A question of medicine answering - Springer Link

MARK NICHTER AND CAROLYN NORDSTROM

A QUESTION OF MEDICINE ANSWERING

Health Commodification and the Social Relations of Healing in Sri Lanka

ABSTRACT. Biomedicine although institutionally powerful in Sri Lanka has not been able to depersonalize illness or promote a notion of treatment efficacy disconnected from social relations. An ideology of healing crosscuts the trend toward health commodification. This paper focuses on three concepts fundamental to the interactive dynamics of t~eatrnent efficacy: constitution, habit, and power of the hand. A movement between two distinct types of health care seeking behavior is described. One is inspired by finding the fight medicine fix, the other by finding a practitioner having a sensitivity toward one's sense of person and all this entails. The commodification o f health, the pursuit of health through medical fixes, is a growing trend in the Third World. To some measure this m a y be attributed to the invasiveness o f the world capitalist system, manifest in a flourishing pharmaceutical industry, which has influenced both over the counter consumer behavior and the prescription patterns of practitioners (Nichter 1989). One of the ramifications o f health commodification in developing countries is a growing tendency for the general public to place more emphasis on medicine than on the doctor. As Carl Taylor once remarked, "medicine has become the doctor." The political economic dimension o f this perception is aptly illustrated by the comments o f a Sinhalese informant, a member o f a rural development group: Most doctors, other than those who operate on people in hospitals, are mudaldli (middlemen, brokers) of medicines. Medicine cures, doctors control the knowledge of medicines and we are made dependent. We do not receive health education about medicines, only about using soap, drinking boiled cool water, and taking immunizations - things from which there is no profit. There are many things we want to learn, but they teach us only what they want us to know. Yet we are not helpless. Just as we have learned to use Sinhala Behet (herbal medicines) so we will learn about ingiHsi (allopathic) medicines through experience. Four points emerge from this informant's statement. First, medicine is a source o f power. Second, doctors are perceived as looking out for vested economic interests, Third, information about medicines is withheld by doctors from the general public as a form of underdevelopment creating an environment o f dependency. Fourth, the members o f this largely literate society actively search for information about medicine use (Abosede 1984). This occurs in a context where medicines are readily available over the counter as long as one knows what to ask for.

Culture, Medicine and Psychiatry 13: 367-390, 1989. © 1989 Kluwer Academic Publishers. Printed in the Netherlands.

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The statement above was made by a semi-literate woman involved in the production of coir rope. Two years prior to our discussion she and twelve of her neighbor-coir producers had formed a development group facilitated by a government employed change agent. The efforts of this group were directed at cooperative economic development, the empowering of these women to gain control over their cottage industry. They joined together to purchase raw materials, lease coconut husk soaking pits, and sell the product of their labor directly in the marketplace, thereby bypassing middlemen. Through their efforts tracing chains of dependency in the coir home industry, these women had succeeded in not only marketing their coir directly, but in pursuing a process of critical dialogue about development issues which extended beyond employment. During the course of their dialogue on exploitation, these women came to question the role of many professions in propagating dependency and underdevelopment. Professionals, including doctors and health workers, were seen as offering services and information which served their own interests and gained them profit, status and power. 1 In the words of another informant: They are mudaldli (middlemen) who wish us to know enough to twist rope, but not enough to weigh our own bundles of coir at the time of selling, enough to seek their services when our children are ill, but not enough to use medicines ourselves. The informant, an impoverished woman having only four years of formal education, articulated her feelings about health providers by comparing their activities to middlemen in the coir business. 2 Using a familiar "coir based" problem solving approach she merged personal knowledge from past experiences with coir merchants, doctors and family health workers. The discourse she produced met with spontaneous approval by fellow group members, and served to galvanize an intense discussion about health problems, medical expenditures and being taken advantage of by practitioners. Stories within stories emerged (Price 1987) as members of the group exchanged complementary experiences in the domains of medicinal treatment and coir production which sparked off commentary, comparison and supporting life vignettes. For some time the discussion proceeded with several outbursts made against family health workers who did not visit the poor, doctors who were more concerned with money than with the patient, incidences of failed treatment and continued expense for reoccurring health problems, etc. 3 Just as the patient is often blamed for their ignorance, the "mudalfdi doctor" was now blamed for health problems due to greed and self interest - both forms of victim blaming failing to adequately account for larger political-economic and ecological factors influencing health status and the structure of health care provision. What was most revealing was the direction the discourse took when one of the anthropologists asked the question: What do you need for better health care, more knowledge about medicines for common problems enabling self care or better doctors? The question was not answered directly. What emcrged was a


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discussion about the relative importance of medicine and practitioner in the effective treatment of illness. It is this issue of treatment efficacy which we wish to address in the remainder of this paper. Equally important to understanding health care behavior in Sri Lanka as health commodification are more subtle factors which influence health care seeking. These factors include individual proclivity to types of care, life style concomitants of care, and the social relations of care. The Sinhalese perceive healing to be an interactive process. The dynamics of medicine power and illness etiology are linked to the dynamics of habitual response, the healing attributes of practitioners and social relations between practitioner and client. Thus conceived, treatment efficacy is not a simple case of finding the best medicine to rectify an objectified illness or humoral imbalance. Rather it involves the identification of both a medicine which is suitable and a practitioner whose treatment is concordant with a patient's lifeworld; that is, sympathetic to "person" in a social as well as a physical sense. 4 Three concepts are fundamental to the interactive dynamics of treatment efficacy, colloquially referred to as "medicine answering" (behet ahanawa) by rural Sinhalese in low country southwestern Sri Lanka. These concepts are: constitution (prak.rti), habit (puruddha), and power of the hand (atgu.naya). Constitution refers to one's inborn state of being and personal characteristics as influenced by heredity, cosmological forces, and the contingencies of the developmental process. Habit refers to a patient's typical, accommodated response to a kind of medicine (or food or climate etc.). Power of the hand refers to a practitioner's personal capacity to heal a patient. Whether "treatment answers" to a patient or not involves not only a practitioner's knowledge of body, habit and medicine but empathy and the quality of communication between the practitioner and patient. Among the Sinhalese, the quality of practitioner-client communication looms large as a factor influencing health care seeking behavior. This is not a novel observation, although reference to communication is often limited to a consideration of discourse, leaving unappreciated those forms of non-verbal and contextual metacommunication emphasized by researchers such as Bateson (1956, 1972). 5 Moreover, the observation is made more commonly by those who wish to contxast the mutual understanding of clients and traditional practitioners with the one-sided communication between clients and allopaths locked into the "clinical gaze" of biomedicine. 6 While it may be true that traditional practitioners share more health concerns in common with the public than do most allopaths, a superficial depiction of practitioner types on the basis of medical tradition is simplistic and misleading. 7 The concepts and practices of traditional medical practitioners are not always understood in the same way by the lay population in South Asia (Leslie 1976, Nichter 1981, Obeysekere, 1976). Moreover, not all traditional practitioners are well skilled in communication and

