agent.
Milk is not only thought of as necessary to consume after an
injection or capsule, but also as a substance which may be used
to limit the action of medicine.25 For example, piperazine citrate, a
deworming medicine is considered to be very heating for the body.
According to indigenous notions of physiology, there are an

220 ANTHROPOLOGY AND INTERNATIONAL HEALTH

optimum number of worms which exist in symbiotic relationship

with the body which are necessary for efficient digestion. When
villagers are told that piperazine citrate will remove all worms,
they become concerned. Some villagers drink milk a few hours
after taking the medicine to reduce its heating action, in an effort
to retain at least a few worms.
The importance given to milk also affects medicine compliance
more broadly. I documented several instances where villagers were
reluctant to take English medicine for long periods of time if a
supply of milk was not available to them (see Chapter 3). Others
reduced the quantity of medicine they were advised to take
because milk was unavailable. Local practitioners who were
sensitive to villagers concerns about the heating qualities of
medicines and the cost of milk frequently recommended the
ingestion of other cooling substances, such as tender coconut
water or lime juice.
While some practitioners are sensitive to folk dietetics other are
not. The lack of attention paid to diet by many cosmopolitan
practitioners has led some villagers to think that English medicine
controls the body in such a way that the effect of food is eclipsed.
For example, village women who deliver babies at PHCs are
commonly offered food which runs counter to traditional
postpartum dietary restrictions. Blackgram, a food classified as
toxic (naju) and traditionally avoided during illness (Nichter
1986), exemplifies this situation. In the hospital, protein rich
blackgram preparations (idli) are served to postpartum women.
Women will often eat such foods while in the hospital, but abstain
from eating them once they have returned home to convalesce.
Several women explained this behavior by stating that when they
were taking hospital medicine, diet did not matter because English
medicine controlled their bodies. In two cases where women
suffered infection following hospital discharge, family members
blamed inappropriate (naju) foods consumed at the hospital for
their illness. One woman explicitly stated that the effects of naju
food had only been suppressed, not eliminated, by English
medicine. As soon as English medicine was discontinued, the
effects of naju had become manifest.
PHC doctors who exercise a lack of sensitivity to folk dietetics
undermine public trust in preventive health programs. Villagers
perceive that PHC doctors know about medicines which reduce
symptoms, but not much about health or dietary needs. While
this impression may not decrease doctors popularity as a
treatment resource for illness, it has affected the villagers
evaluation of their preventive and promotive health advice. This is

POPULAR PERCEPTIONS OF MEDICINE 221

unfortunate since most villagers think it is the doctors duty to

know about local foods and offer advice about diet for health
(Nichter 1984).
PHYSICAL CHARACTERISTICS OF MEDICINE
As mentioned earlier, the form in which a medicine is
administered is highly significant to the villager. It is not
uncommon to hear a patient request a liquid mixture, pills, or an
injection during a consultation. Patients express interest in the
color and taste of medicines prescribed. There are several reasons
for their preferences associated with perceptions of power and
efficacy. Injections, as noted above, are considered powerful and
heating. In the 1970s, South Kanarese villagers classified
injections on the basis of their power by referring to them as
Indian, English, or German injections. German injections were the
most powerful, based on a burning sensation experienced directly
after administration. Injections are very popular, commonly
requested and preferred by those who want quick symptomatic
relief.26 For patients who fear that they may be too weak to
withstand the shock of an injection, injection-powered pills
(capsules) are sometimes requested.27 For infants and those
experiencing chronic debility and weakness, liquid mixtures are
requested not only for ease in administration, but also because
they are considered to be less powerful and shocking to the body.
Preferences for medicine forms influence but do not determine
health care seeking. In instances where dramatic curative action
is required, health concerns may be temporarily suspended. Such
cases do not necessarily have to be life threatening. For example,
injections are not generally popular for toddlers. However, they are
deemed especially effective for the treatment of infected wounds
and rashes where pus is manifest and fear about swelling is
expressed. The heating action of injections is thought to dry up
infected, weeping rashes and wounds.
During a study of skin ailments, I interviewed several mothers
of children with infected scabies (kajji). Most mothers expressed
the opinion that injections were warranted should their childs
condition not improve with home treatment. Five cases of children
aged 37 years suffering from scabies were followed over a three
month period of time. In all five cases, doctors were consulted and
antibiotic injections administered to the children. In three cases,
the children frequented doctors six or more times for injections
during the three month time period. In no instance did a doctor

