Gender,Medicine and Globalisation: The Case of Women Ayurveda Physicians of Kerala,India

Introduction

The field of medicine, generally perceived as a feminine one, shows changing patterns of gender systems within different medical systems and over historical periods and geographical locations. For instance, women healers who dominated the field of medicine in Europe for centuries were displaced by the new biomedical profession that came to be controlled by male practitioners by the fifteenth century. Biomedicine’s advancement as the most scientific and rational medical system through the last two centuries, however, shows rigid gender structures with male physicians placed in positions of authority and women delegated to subordinate roles of nursing and caring or into a few feminised medical specialisations (Pringle 1998). ¹

The practice of Ayurveda and its organisation were transformed in unprecedented ways during the twentieth century into a highly modernised system, while its practitioners carefully asserted its identity as an ancient, traditional and indigenous knowledge system. Training, practice and preparation of medications were shifted from physicians’ homes to newly established colleges, clinics and pharmaceutical units (Banerjee 2009, Bode 2008, Harilal 2012), and modernisation included ‘creolisation’ of knowledge (Naraindas 2014) and innovations in procedures and protocols (Sujatha 2011). However, the extent of such modernisation and its effects have been uneven across the country. For example, the consolidation of various local medical practices into a regional form of Ayurveda was strongest in Kerala and it emerged as a leader in the way in which it modernised and institutionalised its regional heritages. Unlike in many other parts of India where Ayurvedic graduates ended up practising biomedicine for the want of necessary support systems, the college-trained physicians in Kerala were successfully integrated with the private drug manufacturers through their retail outlets that acted as pharmacies and also with the dispensaries established by the state government to form a well networked Ayurvedic medical market. The recent feminisation of the field is also perhaps the strongest in Kerala as indicated by data on student enrolment in the Bachelor of Ayurvedic Medicine and Surgery (BAMS) programme. For example, in the year 2015, out of a total strength of 70 seats in the first year in the most sought after Government Ayurveda College at Trivandrum, 63 were women and out of the 50 seats in the most popular private college, the Vaidyaratnam P. S. Varier’s Ayurveda College at Kottakkal, 44 were women. ²

Gender Relations and Practices in Medicine

Studies show that medical systems develop their own specific gender hierarchies and practices, as they are influenced by prevalent patriarchal structures and gender ideologies in which they operate (Pringle 1998). Feminist analyses of gender systems in medicine have been extensive but their focus has been mainly on biomedicine in the European and American contexts. Some of these historical accounts show a major shift in the gender structure from women healers’ general authority and influence in the field, which they held for several centuries, to state legitimised male authority in the new biomedical profession by fifteenth century (Ehrenreich and English 1973, Oakley 1976). Women were initially barred from entering the new profession in Europe and gender ideologies that constructed women as lacking masculine traits of courage and intellect, and caring as feminine were used as justifications for women’s exclusion, segregation and subordination in the new institutions.

In contrast, the history of Ayurveda shows uninterrupted exclusive male domination from ancient times until the mid-twentieth century. As structures of caste and gender were inextricably linked in India, these interlinkages structured the field of Ayurveda too. For instance, only male members of specific medical families and castes were eligible to practise medicine as an occupation, and the field of midwifery, constructed as a defiling occupation, was relegated to the women of ‘untouchable’ castes. While medicine may have been practised by some of the intermediary castes, these two poles marked the general caste gender boundaries in the various medical traditions that later got organised as Ayurveda in the twentieth century. In the historical accounts of medicine in this region or in the significant body of literature that exists in the various medical traditions, there are no major references to women authors or women practitioners except for rare references such as a midwifery book written by a Hindu lady among the books translated into Arabic in the eighth century AD (Altekar 1962: 180).

Women’s occasional presence and participation in Ayurveda since the early twentieth century has been noted in a few studies but without reference to the social contexts in which they entered the field or how they negotiated prevailing patriarchal norms both within medicine and in the society. ⁴

Feminist studies have also shown that patriarchal constructions of femininity and domesticity produce conditions that lead to vertical and horizontal segregations within medical institutions (Pringle 1998). They argue that social constructions of caring as a feminine quality natural to women premised on women’s biological capacities for birthing form the basis for restricting women’s primary role in society to domesticity and to devalue their domestic labour as unproductive and exploit it as affective free labour. Such constructions of gender roles and gendered ideologies that underpin women’s domestic labour are then extended to devalue women’s labour and contributions beyond the family and to direct them to subordinate positions in other institutions. The structural subordinate positioning of women both within and beyond family, the interlocking of patriarchy and capitalism, supported by the state thus reproduce male privilege in modern societies (Walby 1990). Furthermore, it is argued that the economic and cultural developments under twentieth-century privatisation and globalisation indicate to a deepening of gender asymmetries in all aspects of women’s work—marketised and monetised, non-marketised and non-monetised through conditions that are described as ‘complex inequalities’ and ‘intersecting modernities’ wherein some aspects of the work will be regarded as positive and others as unjust (Walby 2009). As the few studies on Complementary and Alternative Medicine (CAM) shows not only the women turning away from biomedicine for ideological and health reasons are attracted to it but also those who are pushed out of the highly competitive and gendered job markets and seek employment which allows them flexibility to address responsibilities of childcare (Lau 2000). While the expanding market may offer more choices for these women practitioners but that may be at the cost of competing demands on their domestic and professional lives. Women’s ability to negotiate these contrasting domains and their ability to bargain with patriarchal arrangements would then depend on a number of contextual factors.

