Country Doctor in India

by CARL E. TAYLOR, M.D.

1

THE picturesque India of the ruins, snake charmers, and dancing bears which has been accepted as the real India is today little more than a museum piece. India is changing beyond belief behind this tourist facade. It is one of the great revolutions of the world, and although there has been a minimum of physical violence, emotional and sociological patterns of life are being shattered in this cultural revolution.

In a series of five-year plans, India is trying to catch up with the development that the rest of the world experienced during the years when, because of their colonial status, Indians opposed foreign efforts to change them. It is all too easy for Americans to draw a parallel with Communist five-year plans for internal development, especially because of the present tendency to identify Indian policy with Russian. There are basic differences which we should recognize. There are also tremendous problems, mostly cultural, which we should appreciate.

The fundamental difference between Indian and Russian five-year plans of development lies in the basic distinction that Russia is Communist and India is democratic. Russian policies depend on central organization and authoritarian dictation of all phases of development at the periphery. India’s plan, on the other hand, is based on an attempt to bring about a grass-roots change in the thinking of the people, so that the development will grow in each village instead of being forced from the center. Great emphasis is being placed on giving authority to the village panchayat, the five or six men elected by each community in a revival of the ancient system of local self-government. The planning is done centrally but the execution is peripheral, in contrast to the Russian method of planning and executing from the center.

The Indian way is the harder way, because the people must be encouraged to want to change. It is particularly hard because of the rigidity which Indian cultural patterns have developed through the thousands of years of India’s civilization, it is in the villages, where 85 per cent of Indians live, that this encrustation of cultural habit is the strongest. It is right, therefore, that the development programs are concentrating on changing village life.

Two high-school students volunteered to spend a summer vacation in a village in northern India working in an adult literacy campaign. One of our instructors suggested that they teach public health by example, using simple methods of personal hygiene. Rather than follow the regular practice of using the open fields as toilets, he asked them to cover up with dirt when they made their morning trip to the fields. They could easily carry along a khurpi, the general-purpose trowel-like tool commonly used in the villages of northern India for all kinds of digging. Having come from village backgrounds themselves, the students quickly fitted into the village life in every respect but one. This peculiar habit of covering up after themselves stirred curiosity. Then a rumor started: “You had better stay away from those two young fellows; they are sick. In fact their excreta are so poisonous that they have to be buried.”Largely as a result of this rumor, the students had to leave the village without getting anywhere in their literacy program.

In a small village of northern India I learned that persons who looked dead to us Westerners appeared completely normal to Indians. Because of our dispensary work the Khudaganj Panchayat had asked Dr. Singh and me to help prevent the diseases of the village rather than try to cure them. As a first step in health education we were presenting a series of evening filmstrip shows at the village school. In the schoolyard, the younger generation was gathering for the tamasha as we unloaded our equipment. The screen was fastened to a mud wall, and the kerosene-burning projector was adjusted so that it would not sputter. The members of the panchayat appeared, along with the government schoolmaster and the local Congress Party leader. The crowd sat cross-legged on the ground, chattering like mynas. The children clotted together in front of the screen, and we were ready to start.

The Sarpanch, as leader of the panchayat, called for silence and introduced us. I have seldom faced a more receptive audience. As the filmstrip started I asked the children in front to name each of the characters as they appeared. These filmstrips show the health problems of Indian villages by using stick figures doing first what they shouldn’t do, and then what they should. The skinny appearance of these characters on the screen was uproariously funny to the village people, and the first man was promptly dubbed Sikha, which means “the shriveled-up one.” Group participation was excellent; the adults discussed the familiar village problems of feces disposal, fly control, and water sanitation. Everything was going well, but suddenly my bubble burst. To show the results of epidemic disease, the artist had built up the series of pictures to a gruesome climax where whole families were stretched out on their charpai beds with sheets pulled over them to indicate that they had died. But as this picture appeared, a sigh of satisfaction arose from the crowd. “Ah, they have all been cured and are sleeping soundly.”Indians sleep with sheets pulled over their faces to keep off mosquitoes and dust. These people did not look dead at all to my audience.