222 ANTHROPOLOGY AND INTERNATIONAL HEALTH

issue instructions to mothers to boil clothes, cleanse the skin

routinely, or have the child sleep alone.28
In local health culture, kajji is associated with both heat in the
body and impurities in the blood. Pus is thought to originate from
within, therefore the illness is not linked to hygiene. Dietary
restrictions are followed against foods thought to increase pus
(naju foods) or heat in the body. Regardless of this concern about
heat, injections remain a popular treatment modality due to their
demonstration effect and ability to dry weeping rashes rapidly. To
reduce heat in the body associated with injection use, mothers
administered cooling foods and herbal medicine to their children.
As in the case of the postpartum woman who expressed the
opinion that English medicine only suppressed but did not remove
naju from the body, one of the childrens mothers administered
yurvedic medicine to her child following injections to clean the
blood.
Among adults, a health concern associated with medicine taking
is that medicine interferes with digestion, resulting in debility.
Weakness experienced by a patient during an illness in which pills
have been administered is often attributed to the pills disruption
of the patients digestive process and not to the illness. If tablets
cause thirst or a practitioner tells the patient to drink plenty of
water with the tablet, the medication is suspected to be not only
difficult to digest, but heating as well.
Liquids are preferred for bloodlessness (anemia) and weakness
because they readily join with the blood. Medicine in liquid form is
especially preferred by pregnant women who feel that injections
are too powerful and heating (capable of inducing abortion), but
fear that pills might sit in their stomachs. According to indigenous
notions of reproductive physiology, (see Chapter 2), the fetus
grows in the stomach pot and shares the stomach space with
food. Some women perceive pills as not only being difficult to
digest but also causing ill effects for the fetus.
Among lactating women there is a concern that medicine
consumed by the mother is transferred to the baby through
breastmilk. This concern influences two behavior patterns, both of
which have public health significance. First, when taking strong
medication, some women cease breastfeeding temporarily if not
permanently (see Chapter 3). In two cases where this was
observed, a concern about medicine led to sudden weaning and
subsequent histories of infant diarrhea. On a breastfeeding survey
conducted in 1979, more than a quarter of 80 rural women
surveyed cited illness and medicine taking as the reason they
stopped breastfeeding.29 The second pattern, observed in

POPULAR PERCEPTIONS OF MEDICINE 223

neighboring North Kanara District, involved women who

consumed medicines intended for their baby as a means of
transferring the medicines qualities to their children.30 Both
medicines for respiratory infections and diarrhea were consumed
by mothers. Three out of five local doctors interviewed about local
medicine-taking behavior were unaware of this practice. The other
two stated they were aware that some backward mothers did
such things, but did as a matter of routine they not advise against
the practice.
Table 7.1 presents survey data on preferred forms of
medications for specific types of illnesses. It may be noted that
different forms of medication
are preferred for adults, children
under three, and school aged children. For example, injections are
preferred for fever with chills (
jwara) for adults, but mixtures
are preferred for young children with differences of opinion as to
appropriate treatment for school-aged children. Town and village
differences in medicine preference are noted as well. Notably,
injections were just as popular in villages as towns among both
the poor and the lower-middle class. Differences in medicine
preference between the illiterate and semi-literate were not found
to be statistically significant, and are therefore not reported.31
Private doctors are responsive to what they perceive to be
patients medicine preferences because they practice in a
competitive health care arena. By being so, they reproduce
impressions of what constitutes suitable medicines for particular
illnesses and age groups. Pharmaceutical companies in turn are
alert to the forms of medicines which doctors prescribe and
purchase. Medicine supply and demand reinforce one another. An
illustration of the extent to which doctors attempt to meet patient
preferences is provided by data on how doctors dispense injections
to adults. In 1986, I monitored five MBBS (biomedically qualified)
doctors and five popular practitioners not formally trained in
biomedicine (RMP), who nonetheless administered allopathic
medicines. The percentage of adult patients receiving injections
from both MBBS and RMP doctors (n=100 patients per doctor)
ranged from 30% to 60% of patients seen, regardless of their
complaint. A study conducted by Duggal and Amin (1989) in
Jalgaon District, Maharastra State, also reported widespread
irrational use of injections by doctors. For example, these
authors report that in this region 73% of cases of cold, 88% of
cases of malaria, and 88% of cases of measles received injections.
In the next chapter, I discuss microeconomic factors which
foster injection dispensing by doctors. For the moment, I wish to

