Sot. .%I. Med.

Vol. 27, No. 5, pp. 479-489.

0277-9536188

1988

Copyrrght

Printed in Great Britain. All rightsreserved

EXPLORING

PLURALISM-THE
AYURVEDA

S3.00 + 0.00

T 1988 Pqamon

Press plc

MANY FACES OF

CAROLYN R. NORDSTROM
Peace and Conflict

Studies,

University

of California.

Berkeley,

CA 94720.

U.S.A.

Abstract-This
paper argues that because Ayurveda
is commonly
approached
as a single coherent
tradition
of medicine characterized
predominately
by the doctrines. clinical practitioners.
and medical
infrastructure
that supports it, the rich diversity of empirical indigenous
medicine available in the daily
lives of the Sinhalese is often obscured. Thus the numbers of IMPS, the wide range of services they provide.
and the importance
of Ayurveda and Sinhala medicine as basic explanatory
models of health and illness
within the general population
may be significantly
under-estimated
in analyses of Sri Lankas medical
system. In practice, Ayurveda is a dynamic phenomenon
that offers multifaceted
approaches
to healing.
These diverse healing formats develop to meet the constantly changing needs of the society and of illness
patterns. This analysis views illness and health care in terms of the multiple systems of knowledge and
action, phenomena
and interaction,
that characterize
them as well as in terms of the medical treatises and
institutions
that formalize them. In this light, Ayurveda emerges as a plural medical system in itself. As
such, it remains a fundamental
means of defining and treating illness in Sri Lanka.

Key wjords-medical

pluralism, Ayurveda, indigenous medical practitioners (IMPS). Sri Lanka

INTRODUCTION

Mr Werasingha is an indigenous medical practitioner

with a small shop on the main road of a southern
Sri Lankan town. He is also a bookie. His central
location makes it convenient for people to stop by to
seek medical attention
and place bets at the same
time.
Mrs Perera is not called Veda Hamini (female
indigenous medical practitioner)
at all, but is referred
to as Conghee Amma (Mother Conghee; the latter
being a medicinal porridge).
Her speciality is the
treatment of hepatitis. and her practice, carried out at
home. rivals that of the hepatitis specialist with a
large clinic in the center of town. Mrs Perera learned
her skills from her mother. who in turn learned them
from her grandfather.
Her husband is well-known for
his cassipu: a home-made
liquor. People speculate
that with her gift for making hepatitis decoctions, she
helps him with his cassipu. giving it that special
flavor. though no one knows for sure. Thus people
visit her house to cure a serious case of hepatitis and
possibly to buy cassipu, the latter illegal but popular.
Mr Gunawardena
is a Veda who appears traditional in all his mannerisms,
right down to the
white shirt and sarong and the Ayurvedic medical
supplies
in his comfortable
consultation
room.
He received his education from apprenticeship
to a
master, and is registered as an IMP with the government. In addition to his medical practice, however,
this man writes was-kavi for people with enough
money to pay for it. Was-kavi is a complex poem
written
specifically
to curse an individual.
It is
normally the province of exorcists, and then only
the few willing to involve themselves
with such
malevolent
forces. for it is an inherently dangerous
practice. People can come to Mr Gunawardena
to
cure illness or to cause it.
People say they are going to Mr Dissanayaka-the
fracture specialist when they have a broken bone
479

or a sprain. Mr Dissanayaka
is in fact a woman.
She learned her specialty from her father. Mr Dissanayaka, who is long since dead. Even though she
is in her sixties, and has been practicing medicine
for decades, generations
of habit find people still
saying they are going to Mr Dissanayakas
house for
treatment.
Mr Leyanage provides both Ayurvedic and allopathic treatments
to patients.
depending
on their
needs and wishes. He is called, variously,
Doctor
(cosmopolitan)
or Veda (traditional
Ayurvedic
or
Sinhala medical practitioner)
by the community.
In fact, he learned medicine while working in a
pharmacy.
and supplemented
it with studies on his
own. This practitioner
has a thriving practice. and
people say he has a gift for healing (athguniya).
Regardless
of his education.
people
say, his
treatments
work for us.
These five practitioners
all provide medical services
in the same town in Sri Lanka. None. however, fall
within the definitions used by the official health care
system of the country to identify IMPS (indigenous
medical
practitioners)
[I]. The educational
and
governmental
infrastructure
identifies only the traditional Veda, who has gained his or her education
through a rigorous apprenticeship
to a master, or
the professional
Ayurvedic physician; a person who
has obtained a degree from one of the indigenous
Medical Colleges in Sri Lanka, as comprising
the
group of indigenous
medical personnel,
defined as
providing
strictly empirical
herbal-based
medical
services. Regardless
of the formal definitions,
the
practitioners
introduced
in the beginning
of the
paper, and others like them, provide essential health
care services to the general population.
Government
Registries of IMPS list less than a
score of people practicing
in the town and the
immediate surrounding
villages. and estimate that up
to three times that number are actually in practice.
Yet I conducted approx. 100 interviews with people

480

CAROLYN

R. NORDSTROM

providing some form of empirical herbal-based

medicine in the field area, and this does not represent the
full total of practitioners
here. These figures do not
include cosmopolitan,
ritual. or religious forms of
healing.
This paper will explore the diversity of empirical
indigenous
medical
practitioners
in Sri Lanka
today-a
diversity
that is often unrecognized
in
official or academic accounts of the medical system of
the country. In discussing the extensive array of Ayurveda and Sinhala medical practices, the paper will
also focus on why such a diverse range of indigenous
practitioners
exists, and how the general population
navigates the complexities
of this plural system.
Within this framework,
four points will be developed. First, the observation
will be put forth that
AyurvedaSinhala
medicine is a plural system of
medicine in itself, operating within the larger context
of the full complex medical system of Sri Lanka. This
analysis calls into question
the accuracy
of approaching
the tradition
of Ayurveda
as a unified
system of medicine. distinguished
only from cosmopolitan, religious, and ritual traditions. Such dichotomizations can serve to obscure the rich diversity of
healing activities taking place on a practical level in
the daily lives of the Sri Lankans.
To speak of
Ayurveda
as a tradition
implies a set body of
knowledge
practiced consistently
through time. In
reality Ayurveda
is not a tradition
alone, but a
dynamic
that changes
in response
to the illness
patterns emerging at any given point in time, and as
well to the social and interpersonal
needs of the
people.
Second, I will argue that the number of Sinhala
medical practitioners,
and the importance
of Ayurveda as an explanatory
model for illness, are not in
decline. Because many are not registered with the
government,
or go unrecognized
because they do not
fit official descriptions
of practitioners,
their role in
health care services remains under-represented.
Third, many of these practitioners
either specialize
in a particular sub-field of care, or combme several
different traditions of medicine. A number of them,
then. can be seen to mediate different arenas of health
care, and the different doctrines of medicine available
in Sri Lanka. By bridging different medical traditions,
such healers provide a means by which the general
populace
integrates
the complexities
of a plural
system of medicine.
Last. the realities of the health care system-its
structure. function, and dynamics-differs
in terms of
who is discussing it. For example. government
and
university officials define the system differently from
the people who actually practice medicine, and the
system of care as perceived
by patients
and the
general population
is significantly
different
from
either of these two groups. In other words, what the
institutions
teach, what the practitioners
actually
offer. and what the patients perceive the system to be
represent different domains of knowledge and action
in terms of the formal definitions employed by these
various groups. These different, and sometimes contradictory. explanations
all. in fact, serve to define the
reality of health care as it is used by the population
today.
Of importance to this last point is the fact that both