Feminisation of Ayurveda in Kerala

The field of Ayurveda in Kerala, at least until the mid-twentieth century as elsewhere in the country, was an assemblage of medical traditions and practices that overlapped with each other. Some medical lineages in Kerala specialised in toxicology, children’s diseases, mental illnesses and bone setting, and were unique to this region (Varier 2005). Although the physicians of Kerala were not the pioneers of modernisation and institutionalisation of Ayurveda, some of them emerged as leaders in these fields through the last century. The specific path of modernisation followed in Kerala blended and reorganised the plural and specialist lineages under a singular identity of Ayurveda and in the process strengthened certain practices and displaced many others (Girija 2016). These developments consolidated Ayurveda politically and institutionally, and helped resist the hegemonic rise of biomedicine in the region. During this period, several powerful caste- and family-based medical lineages modernised and reinvented themselves as the bearers of the various regional Ayurvedic heritages of Kerala (Abraham 2018). Some of these heritage institutions have today become popular destinations of global consumers of Ayurvedic therapies and are also important players in the field of Ayurvedic tourism. However, neither the modernisation of Ayurveda nor the participation of women in biomedicine, its professional rival, induced any challenges to the male supremacy in Ayurveda.

Unlike elsewhere in independent India where state formation distanced itself from the field of what was termed ‘traditional’ medicine, in Kerala, the state was actively engaged in its transformation. For nearly a century, state was the primary source of funding for modern Ayurveda education. It was only after 2000 that several privately funded colleges were established in Kerala. Currently, there are 119 hospitals and 768 dispensaries in Ayurveda run by the state government ⁵

Although by the 1940s and 1950s a few women trickled into Ayurveda institutions in Kerala as daughters and wives of physicians, a feminisation of the field is observed only since the mid-1980s. This important break in the gender structure of Ayurveda was, however, not the result of any political struggles or produced by any gender reforms initiated by the modernisers of Ayurveda. It was men exiting from the field due to the lowered professional status of Ayurvedic qualifications and the better economic prospects of biomedical profession along with the expansion of modern education among girls in general that produced the grounds for feminisation of Ayurveda (Abraham 2019a). Women from across castes, classes and religion joined these institutions and also found employment in the growing number of private institutions and the large network of state funded Ayurvedic facilities in Kerala. As the interviews revealed, not all qualified women entered the profession or pursued a steady career due to marriage and childcare reasons, yet, a substantial number of them attempted to build a consistent career in the Ayurveda sector. The women physicians interviewed and their female colleagues worked in a variety of medical and health care settings and performed a number of important tasks that strengthened Ayurveda in the state. Their contributions consolidated the regional identity of Ayurveda, furthered a secular and cosmopolitan culture in this field, and also served the newly generated local and global demands (Abraham 2019b).

Studies on women’s education and employment in Kerala, however, show that women’s higher education has not generally resulted in their increased workforce participation, although it was found to be relatively better for women with professional qualifications (Kodoth and Eapen 2005). This is in line with our observation that women with Ayurveda degrees are able to find employment. It has been noted that marriage of women is a major consideration for families in decisions regarding their education and employment. In general, women’s marital status, place of residence and husband’s economic and employment status were found to be significant factors determining women’s employment and scholars have noted that in the case of Kerala, women’s education has not played the transformative role as expected in the economic analyses (Kodoth and Eapen 2005, Mukhopadhyay 2007). Although a number of women sought employment outside the state and the country, within Kerala, they preferred employment closer to their natal or marital homes. There is also a general ‘moral panic’ about women’s work outside their homes, especially if it involved interaction with strange men and stay away from home (Devika 2016). Concerns regarding marriage and public perceptions about women’s engagement with labour market forced women into employment conditions that met social expectations associated with femininity and ‘respectability’, even if the pay was low and working conditions were poor (Devika 2016). The educated and employed women are thus disempowered by the gender ideologies that limit their employment options and as some of the above studies show women are actively socialised into the self-sacrificial domestic ideologies whereby even highly educated and professionally qualified women place their domestic and child care responsibilities above their personal and professional interests. As these studies point out, women’s increased commitment to the reformed domesticity does not mean that men are free from the family centric ideologies as there is now much pressure on them to secure professional qualifications and employment that are valued in the marriage market, a factor that may have discouraged men from a low status career in Ayurveda.