224 ANTHROPOLOGY AND INTERNATIONAL HEALTH

Table 7.1
Preferred Form of Treatment, South Kanara District

+=Very strongly felt (>70% sample); =strongly felt (4070% sample); (I)=
injections; (P)=pills and capsules; (M)=liquid mixture; (H)=herbal;
V=village (n=30); T=town (n=20).

POPULAR PERCEPTIONS OF MEDICINE 225

point out that patterns of medicine dispensing both respond to

and foster popular demand.
Color and Taste
Medicine are scrutinized in terms of colors since colors are thought
to signify a medicines inherent properties.32 For example, black
medicines are thought to be powerful as well as good at reducing
pitta, an yurvedic term used in local parlance to denote nausea,
dizziness, or yellow bodily excretions (e.g., urine, mucus). While
black pills are considered appropriate for vomiting, fever, and fits,
they are not appropriate for digestive disorders, weakness, or
bloodlessness. This is one reason why black ferrous sulfate (iron)
tablets are not popular among pregnant women and those
experiencing weakness due to anemia.33 Both the form and color
of this iron supplement are not culturally appropriate for groups at
risk to anemia.34
White medicines, particularly liquids, are generally attributed
neutral or cooling qualities. They are thought to be more easily
digested by the body than medicines of other colors and are
trusted more when consumed for the first time. Because white
pills are often interpreted as cooling, they are considered
appropriate for fever, burning sensation, body pain, headache,
and a loss of vitalitycomplaints all linked to a excess of heat in
the body.
Red medicines have multiple connotations. For example, red
pills are perceived to be heating and good for wet cough and cold.
Liquid red medicines are thought to be blood producing,
irrespective of whether they are classified as hot or cold. Yellow
medicines are generally thought to be heating and to aggravate
pitta when consumed internally. As a topical medicine, however,
yellow ointments are viewed as purification agents. An association
is made between yellow and turmeric, a traditional blood and skin
purifier used both in the home and for ritual purposes. Burnol, an
ointment purchased over-the-counter, is used for a wide range of
skin infections and cuts. Its popularity is in large part derived
from its yellow color, which villagers associate with turmeric. Here
we have an instructive case where the attributes of a traditional
medicine have been successfully applied to a commercial medicine
with a similar physical characteristic.
Taste, like the form and color of medicine, is also regarded as a
sign of a medicines inherent characteristics (see Table 7.2).
Astringent and bitter tasting medicines are generally regarded as
cooling for the body and are thought to have a positive promotive/