the manner in which practitioners

present services.
and patterns of resort among the patient population.
are grounded
in considerations
that are variously
medical, socio-medical.
and purely social at one and
the same time. For example. as we will see, different
healing traditions
are perceived as having both a
medical and a social status, and these can differ
significantly among, and within. healing specialties.
The ways in which such status markers are used has
a marked impact on the total health care scenario.
Given this diversity of data. fieldwork for this
study was tailored to four levels of inquiry. First.
government
and official descriptions
of the system
were investigated.
Second, observations
of patientpractitioner
relations
were undertaken
in practitioners offices. Third, select patients were followed
in their health seeking activities.
Fourth.
general
household
surveys
were conducted
to ascertain
peoples conceptions
of illness and its treatment.
Central to this study is the argument put forth that
no single knowledge tradition-be
it religious. medical. historical. or popular-adequately
explains social
phenomena.
(See [2] for a discussion
of different
forms of medical knowledge.)
Not only do several
traditions combine to influence medical thought and
action (as in the examples given above). but as well
within each of these, several different orientations
operate. The latter include the doctrinal. the specialist
(the way in which a practitioner
mediates formal
treatises and actual service). and the popular (the
body of information
the general population
uses to
define and give meaning to illness and health care).

SRI LANKAS HEALTH CARE SYSTEM

The health care system of Sri Lanka has been

recognized as a highly diversified pluralistic one for
over a century. Cosmopolitan
medicine is available
either free of charge, from government-run
hospitals
and dispensaries.
or from private practice physicians
for a fee. Leslie [3] and Dunn [4] suggest cosmopolitan medicine as an appropriate
replacement
for
allopathy; colloquially
the term Ingirisi beheth. or
English medicine, is used.
Several forms of empirical indigenous medicine are
found. The most noted dichotomy
is that between
professionalized
(university-trained)
and traditional,
or nonprofessionalized
(apprentice-trained)
practitioners.
This division correlates
roughly with a
distinction
between Ayurveda and Sinhala medicine
(Sinhala beheth) that is made generally throughout
the Sinhalese population.
In general usage in Sri Lanka. the professionalized
system is called Ayurveda. To the average Sri Lankan
this term has come to imply a practice that incorporates cosmopolitan
practices.
The term Ayurvedic
practitioner
refers, in popular language, to a person
who dispenses both herbal and allopathic medicines,
though by law the latter may only be dispensed by
cosmopolitan
physicians.
Though many university
graduates
in Ayurveda
do employ cosmopolitan
practices,
they do not define the term Ayurvedic
practitioner
as the public does, arguing that there
are purist (strictly herbal-medicine)
schools within

Exploring pluralism-The
formal Ayurveda education.
This paper will follow
popular usage, applying the term Ayurvedic practitioner to graduates of the university that follow an
integrationist
approach. (Though Unani and Siddha
are also practiced in Sri Lanka, Ayurveda is by far
the most popular indigenous medical tradition on the
island, and will therefore be the focus of this article.)
As well, acupuncture
and homeopathy
are enjoying
an increase in practice, but are confined mainly to the
more urban areas.
Sinhala beheth provides the majority of indigenous medicine on the island. Traditional clinical practitioners (men are referred to as Veda Mahattaya,
and women as Veda Hamini) are expected to dispense only herbal-based
medication
by the general
public. There are, in addition,
a number of other
healers who provide Sinhala medicine, and who are
not called Vedas because they do not follow the
traditional educational
patterns and modes of practice associated with this group. They will be discussed
in the body of the paper. While few differences exist
in the medical treatises of Ayurveda
and Sinhala
medicine, the latter has come to signify a practice that
incorporates
basic tenets of Buddhism and Sinhalese
culture.
A number of ritual and religious healing traditions
supplement
health care services. Adurukama
provides treatments
for problems caused by demonic
or malign influences external to the patient, and
is performed
by Aduras
(exorcistic
specialists).
Buddhist
priests
(Hamaduruwas)
and Kapuas
(lay-priests)
help correct
illnesses through
ritual
and, in some cases, medicinal therapies. Astrologers
(Gurunnanse)
and fortune-tellers
(Shastra-karaya)
use what is considered
by the Sinhalese
to be
empirical methods to identify and advise on difficult
problems and health issues. Pena-karaya
(see-ers
utilizing trance states) and lamp-readers
(Anjanamkaraya: see-ers who do not utilize trance states) use
metaphysical
ritual for the same end.
These divisions
in the health care arena,- as
presented
here, represent stereotypes
that are used
both by the general population
and in analyses of
the medical system. They are an effective means of
classification
that identify the major healing traditions, the doctrines.
the types of practices,
and
the typical practitioners
associated with each. These
divisions are, in effect. heuristic devices to facilitate
categorization
and communication
among the population and for researchers. A problem develops when
these heuristic classifications
are taken as representing the reality of health care interactions.
The patient population
realizes that in actuality
there are a number of different forms of medical
practice within each of the major healing traditions,
and that many practitioners.
regardless of their training. may offer a combination
of treatment modalities,
blurring the lines of classification used to distinguish
healing formats. These observations
are not equally
realized by all practitioners
or officials, or in all
government
and scholastic publications
dealing with
health care. One can say the divisions outlined in
this section relate to a structural
level of analysis:
that dealing with the institutions
of society. They
are less easily identified
on an interactive
or
phenomenological
basis.

481

many faces of Ayurveda

AYuRvEDA AND SINHALA

kfEDlci~E

In the main body of the paper a number of

examples of Ayurveda and Sinhala indigenous medical practitioners
are given. These people. in addition
to the five practitioners
introduced
in the beginning
of this paper, were all in practice during 1982-1983
in the same urban town in the South of Sri Lanka.
These cases are presented to highlight the trends and
orientations
characterizing
indigenous medical care,
and the needs of the population that give rise to such
varied expressions of health care.
The practitioners
discussed do not represent the
most unusual cases. nor are they the most popular or
representative.
They simply constitute a sample of the
many expressions of Ayurveda and Sinhala medicine
found in the area studied. The examples are intended
to show both the traditional orientations
of indigenous practitioners
and doctrines-and
the stereotypes
generally recognized as characterizing
them-and
the
variations
on these themes found in practice. The
meanings people attach to these variations, and the
services such variations provide to a community, are
explored as an important
component
of the health
care system.
Ayuraedic