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many are as locked into a system of diagnosing etic disease constructs as are their allopathic counterparts. Conversely, some allopaths are responsive to popular health culture (Low 1985). As an epidemiologist anthropologist (McCombie 1987) and clinician anthropologist (Helman 1985) have pointed out in the West, popular notions of illness commonly influence clinicians. In Sri Lanka's competitive health care arena, many private allopaths pay credence to popular health concerns rooted in traditional medicine. For some allopaths this constitutes an unreflective part of their practice emergent in questions asked of patients. For others it constitutes a deliberate and strategic means of fostering communication, expressing empathy and enhancing patient satisfaction with care. Many ayurvedic practitioners address popular biomedical terms and concerns for similar reasons. Our research suggests that maintaining a sympathetic posture toward a patient's life exigencies and habits, and "fitting" treatment to person, strongly influence attributions of "treatment answering" within, as well as across, healing traditions. Emphasis is placed on the individual in this presentation as an agent having personal agenda as well as a group identity,s While recognizing that an individual's illness experience is influenced by a "therapy management group" (Janzen 1978), an action set constituted by family and friends, we suggest that decisions about treatment efficacy often lie outside the corporate group. The ultimate decision of whether treatment answers or not lies with the individual. Within a Sinhalese family, different practitioners are often frequented by various family members for the same kind of complaints. Rationales for this involve lifestyle and treatment modes befitting lifestyle, as well as personal feelings about a practitioner's understanding of one's constitution, illness experience or life problems. The emphasis we place on the personal dimension of healing contrasts with as well as complements the existing research on healing systems in Sri Lanka which have focused on group dynamics and social reintegration (Amarasingham 1980; Ames 1966; Kapferer 1983; Obeyesekere 1969; Waxier 1979; Yalman 1964). In addition to articulating the reciprocal relationship between patient and practitioner/medical tradition and the transmission of moral values reproduced in medical encounters, the concept of treatment answering constitutes an idiom of distress (Nichter 1981) as well as an idiom for power available to individuals in the family and broader social systems (Nordstrom 1988). Through attentiveness to sariraya svabhavaya (constitution), "puruddha" (habit), "atgu.naya" (power of the hand), and "behet ahanawa" (medicine answering), a patient retains a degree of responsibility and power in determining the course of health care and the role of the practitioner. As opposed to being passive, the Sinhalese maintain an active role in negotiating and defining health care in a pluralistic health care arena.


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BODILY CONSTITUTION (SARITAE SVABHA VAYA )

The notion that all individuals exhibit a distinctive sociophysical constitution is fundamental to Sinhalese thinking about health. One's constitutional endowments are affected by the processes and humoral predominances of developmental stages, the characteristics of their immediate physical and social environment, and changes in the movement of stars and planets which influence one's overall state of well-being (Kemper 1980). At different life stages a person's humoral makeup shows marked differences, and has a profound influence on an individual's health. For example, school aged children are generally believed to have a constitution more aligned with the humor "pitta" associated with heat. This makes them better able to tolerate heaty foods, medicines and environmental conditions than infants or the elderly. People having a phlegm (sema) dominated constitution will suffer more respiratory complaints during infancy (a developmental stage marked by sema predominance), and during rainy season (a time associated with sema production). Individuals having a heaty constitution, on the other hand, will fare better during the developmental stage of infancy and the environmental conditions prevailing during the monsoons, but suffer more during adolescence and hot dry seasons. Different constitution types and different life stages are associated with different types and greater/lesser degrees of vulnerability to illness (Nichter 1987). Having a sema adga (phlegm body) constitution, for example, entails the following of a different set of behavioral guidelines for health promotion/illness prevention than those followed by one with a wind (vdta) or heat (pitta) makeup. Each body type is correlated with a concomitant set of dietary, bathing, and lifestyle prescriptions and proscriptions. Moreover a person's constitution, manifest by body type, is associated with distinct personality attributes. For example, a sema person is considered to be prone to overweight, as well as joviality, while a vdta (wind) person is deemed to be quick-witted but flighty and less socially responsible. Socially labeled constitutional attributes influence interpretation of states of health and the parameters of normality for the person. They influence "common sense" interpretations of the bounds of "to be expected" behaviors to particular life situations, and in turn influence health care decisions. Of particular interest to us at present is the notion that people having distinct constitutions respond differently to treatment regimes and medications. 9 No single idea exists as to how any one type of person will react to a particular kind of medicine. Rather, it is felt that people require treatment tailored as much to individual constitution as to illness. Thus for any given illness type, different people will have divergent expectations from practitioners. They may be concerned with receiving treatment and advice which accords with both their felt needs and limitations. Having a practitioner who understands one's life

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contingencies and constitution is a fundamental concern among patients in discussions of treatment answering. A person's constitution changes in accord with age and life circumstance. As one woman explained: I take my children for allopathic medicines for fevers and intestinal disorders - they are better able to tolerate the heatyness and "sdra" (harshness) of these drugs. My mother did the same with me when I was little. But me, now I take "Sinhala behet" (herbal medicine). I can't tolerate the harshness of "Ingir[si behet" (allopathic medicine) now that I am older. I get sick from the heat. When he is here working, my husband often goes to the "Dostora Mahattaya" (allopathic physician) because he wants to get cured quickly so he doesn't lose too much time from work. But he is gone working in the chena fields now. It is hot, hard work, and he is away from his family and not eating as well. He s a y s there he takes "Sinhala behet" when he doesn't feel well because the "Ingirisi behet" is just too strong for those conditions. Many people, as they grow older, alter their medicine taking behavior in keeping with ideas they maintain about the body's ability to interact with strong medicines. This group tends to pay more credence to health as humoral balance. Consequently, their notions about medicine answering tend to extend beyond that of symptom management to that of balancing excesses and restoring physical processes and a personal sense of routine. It is not at all uncommon, for example, to find a person who self administers a decoction of herbal medicine after having received a course of allopathic medication for an illness. Disappointed with the harsh effect of allopathic drugs on their overall health, they turn to Ayurvedic medicine to restore their body to a healthy balance as judged by familiar body signs (e.g. hunger, defecation, activity level and sleep).