2

WAHT is culture? How do cultural patterns influence the success of health and other programs in underdeveloped areas? These questions are being asked increasingly by those of us who are trying to help the needy people of the world. In each area it is necessary to define and understand cultural patterns in order to be of real help.

Culture is a summation of the practices and habits of thought which make up the group heritage of any people. It is a social subconscious. For any individual it represents all that is learned from his social environment, with most of this learning occurring in the first years of life. Prejudices are built into the reaction pattern of every child by the spontaneous and unintentional acts and expressions of family members. This learning is so integrated with the individual’s personality that the locally prevalent habits of thought and action are accepted as being not only right but “natural.”Acceptance is so complete that no other way of thinking seems possible, until the cultural pattern is seen in comparison with other cultures, and perhaps it can be really evaluated only when seen from the point of view of another culture.

The cultural differences between Indians and Westerners can perhaps be illustrated best by comparing our ideas on specific hygienic practices with theirs. Indians consider many of our ways of doing things disgusting and unhygienic, and caste Hindus insist that members of their families who have associated with Westerners, especially on a trip abroad, go through elaborate purification rites before rejoining their own family. As in the Old Testament, many health rules have been clothed in religious garb to strengthen their acceptance by common people.

Hand-washing and bathing play an important part in Indian life. The Western practice of washing in a basin which has been used by all sorts of people is considered unsafe. A better way is to have water poured over the hands, the dirty water falling into a basin or on the ground. Thus the contamination left in the basin has no chance of reaching the hands of another. Similarly the use of bathtubs is repulsive. It is much better to bathe in flowing water or in a sacred tank. If bathing must be done inside a house, the water should be poured over the body a jug at a time. The use of dishes also involves similar taboos against contamination. At public functions where food is served, it is considered proper to have leaf plates and cheap earthenware cups which can be broken afterwards. The use of fingers eliminates the need for silverware.

One of the most interesting medical meetings I have attended in India was one in which the question of brushing teeth came up. Many of the doctors vehemently argued that the use and reuse of a toothbrush was highly insanitary. It was much better, they maintained, to follow the traditional Indian practice of chewing the end of a neem tree twig until the fibers of the end were soft and brushy. The twig then could be thrown away after the teeth had been cleaned, because even in city bazaars twenty can be bought for one cent.

Another practice which is repulsive to many Indians is our using a handkerchief and then returning it to our pockets to be used again. It is considered more sanitary to hold the fingers over the nose in such a way that when, the nose is blown mucous discharge falls directly on the ground. That the same belief applies to spitting is shown by the red splatterings of floors and walls in public places. Westerners in India for the first time sometimes turn to look for the body when they see what looks like freshly spilled blood. It is only the bright red sputum from pan or betel nut chewing.

The problem of excreta disposal is probably the greatest one faced by health workers in India. Prejudices against contact with or even the sight or smell of any kind of human excreta are so great that all attempts to approach the subject rationally create only antagonism. The obsession with trying to protect oneself from contamination is so great that public health considerations are often ignored. Coöperation is obtained when methods are recommended which not only meet scientific principles but also fit in with local cultural patterns.

Vegetarianism is a basic tenet of Hinduism which influences health, if vegetable proteins can be obtained in adequate quantity and quality, a vegetarian diet is compatible with health. Under normal circumstances poor village people can get along, but deficiencies appear under the pressure of the many emergencies which harass villagers. Vegetarian patients with protein and vitamin deficiencies present us with a real problem in cultural orientation when they come to our hospitals. Powdered dehydrated eggs from army surplus supplies were available in large quantities after the war. Many vegetarians refused to eat these eggs even when told that this would cure their nutritional deficiencies. When we tried to get people to add our powdered eggs to their food, they refused and we were stuck with our surplus supplies. Finally one man said, “If you give me that stuff as medicine and not mention what it contains I’ll take it.” Thereafter we simply dissolved the eggs in water or milk and presented the solution to patients as a special medicine.