practitioners

and traditional

Vedas

Mr A. has a practice on the outskirts of town. He

holds a degree from the College of Indigenous Medicine, a school that favors an integrationist
approach
which combines the doctrines of Ayurveda with the
diagnostic
and technological
skills of cosmopolitan
medicine. While there are colleges in Sri Lanka that
follow a purist tradition of Ayurveda (Gampaha
is
the most well-known, and gives a DAMS degree), the
general public associates the term Ayurvedic practitioner with people who hold a DIMS degree.
In Sri Lanka the tendency to use professionalized
Ayurveda or injection doctors (IMPS who routinely
dispense penicillin and other injectables)
over traditional indigenous
practitioners
is not extensive,
though it does exist. People distinguish between these
two forms of medical practice. and say: we know
what symptoms we are suffering. and what kind of
medicine we feel will answer best for the condition at
hand. If we want Ingirisi beheth (English medicine)
we will go to a Dostora (doctor). When we go to a
Veda it is because we want pure herbal medicines.
Mr A. is one of the few DIMS degree-holders
in
private practice in the town. The bulk of DIMS
graduates
practice
either in the government-run
Ayurvedic dispensaries on the island. or in more rural
areas where few cosmopolitan
physicians are found.
Many of them affect western symbols, and dress in
trousers, if men. or saris if they are women. Often
they run their clinics along the pattern of cosmopolitan practitioners,
and a number
of those in
private practice provide at least some allopathic
medicines as well as Ayurvedic ones. As many set up
practices in areas different from their home areas,
they stand somewhat
outside the community
they
enter. This, as well as a desire for upward social
mobility, restrict many of them from the networks of
social interaction
of the general population.
Mr A. is popular in town, not because of his
training, but because people say he has athguniya:

482

CAROLYK

R. NORDSTROM

the gift of healing, in his case, especially with childrens diseases.

Gossip and clinical observations
suggest that as well his individual personality in part
accounts for his success. He is handsome,
with a
roguish charm, and a quick sense of humor. As the
majority of the people who come to him are women
(females traditionally
bring children to consultations)
these two factors carry considerable
weight.
Like many other DIMS graduates, Mr A. dispenses
allopathic as well as herbal preparations,
uses stethoscopes and thermometers,
and has a plastic covered
examining table in his office; things not common to,
or expected of, traditional Vedas. He differs from the
western image affected by many of his DIMS degreeholding colleagues in two important ways, which also
helps to explain his popularity in an area where few
other DIMS physicians are in private practice. Mr A.
dresses like a traditional Veda in a white sarong and
white long-sleeve
shirt, and he interacts
with the
people like a Veda; he maintains his social ties and
traditional
networks in the community
and respects
the popular paradigms
of knowledge people use to
explain and communicate
their illnesses.
Mr A. thus mediates
the professional
form of
Ayurveda as practiced on the island today and the
patterns of traditional
Sinhala medicine known and
respected
widely throughout
the population.
The
differences
between these two traditions,
as both
patients
and practitioners
acknowledge,
lies little
with the actual doctrines of medicine, but with the
attitudes and manner of interaction
affected by the
practitioners.
Mr A. stands firmly rooted in both
contexts of care.
Mr B. fits the stereotypic
image of a traditional
Veda present both in publications and in the common
conceptions
of the general public. He gained his
education through apprenticeship
to a master (parampara): in his case, as in most, to an older family
member. He also took classes at a Buddhist temple
school; learning Sanskrit and Pali and reading the
classical medical texts in these languages. After independence
in 1947, the government
of Sri Lanka
sponsored a network of public schools, and Buddhist
temple schools were dramatically
curtailed
in the
services they provide.
The younger
Vedas today
seldom enjoy the educational
opportunities
once
afforded
by these private institutions.
This practitioner is not registered with the government
as an
IMP. He feels it is too much effort for the few rewards
offered by such an action.
Mr B. wears the white or light-colored
sarong and
a white t-shirt or white long-sleeve jacket associated
with traditional
Vedas. He is older, and wears his
white hair tied in a knot at the back of his head in
the manner of respected elders in the community
(today modern fashion favors a short hair cut for
men, and the practice of tying a knot is decreasing).
His shop has what I call a dark wood and smokey
bottles atmosphere
common to traditional Vedas. It
is a comfortable
environment
with dark wooden
shelves lined with old texts on Ayurveda and smokeycolored bottles of medicines.
Raw ingredients
for
making decoctions are in carefully marked drawers or
wooden boxes. A heavy dark wood desk is the site of
the consultation,
and no allopathic instruments
are
found.

Diagnosis
is done by the classical method
of
reading the pulse and taking a detailed history. Mr
B. takes care to elicit personal and social problems
that might be affecting a patients state as well as
investigating the physiological ones. When discussing
treatment strategies with patients, he is careful to give
advice not only on medicine.
but on the correct
bathing, diet. and activity patterns recommended
for
a particular illness. He does not engage in any form
of ritual healing.
Mr B. is a part of the community.
He knows the
people, the kinds of problems
they face, and the
values and beliefs that guide peoples lives and define
their illness episodes. When he gives advice. it is based
on the trusted knowledge of the society. All of these
traits are expected of a traditional Veda, and generally felt by patients to be lacking in practices based
on cosmopolitan
models. Mr B. is quite adept at
meeting the demands of the community.
and he has
a popular practice. Not all Vedas do.
In general. I have found that government
and
health care officials. professional
medical organizations, and academic surveys tend to portray IMPS
in Sri Lanka in terms of the characterizations
presented
by the two physicians
discussed
above
[S-14]. However,
as we will see. not all Vedas
conform
to this model. In diverging
from these
stereotypes-these
broad classificatory
models-of
professionalized
and traditional
IMPS. other Vedas
provide essential health care services to a community
at times not available from their more traditional
colleagues.
Variations:
world

traditional

practitioners

in a modernizing

The two practitioners

discussed
above practice
general medicine. Within traditional
medical structures a number of specialists exist as well. Some of
these divisions have been noted in the literature on
Ayurveda.
For example. Kutumbiah
[ 141 discusses
the major specializations
within Ayurveda.
such as
internal
medicine,
obstetrics
and pediatrics,
etc.
Djukanovic
and Mach [IS] distinguish
between
preventive
and curative services in the tradition.
Leslie [3, 161 has documented
the different schools of
Ayurveda
thought
(purist and integrationist),
the
different
educational
strategies
(professionalized
and nonprofessionalized).
and varying knowledge
traditional-culture
medicine,
traditions
(classical.
popular-culture
medicine,
folk
medicine,
etc.).
Obeyesekere
[17, 181 has pointed out the existence
of classical
and local traditions
in Sri Lanka.
Dunn [4, 191 classifies medical knowledge according
to local. regional, and cosmopolitan
medical systems.
Each of these divisions is observable
in common
practice in Sri Lanka.
Further specialties exist which have been less formally distinguished.
though they are generally recognized as constituting
part of the medical system.
These reflect the very real needs of the community,
and include such examples as: fractures, poisonous
snake-bites, eye diseases, hepatitis. skin diseases and
boils, childrens
disorders,
sinusitis, intestinal
disorders, and stroke or paralysis.
In addition to these divisions in health care, however, a number of other important
specializations