PURUDDHA

Puruddha is a Sinhalese term used to refer to one's habitual relationship to medicine and healing formats. The term is used either in relation to a kind of healing tradition in general, or a specific treatment for a particular kind of problem. Reference to puruddha may denote a general sense of affinity a person has toward a type (ayurvedic, allopathic), form (mixture, tablet, injection, etc.) or brand (less commonly) of I~eatment. Often these references to puruddha overlap. For example, people will say "Ayurveda is my habit", or "Bona behet (liquid mixtures; literally, drinking medicine) is what I am used to." In most cases this does not mean that the person uses this tradition or medicine exclusively, but that it represents their general orientation toward illness treatment. The same person may later speak of illness-specific habits: for example, using kottamalli (a liquid herbal preparation) for a cold but aUopathic tablets for a fever with watery diarrhea. Referring to puruddha signifies more than the recognition that this kind of


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treatment has proven successful in the past. A person speaking of puruddha infers that they have become "accustomed" to this treatment, that their person or body in the case of a medicine - recognizes and responds in a healthy way with a familiar regimen. What is significant is that a medicine's curative capacity is seen as relative to "person" and not just to an objectified illness per se. This implies a sense of embodied knowledge derived through practice. Puruddha refers not only to physical habituation but also to mental-emotional states. The following statement by a Sinhalese woman reflects a c o m m o n orientation: I usually take Sinhala behet (herbal medicine). It answers better for me. I have always taken it, it was the habit even of my mother's family. It works well for my body - my body knows the medicines and responds well to them. But when we are sick, not only our bodies are sick - we are sick in our minds as well: we don't feel normal, we can't think as we normally do, we can't act as we want. So when I take Sinhala behet, it makes my mind happy as well: I know the routines, the procedures for taking the medicines, I know the taste... I recognize and like these things. They are familiar, and reassure my mind. Now my sister started taking Ingir~si behet (allopathy) because of an illness she had. It worked for her, and she has gotten used to it - both her body and her mind are comfortable with it now. General usage o f the term puruddha may suggest a number of meanings. In a very broad sense, it may denote that a person accustomed to herbal medicine will respond differently to an allopathic medicine than a person accustomed to allopathic medicine. People interviewed who were habituated only to herbal medicine were concerned that they would respond poorly or in an unexpected manner to allopathic medicine. They also questioned whether by taking unfamiliar allopathic medicines their body would lose its affinity to herbal medicine. That is, herbal medicine would become less efficacious after utilizing allopathic medicine. People who utilize herbal medicines exclusively represent a small minority in Sri Lanka. However, the idea that using allopathic medicines will lessen the efficaciousness of herbal medicine is articulated by traditional practitioners who emphasize that the purity of one's blood and the integrity o f o n e ' s digestive capacity are negatively influenced by allopathic medicines. This knowledge is "embodied" by patients of ayurvedic practitioners when they undertake systemic as opposed to merely symptomatic treatment. Corrective herbal medicines directed toward the processes of purification and detoxification are routinely prescribed by ayurvedic practitioners for patients who have taken allopathic medicine. Purification medicines are taken not only to remove the toxic effects of allopathic drugs and return the body to a healthy state, but to facilitate the interaction between the herbal treatment and the patient's body. As one prominent ayurvedic practitioner noted: The body must be able to answer to the treatment; it is not just a question of the medicine answering to the disease. How can a patient's body answer to my treatment when

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edlopathic medicines have upset humored response, when the dried residue of symptoms treated by allopathic medicines block bodily processes? Often when people feel better after taking allopathic treatment it is really that their body is drunk with the power of those medicines. An intoxicated person may feel no pain or may not be able to remember their real problems. That does not mean the problems have ceased to exist. I can no more treat an alcoholic successfully without his going through purification (detoxification) than a person who has used allopathic medicine. But how many people will give up their habits for the sake of good treatment? The number is getting fewer each day. This is the reason allopathic medicine is becoming more popular. Arrack sales are also increasing. One simply has to take these things and forget the source of their problems. But ayurvedic medicine will survive because there is a price to be paid for bad habits, quick cures and the power of allopathic medicine. There is a hangover sooner or later. Allopathic medicine may be able to control some diseases, but a person must answer to himself. Ayurveda answers to the person when they are ready to take responsibility for the way they are living. For individuals who are more accustomed to taking herbal medicine, a concern about the harsh strength (sara) of allopathic medicines figures prominently in their discussions about medicine habit. Allopathic medicines are spoken o f as "shocking" the body and causing side effects which may prove as troublesome as those symptoms originally prompting one to seek treatment. Shock (gesma) is a health concern having broad cultural significance in Sri Lanka. This is reflected in proscribed folk dietetic behavior, notions about the relationship between emotions and illness, and beliefs about spirit attack. The ayurvedic practitioner quoted above extended the alcohol metaphor to express ideas he maintained about allopathic medicine, shock, and habit. He noted that to a person accustomed to heaty arrack liquor, two or three glasses could be drunk with a man still being able to keep his wits about him. For one unaccustomed to drink, or for one who drank only "cooling" beer, three glasses of arrack were enough to make a man fully drunk and incapable of controlling himself. Like that, he stated, for one accustomed to "powerful, heaty allopathic medicine" an injection responds well because the body "knows" what to expect, (i.e. it is not shocked). This is not so for a person who rarely takes medicine, or who is used to milder, non-toxic, herbal medicines. Extending the metaphor further, the practitioner, echoed the sentiments of other practitioners o f ayurvedic medicine interviewed in Sri Lanka and India. He stated that just like alcohol: Allopathic medicine is addictive because it fosters dependency. Once a person becomes accustomed to taking a pill for a headache, instead of addressing digestion as a cause of the headache, the person becomes dependent on the pill to feel well. One comes to believe they need the pill even before they feel ill. The person develops a hunger for medicine; this hunger comes to constitute an illness in its own right. While some people state an allegiance to one medical/healing tradition, most Sinhalese are eclectic in their use of treatment resources in Sri Lanka's pluralistic health care arena. Where illness-specific patterns of curative resort are found, they are closely linked to the concept of habit. A person may have the habit of