Spencer Hatch, a pioneer in village work in southern India, encountered similar problems in disposing of fresh eggs. Careful inquiry revealed that the cultural hurdle he faced was due to fear of eating a fertilized egg. When he could guarantee that all hens were kept in strict zenana wire enclosures where no roosters could get to them he had no further trouble selling the eggs.

A related cultural block against the use of biological drugs of animal origin is sometimes met among strict vegetarians. In my experience, however, this holds true mainly of medicines taken orally. I have treated many Sadhs, members of a small Hindu community of northern India, and found that particularly among their women it was impossible to get them to take oral medicine unless I could prove that only vegetable products were included. Until they came to trust me personally, the only proof they would accept was to see me grind up a root or leaf in front of them. They were always willing to take anything I wanted to give by injection, however, since this did not involve contaminating the oral route.

A few weeks ago almost a hundred students and staff from our medical college were doing a general health survey of a village. The first day of houseto-house visiting went, fine and much information was collected. The second day, when two of our teams arrived at the harijan or outcaste section they were rudely greeted by screaming housewives and slammed doors. I went to see the harijan leader, who was working at his trade of shoemaking. Squatting cross-legged opposite him as he worked on a stone slab, I tried to get the reason for the outcastes’ change in attitude. Finally he came out with the story. The previous day our team had left his home just before noon after examining everyone there. Shortly after noon his ten-year-old son was found to have a high fever. When I asked if they thought we had caused the fever his response was: “What else can we think? If nothing else, you certainly scared the boy so much that he got sick.”

Knowing that Indians believe that fevers are caused by demons, bad air, or fear, I did not try to argue. The success of our health survey depended on my convincing the village folk in terms that they would understand. I asked to see the son. After some persuasion the mother carried from the dark inner room an obviously feverish and toxic lad. My assistant stepped over to get the history from the boy while I engaged both parents in conversation. Suddenly my assistant turned to us saying, “This boy says he wasn’t examined yesterday.”Surprise showed on the faces of the parents, while the boy spoke up and said, “Sure, I got home from school right after they left.” Following this break we examined the child, found early pneumonia, started treatment, and re-established our rapport.

3

INDIANS think that the approach of Western doctors is entirely too materialistic. Religion permeates every phase of their life, and religious beliefs are of special importance in questions of health and disease. The cold scientific attitude which certain Western physicians cultivate seems heartless to most Indians. The technical skill of the physician is considered secondary to his ability to align divine powers on the side of the patient he is trying to cure. Old-school Indian practitioners pride themselves on their human touch and practical psychology. In this they resemble our old family doctors and modern advocates of the psychosomatic approach to medical care.

The most crucial moment in the doctor-patient relationship comes when the physician completes his examination. Very formally then he is supposed to make a statement of prognosis which enlists divine aid. The equivalent of an incantation is expected, such as “By the grace of God this patient is going to get well.” The prognosis must be favorable and definite. He can then go on to throw in any qualifications that he thinks necessary.

Shortly after I started to practice in India, a young doctor took me to his home in a neighboring town to see his sister who was said to be dying from typhoid. The father was a hakim of great reputation and had a lifetime of experience in the practice of the old Unani or Indo-Arabic-Greek school of medicine. He was not only a wise practitioner but also a highly cultured gentleman. His English was fluent, he had traveled extensively, and he seemed to me to have achieved a unique blending of Eastern and Western culture. The girl was in her second relapse of very severe typhoid, which was complicated both by cardiac damage and a severe nephritis with advanced uremia and deep coma. It was immediately evident that the prognosis was hopeless, but I went through the motions of a thorough examination. Then we adjourned to the hakim’s study.