Globalisation and Local Ayurvedic Re-arrangements

The steadily growing interest in Ayurvedic ideas and practices in the countries of Europe and North America since the 1970s has been described by many scholars as the ‘globalisation’ of Ayurveda (Alter 2005, Reddy 2002, Wujastyk and Smith 2008). The focus of these studies, however, has been on specific trends in the spread of Ayurvedic ideas, practices, literature, cult personalities and institutions in these countries and do not consider the growing popularity of Ayurveda to non-Western destinations such as the Arab countries of the Gulf region or Southeast Asia. For example, Ayurvedic practices specific to the Kerala region have been popular among the local population in the Gulf countries and Kerala has become a major destination of Ayurveda for them. This is not surprising considering the close business and labour ties between Kerala and the Gulf countries. Analysis of globalisation of Ayurveda, especially when viewed from the locations of its origin, therefore, needs to engage with all forms of its transnational travels, as the diverse overseas interests and specific configurations there could produce complex and even conflicting demands on the former. Thus ‘globalisation’ of Ayurveda in this article refers to the transnational demands for its ideas and services in destinations both in the West and in the Gulf countries since the 1980s and 1990s and the local conditions that facilitate the outward flow as well as the effect of such flows on the endogenous system.

The studies on the Western variety of Ayurvedic globalisation traces its origin to the counter culture movements of the 1960s that introduced certain ideas of orientalist spiritualism and yoga that promised alternate life styles based on self-knowledge. Maharishi Mahesh Yogi and Deepak Chopra emerged as cult figures by the 1980s and their institutions became centres of Ayurveda in these countries (Wujastyk and Smith 2008). Ayurvedic knowledge from classic texts formed only a rudimentary part of the spiritual discourse and philosophy of alternate life styles that they promoted. Workshops on Ayurveda conducted by these new age spiritual leaders for the CAM followers resulted in some of them seeking Ayurvedic services in India and a few enrolling themselves for courses of short duration in Indian institutions. Kerala, with a highly literate population, reasonably well-developed infrastructure oriented to tourism, good network of Ayurveda institutions and, more importantly, the availability of a wide variety of Ayurvedic services offered by trained physicians, became a suitable destination for them.

What is described as the ‘globalised’ Ayurveda in the West is however not the same in the various countries as they differ in the specific strands that are popular, in the locally available training programmes or the legal framework that governs Ayurvedic products and services. For instance, in countries such as Britain and Germany, the popular demand for CAM and the sustained efforts of organisations of Ayurveda practitioners have secured them certain minimum state recognition under which qualified doctors can acquire training in Ayurveda (Warrier 2014). In Germany, the popular trend is to incorporate components of Ayurveda in the biomedical therapies especially for chronic ailments. Clearly, these are indications of the growing interest in Ayurveda among the qualified biomedical doctors and their attempt to gain legal status for their hybrid practice in these countries. In Britain, some estimates show that ‘one in two general practice will offer some access to CAM’ and in the United States ‘over one-third of physicians themselves practice at least one such therapy’ (Saks 2008: 33). The public demand and doctors’ willingness to incorporate CAM are likely to push legislations that favour formal training in CAM including Ayurveda. As the current Ayurvedic training available in these countries follows lineage-based tutoring, it is not surprising that several competing lineages have emerged there. Unlike the hybridisation between biomedicine and Ayurveda observed among biomedical practitioners in Germany, in the United States, the lineage practitioners combine astrology (jyothisham) and/or Yoga to assert their differences and superiority in order to compete with other lineage claimants. Thus, Ayurveda in two forms, medicalised and spiritualised, are popularised by various New Age spiritual leaders and Ayurveda practitioners in these countries (Frank and Stollberg 2004).

Although the field of CAM is dominated by women and holds lower social status than the orthodox medicine in the above countries, both the spiritualised and hybridised Ayurveda seem to be dominated by men. The above-mentioned studies do not discuss gender patterns in globalised Ayurveda among practitioners or followers. Various descriptions nevertheless indicate that within the feminine field of CAM, Ayurveda is an exception as it is led by male leaders such as Mahesh Yogi, Vasant Lad, Deepak Chopra, Svoboda, Frawley and others who have obtained either a professional BAMS degree or some form of training in Ayurveda from India and have built their distinct tutor lineages in these countries. But a few women physicians are enlisted on the websites of UK-based Ayurveda Practitioners Association (APA) ⁸