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using herbal medicines for the treatment of skin disorders, broken bones, snakebite, colds, indigestion, general malaise, and to clean out the bowels bimonthly through the use of a purgative. At the same time, they may maintain a habit of taking allopathic medicine for fever, body pain, watery diarrhea, heart problems, and infected wounds. Other informants utilize both types of medicines claiming that for them a combination of allopathic pills and herbal decoctions is most effective. Explanations concerning treatment preferences which begin with reference to habit often turn to a discussion about a particular practitioner's sensibilities. The topic of "treatment answering" nearly always entails a discussion of treatment that is as social as it is medical. The Sinhalese pattern of discourse which refers to a practitioner's sensibilities as a means of indirectly speaking about competence contrasts with a pattern observed in the United States. In the U.S., patients commonly use discourse about technical competence as an indirect way of commenting about a practitioner's sensibilities and interpersonal style. Indeed, many malpractice suits articulated in the language of competence are prompted more by a patient's anger with the way in which they have been treated interpersonally, rather than technically. In Sri Lanka technical competency is rarely a focal point of discussion. Discourse on treatment answering tends to focus on a practitioner's kindness and caring. Among the Sinhalese, many people maintain a set of treatment expectations involving medicine habit which cross-cuts ayurvedic-allopathic distinctions. The most common of these is the felt need that a sick person requires both tablets and mixtures, "tablets to eat and mixtures to drink" (Nichter 1987b), as a necessary part of their treatment. Indeed, the felt need for a liquid mixture is readily apparent if one observes the ill either on their way to an allopathic clinic or an ayurvedic practitioner. Someone who is ill is easily identified by the towel they wear on their head and the empty bottle they carry in their hand. The rural population is so accustomed to this pattern of medicine taking that they openly express surprise when both forms of medication are not given in combination. Once again, informants spoke of this as "their habit", of their body not responding well to only one form of medicine, and of their feeling a sense of physical unease and dissatisfaction when their expectations were not met. The feeling of generalized dissatisfaction associated with unmet expectations raises another "habit"-related issue. The efficacy of a treatment is judged by one who is ill partly on the basis of how family and acquaintances respond to their treatment. Engaging in familiar patterns of behavior insures that anticipated social responses to illness will take place. Taking medicine entails social relations. People are accustomed not only to kinds of medicine, but ways of behaving associated with different kinds of medicine. Medicines communicate meaning and involve particular types of social interaction; they do not just act on symptoms and have "placebo effects."

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Different meaning complexes and types of illness behavior (e.g. sick role) are associated with allopathic and ayurvedic medicine respectively. For example, taking ayurvedic medicine may entail different expectations and perceptions of recovery than that associated with the taking of allopathic medicines. It may require the following of different dietary, bathing and work related behaviors which involve a person in kinds of social interactions which are quite distinct from those associated with allopathy or with exorcism. On the other hand, habitual health care related behavior, such as folk dietetic behavior, may be generalized regardless of the kind of treatment undertaken. One's personal investment in puruddha, as habitual medicine taking practice, is multi-dimensional. It involves both familiar body and social response, the socialization of sickness, and the articulation of individual needs and identity. Medicine taking practices may constitute an idiom through which a desire for particular types of social relations may be expressed. It may also serve as "one point along the path of legitimization of a sick role associated with illness which are principally defined in terms of psychosocial criteria" (Morsy 1980: 95). A last point with respect to habit is that medicine taking patterns reflect life contingencies, and therefore change in accord with factors such as work and age, as well as perceptions of health, vulnerability and person. Many people we interviewed who presently utilize allopathic medicines do so because of the dictates of their busy work routine. Several spoke of wishing to utilize ayurveda "when time permits" this style of treatment (e.g. the preparation of herbal medicines and the following of dietary prescriptions). A number of young people for example, commented that they anticipated changing their medicinetaking behavior when they became older. A commonly expressed idea was that the taking of allopathic medicine was part and parcel of a hectic life style. However, these medicines were not good for the body over time. As one informant noted: They [allopathic medicines] wear down the body just like riding the bus several hours a day does as you go to and from work.., you get used to it and it doesn't bother you and then one day you know you can't do it any more. Some people can ride the bus for twenty years, for others twelve years is too much. You know, your body becomes ill. It's like that with Ing&[si [English] medicine. One day you know it just won't answer and when you take it you feel that it is spoiling your body. It happened to my mother. Now she takes Sinhala behet most of the time, only for big diseases will she go to a doctor. Even then she will take Sinhala behet for days after to remove the heatiness from her body. Medicine taking habits which appear to favor a particular medicine tradition in general or illness specific treatment, may not be viewed as the "best treatment." Rather it may reflect the exigencies of one's life and an estimation of what one can "get away" with now. At different points in a person's life, habits may change significantly concordant with changes in life their situation as well as


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changes in their evaluation of their own condition as influenced by constitution, age, and illness history. POWER OF THE HAND (ATGUN.AYA/ATV,~SIYA) One reason the Sinhalese tend not to decontextualize illness is because they recognize that each individual has a unique constitution and set of personal as well as social attributes which make a difference to treatment efficacy. During an illness episode, a person may not only seek a practitioner who can cure their ailments, but a practitioner who is sensitive to their particular physical and social circumstances, a practitioner who has atgu.naya for them. Atgu.naya refers to the gift of healing a practitioner is credited as having, irrespective of the medical/healing tradition to which they belong. Not all practitioners have this gift, and it is often attributed to the curing of particular illnesses or categories of people (e.g. children). It is common for a person to consult a practitioner they have heard has atgu.naya when routine treatment has failed. This practitioner may be associated with the same medical tradition they are accustomed to using or hail from a different healing tradition altogether. The issue of what kind of a person is thought to have power of the hand is complex. According to some practitioners it is an inherited gift, while according to astrologers and palm readers the gift is a feature of specific cosmological configurations. In each case, one is born with the gift or destined to have it. This is not how most laypeople perceive of power of the hand. Commonly, the gift is associated with the fundamental Buddhist values of compassion, kindness, and dedication to serving humankind. These values are contrasted to a marketplace "merchant" mentality where a patient is approached as an object of payment for technical services rendered, and not in terms of s~vd, service of humanity. Within Sinhalese culture one finds a long tradition of s~vd-based transactions. Though a market-exchange mentality underlays most service transactions, people who work in the domain of health are expected to be motivated in large part by s~vcL1° Indeed, a practitioner's devotion to the profession entails displays of sgvd. If a practitioner follows a strict fee-for-service market philosophy, they are suspect in the eyes of the populace. Their dedication, and concordantly their ability to heal, are questioned. As one informant explained: Doctors should go into practice because they want to help people, and because they f'md they have a skill for it, If a doctor or a veda just wants to build a big house and get higher social prestige from having fancy things from the payments of patients, how can he or she be devoted to medicine - how can they really care about our problems? How can such a person have compassion and "atgu.naya" for us?