Exploring pluralism-The
exist which are little represented.
and often completely unrecognized.
in formal discourse on IMPS.
Some practitioners
offer distinct specialties of treatment, such as drug and alcohol addiction
reform;
hydrocele.
gynecological
complaints
or sexual disorders; mental illness; nonspecific
wasting or debilitating conditions;
rehabilitation
for trauma and
accident patients requiring long-term care; or care for
victims of violent crime who wish to remain anonymous (such as domestic or police violence). There are
practitioners
who provide only primary health care
on an informal basis. and others who offer a combination of services normally defined as standing outside traditional
Sinhala medicine, such as medical
care with astrology or ritual-based services. Some are
unusual in that their own personal characteristics
or
mode of service presentation
place them outside the
typical characterizations
associated with traditional
IMPS and the treatments
she or he provides.
As apprentice-trained
Vedas provide the bulk of
indigenous medicine on the island, and some argue
the bulk of all medical services [5], distinctions
concerning their practice become fundamental
to an
understanding
of the daily realities of health care
among the Sinhalese. Two examples illustrate some
of the nontraditional
approaches
exhibited among
Vedas today.
Fish mudalali (vendor) bone-setter is the name
given to a young man known both for his tasty fish
and his treatment of fractures and dislocations.
Most
Sinhalese feel fractures are treated more successfully
by indigenous medicine than by cosmopolitan
care.
The fish mudalali, however, does not fit the image of
the traditional
bone-specialist
Veda in white sarong
and dark wood and smokey-bottle
office. He wears
trousers and has a head full of unruly hair. If he is
not home, patients come to his stall lined with fresh
fish to seek treatment.
He does not have many
pre-prepared
medicines, but either makes them on the
spot or tells the patients families how to make or
obtain them. He learned his skill from his father
and uncle. and uses only Sinhala beheth (medicine).
Fish mudalali has a patient-load
that rivals many
traditional fracture-specialists
with formal shops. He
is also among the more successful fish vendors.
Mr H. has an interesting approach in that he not
only provides a specialized set of services, but provides them in an unusual way that appears to further
their relative effectiveness in practice. His shop, near
one of the main t-ansportation
centers in town,
frequently has an unattended
look that belies its true
popularity. Though classified generally as a Veda (he
is registered
with the government
as an IMP in
general practice), his only resemblance
to the traditional Veda Mahattaya is that he learned medicine
through
apprenticeship
to his father.
He wears
trousers and his shop is lined with ready-made tin and
bottle containers
of medicines he has prepared.
This practitioner
assures the curious that he sends
packages of medicines throughout
the country, and
that people come from distant towns to consult
him. Like some of the more contemporary
and
nontraditional
Vedas. he advertises his services and
products in newspapers and in leaflets. This practice
represents
a recent adaptation
of specialists,
especially those offering cures for more controversial
or

many faces of Ayurveda

483

stigmatized
disorders,
in order to reach a larger
percentage
of the population.
Considering
the fact
that the literacy rate of Sri Lanka is well over 80%,
the impact of such advertising can be significant.
Mr H. says the response, both in mail-orders
for
packaged medicines and in number of patients, is
high. The reason, he says. is that he cures sexual
disorders with. in his words. remarkable
success.
While he treats normal cases of impotence. frigidity.
homosexual tendencies and the like. he specializes in
some of the more complicated cases, especially those
of young adults. He keeps detailed records of his
cases, including the letters people write him concerning their problem-sent
either to request medicine or
to introduce
themselves
before visiting. Letters of
introduction
are not common
to Sinhala medical
practice, but afford a solution to a problem unique to
sexual or other stigmatized disorders. In Sri Lanka
these disorders
are seldom openly discussed.
As
patients infrequently
travel to healers alone. but are
instead accompanied
by family members and friends,
talking about these sensitive matters in front of such
people can be problematic.
Introductory
letters can
help to enlist a practitioners
discretion.
Two examples from Mr H.s files illustrate patient
dilemmas he commonly encounters.
One is a young
man about to be married.
In Sri Lanka. a high
premium
is placed upon a womans virginity at
marriage, and many men and women approach this
institution with little sexual experience. The matter is
further compounded
as this topic is not openly
discussed in Sinhala society, thus restricting the availability of accurate knowledge on sexual relationships.
Frequently, people about to be married approach the
wedding night with some trepidation.
In this case the
young man was experiencing dizziness. ringing in his
ears, spells of violent heart beating. difficulty in
breathing,
a feeling of constriction
throughout
his
body, and a conviction that his penis was shrinking
and drawing into his body. His wedding was weeks
away and he was concerned he would be unable to
perform successfully on the nuptial night. Mr H. said
some medicine and an educating discussion
about
sex and the honeymoon
night solved the mans
problems.
In another case. a young woman had written to the
Veda with a delicate problem:
she had engaged
in some sexual practices and now was suffering a
number of physical complaints.
She lived in a town
8 hr driving distance from Mr H., and had not come
for a personal consultation:
the entire transaction
between the two took place by mail. The Veda
said guilt, fear over her family finding out about this,
and a lack of understanding
of sexual matters had
manifested
themselves as physical disorders. Again.
medicine for the physical ailments and advice on her
personal problems had cured the girl. Several weeks
after the Veda had written to her she wrote back to
thank him profusely for his help, saying her life was
changed and she was now a happy. healthy woman.
Mr H. is unusual not only in his medical specialty
but in his appearance
and style of practice as well.
People agree that his mannerisms
are quite different
from those of both traditional
Vedas and Sinhalese
men in general. According
to the Sinhalese he is
effeminate in his actions, flamboyant
in style. and

484

CAROLYN

R. ?ri0RDsT~0~

discusses sexual matters with an ease. and sometimes

a rudeness, uncommon
in general society. But those
suffering from the problems he specializes in agree his
services are invaluable.
Traditional
Vedas, such as Mr B. who was discussed above, represent the ideals of society and the
values of health common to the populace. Because of
this they are successful in re-introducing
the ill back
into both the physical and social states of positive
health. People may be somewhat hesitant, however.
to take to them problems that are considered
antithetical to these values. Mr H. stands outside of these
paradigms.
Eccentric but intelligent and willing to
help, he provides people with advice and medical
attention for dilemmas they are embarrassed
to take
to the traditional
Vedas. Furthermore.
because he
treats so many of these cases, his expertise
and
knowledge in these areas often far surpasses that held
by the more traditional healers. People say that while
Mr H. is a Veda, he is a different kind of Veda, and
he is providing
services that meet the needs of a
changing and modernizing
world.
Local-level healers
There are a group of healers, predominately
female
who, though virtually unrecognized
in government
and research analyses of the islands health care
system, are a primary health care resource for the
general population.
They tend to work out of their
homes on an informal basis rather than maintaining
formal clinics, and practice medicine in addition to
their other domestic obligations.
They provide care
based on the tenets of Sinhala medicine,
but are
rarely referred to as Vedas by the population.
Because they are an important resource in virtually
every community,
I call these people local-level
healers, though no formal group-level
designation
exists in Sinhalese. Instead, each is called by a
personal reference, often with a kin suffix, that in
some way denotes the healers skills. This involves
terms that refer to their specialization,
theirlocation,
or their actual name. The example of Conghee
Amma was given in the introduction.
Other examples include Karunawa Aca (Elder Sister named
Karunawa)
who provides general medical care, and
Prospect Hill Healer (who lives on Prospect Hill), a
lady who is considered particularly adept at treating
maternal and child disorders.
In some cases people
simply say we are going to J.s place, J. being the
house or family name where a well-known
healer
lives. Everyone knows that means a person is going
to consult with Mrs J.
When asked why local-level
healers are often
female, people generally respond in a manner similar
to the person who explained:
Well, men can be
local-level healers. and there are some, but most men
work, and their work takes them away from home for
many hours of the day. Thus if we fall sick and go
to their house, chances are we wont find them at
home. Also. because women tend to stay in their
home area more. they know us, our problems, and
our histories. They care about us; They are better
equipped to help us because of this. Several people
were less tactful in their answers, as in the case of a
householder
who said: If we fall sick and go to a
mans house he may be partying with his friends or

