Dr.Aarathi Prasadis a U.K.-based geneticist with Trinidadian and Indian roots. For her second book, In the Bonesetter’s Waiting Room , Dr. Prasad travels across India, speaking to a diverse group of healthcare practitioners in order to present snapshots of the multidisciplinary medical systems at work in the country today. India currently spends 1 per cent of GDP on health provision (other countries on average spend 6 per cent), and 800 million Indians have little or no access to modern health care. These medical tales are recounted not just to highlight disparities and problems but to demonstrate how individuals can act as powerful catalysts for change. Excerpts from an interview:
Your first book explored the idea of virgin birth, what made you want to explore India’s ancient systems of medicine?
I like playing with ideas that are against or parallel to the flow of conventional thinking. Like the idea of what a parent is and who society and biology dictates should reproduce and when. Academically, I come from a science/tech background, so my experience of Indian science normally interfaces with research that is cutting edge. But Ayurveda, as a tradition, was very strong in my family. My mother often spoke of my grandfather’s research — in the 1950s he was a government adviser on indigenous systems of medicine. I was interested in how traditional systems of medicine are regarded in India today, but the book is really about pluralistic medicine: how people approach health and disease and why, being that health care everywhere in the world is getting more scientifically and societally more complex.
There’s fascinating stuff here — rhinoplasty circa 800 BC, fish doctors, flowers for rabies, aloe for cancer, hakims and ashtavaidyas — how firm was your quackery radar in place while making these travels?
Being a geneticist has made me very critical. I don’t mean that in a negative way but science can only really move forward by being self-critical. As I met different types of doctors I wanted to know what their prescriptions did and why their medicine might work in the way they thought it to. It’s difficult though, when recipes are long-held family secrets. When that was the case I’d ask how the secret medicine acted on the body and through what route it was going to effect a cure. For a patient, being asked to trust a doctor somewhat blindly has an element of faith healing about it. In western clinical medicine there’s a wealth of information that can be accessed if you were really interested in what drugs do and what’s in them. It’s not always comprehensible to everyone, and most of us don’t open a box of tablets and diligently read the information sheets. So we all take medicines on some faith because it was prescribed by someone who knows more than we do. That being the case, my radar was not set to judge but to interrogate within the context of place and type of illness.
One of the great disparities your book reveals is the difference between rural and urban health care in India. Could you speak to those differences and how they could be minimised?
At the moment India is around 70 per cent rural in terms of population distribution. This large section of India’s population is also some of the poorest. The issues they face include lack of good medical facilities and a reluctance of well-trained professionals to go there to staff them. What’s also been inadequately spread seems to be public health training and education. Malnutrition is rife. These three factors (poverty/poor nutrition, education, lack of medical professionals) form a very toxic Venn diagram. In the coming years we’ll see the urban-rural population figure rapidly changing because of greater urbanisation and migration of rural people to urban centres, so what we’re looking at is how to manage health inequity. Even when the rural poor move to cities, they are still more likely than not to live in insalubrious conditions, and may find the best-equipped hospitals inaccessible to them for financial reasons. However, there are many rural-urban migrants who move to cities precisely to access health care. Many migrants have ended up in Mumbai’s Dharavi for that reason. But in urban slums they also face infrastructural problems. Remedying this is beyond the remit of just doctors. It needs a joint approach. In response to how to get dedicated doctors and nurses to go live and work in rural areas, Dr. Devi Shetty of Narayana Health sort of told me — you don’t. Instead, you set up colleges of excellence within rural areas, you make medical education cheap, or free, that way local people train close to their own communities and will be more likely to practise there.
Why is mental health such a dire issue in India? How has traditional and allopathic medicine failed in this respect?
Mental health is a dire issue everywhere, but in India there’s a marked lack of psychiatrists, and what’s more, psychiatrists who take into account cultural context. I was taken aback to hear in Dharavi that development of mental illness was not considered to be associated with former trauma (this was specifically in the case of gender-based violence). Western medicine has tended to treat the body, or to treat the mind. Traditional healers are interesting for their nuance here. The Asian perspective tends not to separate body from mind, nor body and mind from environment. I think there’s an understanding in traditional systems of a link between difficulties in life and a distressed state of mind, and traditional healers can cleverly work with that understanding. This is not in reference to professionalised traditional systems like Unani or Ayurveda, but there are many more systems of folk healing in which terms like ‘possession’ are still used to account for mental illness, where cures are sought in exorcism, prayer or physical injury. It’s saddening to see that in both modern and traditional practice there’s a commonality in the difference in outlook for male and female patients — the nonchalance often about calling a woman ‘mad’ and not taking her to the hospital, where a man would be allowed treatment.
What would you say is the driving force of the many inspirational people you met like Dr. Shetty whose cardiac centres treat the poor for free, Pawan Sinha’s pioneering research in treating blindness, the sanghinis in Dharavi like Bhanuben? Will India have to continue to rely primarily on these individual efforts?
If the government commits to increasing public funding into high-quality, accessible, free health care for all, then no, it will not be so dependent on the goodwill and passion of a few individuals. The driving force of the people I met is to reach out to as many people as they and their institutions personally are able to help. Many of them are also trying to speak to local governments, to work with blind schools, to train community health workers. These forceful individuals have predominantly committed personal money, land, and investment into bringing great quality health care to people.
During your research you must have come across all kinds of extremes — 640 million people with no access to toilets versus a $280-million fairness industry — what does one do with these kinds of imbalances?
I think I was in an almost constant state of some kind of cognitive dissonance during my travels for this book. One day I was interviewing women in Dharavi about the sexual attacks they faced in communal lavatories. Then I headed to the Taj Mahal Palace hotel in Colaba for my last meeting of the day. My daughter had wrapped bright blue plastic bags around her feet because of the sewage that mixes in with the flood water flowing through the small alleys in the slum. So we walked up to the bar like that, passing Porsche 4x4s pulling into the driveway as we went in. The pricey hospitals offering cosmetic surgery are only a short drive from Dharavi too. That’s where we were headed next, to talk to women who were paying a lot of money to have clearer skin. It’s probably the most important question to tackle, what to do with such imbalances? In the last decades, the wealth of billionaires and the middle class with disposable income has rapidly increased in India, but all reports say that in all this generation of wealth, poor people are getting poorer. Going forward the focus has to be on equity as well as economic growth. The development economist Jean Drèze described India as a world champion of social underspending. So the basic necessities for social equity — adequate public funding of high quality health care, education, infrastructure for sanitation, water, housing — must be prioritised. It’s not optional.