Atgu.naya is associated with a concept of "power" distinct from yet merged with technical aspects of curing. Informants pointed out that practitioners with atgu.naya pay closer attention to the details of a patient's problem. This enables

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them to see things overlooked by others who in the haste of a consultation are "blinded by arrogance and pride." The assessment of atgu.~ya is personal. Often there is not a consensus as to who has power of the hand. Even when a practitioner is widely attributed to have power of the hand, it is recognized that he does not have this for everybody. The Sinhalese recognize that practitioners, as individuals, interact with individual clients. As such it is likely that practitioners will not treat all people alike. A practitioner's power to heal a particular patient resides as much with the meshing of the patient and practitioner's personal attributes and interests as it does with technical skills and general adherence to Buddhist virtues. The following fieldnote entry illustrates this point. A neighbor, Mr. Peiris, and his eight year old son were about to travel three quarters of an hour by bus to consult a doctor in a rural town. What struck me as odd was that five miles in the opposite direction lived Dr. Rathnayake, a practitioner having a good local reputation and commonly frequented by Mr. Peiris, his wife and their ten year old daughter. I queried Mr. Peiris about the boy's problem (a case I suspected to be recurring otitis media) and was told that Dr. Rathnayake's medicine did not answer for his son. I asked if it was a case of Dr. Rathnayake having ineffective medicine, wondering why then other family members consulted him. No, I was told, the doctor's medicines were good. Mr. Peiris was quite satisfied with the treatment that the rest of his family received. Puzzled, I continued to pursue the matter with Mr. Peiris as he waited for a bus under the shade of a large mango tree. "It's a question of kindness," Mr. Peiris said. "Dr. Rathnayake isn't a kind man?," I asked. "He is a kind man," Mr. Peiris stated, "but one does not have the same feelings toward everybody. Toward myself, my wife, and my daughter, Dr. Rathnayake is kind and his medicine answers. For my son he has no interest. Others who have the same problem as my son are cured by his medicine, but not my son." I asked Mr. Peiris whether he was going to consult an ayurvedic doctor or another allopathic doctor when he reached the town. He told me that he would visit another allopathic doctor recommended to him by a friend who also had a son. "But why doesn't the medicine answer?" I asked again. "I cannot say," stated Mr. Peiris, "perhaps Dr. Rathnayake is jealous. He has a son the same age." The bus arrived and Mr. Peiris was off. I decided to talk to Mrs. Peiris. From her I learned that the boy had been treated for ear ache for five months. Each time Dr. Rathnayake gave the boy a course of antibiotics, the condition cleared up for a week or two and then returned. "HIS medicine doesn't answer for my son," stated Mrs. Peiris. "It begins to answer and then for some reason, its power is blocked (behet gunaya balavenava). We consulted an astrologer, but no graha dosa (planet problem) was indicated." In a number of interviews, informants spoke of the power of medicine being blocked when a cure was not realized. Follow up research revealed a range of forces capable of blocking medicine's power, including spirits and demons, curses by evil people (ko~.'vina) and a "bad time" (naraka velc~va) caused by the negative alignment of stars and planets. Two other sets of factors emerged which were more social and emotional in nature. The first includes feelings of jealousy and contempt directed by others toward the patient. The second involves feelings of fear and aloneness on the part of the patient. One close informant was observed to hand medicine to his three year old son


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to give to elders when they returned home from a visit to the government clinic. When asked about the meaning of this action, he replied that the child gave the medicines to his eiders in innocence and with a pure heart. In so doing the properties of the medicine would not be blocked by the unknown intentions of others. To the question "what others", he replied in a vague way referring only to the impersonal way people were treated in the clinic. Interestingly, he did not question so much the quality of the medicine distributed at the clinic as the quality of service evaluated in social relational terms. He did not identify clinic staff as money minded but, on the other hand, he did not view them as s¢vd minded either. The informant's practice of having his son offer medicines to loved ones in innocence may be viewed as a means of disassociating these medicines from any negative feelings which might be latent. In a sense, this act serves as both a form of emotional purification and as a way of attaching loving intention to the substance of medicine. This act illustrates the difference between passive medicine taking, where medicine as a commodity is the fix, and the dynamics of medicine giving where what is exchanged and valued is more than a material substance. In the latter, medicine is imbued with the qualities and intention of the giver. 11 Medicine is a resource and a vehicle. When a person attributes atgut~a,ya to a practitioner, they imply that the practitioner has altruistic motivations and/or a sympathetic understanding of their illness experience and state of well being in the context of their lifeworld. The latter entails empathy, a process involving metacommunication and the acknowledgement of tacit knowledge as much as overt discourse; social relations as well as interpersonal and negotiated knowledge (Young 1981); and a sensitivity to what Bateson has referred to as "signals of state". 12 A practitioner's questions, gaze, touch, and attention to areas of body or social life signalled by the metacommunication of context (e.g. who accompanies a patient, past messages) not only establishes empathy, it influences a patient's presentation of symptoms, self and situation. It is likely that in some instances a patient only perceives that the practitioner understands them due to transference and/or an intense psychosocial need for affiliation. Patients often interpret a practitioner's actions or words in a manner which fits their psychosocial needs and rationalizes their actions. This may be illustrated by a field note envy from an interview with an informant following a visit to a local doctor. Q: Why does Dr. Fernando's medicine answer for you? A: His treatment is correct, he knows where the trouble is. Q: Is this because he asks you many questions? A: He asks questions like other doctors, no, not more questions. Q: Then how does he know? A: He sees my body. He knows the work of fisherman and their habits. He knows how

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our life changes when the catch is good and bad. He sees both our symptoms and our problems, the fish and the net. Q: Do you talk to him much each time you visit him? A: He sees my body first and then I tell things. Today he looked in my eyes and asked if I had been drinking arrack. I told him that I drank a bottle two days ago with a few friends. I also told him about how I had eaten breadfruit for the last week because we have little rice in the house. He didn't scold me about drinking, but gave medicines for my afirna (nausea and diarrhea). Q: What complaint did you present to the doctor when you first went into his office? A: Weakness - I must have strength to be able to work. Q: What medicines did you receive from Dr. Femando? A: A white medicine for afirna. If you cannot digest food there is weakness. The doctor told me I should not eat breadfruit. I should eat rice for the next ten days. In this case, the practitioner's gaze directed towards the informant's eyes, ostensibly to check for signs of anemia, accompanied by his question about drinking in a community hit by hard times, elicited information pertaining to diet. To the patient, the link between the doctor's actions and questions turned around the popular notion that the eyes are a good indicator of heat in the body (manifest as redness). The folk dietetic classification of both arrack and breadfruit is ushnay - very heaty. The doctor's questions following an examination of the eyes initiated discourse, a production of knowledge, which might not have been elicited if the doctor had decontextualized the trouble, defined it as anemia, and prescribed B complex and ferrous sulfate. The patient's feeling that the doctor understood his situation and the fact that he did not scold him (verbally or nonverbally) resulted in the patient constructing an illness narrative in which the doctor had atgu.naya. The narrative revolved around the theme of special entitlement and involved the division of scarce resources within the family. In the narrative it became apparent that the doctor's treatment addressed a conflict involving social relations and resource allocation in the informant's family. At a time when the rice staple could not be afforded for routine household consumption, the patient had shared a bottle of arrack with two friends. These were friends with whom he felt at liberty to request a drink to forget hard times. They were not friends, however, he felt at liberty to borrow money from for his family's rice needs. In the informant's mind, his need for rice superseded the food needs of other family members as he was the primary wage earner. He perceived his diarrhea to be caused by "heatiness" resulting from the consumption of jackfruit and triggered by a few shots of very heaty arrack. His wife managed the household food resources and favored his needs less than he felt was his due. By directing attention to weakness, a symptom linked to work capacity, in addition to indigestion, the man's special dietary needs became an issue. The doctor's medicine and dietary advice legitimated the man's need for rice, a