he may have taken too much alcohol. They cant treat

US very well that way. This doesnt happen
with
women.
(Public partying
or drinking
alcohol is
sanctioned
for the women of Sri Lanka.)
Veda Amma (Veda Mother). the nickname gtven
by the neighborhood
community to one of the popular local-level healers in town, provides an example of
the role such women play in health care. She is a
housewife and a grandmother,
and lives in one of the
more populous areas of the town. This women treats
what she calls the common everyday illnesses that
plague people: stomachaches,
toothaches.
diarrhea,
illnesses caused by frights. etc. She learned her skills
from her mother,
and has supplemented
them
through the years with informal studies of her own.
She does not maintain an ofice. ready-made medicines, or regular consultation
hours; when a person
falls ill his or her family brings the patient to Veda
Ammas house for treatment at any hour. People tend
to go to her when they feel their own knowledge of
home remedy is inadequate to treat an illness which
is neither serious nor sufficiently acute to warrant
hospitalization
or a visit to a Vedas or Dostoras
office.
Like most other local-level healers. Veda Amma
follows a service rather than a market orientation
in
her practice-another
fact that contributes
to the
popularity
of these healers. People who practice
medicine as a full-time profession
often formalize
their practices, setting office hours and exact fees to
be rendered upon consultation.
For the Sinhalese,
who have long maintained
a tradition
of servicebased transactions,
these are somewhat
suspect
practices. People feel a true healer should not be
preoccupied
with economic transactions
and making
money as an objective:
healing and community
service should
be the desired
goals. Local-level
healers commonly work according to these respected
principles.
They may take foodstuffs or goods for
payment, or may defer fees altogether, knowing the
patients family will return the favor when they are
able to do so.
In most instances patients will go to local-level
healers three times for treatment: in the morning, the
evening, and the following morning. If her therapies
answer and the patient is improving as expected. the
healer will work out a recuperative
regime with the
patient. If, however, the patients condition is not improving after the third visit. he or she will be taken to
a clinical practitioner
(indigenous or cosmopolitan),
to the hospital, and/or to a ritual healer.
Veda Amma restricts her medicines
to herbalbased preparations.
She either tells a patients family
how to prepare these or. if she has time or if a
decoction
is difficult to prepare, she may make it
herself. In addition she advises on bathing, diet, and
activity patterns necessary for a complete cure. As she
is a permanent
member of the community
in which
she lives, she knows many of her patients and the
problems they face. and she often sits with them and
discusses the personal problems and social dilemmas
that are impinging on their health.
Because of Veda Ammas own educational
background, she is capable of providing another form of
healing distinct from that of Sinhala medicine. She
chants mantras: protective
verses against malign

Exploring pluralism-The
influences.
This is normally
done by an adura
(exorcist).
and thus represents
a combination
of
healing traditions.
The Sinhalese believe that if any
supernatural
influences are compounding
an illness,
medicinal treatments
will not prove effective until
the negative influence is cut (kapanawa).
Chanting
may be called the primary health care of exorcism;
if it doesnt work, more sophisticated
rituals are
performed
by aduras.
Local-level healers may treat only one illness, a
specific group of diseases. or provide general medical
treatment.
While most base their remedies on the
Sinhala medical tradition,
they may restrict themselves to this. incorporate
both empirical Sinhala and
cosmopolitan
medicines,
or combine medical and
ritual healing activities.
Some incorporate
astrological or fortune-telling
services in their practices.
The fact that a number of local-level healers combine healing traditions
is important
to many Sinhalese as. in popular practice, they do not apply a
strict Cartesian mind/body
dichotomy
in explaining
illness. Because they see the many forces that constitute a conscious
being-physical,
psychological,
social, cosmological,
etc.-as
forming an integrated
dynamic. they view disruptions
in any of these domains as being capable of affecting the well-being of
an individual. A complete cure depends on successfully addressing all of the imbalances
in a persons
life. Healers who address several realms of disease
etiology can provide what people consider to be a
more comprehensive
healing regime.
Local-level healers like Veda Amma provide both
essential primary health care services and locus of
important
socio-medical
knowledge for the general
community.
These healers are expected
to keep
abreast of the recent developments
in illness patterns
and treatment modalities. As well they are expected
to respect
and maintain
the valued
Sinhalese
traditions
and body of popular
Sinhala medical
knowledge.
They are, in effect, mediators
between
the more professional
and the more popular (local
or home-level)
systems
of medicine.
They lielp
translate strictly medical concerns into information
comprehensible
to the general public.
The importance
of Ayurveda/Sinhala
medicine,
both as a healing system and as an explanatory
model for illness, is significantly under-represented
in
accounts of Sri Lankas health care system that do
not take local-level healers into consideration.
Yet to
establish the full range and impact of such healers is
difficult at best. Because they have no official recognition in the health care system (they take no formal
education
and are in no way registered
with the
government),
do not keep formal clinics, and do not
advertise
with signboards
or announcements,
the
only way of discovering them is by extended household surveys and in-depth interviews with a broad
cross-section
of patients.
Mrs N. is an example of what might be called the
professionalization
of the local-level healer. The
Sinhalese do not categorize her in this way, but refer
to her simply as Veda Hamini or Dostora
Nona
doctor),
or
(Lady Veda. Lady cosmopolitan
that woman with a clinic on Main Street. Unlike
local-level healers. however. women and men equally
provide services like Mrs N.s.

many faces of Ayurveda

485

This woman
runs three successful
offices in
different locations on the outskirts of town. People
say she is professional
in her demeanor, yet shows a
real concern for the patients and the problems they
bring to her. Mrs N. demonstrated
this by explaining
to me: We all know that abortion is antithetical to
the medical. social and religious laws of our country,
but if a young girl comes to me with an unwanted
pregnancy. how can I simply condemn her and send
her away like many doctors do? Such a person is
really suffering, and I must help her to deal with her
dilemma in some way.
Breaking
from the common
patterns
of professional clinical practitioners,
she wears a housedress
(and not a sari) like the traditional
Veda Haminis
and local-level
healers. Visible in her offices are
traditional Ayurvedic and modern allopathic supplies,
and acupuncture
instruments
as well. She provides
several forms of medical treatment and has at least IO
diplomas framed on her walls.
Discerning Mrs N.s educational background is not
easy. She learned Sinhala medicine from a family
member-but
did not apprentice
as strictly or as
long as is traditionally
demanded.
She attended a
course on how to give injections and studied some of
the basics of allopathic
primary health care, birth
control, and pharmaceuticals.
She has learned some
homeopathy,
either by attending classes or by a short
apprenticeship
(it is not clear which), and has passed
a class in acupuncture.
She intends to take more
advanced classes in both cosmopolitan
medicine and
acupuncture.
She is adamant that she never treats beyond her
skills, and will use techniques
and medicines only
after she has studied them. For example, she states,
she only recently began to give penicillin injections,
and then only when she had completed a class on the
subject. If she feels her skill is not adequate to meet
a patients
needs, she carefully refers them to a
practitioner
thought to be more competent
in the
area. Mrs N., like many other such practitioners,
is
quick to point out that this is not purely professional
etiquette or altruism. If a patient gets worse or dies
from treatments
we have given, our reputation
will
suffer and our clientele steadily decrease. If we have
any doubt as to our ability to successfully treat a
condition we will refer the patient. If our referrals are
not made with the best interests of the patient in
mind-if
we refer a quack-the
patient will lose
faith in us and never return.
Mrs N. is somewhat unusual in her dedication to
continuing education and in the number of medical
traditions
she incorporates
into her practice. However, the pattern of service she provides,
and an
educational
background
that does not strictly fit
that accepted for the major medical traditions,
is
similar to many other practitioners
operating today.
Usually such practitioners
are found outside of the
major urban areas where the services of cosmopolitan
doctors and traditional Vedas with office practices are
less common.
They often provide patients with a
locus for obtaining several forms of clinical medical
treatment. Most provide at least two major forms of
medicine
(often
Ayurveda/Sinha]a
and cosmopolitan),
yet unlike many of the more formally
recognized
clinical practitioners,
they ground their