226 ANTHROPOLOGY AND INTERNATIONAL HEALTH

medicinal value. Herbs having a bitter/astringent taste (like black

tea) are labeled bitter (kanir) and are commonly used as folk
medicines. For example, a number of kanir herbs and shoots of
budding trees are used as preventive medicines (
) for
young children, as well as being used as general medicine for
stomach aches, fever, and blood impurities. Salty medicines, on
the other hand, are viewed suspiciously by villagers and thought
harmful for the bones (causing brittleness) if taken for any length
of time. Pungent medicines are considered appropriate for cough
(as they melt mucus) and as digestive aides, but they are
considered inappropriate for skin diseases, urinary tract disorders,
or rheumatic complaints.
Lightness and Heaviness
Perceptions of the inherent lightness and heaviness of substances
affect the way in which they are evaluated as curative resources.
Medicines as well as foods are considered to be inherently heavy
or light. Light is a concept which connotes relative digestibility and
low shock impact on bodily processes. Those who are young,
pregnant, weak, or convalescing are thought to require restorative
medicines and supplements which are light and easy to digest.
Healthy persons who wish to enhance their present state of health
or improve their weight are attracted to medicines which are
associated with heavy and strength producing substances.35 An
important distinction is made between: 1) substances which are
appropriate for the ill as resources promoting convalescence when
ones digestive capacity is weak, and 2) medicines and foods
promoting positive health when ones digestive capacity is strong
(Nichter 1986).
An analogy provided by one informant was that digestion is like
an internal fire. A weak fire must be protected and fed small twigs
(light foods) until it catches, while a burning fire may be fed
branches (heavy foods) causing it to blaze. This distinction
impacts on medicine-taking behavior. Tonics and supplements are
taken during illness and convalescence to protect digestive
capacity as well as to provide nutrient resources. Products like
glucose powder have become immensely popular in India as health
supplements marketed as light sources of energy which are easy
to digest as opposed to sugar or jaggery which are considered to
be heavy. This central concern in popular health culturethe
digestibility of a productis often highlighted in medicine
advertisements.

POPULAR PERCEPTIONS OF MEDICINE 227

Table 7.2
Associations Between the Color, Taste, and Effect of Medicines

228 ANTHROPOLOGY AND INTERNATIONAL HEALTH

LOCAL INTERPRETATION OF POLYPHARMACY

Combinations of medicines with different physical characteristics
are sometimes interpreted in relation to folk beliefs about the
balancing of hot/cold and reducing body humors. Villagers
perceive practitioners to counterbalance the adverse effects of one
medicine with another medicine. For example, white tablets issued
along with red tablets may be interpreted as cooling tablets issued
to counterbalance heating tablets. White pills prescribed with a
red colored mixture, on the other hand, may be interpreted as a
medicine dispensed to dry up one bodily secretion accompanied
by a liquid medicine to promote blood production.
Such reasoning influences the medicine purchasing behavior of
impoverished clients. I have observed clients come into a chemist
shop with a medicine chit from a PHC doctor containing a list of
several medicines. If clients cannot afford all the medicines
prescribed, they may select medicines on the basis of cost as well
as folk evaluation of the overt qualities of the medicines
prescribed. In some cases, clients will ask the shop attendant
the purpose of prescribed medicines (see Chapter 7). In other
cases, it is the form and color of various medications which
influences the combination and amount of medicines purchased. I
have also observed patients presented with a mix of medicines
which they feel are not an appropriate combination.36 Clients
prescribed only pills, capsules or an injection may ask an
attendant at the chemist shop for a suitable tonic or mixture to
complement or counterbalance the medicines prescribed. In such
cases, medicines marketed as increasing digestion, blood, and
strength may be recommended by counter staff.
One reason why villagers are generally more willing to take a
longer course of medicines from yurvedic practitioners than from
doctors of cosmopolitan medicine is that they are provided fuller
explanations about the medicines they are dispensed from
yurvedic practitioners.37 Patients often discontinue English
medicine when symptoms have abated although they may continue
herbal treatments which they perceive as aiding in convalescence
and assisting in normalizing body processes. An illustration of this
pattern and its clinical consequences has been provided in a
detailed ethnographic study of Kyasanur forest disease (Nichter
1987). In this case, doctors attributed a relapse of the illness to
patient noncompliance after returning home from hospitals.
Patients, particularly the elderly, discontinued medication after
symptoms abated because they were afraid that the number of
tablets they had been consuming would interfere with their