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culturally valued source of strength and health. The surplus meaning carried by the practitioner's advice indexed social relations within the family. Whether or not the doctor in fact supported his patient's need for special considerations, above and beyond the necessities of treatment, is open to question. The point is that his actions were interpreted as if he understood and supported his patient's position. Even when communication between practitioner and patient is deemed good this does not mean that a practitioner will be credited with power of the hand for all kinds of health complaints. The Sinhalese do not presume that a practitioner has the same sensitivity toward nor knowledge of all illnesses. Therefore, a practitioner may be judged to have atgu.naya for only certain illnesses by a particular patient. This raises a point with respect to triage. A practitioner's acknowledgement of their limitations does not necessarily detract from a patient's judgement of their power of the hand for them. Indeed, in one case an informant affirmed that a practitioner had power of the hand for him when he referred him to another type of practitioner for complementary treatment. The informant was impressed that this allopathic practitioner recommended that he see an ayurvedic practitioner for digestion and blood related problems following a long course of antibiotics for diarrhea. He could have continued treating me and being paid, but he was not money minded. Ten doctors had tried to cure me before and had failed. His medicine answered because he looked into the problem and did not just prescribe medicines like the others. He asked me questions about my diet, my job, and how often I took tea and whether I took plain tea or milk tea, the well from which we take water and my bathing habits. He asked about my family. He gave me Ingb'~si medicine for five days. The diarrhea stopped, but he knew I felt weakness and heatiness. I felt I should go back to work. He told me I should not do this until a course of medicine was taken to increase my blood. This meant I had to remain at home and take special diet. My wife said the doctor had atguna,ya for me and I should do as he requested. The doctor gave me a chit explaining my problem and the name of some ayurvedic medicine. He knew the kind of medicine I needed although he does not give that medicine. He asked me to see a nearby ayurvedic practitioner whom he said had good medicine. I've been taking this medicine for one week and already I'm feeling sla'ong. After another three days I will return to work. I informed my office about my treatment and was granted leave. Three points about this case may be highlighted. First, the questions the practitioner asked the patient addressed broad health concerns. These ranged from routine biomedical concerns associated with differential diagnosis to behaviors like bathing which reflect traditional health concerns. Second, the practitioner's referral of the patient enhanced the possibility that he would follow the doctor's advice concerning convalescence. The dictates o f ayurvedic treatment accorded with the doctor's advice to take rest. The referral insured that the patient's family would continue to treat the person as vulnerable even though his primary symptoms had abated. Convalescence is understood differently when one is under ayurvedic and allopathic treatment. Ayurvedic treatment is

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expected to take longer and involve more than symptom management. While a member of the lay population may or may not know about the specifics of balancing humors, credence is paid by all to normalizing bodily processes. The patient's referral sanctioned a retention of the sick role during his convalescence. Third, although a distinction may be drawn between the practitioner's power of the hand and the capacity of medicine to cure, the two are often coextensive. The patient's illness was managed as a result of the doctor's special ability to select medicines which accorded to his body, life and illness. Just as important, the properties of an ayurvedic medicine were necessary to restore his health following his interaction with the doctor. Two final observations may be made with respect to power of the hand and health care seeking behavior. The interactional basis of attribution of power of the hand mitigates against the formation of comprehensive longstanding ties to individual practitioners by families or individuals. The notion of power of the hand fosters practitioner shopping. It also counterbalances habituation as a form of embodied domination. Despite what one's medicine habit is and the conditions under which this habit has come into being (choice, access, free availability, constraints of work or lifestyle) power o f the hand may override habituation in determining efficacy of treatment. Conversely, ideas concerning power of the hand may foster the reproduction of tacit knowledge through acknowledgement of a practitioner who supports particular habits, practices and all they entail.

MEDICINE ANSWERING (BEHET AHANAVA) People consult practitioners both for quality medications and for the quality of their care. In some cases one consideration takes immediate precedence over the other. Sinhalese use the term "answering" to refer to both the curative properties of a medicine relative to one's constitution and medicine taking habits, and the individual capacity of a practitioner to cure a specific patient. In popular discourse, these two notions are distinguished by reference to "that medicine" and "his/her medicine". Reference to "that medicine answering" specifies that a type of medicine is suitable for one's body and interacts with it in a healthy way. Reference to "his/her medicine answering" is made when a person wants to stress the importance of agency, of a particular practitioner's healthy interaction with a patient, as the primary factor in treatment efficacy. The distinction is common in discourse. For example: You must not confuse the medicine with the practitioner. When I had a bad cold (una hembirissdva) I knew that it would respond to Sinhala behet so I went to the Veda Mahattaya down the road. It was the medicine I was interested in, really. That medicine answers for me. When I told my neighbor about this, she said, "oh, his medicine doesn't


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work for me" referring to the Veda Mahattaya I went to. She goes to another Veda for the same medicines when she is sick because he has atgu.naya for her. You see, even though

it is the same medicine, it answers better if it is given by a person who has the gift of healing for you. Now another friend, upon hearing of the treatment I took, said "that medicine doesn't answer for me"; referring to Sinhala behet. He takes Ingir~si behet for similar problems. It's not the practitioner that matters to him, it's the kind of medicine. We observed that the more ambiguous the identity of an illness and the more vulnerable a patient felt, the more likely reference would be made to a practitioner's power of the hand, "his medicine," when treatment efficacy was discussed. Reference to "his medicine" when speaking of medicine answering underscores the interpersonal dimensions of healing, while consideration of the dynamics of constitution, habit and power of the hand reveals the interactive dynamics of healing. The whole issue of treatment answering calls into question the generalizability of patterns of curative resort data, particularly data derived from hypothetical questions about illness. To the Sinhalese, as important as the medical tradition to which a practitioner belongs is the type of social relationship the latter establishes with patients. In a world where the practice of commercial medicine is increasing, a concept of treatment efficacy which indexes the importance of social relations provides a meaningful balance to the health commodification trend. Biomedicine although institutionally powerful in Sri Lanka has not been able to depersonalize illness nor remove treatment efficacy from the arena of individual expeiience. Biomedical hegemony is crosscut by a residual cultural ideology emergent in medicine answering discourse. This coexisting ideology at once challenges a biomedical model of illness, where the patient assumes the position of an abstraction, yet explains the efficacy of a medicine or practitioner associated with the biomedical or any other system of health care.