The impression of being with persons of a Western rationalistic approach was so strong that, without thinking, I spoke as I would have to a fellow doctor in America and started by guarding my prognosis. I said, “Of course, you realize that your girl’s condition is extremely critical and her prognosis poor but —" The shocked look on the father’s face stopped me. He threw both hands in the air and cursed me for having placed a curse on his daughter. He dissolved completely into a frightful demonstration of loud wailing and crying; he pulled his hair and beat his breast. His constant refrain was that I had placed the curse of the Chistian God on his daughter and now she had no chance of recovery. The doctor son quickly ushered me out and on our way home explained to me the cultural practice of first enlisting God’s help. My chagrin was made more acute by the fact that I was in India as a Christian missionary. In spite of my best efforts, my friendship with the family was never re-established.

Having learned the hard way, I have never since felt the slightest hesitation about bringing God into my medical practice. I should have learned this in boyhood from watching my father in his medical work in Indian villages. He brings God into his daily life with Scotch Presbyterian forthrightness, and the village people love him for it. I have heard them say that he is a better doctor than the most famous surgeons in the biggest hospitals because he is a godly man.

Many doctors in India are afraid to undertake care of patients with a poor prognosis. They fear the public reaction to the death of the patient and the blame that will come to the doctor. It has been my experience that if J am careful to point out to them that the prognosis really lies in the hands of God and I am only an instrument, then divine responsibility for the result, will be accepted by the fatalistic villagers. If I take the more “scientific” attitude of explaining causation in natural terms, and therefore take the responsibility for a correct causal analysis and the application of effective countermeasures, then the people tend to hold me directly responsible. The more I see of practice in the complex Indian milieu the more I am convinced that the former is the correct approach.

4

OF THE several programs for rural development which have been started in India, the most ambitious are the government’s Community Development and National Extension Projects. These are financed mainly by the central government, and much of the direction and planning has come from American philanthropic foundations. Some techniques have been taken over directly from the extension programs developed by county agents and other extension workers in projects in the States. The patterns and principles according to which these programs can be effectively put across in India have been worked out through years of patient study and experimentation by people such as Gandhiji; Tagore at Sriniketan; F. L. Brayne, a British colonial officer; and Spencer Hatch and Bill and Charlotte Wiser, who worked as missionaries.

The basic principle underlying our approach has been stated by the Wisers as “answering only felt needs.” Until a person knows that he needs something, he will neither buy it nor thank you if you give it to him. In health work we must start with the medical problems that villagers spontaneously bring to us in dispensary and hospital. It is not much good talking to a man about preventing diseases, building houses with more ventilation, getting better breeds of cattle, growing better wheat, or the evils of Communism when he is miserable with a big ulcer on his heel or when his only son is shivering with a malaria chill. The villager’s logical reaction is “But this is where I hurt” or “Help my son and then we’ll talk.”

Because we meet primary needs, the villager will listen and learn as we try to teach him about other needs. Each patient seen in dispensary can serve as a sounding board for a short comment on disease prevention by a member of the dispensary team. In evening filmstrip shows, audience participation is encouraged by getting the youngsters, who always sit down front, to name the character, and the older persons to suggest solutions for the problems raised. If we do our health education right, the villager will see needs he was never aware of and think that he figured out these needs himself. He will learn about germs and discover that the causes of disease arc not bad-tempered gods and goddesses. Then he will ask if something can be done about prevention, and together we can work out solutions for the problems.

Now we come to the next principle as stated by the Wisers: “Help the people to help themselves.” The most effective measures in the villages will be those that the villagers can carry out themselves. Controlled research studies are being done to adapt the complex methods of the West to the simple resources of the village. In applying these measures we work with the villagers, not being afraid to get our hands dirty if there is a pit privy to be dug or a well to be improved. The demonstration method of working with people as they help themselves is the slow democratic way, more laborious but more lasting than Communist methods of party dictatorship. This leads to long-term building rather than short-term programs for political impact only. It is important, however, to build on successes, starting with projects from which benefits are quickly evident.