POPULAR PERCEPTIONS OF MEDICINE 229

digestive process and recovery. Anorexia, a significant feature of

the disease, supported this impression. I have observed a similar
pattern among TB patients who seek treatment only during acute
episodes of illness. Many private doctors treat such patients with
streptomycin injections in an ad hoc manner for a week or two.
When symptoms abate, patients purchase tonics and medicines to
increase their appetite in lieu of completing a course of
medicine.38
During acute illness, health concerns related to the effects of
medicines are eclipsed by immediate needs. Medicines are
evaluated on the basis of their ability to dramatically reduce
symptom states. In the case of chronic illnesses, where the
demonstration effect of medicines is less dramatic and side effects
more notable, concern about the impact of medicine on the body
takes on greater importance. The effect of medicines on healthy
bodily processes is weighed differently. Medicines are evaluated on
the basis of how they affect health, defined in relation to bodily
processes (e.g., digestion, defecation, sleep) as well as social and
work related activities. In situations where culturally valued bodily
processes (e.g., menstruation) are compromised, medications may
be suspended except when acute symptoms flare up and demand
symptomatic relief.
CONCLUSION
In this chapter, I have focused on popular perceptions of medicine
and illustrated how such perceptions underlie consumer demand
and medicine-taking practices. A greater appreciation of how
medications are viewed by the lay population provides valuable
insights into why illness, age, gender, and class specific patterns
of medicine-taking behavior exist. Such insights are clearly
different from data generated by studies which focus on patterns
of curative resort to therapy systems. The latter place too much
emphasis on system choice and not enough on contingencies
which lead people to use different types of medication, at different
times, for different purposes. Moreover, studies of therapy systems
have limited value in contexts where eclectic treatment is common
and commercial forms of patent indigenous medicines are
undistinguishable from allopathic medicine.
The ways in which popular ideas about medicine influence
health care seeking, medicine compliance, and self-regulation are
underappreciated by many in the international health field. In the
field of medical anthropology, there has been a tendency to
privilege explanatory models (EM) of illness when conducting

230 ANTHROPOLOGY AND INTERNATIONAL HEALTH

ethnographic research. Explanatory models of medicines are just

as important to consider as explanatory models of illness when
studying health care behavior. The two often influence one
another in contexts where diagnosis by treatment is common and
the type(s) of medicine prescribed and consumed mark illness
severity as well as patient identity. At issue is not only what types
of medicine are deemed appropriate for different illnesses, but
which medicines are appropriate for different types of people.39
It is prudent to consider what it is about specific types of
medication, or combination of medications, which make them
popular or unpopular for the treatment or prevention of a
particular illness (or a range of illnesses). This is no simple task. It
requires a broad based investigation of issues ranging from
indigenous notions of ethnophysiology to color symbolism, from
cultural conceptualizations of power to health concerns related to
medicines gleaned from the observation of other domains of life.40
Such study demands not only a consideration of medicines in and
of themselves, but also of contingencies set up by medicine
taking. As we have seen, advice given to patients by practitioners
about medicines is often interpreted in relation to preexisting
conceptual frameworks which lend themselves to particular types
of action. Foods and supplementary medicines recommended
along with a medication may mark its identity. These substances
may be perceived to enhance the effect of the medicine, reduce its
immediate side effects, restore bodily processes once medications
have managed symptoms, or may serve to control the power of the
medicine.
What can contextualized studies of medication contribute to
international health? Such studies are obviously relevant to social
marketing approaches to popularizing public health fixes. They
are also important for health service research. If the types of
medicine being distributed to high risk segments of the population
are not being utilized, it is worth considering whether the
characteristics of the medicines employed are deemed
inappropriate, or whether it is the system of therapy which is
unpopular for the task at hand.
In South Kanara, an ethnographic study of medication use led
to an understanding of why so many South Kanarese women did
not find black ferrous sulfate tablets an appropriate form of
therapy for bloodlessness (anemia) during pregnancy. Since black
ferrous sulfate tablets were not popular among pregnant or
postpartum women, it is worth investigating whether an
appropriately colored liquid tonic might be more acceptable and
cost effective.41