CONCLUSION The dynamics of health care seeking is multidimensional. To focus on single explanatory factors (e.g. access to and availability of health care resources, beliefs about etiology, the commodification of health, the economics of health, or patient-practitioner relations) is to obscure the complexities of decision making. This paper focuses on an oft-neglected set of interactive factors that influence the care seeking process within the parameters of economic constraint. Through examining the concept of medicine answering, this paper highlights the fluid manner in which the pluralistic health care arena is negotiated and health care needs are articulated by the Sinhalese. These are a number of options open to the Sinhalese as a means of explaining why a treatment does not answer for one person, but answers for another person having what appears to be a similar complaint. These reasons include "why"

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issues relating to multiple causality, "how" issues relating to the manner in which the mode or type of therapy works in relation to a person's constitution or habit, "when" issues relating to the time period during which treatment is attempted (e.g. naraka veldva), and "who" issues relating to the motivation of a practitioner and the social relations established between practitioner and patient. It has been widely recognized that the coexistence of multiple therapy systems and ambiguity serve an adaptive role by providing people with alternative sources of care and hope when one system of treatment fails to cure a given illness. As Kundstadter (1975:376) has noted, "Multiplicity of interpretive systems increases ambiguity. Ambiguity may be preferable in the face of an uncertain and uncontrollable world; diversity may give strength." Among Sinhalese it is not just the presence of pluralistic medical traditions which provide ambiguity and alternatives. Practitioners are themselves judged to have different healing capacities for specific individuals. The complex of factors we have highlighted serves to insure the integrity of therapy systems by protecting them against claims of being inefficacious. Not only may a medical system in question claim effective treatment for one, not all, aspects of an illness, but one practitioner's failure to cure does not constitute an indictment of a medical tradition. Intra- and inter-personal dimensions of treatment efficacy are recognized. In Sri Lanka today, medicines are increasingly viewed as technical fixes and medical practitioners as money-minded. We have argued that this does not mean that doctors are seen simplistically as medicine brokers motivated strictly by capitalist gain. Within Sinhalese Buddhist society, s~vd and interest in economic gain do not preclude one another. A theme which emerged in several interviews with lower and middle class informants was that doctors are motivated by money when treating some, but not all patients. If a doctor's motivation is simply his fee for services then it is just as well that a person acquires medicines over-the-counter after learning about them through previous experience. After all, if they are to be related to as an object, then commercial medicine fixes serve them just as well with or without the doctor as medicine broker. 13 On the other hand, when medicines do not answer for familiar problems, the skills and sensibilities, the healing capacity, of practitioners are necessary. Cultural expectations are not met when a doctor treats a patient as object and illness as decontextualized disease once routine medicine fixes have failed. It was the anger born of such interactions which women in the change facilitation group conveyed to us. These women did not complain about practitioners lack of competency, for the competency of doctors is, in general, highly regarded. Rather, it was the commodified service offered in place of personal care and s~vd which was criticized. One might argue that this would be true in most cultures. What is distinctive in the present case is the cultural concept of "power of the hand" which explicitly connects healing capacity to practitioner motiva-


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tion and the quality of social relations. When one form of commercial commodified care does not yield expected results, a patient may either seek another technical fix from a medicine broker (be this a doctor, pharmacist, or shopkeeper) 14 or search for the services of a practitioner having power of the hand for "person" and problem. A movement exists between two distinct types of care seeking behavior, one motivated to find the right medicine fix, the other to fred a practitioner having power of the hand. One finds a movement from a commoditized to a person-centered mode of reasoning. Such movement is based on contingencies, on an individual's acknowledged sensitivity toward constitution, habits, and life-situation, as well as on some measure of reflexivity. Another dimension of health care seeking behavior remains to be considered. A person may seek a treatment as temporary relief from a problem seen as a result of an unhealthy life situation, or alternatively a treatment which requires a change of life. Many informants, particularly those subjected to a lifeworld revolving around a set work cycle, realized that the conditions of their work (workplace, transportation, hours) produced not health but sickness. The definition of health which temporarily guided their behavior was that of functional health, health determined in relation to work roles and tasks, not a sense of personal experiential health (Kelman 1976). For these people, technical fixes match the exigencies of functional health problems. Pain is matched with Disprin or Panadol if not arrack, when they do not have the wherewithal to remove themselves from environmental sources of pain or the power base to change the conditions from which this pain arises. When seeking temporary symptomatic treatment, convenience, speed and cost figure prominently in care seeking behavior. While a cure is always hoped for, of more immediate importance is the management of symptom states affording the minimal capacity to fill a work role. When symptoms do not subside or become worse a patient seeks more than convenient forms of commercial medicine. At this juncture a practitioner with power of the hand is often sought. A practitioner believed to have power of the hand may or may not offer systematic as opposed to symptomatic treatment. Individual assessment of a practitioner's power of the hand reflects a person's sense of propriety and expectations. For patients who cannot alter the conditions of their lifeworld, symptom management which takes into account existing life conditions constitutes a chief criterion for judging power of the hand and treatment efficacy. On the other hand, if persons are able and willing to change their life conditions, a practitioner who addresses life conditions is sought. The commodification of health is a powerful trend in Sinhaiese popular health culture fostered by marketing strategies of ailopathic and contemporary traditional pharmaceutical companies, treatment practices of busy practitioners, and time constraints of working people. It is important to consider the range of

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responses to this trend. As Worsley (1985) has pointed out with respect to world systems studies of political economy at large, it is necessary to look beyond generalizations to the agenda of real individuals and how they are influenced by economics and the social relations they entail. It is important to take cognizance of how social actors respond to life pressures and market seductions; of how preferences, evaluations, morals and values at once change and mobilize cultural repertoires in creative ways (Archetti 1986). This is a mandate for a major undertaking in anthropology. In the field of medical anthropology such an undertaking demands that we move from studies of how predisposing, enabling and service factors influence health care behavior at large to studies of illness narrative and life history. In this paper we have set some ground work for such an enterprise by arguing that the question of treatment answering is an issue which goes beyond perceptions of medicines, practitioners, and patterns of curative resort to a consideration of social relations, habit and lifeworld. A final point which emerges from this study of cultural interpretations of treatment efficacy involves self awareness and individual differentiation within Sinhalese culture. It may be asked whether individuals in Sinhalese society are aware of self as a unique identity beyond the social significance of roles assigned by society, a construct Mauss (1938) has referred to as 'person'. 15 Studies of ritual healing often emphasize the realignment of social relations within groups. These studies tend to focus on 'person' and the integrity of social systems while leaving out a consideration of the individual. Medicine answering discourse and the search for a practitioner with power of the hand index a private and more individual and strategic dimension of sickness behavior. Individuals within Sinhalese families are provided a culturally sanctioned mandate to seek and align with practitioners of their own choosing in the name of atgu.naya. In this process, a range of feelings may be conveyed by the surplus meanings attached to symptoms, medicines, and health care seeking efforts. In addition, a sense of self may be articulated to significant others through discourse about treatment efficacy. This sense is revealed as much in "the telling" of illness narratives as the searching for practitioners with power of the hand.

