Sunday, May 19, 2013
NGOs, Social Work & Social Transformation in the era of Twenty 20 Match!
NGOs, Social Work & Social Transformation in the era of Twenty
20 Match!
- Vasudeva
Sharma N.V.*
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oday we have Twenty 20 Cricket match. We have fun and it’s thrilling. And it’s over in a few hours. You are famous overnight. Very much result oriented. Social Work is also increasingly being seen in the same manner by many – individual donors or CSR-Corporate Social Responsibility or govt or even a bilateral organisation. In this context, Michael Reisch aptly says that ‘social work practice is forced to shift from long term sustainability to short term outcomes’ (Michael Reisch, 2011)[1]. The face of ‘Social Work’ is forced to change by other agents who are behaving as ring masters than the wish of the stake holders. If we, the professional social workers succumb to this, soon all our theories of conscentisation, Community Organisation, Case work, etc may have to be restructured to suit the quick fix approach!
Social
Work and Social Workers are considered as change agents, catalysts and
facilitators who steer social change and transformation among individuals, groups
and society at large. Social Work is said to emerge in a crisis to ease
tensions and solve problems and sustain the effort. Social Work is also a
profession that maintains social order, by institutionalising preventive
measures[2].
Radical social Work
T
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he
very term Social Work in itself was termed as radical a few decades ego.
The moment one started thinking about the sad state of the society, its
status, situation, necessary interventions, problems faced, etc., you are
looking and thinking different. You are not in the normal situation, you are
questioning the authority, you are trying to inform the uninformed, motivating
the people who don’t have to struggle to have, and you are questioning the duty
bearers and encouraging or engaging the right holders. You are talking about
structural changes addressing the needs and requirements of the oppressed, and
then you are radical. Thus collective campaigns and collective activism were
recognised as radical social work. [These
are normally (going with the dictionary also) recognised as fundamental work,
essential, deep seated, sweeping, thorough, drastic and some time extreme,
extremist, uncompromising, militant, revolutionary, die hard...]
It
is very difficult to capture the application of radical social work for social
transformation in a definition. Again radical social work is highly contextual
and situation based. A person who advocates fundamental political, economic and
social reforms by direct and often uncompromising methods is recognised as a
‘radical person’. [So, don’t miss read
it as ‘rash’ person. Many individuals who take rash actions tend to crown
themselves as radical]. Dictionary defines ‘radical’ as ‘thorough going or
extreme, especially as regards change from accepted or traditional forms; a
radical change in the policy of a group or a company’[3].
·
The Social Work Dictionary defines radical
social work as, ‘An orientation in
social work that focuses on the injustices in institutions, culture, and social
practices that cause further disadvantage to the poorest and most vulnerable
groups. (Barker, R.L., (2003). The Social Work Dictionary. 5th ed. Washington, D.C.:
NASW Press.)
·
Seek to change
oppressive institutions and practices primarily through social and political
activism and organizing communities rather than through case-by-case
interventions. (Barker, R.L., (2003).The Social Work Dictionary.
5th ed. Washington, D.C.: NASW Press.)
The most
important aspect here is that radical social work looks at fundamental changes
and addresses the issues at a macro level, than addressing individual cases at
micro level. E.g, as and when the state
tries to shirk its responsibility of welfare, services to the people, the need
for thinking differently becomes inevitable. You can engage yourself in providing
services to a child, a family or a group or to a community. But, when you start
questioning the system, ‘why’ this situation is and address the root causes,
policy, programme, and target the law makers and the administration in a
strategic manner, you enter the sphere of radical interventions or radical
social work demanding for equitable social development.
There is a
slight difference between what we studied in social work classes to what we are
observing in social work practice. By this I am not undermining the social work
studies. The schools of social work are teaching us about long term sustainable development plans as a core
value. But the Govt and the NGOs are getting satisfied by short term gains, I
mean short term benefits. The terms like sustainability, long term vision,
sustained development, etc., are slowly disappearing in the so called one year
development plans. (From 5 day test cricket matches, we found results in one
day matches, now more than the result you want thrill. So enters Twenty 20!).
So also the murky tripartite understanding of Corporate, Govt and NGOs in fixed
(match) developments in short durations! They are misrepresenting social
dependency models as ‘social work’. Social Work should be seen from Paulo
Freire’s conscientization point of view, ‘the process of developing critical
awareness of one’s social reality through reflection and action’ for social
transformation.
Look at
some of the recent development political mantras
that said to bring change in the society! ‘Cash transfer and doling of ration
to family’ is forced on the people, who would not even question it now. They
see the money in their account and provisions at their door steps, but not the
consequences they may have to face in the coming days - shrinking allocations
by the Governments to social welfare.
You question this as a responsible social worker, with a radical mind,
but get branded as anti-establishment, so anti social! So also when you
understand that there is some fishy dealings in the Anganawadi food procurement and supply and raise it in an
appropriate platform, you are actually risking your life! So, most chose
otherwise. (Satyam brooyat, Priyam
brooyat, Na brooyat satyamapriyam!
Let Mahatma, probably the most radical social workers of the last
century rest in peace).