POPULAR PERCEPTIONS OF MEDICINE 231

Studies of medicine-taking behavior are also warranted if they

help identify dangerous practices associated with popular
misconceptions (and unrealistic expectations) about medications.
This includes innovative ways drugs are used in keeping with
perceptions about their inherent properties. The taking of
E.P.Forte and chloroquine as abortifacients is a case in point.42
Another example is self-treatment with antibiotics for curative as
well
as
prophylactic
purposes.
Antibiotics
are
used
prophylactically by some Indian males to prevent sexually
transmitted disease prior (or subsequent) to frequenting a
prostitute. Others self-treat the first symptoms of illness which
they associate with risky sexual activity. Given the spread of
AIDS, ramifications of this practice in lieu of condom use are
obvious.43
Public health practitioners can also benefit from studies of
medicine-taking behavior which focus on perceptions of when
medicines should and should not be taken. The timing of
promotive and preventive health fixes impacts on their popularity
beyond the issues of access, economics, and convenience.44 For
example, in South Kanara, it is deemed culturally inappropriate
(especially for children) to take piperazine citrate during
monsoons. The heating properties ascribed to piperazine citrate
are considered particularly dangerous at this time of general poor
health, humoral imbalance, and overall vulnerability (Nichter
1986). Elsewhere (Nichter 1990), I have described how the timing
of vaccination programs also have an impact on their acceptance.
While anthropologists can be an immense help in tailoring
health intervention programs to local contexts, they must take
care not to become party to simplistic or short sighted approaches
to primary health care. This de mands a fair degree of reflexivity
and the viewing of problems and alternative solutions from a
number of different vantage points. The focus of applied medical
anthropological research on pharmaceutical practice must extend
beyond the purview of compliance to a critical examination of
social and economic factors driving both the distribution of
medicines and information about these and other biotechnical
fixes. In order to hold themselves accountable, anthropologists
must look beyond solving immediate health service problems to
the conditions which foster ill health and social resources
available to alter these conditions. Only then can anthropologists
gain perspective on the relative utility of biotechnical fixes and their
social consequences. In need of consideration is not only how a
community can be encouraged to accept a particular medical fix
but also questions such as the following: To what extent does the

232 ANTHROPOLOGY AND INTERNATIONAL HEALTH

use of a medical fix which promises protective health reduce

concern for community hygiene and undermine a sense of social
responsibility?45
In this chapter, attention has been focused on cultural
perceptions of medicine quality which impact on patterns of
consumption. Studies of medicine demand need to be
complemented by studies of medicine practice, production, and
marketing so we may better understand how each influences the
other. In the next two chapters, these issues are considered.
NOTES
1. South Kanara (Dakshina
) is a bilingual region. Reference
will be made in this chapter to both
and
languages.
2. My characterization of this villager is used as a heuristic device and
is not meant to gloss over differences in local perceptions of
medicine. Through my discussion of this villager, I introduce
common impressions about medicines which I recorded between
1974 and 1990. During periodic visits to South Kanara I interviewed
several hundred patients seeking medical aid, recorded numerous
conversations between members of therapy management groups,
and observed interactions in the shops and clinics of a cross-section
of practitioners.
3. Assumptions that folk health culture was closely related to
yurveda were common in the pre-1970 anthropological literature.
See, for example, Opler 1963 and Gould 1965.
4. See Durkin-Langley (1984) for a discussion of multiple therapy
system use. It is pointed out that data on treatment preferences is
often quite distinct from actual therapeutic choices. Illness-specific
patterns of treatment are the exception more than the rule. See
Lane and Millar (1987) for a critique of cognitive models of
therapeutic choice which neglect structural variables such as class,
gender, and relative status associated with resource entitlement.
5. On this theme, see Nichter and Nordstorm 1989.
6. See Lindes (1987) more general discussion of popular explanatory
models which entail the appropriation of parts of expert systems of
knowledge held by elite groups modified by cultural common sense.
In this case, yurveda has both influenced and been influenced by
popular aesthetics as they are lived in the everyday world.
Aesthetics influences health related practice as well as reasoning
based on relations of correspondence.
7. The body in yurveda, like in Chinese medicine, is fluid and
nonanatomical, composed of an ensemble of processes (Sivin 1987:
91). Of late, these processes have come to be described in relation to
an anatomical body which Farquhar (1994b:92) describes (in the