Two dangers must be avoided. It is wrong to do too much for people, especially things that they can do themselves. It is also wrong to force them to do things for themselves before they are properly motivated. Much was learned about the importance of these principles from the work of F. L. Brayne in the Punjab from 1920 to 1932. Brayne was a conspicuous example of an enlightened British colonial officer. While serving as District Magistrate with complete executive responsibility for Gurgaon District, he tried hard to improve the life of the villagers. He prevailed on village people to provide their mud houses with ventilators, smokeless fireplaces, and proper drainage. He introduced soakage pits and compost heaps, improved wells, and privies; sponsored better agricultural methods; and urged the use of good seed and better breeds of cattle, goats, and chickens.

The results he obtained were phenomenal. Villages in Gurgaon District became models to which visitors could be taken with pride to show what the British Raj had done for the Indian villager. Then Brayne was promoted to do for the entire Punjab what he had done in Gurgaon. When Brayne’s personal supervision was removed, the original program faded away and the villagers reverted to their ancient practices, with only sporadic continuation of the improved methods.

In Brayne’s later writings and in the sociological studies of Darling, Gandhiji, and Lala Deshraj, the reasons for the failure of this program are analyzed. The greatest lack appears to have been one of motivation. The villagers were induced to make the changes not because they saw the need for them but because of governmental pressure. If they made the improvements they were paid bonuses; if they did not they were punished or fined. When the close check maintained by Brayne was removed, most of them returned with great relief to their traditional methods of doing things.

This does not mean that village people cannot be led; it means that they choose carefully whom they will follow. A trusted leader’s word has more influence than hours of reasoning. Oftentimes the best leaders in introducing something new are children who show their parents what they have learned in school. The importance of group discussion and audio-visual aids in changing the thinking of people is recognized and used.

Having learned from pioneers in the work of village development, the present generation of village workers is optimistic about the possibility of raising the standards of living in rural India. Under the Community Development and National Extension Service, work has been started in 90,000 villages. A Ford Foundation program trains workers in the modern approach to village culture and methods of improving village life. They learn something about better agricultural methods, home industries, sanitation, literacy, and social organization. Then they go to live in the villages, working through the natural leaders of the community in influencing village practices. Specialists are available for consultation as technical problems arise. Although the program has been going only about four years, significant changes are increasingly evident.

In carrying out these programs we must be sure that what we are recommending in a practical way will in itself not cause harm. The concept of preventing rather than curing disease is strong in Indian culture. Many of the traditional ways of living have subtle importance in disease prevention that does not become apparent until the method has been changed. It is essential, therefore, to be aware of the possibility that well-intentioned proposals of “rural uplift” may actually do more harm than good.

Malaria has often become epidemic as a result of attempts to improve the standard of living. Irrigation schemes and water-power projects are notorious in causing malaria to spread; more subtly, improved housing has spread the disease. In many village homes cattle, buffaloes, and goats are stabled in an anteroom of the house where they are safe from robbers. This is a manifestly unhygienic and unesthetic way of living. Mosquitoes, however, have to pass through this room in order to get to the family, because there are no windows. Since mosquitoes are interested in a blood meal, they often stop to feed on the animals. Before villagers are persuaded to stable cows and buffaloes properly, an antimalarial substitute for this animal barrier should be provided.

Similarly, the practice of cooking over open fireplaces in village homes creates a concentration of smoke that a Westerner can scarcely endure even after years of conditioning. Much of the coughing which punctuates the winter nights in northern India is due to the smoke. It is desirable to introduce smokeless fireplaces or outdoor cooking units. But mosquitoes can stand smoke even less than human beings, and smoke therefore retards the spread of malaria. Again, before introducing better cooking methods, other malaria control measures should be made available.

Indian culture is one of the most complex in the world. The origin of present practices and beliefs is lost in centuries of sociological solidification. Everyone agrees that development must come, whether by evolution or by revolution. Through the recognition and harnessing of basic cultural drives, it will be possible to have evolutionary progress which will retain many of the fine and unique features of Indian culture.