Social Work for Social
Transformation
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hile
respecting the need for service delivery in some sectors we have experienced per se social work being largely
misunderstood as social service in the current context, has largely compromised
with the ruling class and community. Such groups also fall in line to take ill
designed and under budgeted Government programmes and projects and struggle to
meet the so called goals and objects. I strongly feel that such sub contracting
of Govt. Projects and programmes are responsible for slow growth and puts off
the fire of ‘rights’ based approach.
Rajaram
Mohan Roy raised a question on the situation of widows and said that they too
are human beings. Basava, a 12th Century thinkier, questioned the caste
class structure and saw a radical possibility of equality. But, many of these
could not be digested by the then society.
Dr.Sudarshan,
who initiated Vivekananda Girijana Kalyana Kendra-VGKK in Biligiri Rangana
Hills, Chamarajanagara, Karnataka, raised the rights issue with respect to
tamarind trees ownership in the tribal habitats in the forests. He argued that
the tree patta/ownership title deed
should be of the family and the man of the family cannot be the sole decision
maker. This questioned the very fundamental belief of the social system. The
Government, tribal jury, leaders and the middlemen who were making the most
profits by deceit practices were shocked. Dr.Sudarshan’s perspective towards breaking
the cycle of exploitation and ending impoverishment, indebtedness, gave a radical touch to the whole development social
movement in the region.
Most
radical social workers are not from schools of social work Dr.Sudarshan,
Mr.Hiremath or Ms. Aruna Roy or Mr.Aravind Kejriwal. There are exceptions like
Prof. HMM or Ms.Medha Patkar who are from schools of social work but continued
to question and took radical steps in upholding the rights of the people.
Going with
the good old Social Work terms, these are efforts to reduce structural
exploitation; reduce inequality and societal transformation, through
questioning, thinking about an alternative, finding a new perspective and
organising people around an idea. For that matter Gandhi could be the best
example for ‘radical thinking and radical approaches to address an issue’. The
radical social work approaches once opposed are now part of the ‘new society’;
order and the way of living. But, still there are very many areas which need
intervention, rather radical intervention, using social work methods.
Radical approaches
I
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n the midst
of several theories on radical social work and social development, there is
also an approach which claims that ‘radical social workers criticise the
state’s intervention’ (Braverman, 1970’s). I beg
to differ with Braverman’s statement.
Child
related social problems are endless. Government, NGOs, international bodies,
now CSR all are attempting to address them: homelessness, orphans, destitute,
disability, cruelty, discrimination, malnourishment, deaths (IMR U5MR), child
marriages, child labour, devadasi
system, trafficking, infanticide, what not? When the Govt or international
bodies are failing to solve the problems, the societies apathy towards the
burning issues, local governments and peoples representatives (MLAs and MPs),
media are not bothered about them who should raise voice? Do you expect
children to come up in groups and masses to come out on streets to demand?
Who raises
voice for them? Most NGOs indulge in providing
services in a ‘piece meal approach’.
You just treat the symptoms or the wounds seen over the skin and feel good
about it. Even the victims will praise you. The govt just wants this and
provides inadequate (sic) funds in
various names. Corporate Social Responsibility also echoes the same mantra. Only few look beyond the
symptoms. What are the causes? Here you start Questioning. Question the
inadequacies and demand for rights and the privileges to live as human being in
the society. There you enter the sphere of Radical thinking – radical social
work and development.
Raise
questions on the fundamental aspects, the root causes, take a step to straighten
the law makers, catch hold of the media to write on real issues, pull up the
local government and wake them up with real facts... and make the system work,
move the rusted wheels turn to act. If need be, oil them... that is radical and
such social work interventions are needed to bring social transformation now.
For our
discussion, I have taken methods in radical social work as referred by Ana
Miljenovic[4] Radical Social work for
social change- a. Demonstrative
Activities; b. Cooperative
Activities; c. Formative
Activities; d. Transformative
Activities. I also connect some of our works and
experiences from the field to them.
1.
Demonstrative Activities: We had a
long standing question, about Grama Panchayats, the village level local self
governments: why they are not taking responsibility of the children in their
jurisdictions? (Bellary district, 2003)[5] This was a new and amusing
question to the Panchayats and the
Department of Rural Development and Panchayat Raj, GoK. We asked them some
obvious questions, ‘do you know that there are children in your villages?’ This
followed by, ‘can you tell how many children are there in your Panchayat?’
Although the GP members accepted the existence of children, they were not aware
of the number of children, male female break up or the status of the children –
health, protection, birth and death rate, school drop out, child labour, Sc/St,
minority, etc. What followed was a demonstration of data collection and
analysis about children in about 15 Grama Panchayats and presentation of the
same to the Panchayat community, comprising of elected representatives, service
providers, children and adults. A startled GP members and service providers
found that given a chance, with information, community and children can
participate and raise issues for solutions.
What followed was getting a Government approval in the form of a
circular to conduct formal, ‘Child Rights Special Grama Sabhas’ in every Grama
Panchayat of Karnataka (RDPR, 2006). Today you find children actively
participating in the special Grama Sabhas and getting solutions to the problems
they are facing.
From Panchayats, let us move to the State level. Can you expect
the Members of Legislative Assembly (MLAs) to talk about children passionately
in Assembly meetings? It is happening now in Karnataka. Legislators not only
raise questions and ask the Govt to take stands on child rights issues, they
are now organised into Karnataka Legislators’ Forum for Child Rights. They show
interest and seek information to protect the interests of the children.