NOTES 1 The case of this change agent group is used because it provides a powerful example of local feelings about "mudal.rqi medicine." We are not inferring here that the Sinhalese are passive and require change groups or facilitators to recognize dependency relationships in the health or economic sector. Indeed, in a number of cross class interviews with informants, the theme of mudalali medicine emerged. People's insight into the business of medicine influences their efforts to obtain treatment and negotiate Care.

2 The coir problem solving frame was extended to experiences in the health arena. One


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notable instance involved misunderstanding of a supplementary food program. One unscrupulous tactic used by middle men to exploit coir and tea plantation workers is to underweigh produce and not involve producers in the weighing-in process. Women in this change group learned to weigh their own coir rope and demanded the right to witness weighing operations. During the discussion on health workers these women accused health workers of manipulating the weighing of their children in an effort to hold back supplementary food allocations. They did not comprehend why some children received food allocations on some months but not during other months. The road to health chart used by health workers had not been adequately explained to them and they did not participate in the weighing of their children. "The family health worker is just like the mudalalis we had to face in coir," stated one informant. To an outraged health officer it was suggested that this critique constituted just the impetus needed to popularize community participation in child survival. If these women could weigh coir they could weigh their own children. Guidelines might then be negotiated with them regarding food allocation once the criteria used for defining nutritional risk were better understood. 3 Price (1987) has likewise documented lay perceptions of doctors in Ecuador as being greedy and not to be trusted. As in Sri Lanka, she notes that a "person theory" may be applied to practitioners who are positive deviants to this negative stereotype. In the Sri Lankan case, cultural perceptions of "medicine answering" index personal attributes of both patient and practitioner as well as the quality of their interaction. 4 Ideas about treatment efficacy involve and call attention to individual proclivities as well as "dividuality" described by Marriott and Inden (1977) and Daniel (1984) as a fluid state of self marked by unboundedness. Applying this concept to medicine exchange, the intention and qualitative state of the medicine giver and the medicine receiver are contiguous. So conceived, healing entails attentiveness to the quality and social relations of exchange. 5 As a systems theorist, Bateson argued that a message must always be interpreted in relation to other messages, that is metamessages, within context. Context applies not only to an external environment but an interpersonal environment established by message exchange. 6 Practitioners of all medical traditions exploit a variety of communication skills and styles appreciated to varying extents by different types of people. In Sri Lanka, just as in the U.S., different kinds of people relate well to more authoritarian-didactic, or to more humanistic-relational approaches to care and persuasive communication. Communication style preferences and expectations from doctor-patient relationships are influenced by a combination of interactive factors including cultural values internalized through socialization, prototype relationships, and transference dynamics. 7 It is time that we move beyond generalizations and consensus thinking about practitioner types and patterns of health care seeking behavior in medical anthropology. What needs to be considered are 1) factors influencing intracultural diversity in the choosing of practitioners, 2) the relative importance of the commodifled medicine fix and the therapeutic relationship, 3) conditions where it is cure or symptomatic relief as distinct from healing that is the immediate objective of treatment and 4) what underlies personal interpretations of treatment efficacy. s Our use of the term individual is conventional and denotes the sense of an agent having agenda and choosing courses of action. The problematic of the "individual" in South Asia lies outside the scope of this paper. Our use of the term individual should not be confused with individualism in Dumont's (1970) use of the term. The latter signifies a western concept associated with equality - if not the disguise of equality in a world marked by competition and inequality in achievement (Beteille 1980). 9 Good (1980) has noted that in Iran responsiveness to various therapies, especially food and herbal therapies, is perceived to vary with temperament. Temperaments are thought to vary by individual as well as by gender, place in life cycle, etc. 10 A question arises as to whether atgu.naya is associated with popular Buddhist notions

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11

12

13 14 15


involving the gaining of pin. (merit). Although not directly articulated by informants, tacit knowledge embodied while people are engaged in the culturally proscribed behavior of visiting the sick might well index notions ofpi~, contribute to practitioner expectations and underscore perceptions of power of the hand. Support for an association of pin. and atgu.naya is also found in the popular idea that power of the hand is something which may be gained and enhanced through sdvd as well as diminished and lost through bad deeds. In South India (Karnataka) power of the hand (kayi guna) is often ascribed to a child of a famous practitioner - but not all children. Power of the hand may be increased by punya (merit) and the recitations of jappa (sacred verse) while maintaining special purity regulations. In South India as well as Sri Lanka power of the hand attributions are often perceived as more important than specific medical systems for healing. In classical Ayurveda, the patient's karma is also perceived to affect the healer. Nichter (1983) has noted that in ayurveda the reciprocal relationship between patient and practitioner is conceived in terms of an exchange of substantive qualities and interactive karma dynamics. Empathy has been defined in a number of different ways ranging from "emotional participation" to "objective and insightful awareness of emotions, behavior and experience"; "understanding as distinct from siding with another (sympathy)" to "imagining another's inner experience though it is not open to direct observation"; "vicarious introspection" to "thinking about as opposed to thinking with another." In the present ease sensitivity to metacommurLication and the acknowledgement of tacit ideology are stressed as features of empathy. Abosede (1984) in a study of self medication in a small town in Sri Lanka notes that people have more confidence in treating themselves for common ailments than from the routine decontextualized care offered to them by primary health care personnel. Eliot Friedson (1970) has written in some detail on those social conditions which favor the perception of doctors as shop keepers. It is beyond the scope of this paper to consider the extent to which a pervading sense of uniqueness is conveyed by a physiomorphic sense of constitution (Ohnuki-Tierny 1984). This implies that one's psychological as well as bodily state is predisposed by constitution. A sense of self would be associated with one's constitutional endowments.

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Department of Anthropology University of Arizona Tucson, AZ 85721 Peace and Conflict Studies University of California Berkeley, CA