486

CAROLYK

R. NORDSTROM

services in popular
Sinhala medical and cultural
concepts of health care, and do so in a language
comprehensible
to the general public. Many Sri
Lankans feel the latter is under-represented
in strictly
cosmopolitan
practices,
a fact that attests to the
popularity of healers such as Mrs N.
These practitioners
tend to synthesize urban/rural
health care systems and professional/nonprofessional
or cosmopolitan/Sinhala
medical approaches.
This
provides an interesting
professional
counterpart
to
local level healers like Veda Amma, who often combine Sinhala, and possible cosmopolitan
medicine,
with ritual forms of healing like chanting, and advice
systems like astrology and fortune-telling.
Religious

and ritual medical

practitioners

Buddhist priests have long been associated

with
healing, and their position vis-ci-uis the medical system
has taken an interesting turn since the professionalization of Ayurveda became institutionalized
during
the last century. Not all monks learn medicine, but
those that do learn it in addition to their Buddhist
education as novices in a temple, apprenticing
to a
master there. They learn Sanskrit and Pali, and study
the classical texts written in these languages.
Since the term Ayurveda
has come to signify
professionalized
indigenous medicine based on integrationist
principles
in the minds of the public,
Buddhist priests have moved into the position of
representing
a major source for purist and classical
doctrines of indigenous medicine. (Graduates
of the
purist colleges also fall into this category, but they are
fewer in number than the priests.)
There is. however, an interesting twist in the services priests provide. Classical Ayurveda, as taught in
Sanskrit texts, stands as a medical doctrine alone.
Sinhala medicine, on the other hand-by
far the most
popular form of indigenous medicine practiced in Sri
Lanka-has
incorporated
some of the basic tenets of
Buddhism. Buddhist priest-practitioners,
while maintaining the classical philosophies
of Ayurveda, also
stand as a formal center for Sinhala medicine, both
because of their religious orientation
and because of
their close association
with a wide range of community concerns. Thus in reality they represent what
might be labeled a classical Sinhala medical tradition.
The case of Hamaduruwa
(monk), a middle-aged
Buddhist
priest
demonstrates
the impact
these
healers can have on community
health resources.
This priest is most famous in the area, outside his
respected priestly duties, as a poisonous
snake-bite
specialist. In a tropical country heavily populated by
cobras. vipers, banded-kraits.
poisonous centipedes,
scorpions
and a host of other stinging and biting
creatures. such a specialty is an important
one. Few
Sri Lankans trust allopathic treatment when it comes
to poisonous bites. and many will travel miles past a
major hospital by bicycle, car, cart, or foot to seek the
services of specialists such as Hamaduruwa.
People
say that of all the snake-bite physicians in the area,
this priests cures are among the best. People of all
castes and classes come for treatment,
and at the
temple grounds Mercedes as well as bullock carts are
parked.
This priest. like a number of Vedas, keeps detailed
records on all the patients he sees; citing complaint,

diagnosis
and treatment
prescribed.
A perusal of
these records shows two noteworthy
facts. First.
Hamaduruwa
treats a wide variety of illnesses.
Though hes noted for curing snake-bites,
people
come to him for everything
from stomachaches
to
typhoid, from frights to general malaise. Most feel he
is competent
in general medicine, and find his prescriptions beneficial. This is evident in the second fact
of interest: his latest record book, covering approx.
2.5 years (the early 198Os), lists over 30.000 separate
patient entries. These include only medical consultations and not those associated with religious/ritual
healing ceremonies. In a town of 25.000 population,
Hamaduruwas
patient load is significant. and rivals
the most successful AyurvedicSinhala
and allopathic
physicians.
As in the case of local-level healers, the impact
Buddhist priest-physicians
have on the general system
of health care. and thus the importance of indigenous
medicine
as a preferred
healing option.
is often
under-estimated
in surveys on the topic. As many
are not government-registered
IMPS, and generally
practice only on the temple grounds, inquiring at
each temple in an area is often the only means of
finding out which have trained physicians, and what
services they provide. Hamaduruwa,
like many other
healers, cannot
remember
any official or scholar
consulting him about his practice or patient load, and
thus these figures do not enter published statistics
available on the health care services of Sri Lanka.
Hamaduruwas
popularity
lies to a large extent
with his skills as a medical practitioner
and with his
engaging personality
that puts patients at their ease.
But, as is true of all priest-practitioners,
he is capable
of providing people with an important combination
of services. As has been noted, the Sinhalese believe
that the mind and body operate
as a dynamic
complex. Illnesses cause mental and personal distress,
and an individuals worries and problems can lead
to physical exhaustion
and disease. This priest can
minister both to the patients physical disorders and
to their fears, questions, and personal dilemmas surrounding the physical state. As Evans-Pritchard
[20]
demonstrated,
illness raises a host of epistemological
and ontological
questions;
why me being one of
the most basic. Priest-physicians
can provide
a
paradigm of explanation
that mediates the physical,
the existential, and the cosmological.
Not all priest-physicians
provide straightforward
general medicine as does Hamaduruwa.
The following two examples of priest-practitioners
demonstrate
popular medical practices found in the general population that do not fall within the narrow confines of
formal descriptions
of Ayurveda. The first is a man
whose skills are famous even in large cities quite a
distance from the town in which he practices. While
he provides general medical care, he is also noted for
certain opium or marijuana-laced
gels that I call
desserts. They are sought after by men to give their
wives for honeymoon
nights, or by people who are
having social parties where they want to make sure
the guests have a good time. In these instances the
gel is often actually made into a tasty dessert where
its properties are diluted to reasonable proportions.
The other priest provides a service to the community that is not readily available in many health