These are examples from radical demonstrative activities where
such an intervention was not in existence considering children as citizens of
this country and also confirmed that people, including children have capacities
and with information can take responsibilities too.
2.
Cooperative Activities: We keep
hearing about people and organisations coming together for a cause or a purpose.
Such coming together for a common cause or purpose is also referred as
networking. Building alliances, collaborations, coalitions and forming into
groups is a legitimate method to apply pressure to demand justice. Alliances
are formed for a wide range of issues now a day at local level and national and
international level. What is radical in this is holding on to the network and
its cause for a sustained period and moving ahead from one level to another.
With groups having a child rights perspective, we initiated KCRO-Karnataka
Child Rights Observatory.
Another example in this
sector is the Annual Children’s Parliament and interaction with the Chief Minister
of Karnataka at Vidhana Soudha. This
is a cooperative effort between NGOs with KCRO network and the Karnataka
Legislators’ Forum for Child Rights.
3.
Formative Activities: In our
pursuit to spread awareness and educate the concerned stake holders, we go on
our own (self invited) to various forums and educational institutions to share
our experiences. Motivating the students (social work, women’s studies, media,
sociology and political science) to learn about the situation of children from
rights perspective and take up evidence based studies in the society and document
the learning for better action. Although it is not rocket technology, it is a
special and specific knowledge transfer to put an element of rationale in the minds
of the future professionals.
4.
Transformative Activities: The
activity which need long term follow up and patience to see that legislative
reforms are brought in. In the last 25 years we have seen several laws formed
and changed in the interest of children. eg., RTE, JJ Act, Child Marriage
Prohibition Act. All these were possible due to radical thinking and approaches
by some individuals or groups. This also includes legal activism. Taking the
right questions to the courts on the situation of children. I can also cite the
‘Question Hour Analysis’ of the business of the Karnataka Legislative Assembly
and Council of Karnataka to fix the responsibility of the legislators for the
welfare of children, who are the most oppressed and voiceless.
Conclusions
W
|
ith all
these, if you think radical social work has found its place among social
workers, you are wrong. Almost all the radical social work approaches for
social transformation are seen as ‘trouble making’ (who throw stones into still
waters). Radical is right based approach. When you question the system, which
is in order (!) from many decades the system refuse to change. If we have to
have social development in a sustainable manner, the only way now is to go on questioning
the exploitative, oppressive order.
You are not
liked by Government, but media loves you momentarily (as long as you give them
juicy news), support agencies or funding agencies distance themselves away from
you and even the social work associations keep you at bay! The Association is
very weak and does not recognise the radical social work approach as important.
Police are not happy if you desperately come on the street questioning their
authority or inability to protect; courts sulk when you doubt their ability in
some obvious cases when they delay justice; media is unhappy when you want more
space for real social issues!
Similarly,
even now not all social work education institutions have taken practitioners to
teach the social work students on practical and radical social work approaches.
Mere theoreticians will not be equipping the future social workers, rather the
most required radical social workers. With
these discussions, I foresee in the near future schools of social work
documenting the experiences of radical social work in India and thereby
evolving theories to equip the budding social workers.
###
[1] Being a Radical Social
Worker in Reactionary Times, Michael Reisch, Keynote Address to the 25th
Anniversary Conference of the Social Welfare Action Alliance Washington, DC –
June 10, 2011
http://www.socialwelfareactionalliance.org/reisch_keynote_110610.pdf
* N.V. Vasudeva Sharma, Executive Director, Child Rights Trust,
4606, 6th Floor High Point IV, Palace Road, Bangalore 560001 Mob.
09448472513 vadeshanv@gmail.com
Former
Member, Karnataka State Commission for Protection of Child Rights and Former
Chairperson, Child Welfare Committee, Bangalore
Saturday, May 18, 2013
OLD PEOPLE OF MAKUNTI -H.M.MARULASIDDAIAH
OLD PEOPLE OF MAKUNTI
H.M.MARULASIDDAIAH
Makunti is a small, multi-caste, kin -
oriented village located in the Malnad track of Karnataka. The people are
generally following their traditional occupations according to their caste. The
population of the village was 1,630 (850 males and 780 females) and the total
number of households was 315.For the study, persons aged 55 and above were defined
as old. Accordingly, there were 154 elderly persons (81 men and 73 women) in
the village.
Makunti people use different terms to identify
the elderly or old persons: Yajamana, Hiriya, and Muduka; Yajamani, Hiriyalu
and Muduki are terms for women. The term Hiriya means the elder, the leader,
the husband and the older person. The term Yajamana means, in addition, the owner
and the employer. But Muduka means older person only. Every Muduka is not
considered asYajamana or Hiriya. For, the younger people also occupy the seats
of Yajamana or Hiriya. These are the terms of title. But the convention
requires the Makunti people to address all the older persons with the term
Hiriya. When a person becomes a grand- father of his son’s child he is known as
Ajja or Tata in relation to the newborn. For a grandmother the terms used are
Ajji or Avva. The terms are used not only to identify one’s grandfather or
grandmother but also used for addressing any old person by any one.
Normally the eldest son leaves the family
after his marriage. Owing to the departure of the eldest son the family suffers
changes, no doubt. But it is welcomed by the family as well as by others, as it
is considered to have averted the major disaster for the family, i.e., the
partition of it. The eldest son, however, would allege that his younger
brothers, their wives and children are always helped and supported by the
parents, and not his wife and children. The departure of the first son, though
it averts a major crisis, does not cease to create a series of tensions in the
family. It is, in a way, the beginning of the family break-up and it is a clear
indication of the declining authority of the elderly persons.
An interesting point is to be noted here
with regard to the partition of the family. If both the parents are alive, and
if they desire to live together, they may do so. The parents would be given a
portion of the house, a piece of land or whatever that is decided by the
village elders who sit in judgement on such occasions. But often the parents,
along with the land, house, utensils, ornaments, grains, money and such other
trival things, are also divided. It is found that if the choice is left to the
sons to choose between the two parents, they would prefer the mother to the
father and if the choice is given to the daughters- in- law they would prefer
the father-in-law to the mother- in-law. The son probably thinks that the
mother would work in the house and look after him and his children well; while
the daughter-in-law probably feels that the father-in-law would not interfere
in domestic matters, unlike the mother- in- law who would always pass critical
remarks, pointing out the “defects” of the daughter- in-law. This type of
choice has psychological implications. If the parents are given the choice,
they would prefer to stay with the youngest son if he is unmarried or has
married their grand- daughter. Otherwise, they would prefer to stay independent
of their sons.As has already been stated, the partition of the family takes
place during the advanced age of the older parents. The persons, who are
relatively young, say between the years of 55 and 64, are actively engaged in
the organization of their family. Those who are above 64 years are mostly widowed
and have lost interest in their life and they are removed from the sphere of
controlling and co- ordinating the threads of family life.
Family life in Makunti is shaped mainly by the
agrarian economy, and even those who are not agriculturists are also influenced
by that economy as they play complementary roles to those of the agriculturists.
There are rich young men of agricultural occupations who have brought new
things from the urban communities to be used in their homes. Changes, therefore,
are found in the types of vessels, kind of dishes and in the mode of eating.
Otherwise the traditional way of family life continues to influence the
members.
The kinship and the sub-caste are the wider
spheres for the activities of the older persons. In the family the elderly person,
the father or the grandfather, may be ignored. But the kinsmen do not disregard
the elderly person unless they have special reason to do so. The older person
is either a grandparent, or a relative-in-law (a near relative always), and he
or she is on the periphery of the kinship world. The person is consulted on
various domestic, marital, religious and legal matters. The older is the one
who is spared to attend to the relatives whenever the latter is in need of such
help. Sometimes the old man is seen guarding his relative’s house when the
owner is gone on urgent business.
During various rituals, the older persons
are specially invited by the relatives, and especially on the ceremonies
connected with the child, and of marriage and death. In Makunti, on the third
year of the child, a ceremony called Chettigavvana Vara is performed.
Chettigavva is the deity of children’s diseases. The deity is to be propitiated
or appeased, so that she will not trouble the child, and in addition, she is
said to prevent any evil spirit from attacking the child. It is the maternal
grandparent who is very much interested in attending such functions.
Settling marital alliance of the partners
is still in the hands of the elders; there are deviations in the village of
course. Some young men have tried at selecting their own partners against the
desires of their parents. There are also instances of divorce. Apart from attending ceremonies, the
elders are associated with solving disputes that arise between kinsmen; of
course the elders of the Lingayat caste are also the elders of the village.
That way there cannot be much distinction in their case between the two spheres
(caste or community) of activities. But the relatives prefer the elderly
persons of their group to take the major role in the solution of their
problems.
Though the older persons in Makunti are
playing still their traditional roles in their families, among kinsmen and
caste fellows and in the village as a whole, they are losing their grip on the
younger persons. Much against their desire, their sons get the property and
family divided, try to get brides of their liking, spend money on things which
the older persons consider it to be a waste, oppose their decisions and even at
times beat them. Formerly, the kinsmen and caste people, it is said, used to
consult the aged, follow their advice in a number of matters and rarely went
against their decisions. But now the elders are not consulted on certain
important matters. In the case of village administration, it is quite visible
that the younger persons have replaced the elders, and the earlier actions of
the latter with regard to the developmental activities in the village are
severely criticized by the former. The replacement of the aged by the young,
how-ever, has not led to the improvement of village conditions. Disputes
between the villagers, the kinsmen and even between the brothers are nowadays
taken to court of law instead of to the elders for solution.
The changes taking place in the community
are not welcomed by the aged. They show their distress in a number of ways.
Their declining authority has added another dimension to their age- old
problems. They feel they are not sufficiently fed and clothed by their sons and
relatives. The aged attribute all this to the play of Kali, the Lord of Kaliyuga.
Some feel it may be their bad fate or their action in their past life (Karma).
However, the neglect of the aged by the young and immoral actions committed by
the people are clear indications, according to them, of the onset of Adharma
(unrighteousness). Similarly, the failure of rains, frequent visits of famine,
low rate of agricultural yield and the rampant poverty are, they believe, due
to the neglect of virtuous ways of living by the people in modern days. And
some young people also agree with them.