Exploring pluralism-The
care facilities. He has set aside a number of rooms
near his lodgings for alcohol and drug abuse cases. It
is in effect an informal in-patient program for people
who want to overcome
problems
of dependency.
He uses herbal-medicines,
Buddhist teachings,
and
persona1 counseling to help these patients overcome
their addictions.
In a country
where alcoholism,
and to a lesser degree drug dependency,
is a major
socio-medical
concern,
the priest offers care of
fundamental
importance.
The final example demonstrates
the importance of
social status considerations
in the health care behaviors exhibited in the community. Classical Ayurvedic
texts cite exorcism-the
control
of demonic
and
malign influences-as
one of the eight major specializations in the medical tradition [21]. However, in Sri
Lanka today the traditions
of Ayurveda
and of
exorcism have become firmly divided. Walters (personal communication)
has noted that in his fieldsite
in a rural Sinhalese community
in the north of the
island this strong division is not evident, and Vedas
there commonly
give medicinal treatment
and perform ritual cures simultaneously.
Whether this represents a difference in practice between the North and
the South of Sri Lanka, or whether this is peculiar to
the small village in which Walters worked is not clear.
In the South, exorcistic
rituals are considered
effective and meaningful
curative modes medically,
but of low status socially [22]. Thus it is not infrequent to find people who desire the help aduras
(exorcists)
can give, but who wish to keep this
information
restricted from their general social and
professional associates. In my study, I found very few
people who had not consulted an adura at least once.
I also found that only a small group of people would
admit to using the services of such a person openly
and in social (rather than in healing or in private)
contexts. This double-bind
has produced Vedasand I use the quotation marks on purpose-such
as
Mr X.
Mr X. was trained as an adura by his father,
himself a master at exorcism. He says he provides a
full range of adurukama services, and administers or
prescribes only the most basic Sinhala medicines if he
uses them at all. Unlike the other aduras in the area,
Mr X. says he has a large clientele, and treats a
significant
number of upper class and high caste
people. Patients come from distant cities to seek his
services. Also unlike other aduras. Mr X. is frequently referred to by his clients as Veda Mahattaya-a
practice that the patients themselves,
and
not the practitioner.
seem to perpetuate. Mr X. seems
unconcerned with the actual title people apply to him.
In a lengthy discussion with this man we became
curious as to why the title Veda was used in
addressing him. The answer, it appears, lies with the
social status accorded
to the various healing professions Today, the empirical medical practices of
Ayurveda and Sinhala medicine are associated with
higher. and more desirable. caste. class, and urban
progressive
statuses than is exorcism with its more
ritual and supernatural
overtones.
Status indicators
change over time. but peoples beliefs in the efficacy
of curing traditions, and their need for supraphysical
modes of healing. like exorcism, often remain constant. Mr X. is respected for his exorcistic prowess,

many faces of Ayurveda

487

but less so for the actual tradition

of healing he
represents.
By calling him a Veda Mahattaya,
and
by telling ones associates one is seeking treatment
from such a gentleman, patients can avoid the stigma
of going to an adura while enjoying their services.
This appears to be particularly true in the case of the
higher social castes and classes, and to people concerned with social mobility.
Similar processes
of
social identity negotiation
have been discussed by
such authors as Berreman (231 and Goffman [24].
Mr X. makes no effort to conform to the stereotypical image generally associated
with Vedas. He
neither dresses like. nor conducts himself as one. He
does not maintain a special shop in town or in his
house, and keeps none of the traditional
medical
trappings
of a Veda. Unlike many other aduras,
however, he performs more treatment ceremonies on
his own premises rather than going to the houses of
his patients.
Practitioners
such as Mr X. and the Veda described
in the introduction
to this paper who performs curses
in addition to his regular medical practice bridge the
gap between the traditions
of medicine and ritual
healing that exist on a doctrinal level, and integrate
them with popular traditions of concern to the community. In addition, because of the way they interact
in the health care context they provide people with a
means of circumventing
social status constraints
that they hold important.
This last point supports
the observation
that
patterns
of resort
and
patient-practitioner
relations are molded not only by
the services offered through the various healing traditions. but as well by distinctly nonmedical criteria.
The variations in indigenous medicine are a result of
a combination
of physical. socio-medical
and purely
social concerns.
Issues of social status and identity can be seen at
all levels of health care. Degree-holding
Ayurveda
physicians
may dress as traditional
Vedas because
this form of medicine is more trusted and respected
medically by the community.
IMPS may dress in
western clothes. or set up their offices to resemble
cosmopolitan
practices because these are respected
more socially (not medically), and are markers that
confer higher social status.
Buddhist priests are often asked to treat marital,
and mental
problems
sexual,
substance
abuse,
because going to the temple is a common practice in
the daily lives of Sinhalese and does not necessarily
signal the existence of a problem to curious neighbors
and friends. A visit to a medical practitioners
office,
on the other hand, is a public marker that an illness
or a problem exists. As certain priests are considered
equally qualified to clinical practitioners,
discretion
becomes an important
criteria in soliciting help for
stigmatized disorders.
Local-level healers are frequently a first choice of
primary health care, but are seldom mentioned
in
surveys or in clinical encounters
with physicians as
people feel they will be judged harshly for patronizing
uneducated
practitioners.
Astrologers,
fortunetellers, and people who use trance-states
to diagnose
problems are a primary source of medical advice, and
some even provide medicines and healing ceremonies,
yet they are seldom recognized socially or medically
as belonging to the medical system [25-271.

CAROLYN

488

R. NORDSTROM

People may take socially stigmatized

conditions
such as filariasis. venereal disease. or unwanted pregnancies to discrete public health officials or trusted
midwives in their homes, and call them Veda or
Dostora, rather than admit these problems to family
practitioners
or to hospital-based
staff who have little
regard for protecting the identity of the patient.
CONCLUSION
To

understand a complex system of health care and

the medical traditions that comprise it, it is important
to understand
the structures,
socially accepted role
definitions, and the formal descriptions
that characterize it. And it is important
to recognize that these
alone do not adequately
define the realities of the
actual practices taking place in the daily lives of
people. In addition one must look at the true spectrum of services practitioners
provide, and why, and
at the reasons motivating
people to select certain
forms of health care over others.
The needs people have when facing an illness
episode are extensive and multifaceted,
and it is
important to see the way they are played out on the
larger screen of Sri Lankan society; one not confined
solely to physical complaints
and medical concerns.
It is the way in which people meet these needs within
the context
of the structures
and doctrines
that
formally define a medical tradition that determines
the true dynamics
of that system. In effect, the
pluralistic health care system is not a set structure
to be used, but a dynamic that is negotiated
and
mediated by all the actors: patients, practitioners,
and
officials alike.
To limit research solely to the level demarcated
by
official definition-that
which exists on the structural
or institutional
level; to the realm of practitioners;
or
to the actual practices of the patients themseivesgives an incomplete
picture of the true health care
system. Each group defines the system in terms of
their own place in it and, more importantly,
in terms
of their own needs: legal, social and personal. Questions of the wav in which health care is delivered, the
problems of sigma. the issues of social status, the
changing
needs of a modernizing
community,
the
need for trust and a meaningful
framework
for
interaction.
and the personal characteristics
of both
patients and practitioners
are fundamental
to the
health care process. This can be seen as similar to
Rosens concept of Bargaining for Reality [28].
Practitioners
juggle pressures to conform to the
formal expectations
defined by the tradition
they
were trained in (and by law) and to conform to the
needs and demands
of a multiplex
and changing
patient population and social community. There is no
set mechanism by which this can be done. As we have
seen in the examples given above, practitioners
each
respond to these variable demands in an individual
way. Some adhere to more traditional formats, some
combine existing traditions,
and some respond in
creative and unique ways.
What we find is that the practitioners
who adhere
to the more traditional
and professional
forms of
medical practice, especially those based in clinical or
institutional
settings, tend to be the only ones recognized as IMPS in formal surveys of the medical
system. I suggest here that because of this tendency