According to the villagers, a virtuous
person is one who respects and obeys the elders, protects the parents, is
polite and speaks always the truth, does not deceive others, does not think in terms of breaking
away from their parents and brothers, marries the girl selected by the elders
and lives with her for life, looks upon all women (excepting of course, his
wife) as his mothers and sisters, earns his living honestly, does not flaunt
his wealth, does not look down upon the poor and the depressed, and does not
break the traditional practices set by his caste and forefathers.But these
ideals of behaviour are not always found in all the persons, even including the
aged. People quarrel for trival matters, elope with girls, divorce wives, steal
from fields, deceive the kin and the aged, beat the parents, run away from home
leaving their wives and children to starve, and speak lies. It is insisted by
the aged that the number of violators of Dharmic norms and the incidence of
sinful actions are increasing these days.
(Dr. H.M.Marulasiddaiah was professor and
Chairman,
Department of Social Work, Bangalore University
Aging Population in India: The Health System Role of Traditional Medicine- Unnikrishnan Payyappallimana
Aging
Population in India: The Health System Role of Traditional Medicine
Unnikrishnan
Payyappallimana
Introduction
India
has experienced a major demographic transition in the past few decades
resulting in a substantial increase in the aged population. Consequently there
is increasing burden on the health system. Neither the current healthcare
infrastructure nor the professional capacity is equipped to handle this
situation. This is further challenged by the fact that there is no social
security system in the country and over 80 percent of the health care is
accessed through out of pocket expenditure. Changing social support systems,
rapid urbanization, deteriorating environment further complicate the situation.
In
this context, the article explores the relevance of traditional systems of
medicine in the country for improving healthcare for the elderly population.
The article briefly highlights certain unique principles and features of
traditional systems of medicine in geriatric care by focusing on Ayurveda, the
most popular traditional medical system in the country. The article takes two
fold approaches to address the challenges i.e. from the point of view of
individual care what measures are desired and from a health system focus what
policy directions are needed to integrate these systems into geriatric care.
Indian
life expectancy has increased by 25 years in the last 5 decades. This has
resulted in tripling of elderly population in the country. India is going to become the second
largest country in the number of elderly in the world. It is expected
that by 2026, 12.4 percent of the population will be in the above 65 age
category (Patwardhan 2012, Dey et al. 2012). Extrapolated figures indicate that
elderly population (60+ age group) will be 100 million in 2013 and will raise
to 198 million by 2030 (Government of India 2011). Two thirds of the elderly
population live in rural areas and around half of them have poor socio economic
status thus making health service a major challenge (Dey
et al. 2012).
Due to the diverse stages of social, political and economic development there
is considerable disparity among Indian states in the demographic transition and
their consequences. It is anticipated that the South India will face a faster
transition as compared to the North owing to this. Another critical fact
to take note of is that around half of the elderly population is dependent and
70 percent of elderly are women (Dey et al. 2012). It is estimated that 51% of
Indian elderly will be women by 2016 and compared to males, women have poorer
health status (Government
of India 2011).
Health Systems Challenges
in an Aging Society
International instruments such as the United Nations Human Rights
Commission, Millennium Development Goals (MDGs) and the World Health Organization
(WHO) have increasingly acknowledged access to appropriate healthcare as a human
right. At the same time the
situation of the aging population in the country is challenged by the fact that
the health system is not adequately equipped to take care of these emerging
needs. There is a huge out of pocket expenditure of almost 83% for outpatient
care which is not covered by any insurance at all (Duggal 2007; 2009).
Availability, accessibility and affordability of health services continue to be
major issues. Declining social support systems,
reduction in disposable income post-retirement, family nuclearization, lack of appropriate
social security policies, increasing chronic disease morbidity, high
diversity and heterogeneity in different regions in the country, reduction in post
retirement earning, gender, caste and religious based inequities are some of
the key contributing factors. Elderly health is also dependant on several other
factors such as marital status, education, economic freedom, sanitation and so
on (Dey et al. 2012). According to the
2004-2005 National Family Health Survey, only 10% of the households had atleast
someone in a family covered under any type of health insurance. Only the
privileged groups of the society avail insurance coverage and most needy are
left out. Often elderly are excluded from insurance coverage due to certain age
limits or based on their previous health status (Dey et al. 2012). Due to reduction in income postretirement
most are unlikely to be able to pay the insurance premium regularly.
Being a transition economy with huge
diversity and disparity, the pattern of morbidity has been quite unique in the
country. While infectious diseases continue to exist, chronic diseases have
already reached epidemic proportions. This places a huge stress of the health
system. According to the 60th round National Sample Survey around 8%
of the elderly population is confined to home or bed and 27% of those aged 80
years are bedridden (NSSO 2006).
Traditional Health
Systems and Their Role
The following section gives an overview
of traditional systems of medicine and examines their role in addressing
healthcare challenges of elderly. Traditional medicine
refers to health practices, approaches, knowledge and beliefs incorporating plant,
animal and mineral based medicines, spiritual therapies, manual techniques and
exercises, applied singularly or in combination to treat, diagnose and prevent
illnesses or maintain well-being.” (WHO 2002) Further the term complementary
and alternative medicine (and sometimes also non-conventional or parallel) are
used to refer to a broad set of healthcare practices that are not part of
country’s own tradition, or not integrated into the dominant healthcare system.
This is a broad and inclusive definition which makes it difficult to find a
region or a country without any form of traditional medicine. It is often known
through a variety of names such as traditional medicine, alternative medicine,
complementary medicine, natural medicine, herbal medicine, phyto-medicine,
non-conventional medicine, indigenous medicine, folk medicine, ethno medicine
etc., based on the context and the form in which it is practiced. Chinese
medicine, Ayurveda, Herbal medicine, Siddha, Unani, Kampo, Jamu, Thai,
Homeopathy, Acupuncture, Chiropractic, Osteopathy, bone-setting, spiritual
therapies, are some of the popular, established systems (Payyappallimana 2010).
There is an emergent interest in both
developed and developing countries to integrate traditional medicine/complementary
and alternative medicine (TCAM) in public health systems. Diversity,
flexibility, easy accessibility, broad continuing acceptance in developing
countries and increasing popularity in developed countries, relative low cost,
low levels of technological input, relatively low side effects and growing
economic importance are some of the positive features of traditional medicine
(WHO 2002, Payyappallimana 2010).
Though these systems differ in their approach to clinical
principles or management methods they share a common worldview. According to
this the macrocosm (outside universe) and microcosm (living being) are
inherently related and have common elements. These systems also have similar
perspectives such as ecological centeredness, an inclusive approach to
non-material or non-physical dimensions, and holistic approach to health
management considering physical, mental, social emotional, spiritual,
ecological factors in health and wellbeing. “Fundamental
concept is that of balance - the balance between mind and body, between
different dimensions of individual bodily functioning and need, between
individual and community, individual/community and environment, and individual
and the universe. The breaking of this interconnectedness of life is a source
of dis-ease,” (Bodeker 2009:
37). Other unifying
attributes are their popular and public domain character and orientation to
prevention and self help. Mostly these systems focus on the functional aspects
of health and diseases, whole system approach to health, multi-causality,
subjective, qualitative, individualized and personalized management and
consider both physician and patients both as active agents in healing.
According to WHO between 60-80% of the population in developing
countries and a growing percentage in developed countries continue to avail
services of traditional medical systems (WHO 2002). However the slow official
response shows the lack of correspondence between public choice in health
seeking behavior and the policy processes in different countries. Proof of
efficacy, quality, safety and rational use continue to be major challenges in
the sector.
Increase in chronic diseases, better awareness about the limitations of
conventional medicine, growing interest in holistic preventive health,
increasing evidence of clinical efficacy, better clinical care, easy access
especially in rural areas and cost efficacy are some of the key reasons for the
resurgent interest in traditional medicine. In countries like India the per-capita
ratio of practitioners of TCAM is higher compared to conventional medicine. In
rural areas easy access, availability and cost are key aspects of utilizing
traditional medicine whereas in urban areas it depends on concerns about
chemical drugs and interest in natural medicines, limitation of conventional
medicine, greater information access are some of the reasons for accessing
traditional medicine. Thus in a public health context availability,
accessibility, affordability, utility, quality, efficiency and equity become
relevant in accessing healthcare (Payyappallimana 2010).
Indian Context
of Traditional Medicine
In the
subcontinent varied forms of codified medical systems such as Ayurveda, Siddha,
Unani or Tibetan medicine (Gso-wa-rigpa) have long coexisted along with a rich
non-codified folk form of knowledge. There are also several allied disciplines
of traditional medical knowledge such as yoga and several newly introduced
knowledge streams. The codified knowledge systems like Ayurveda have evolved in
last 3-4 millennia and have unique worldviews, conceptual and theoretical
frameworks for health management. The current available oldest Ayurveda
literature is codified in 300 BCE which shows its antiquity. These systems have
their distinctive understanding of physiology, pathogenesis, pharmacology and
pharmaceuticals which are different from Western medicine. These systems have
been institutionalized through national councils, uniform syllabus and
education systems. In India there are around 800,000 licensed practitioners
belonging to these medical systems, a huge human resource for any public health
intervention. Much more diversity is available in the folk knowledge traditions
otherwise known as local health traditions which are community specific and
ecosystem specific. They use locally available medicinal plants and other
resources for healthcare. They include an array of practices such as household
level health practices (home remedies, food and nutrition, health related
rituals and customs etc.) to specialized healers treating fractures, poison,
pediatric ailments, skin disorders, mental health and so on. They are mostly
orally transmitted, and highly dynamic. Though they differ substantially based
on the ecosystem in which they are practiced they share common value systems
and similar modes of transmission in communities. These are not legally
recognized and often considered invalid yet continue to exist in communities
due to social legitimacy and patronage.
Apart from these
native traditions there also exist an extensive machinery of homeopathy
practitioners which has been institutionalized in India and comes under the
department of AYUSH[1],
the Ministry of Health and Family Welfare. The traditional medical resources
also include allied disciplines such as yoga, various approaches of meditation,
breathing, martial arts, marma chikitsa,
massage techniques which contribute to health and wellbeing. There are also new
forms of complementary and alternative medical (CAM) knowledge which have been
imported from other countries in the recent decades and have become popular
like acupuncture, phytomedicine or herbal medicine, osteopathy, reiki, shiatsu,
and so on which do not have formal recognition yet practiced in India.
Life, Health and
Aging in Ayurveda
This
section examines how Ayurveda, a major Indian traditional medical system views
aging and what healthcare response is feasible from the point of view of
Ayurveda. Caraka Samhita, the olderst traditional treatise available today
starts with a chapter on long life (deerghamjeeviteeyam).