the numbers of IMPS, the range of indigenous medical services. and the importance
of both in defining
and treating illness for the general population
are
significantly
under-represented
in analyses of the
Sri Lankan medical system. Ayurveda and Sinhala
medicine continue to stand as central paradigms and
practices-for
knowledge
and action-in
the daily
lives of the Sinhalese.
Leslie [29] and Nichter [30] both discuss the various
expressions
of indigenous
healing
systems as a
continuum
of health care services. This is a valid
analytical approach. however I find that is useful to
see these expressions as a diversification
of services,
as variable responses
that develop and change in
response to the needs and pressures of both the social
community
and the illness patterns exhibited over
time. Cosmopolitan,
indigenous,
ritual and popular
traditions
need not be placed respectively within a
continuum:
practitioners
and patients may provide
and use services that as easily mediate cosmopolitan
and indigenous medicine; empirical and ritual healing: and doctrinal and popular systems of knowledge.
The concept of mediation is used as an addition,
and not as an alternative,
to Leslies and Nichters
approach that states the different traditions of healing are not discrete and isolated from one another.
Practitioners
do not stand squarely in the tradition of
medicine they are defined as representing.
Often they
straddle either technical, performance.
or knowledge
categories of more than one tradition. They thus help
translate formal doctrinal information
between traditions, and into the popular patterns of knowledge
held by a community.
It is in this sense that people say they are not faced
with choosing between competing
systems of medicine. Rather,
they negotiate
different health care
options within a single encompassing,
though complex, arena of health care that is seen as integrated.
This supports Amarasinghams
[30] conclusions that
the plural medical system need not be viewed as
containing
contradictory-either/or+choices.
The
practical knowledge that foments health care interaction is continually
recirculated
and up-dated by
the practitioners
that mediate the formal doctrines
and community
needs. The different
systems of
knowledge-doctrinal,
specialist,
and popularshould not be viewed as blended indistinguishably
together
by this process, but as being articulated
tlis-d-ok one another in a comprehensible
way.
In sum, Ayurveda may better be understood
as a
system of knowledge
as well as a tradition,
as a
dynamic as well as a doctrine. Its practice may better
be analyzed as forms of action in addition to enactment. It then emerges as a dynamic phenomenon,
and a plural system in its own right. Ayurveda can
then be addressed as a flexible and multiplex system
whose expressions
differ among people and change
over time. As such. it continues to exert a profound
influence on the lives and the health of the Sinhalese.
REFERENCES

1. Neumann A. K. el al. The role

medicine practitioner in two areas

of the indigenous
of India-report
of

a study. Sot. Sri. Med. 5, 137. 197 I.

2. Young A. Mode of production of medical knowledge.
Med. Anrhrop. 97, Spring 1978.

Exploring pluralism-The
3 Leslie C. Asion Medical Systems. University of California Press, Berkeley, Calif., 1976.
4. Dunn F. L. Traditional Asian medicine and cosmopolitan medicine as adaptive systems. In Asiun Medical
Systems (Edited by Leslie C.). University of California
Press, Berkeley, Calif., 1976.
Simeonov L. A. Berler Health for Sri Lanka. World
Health Organization, New Delhi, November 1975.
Wanninavaka P. B. Ayurvedu in Sri Lanka, Ministry of
Health, Sri Lanka, June 1982.
Annuul Health Bulletin. Ministrv of Health. Sri Lanka,
1980.
Fernando S. Herbal Food and Medicines in Sri Lanka.
The National NGO Council of Sri Lanka, Colombo,
1982.
9 Medical care and public health. Econ. Rm. S(lO), 3,
1980.
IO Wijeratne G. Development of health manpower with a
view to the possibilities of integrating western and
traditional systems of medicine. Unpublished report,
1979.
Joint Committee on Health Policy.
II UNICEF-WHO
Communiry Involvement in Primary Health Cure: A
Srudy of rhe Process of Community Motivation und
Conrinued Participation. World Health Organization,

Geneva, 1977.
12 Waxler N. E. Social change and psychiatric illness in
Ceylon: traditional and modern conceptions of disease
and treatment. In Culture-Bound Syndromes, Ethnopsychiurry and Alternuiive Therapies (Edited by Lebra
W. P.). University of Hawaii Press, Honolulu, Hawaii,
1976.
13. Silva K. T. Community, disease and participatory approaches in health care. Econ. Rev. Sri Lanka, June
1983.
14. Kutumbiah P. Ancienr Indiun Medicine. Orient Longman. Bombay, 1962.
15. Djukanovic V. and Mach E. P. Alternative Approaches
lo Meering Basic Health Needs in Developing Countries.

World Health Organization, Geneva, 1975.

SSM

275-F

many faces of Ayurveda

489

16. Leslie C. The professionalization of Ayurvedic and

Unani medicine. N. Y. Acud. Sci. Series II 30, 559, 1968.
17. Obeyesekere G. The cultttral background of Sinhalese
medicine. J. Ind. Anrhrop. Sot. 4, 117-1969.
18 Obeyesekere G. The impact of Ayurvedic ideas on the
culture and the individual in Sri Lanka. In Asiun
Medical Systems (Edited by Leslie C.). University of
California Press, Berkeley, Calif., 1976.
19 Audy J. R. and Dunn F. L. Health and disease (Chap.
15) and Community health (Chap. 16). In Human
Ecology (Edited by Sargent F.). North Holland.
Amsterdam, 1974.
20. Evans-Pritchard E. E. Wirchcrufr, Oracles, and Magic
Among the Azunde. Clarendon Press, Oxford, 1976.
21. Cur&u Sumhiru. National Institute of Sciences of India,
Calcutta, 1965.
22. Kapferer B. A Celebration of Demons. Indiana University Press, Bloomington, Ind., 1983.
23. Berreman G. Prologue: behind many masks: ethnography and impression management. In Hindus of the
Himuluyus: Elhnogruphy and Chunge. University of
California Press. Berkeley, Calif., 1972.
24. Goffman E. The Presentation of Self in Everyduy Life.
Doubleday, Garden City, N.Y., 1959.
G. Medusus Huir. The University of
25. Obeyesekere
Chicago Press, Chicago, Ill., 1981.
26. Kernper S. Time, person, and gender in Sinhalese
astrology. Am. Ethnol. 744, 1980.
27. Amarasingham L. R. Movement among healers in Sri
Lanka: a case study of a Sinhalese patient. Culr. Med.
Psychiut. 4, 71, 1980.

28. Rosen L. Bargaining for Reality. The University of

Chicago Press, Chicago, Ill.. 1984.
29. Leslie C. (Ed.) The ambiguities of medical revivalism in
modern India. In Asian Medical Systems. University of
California Press, Berkeley, Calif., 1976.
30. Nichter M. Health ideologies and medical cultures
in the South Kanara Areca-Nut Belt, Vols I and
2. Unpublished Ph.D. thesis. Department of Social
Anthropology, University of Edinburgh, March, 1977.