The mythological origins of ayurveda according to this chapter is that great
ascetics disturbed by diseases in their religious observances due to worldly
indulgence, gathered in the abode of Himalayas to seek a solution to the
problem. Wishing for a long and healthy life they sent Bharadvaja as their representative
to Indra, the king of devas, who had received the knowledge through a lineage
originating from Brahma. Brahma in turn revealed this knowledge of life to the
ascetics through Bharadvaja. Whereas the mythical origins and anecdotes may
have layers of meanings intertwined in the cultural context what is most interesting
is Ayurveda’s pursuit for healthy and long life imprinted in these lines.
The
term Ayurveda is comprised of two words Ayu (longevity of life) and veda
(knowledge), the word Ayu is further explained as sukha ayu (happy life), hita
ayu (sustained happiness), and deerghayu
(long life) thus extending the definition of longevity to include a holistic
approach to health and wellbeing. This perfectly signifies the role of Ayurveda
in geriatric care. Health according to Ayurveda is a balance of structural and
physiological principles (dosas and dhatus) of the body, excretory mechanism
(mala), and a balance of self (atman), sense organs (indriya) and mind (manas). Ayurveda has primarily a predictive and preventive approach
to healthcare management with self awareness and self reliance as its focus. From
this perspective health is a state when one is established oneself (svastha). This is based on the
understanding that each individual is born with a specific constitution and
predisposition for health and disease. Maintaining the balance of one’s
constitution (which is unchangeable though tendencies can be modified to
certain extent) is healthy state while promoting a positive approach to health
and wellbeing.
Though
the exact cause of aging is not discussed in detail, it is mentioned that it is
a natural state of ‘disease’ (svabhavabala
roga) among other such six other states such as hunger, thirst, sleep, and
death. Describing that no cause is needed for natural decay, Caraka says that
the growth or deterioration depends on two factors such as daiva (effects of the past) and purusakara
(efforts of present life). By stressing the importance of time (kala) Caraka says growth depends on
place and time of birth; quality of seed and soil; diet; mind; natural
mechanism; physical exercise; cheerfulness etc., which are essential for growth
(Tiwari and Upadhyay 2009).
According
to most Indian traditional medical systems there are three dosas (roughly correlated as humors) in the body namely kapha (nourishment principle), pitta (transformation), vata (movement and destruction).
Starting from early stage of life, nourishment, transformative and movement and
destruction factors will be strong respectively. In other words towards late
stages of life vata principle
manifests strongly in the body thus leading to diseases of neuromuscular and
musculoskeletal conditions. Apart from this, each individual by birth acquires
either singular or a combination of the characteristics of these dosas known as prakriti (physical and mental constitution). Similarly every
factor such as seasons, geographical regions, tastes, food items, medicinal
plants and so are classified on the basis of the relative preponderance of
these dosas. These are cardinal
principles in understanding the predispositions of health or disease, diet,
lifestyle or suitable medicines for an individual. Equilibrium of these
principles is the desired state of health.
Geriatrics
is one of the eight core branches of Ayurveda since its written history. Rasayana or jara chikitsa mainly deals with rejuvenation, improving growth and
reducing deterioration of the body. Jara indicates a process of reduction in lifespan
due to changes in the body (Tiwari and Upadhyay 2009). This encompasses concept
of vayasthapana (stabilizing or
regulating aging), rejuvenation, regeneration, immunomodulation and so on.
There are different approaches to rasayana (Patwardhan 2012). Early aging which is an unnatural state can
be prevented by this treatment, at the same time it can slow down the process
of natural aging. Rasayana also
encompasses other topics such as healthy living and social conduct. Treatment
regimens and medicines have effects on promoting longevity, strength,
stabilizing and regulating aging, promoting intellect, memory, alertness and
minimizing fatigue (Badithe and Ali 2003).
There
is also a systematic approach to social and community health involving an
intricate psychosomatic approach. Svasthavrita
(healthy regimen or preventive care) a central tenet of ayurveda reinforces
this approach through elaborate daily and seasonal practical advices.
Coming
to the curative dimension, some of the major diseases encountered during old
age are arthritic conditions, rheumatic and neurological conditions, dementia,
Alzheimer’s disease, psychiatric disorders, physical disabilities due to injury
and slow healing, skin disorders, impairment of sense organs (chiefly visual and
hearing impairment), mental morbidities like anxiety or depression due to
social isolation and feeling of alienation, lack of immunity and infections
like pneumonia, tuberculosis (multidrug resistance), dietary problems of the aged mainly due to teeth loss, low
backache, chronic bronchitis, hypertension, digestive disorders, aneamia etc.
Additionally for those who already suffer from chronic conditions like diabetes,
cardiovascular disease the secondary effects during old age can be challenging.
In stages of conditions with syndromic nature, conventional symptomatic
medications like those for pain, antidepresents, anti-inflammatory agents,
laxatives cannot address the basic cause, may create dependency on these
medicines and chronic after effects. This can also lead to loss of autonomy,
inactivity and so on. In such stages there is a definite preventive, curative,
promotive and palliative role that traditional management regimens can
contribute to. Apart from these ayurveda advice on diet which is constitutionally
and seasonally planned, physical exercises based on yoga or other exercise
forms especially sensitive to brittle bones and joints have an important
function. Spiritually oriented meditative exercises, breathing techniques,
daily and seasonal diet and lifestyle modifications based on traditional
medical principles, personal and social behavior and so on also have key
contributions to make.
Panchakarma therapy
consisting of major purificatory and rejuvenative management methods as per
ayurveda also has an important role in geriatric care. For instance regular oil
application based on the individual constitutional specificities and health
condition requirements is a good support for maintaining health. This would
help reduce the healthcare costs. Early monitoring and surveillance can also
produce good results.
Apart
from the formalized, institutionalized traditional medical systems, local
health traditions also has a lot to offer in rural healthcare and especially in
areas like gender specific interventions due to the fact that public health
facilities are often not used by women.
Need for Policy Support
The
approach to universal health coverage and health system development in India is
predominantly based on modern medical approach. In the National Health Mission
programs traditional medicine is integrated marginally and mainly in the form
of dispensable medicines and not as a holistic health care approach. In most
national programs traditional medicine appears in the form of inclusive,
politically correct, tail-end statements. Why are Ayurveda and other traditional
medical systems not called for to address the healthcare challenges of the
elderly? There is a lot that TRM can offer in terms of preventive care, healthy
lifestyles, early detection of likely manifestation through methods such as prakriti analysis, treatment methods
such as panchakarma particularly in
the case of chronic, debilitating conditions. National program for Health Care
of the Elderly is a comprehensive health strategy by Ministry of Health and
Family Welfare. Such programs should integrate holistic practices of AYUSH
systems and their infrastructure not as pilot schemes but as large scale
interventions across the country. This requires creation of traditional
medicine resource centres, capacity building for medical and paramedical
professionals with special focus on the strengths of TRM in chronic care. This
also requires continuous generation and updation of evidence base for the TRM management.
This would enhance the confidence among AYUSH professionals on their relevance
in gerontology. This is important as public health today is an unfamiliar
terrain for AYUSH professionals. It is a welcome move that AYUSH department has
promoted Centres of Excellence in Geriatrics in the recent past. These centres
should actively engage in research and capacity development in the sector. It
is also important to promote geriatrics focused education in undergraduate and
postgraduate AYUSH programs in the existing academies of traditional medicine
in the country.
In
policy discussions on traditional medicine multilateral bodies have given broad
guidelines on how to systematize traditional knowledge with due consideration
to quality, safety, efficacy and rational use. These issues will have to be addressed
for any traditional medicine based public health intervention. One of the hurdles
with respect to traditional medicine is the widespread quackery and cross
system practices that exist in the guise of TRM. Continuous surveillance
systems need to be established for monitoring safety of these practices.
Inorder to assure quality, rational drug use and cost efficiency, essential
drug lists with region specific requirements are a must.
An
important dimension that any traditional medical intervention should create is
self reliance in management of primary healthcare problems of the elderly. It
should also promote a positive approach to health and wellbeing as well as
improve resilience of elderly population. As a rural community based self
reliant healthcare model, India as a biodiversity rich region of the world has
immense potential in developing a locally driven healthcare and nutrition
development model particularly for regions where health access poor, yet are natural
resource rich in the country. Such an approach is especially important for
reducing healthcare costs while assuring self reliance among communities. This
also requires enormous commitments from the professional medical fraternity for
planning, implementing and monitoring of such community centred health delivery
programs.
Finally,
elderly population requires long term, regular care which calls for systems of
care of a longer term basis. In a country like India which is based on family
care taking, home care givers have a significant role to play. Home care
workers need special training in geriatric care through traditional medicine in
particular in the area of neuromuscular, musculoskeletal and other degenerative
conditions. Many studies show also that family continues to be primary care giver
in the country. This calls for better awareness among households about the
various management approaches of elderly care among family members. There
should be capacity both for family members and care givers for systematically
giving feed back to the health system. This will help develop a need based
primary healthcare approach. Adequate knowledge and awareness of health
conditions, their prevention or treatment, healthy lifestyle are necessary for
implementing such public health interventions.
Conclusion
It
is clear that informal care is far important than formal care in the area of
geriatric care chiefly in countries where family care has been the norm, and as
no government can provide for the demands of a fast aging population. Approach
to elderly care should be based on the vision of reinforcing family and
community based care in a locally driven process appropriately harnessing
locally available resources and knowledge. One of the rich resources that the
country possesses is the strength of its traditional knowledge systems and the
abundant natural resources in the form of medicinal plants and nutritional
resources. The traditional systems have different and unique approaches to
healthcare. Methods like rasayana
which are means to revitalize ailing and aging bodies have not been adequately
studied and thus needs due research consideration. As Patwardhan (2012) notes,
going by the recent statement of the World Health Organization, integration
such a holistic health care approach is definitely likely to yield ‘not just
years to life but life to years’.
References
Badithe, T.K. and Ali, R. 2003. Aging Research in
India. Experimental Gerontology 38: 597–603.
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(Dr. P. M. Unnikrishnan
is Research Co-ordinator of the UN University Institute of Advanced Studies at
Tokyo.)
[1] AYUSH department
under the Ministry of Health and Family Welfare is the apex body for regulating
Ayurveda, Yoga, Unani, Siddha and Homeopathy systems in the country.
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