In comparison to the Western countries, the popularity of Ayurveda in the Arab countries shows vastly different trends. Because of the large-scale labour migration since the 1970s and the large expatriate population there, it is not surprising that the Kerala style of Ayurveda has taken deep roots in this region. The Arya Vaidya Sala (AVS) Kottakkal from Kerala established its first branch in the UAE in the 1980s, and since then there has been a steady increase in the number of Ayurveda clinics in this region. For instance, in Dubai alone it was estimated to be more than 40 in the year 2012. ¹⁰

A significant proportion of the visitors from Gulf countries also seek Ayurvedic treatments in the numerous establishments in Kerala. In 2012, it was reported that nearly 60–65 per cent of Gulf Arab tourists to India were seeking treatments at Kerala’s renowned Ayurvedic clinics. ¹¹

Besides running its own institutions, the state supports and authenticates the diversified Ayurveda in Kerala, which is evident from the publicity that the state Department of Tourism gives to this sector. Its website advertises prominently Ayurveda as a major tourist attraction and provides links to the various accredited Ayurvedic facilities which include 86 Ayurveda centres, 18 Ayurveda hospitals and three Yoga centres. ¹³

Women Physicians in Medicalised and Spiritualised Ayurveda

The women physicians whom I interviewed, including the medical students, were well aware of the global trends in Ayurveda and the demand for ‘spiritualised’ and ‘medicalised’ services. They were critical of such market driven bifurcations which in their view misrepresented the true worth of Ayurveda and also misinterpreted its knowledge. Two women Ayurveda physicians whose establishments offered services to Western clients stated that they often encountered clients having incorrect or exaggerated notions of Ayurveda acquired through their limited exposure in their own countries. ¹⁵

But there are other practitioners who clearly bifurcate their practice as either medical or wellness, by drawing upon the divisions generated by the globalised Ayurveda in the West. Practitioners use such distinctions to protect the authenticity of their medical practice and at the same time to reap the economic benefits that globalisation offers to local Ayurveda entrepreneurs. The second woman physician, married into a lineage medical family and tutored by her father-in-law in the family therapies, had established herself as a successful physician. While she inherited the clinic and its clientele established by her father-in-law in his small town and had made a name for herself in the region, she acted as the chief physician in the new institutions that her husband established. One such institution was exclusively for medical Ayurveda and another modelled as a resort in terms of comfort, decor and ambience, meant exclusively for Western clients. This is an instance wherein the globalised Ayurveda, as Warrier (2011) argues, has impacted practices in its original locations. It is pertinent to note here that women’s commitment and hard work channelled through the institution of marriage saved medical lineages that would have ended otherwise. The son, as a young man, had refused to join the low status Ayurveda college, but later realised the entrepreneurial potential in pursuing father’s medical legacy combined with wife’s skills and fame went on to establish new institutions. As the woman physician said, in response to my query about how she managed the conflicting demands of the two institutions, that she was most happy with the treatment centre where she produced efficacious outcomes, especially in those cases where biomedical practitioners were unsuccessful. In the resort Ayurveda, she had no major role as a physician and occasionally addressed clients’ queries. She was not involved in the major financial or managerial decisions and was happy about it but when asked about her personal dreams said perhaps she would have been more interested in building centres to treat women’s and children’s ailments. Thus, careers established through marriage can subordinate women’s position in the field and tame her agency despite her capabilities.

It was quite evident from field data that globalisation of Ayurveda had impacted and reorganised the local institutions and social relations in which Ayurveda operated, one of which was certainly the elevated role of women as physicians in the field. It was also evident that women’s enhanced role both within medicine and in society did not lead to their individuation as their new roles were circumscribed by the gender norms and their newly acquired professional power seemed insufficient to transcend the institutionalised gender power relations within marriage and family. These women and others enjoyed certain degree of freedom in their decisions as physicians, enjoyed higher social status and better material comforts that came from their business, but stayed away from taking up leadership and entrepreneurial roles. In some instances, women physicians became partners in the new entrepreneurial efforts after marrying a male physician and together they set up treatment centres that idealised family settings and relationships (Abraham 2019b). Many women were found trying for a government job, which offered security and fixed timings, closer to their homes so that they did not have to compromise their domestic and childcare responsibilities. Thus, masculine domination remained unchallenged both within the medical field and in their homes as women’s professional choices reinforced the prevailing gender norms of marriage and domesticity. Women were well socialised into these norms were obvious from their responses that they preferred to spend time with children, helping them in their studies or cooking their meals rather than take up the responsibilities of running institutions.

The social status of women practitioners differed based on the type of institutions that they worked for irrespective of the income they earned. Although state promotes tourism as one of its major sectors of employment women employed in this sector are viewed with suspicion and Ayurveda physicians are no exception to this general view. As a result, women physicians in this sector have relatively lower social and professional status when compared with those in the family based or other medical institutions. As women are expected to interact with strange men and as the clinical exchanges and Ayurvedic therapeutic procedures involve interactions in private settings seem to enhance such societal suspicion. This is however, not the case with women in biomedicine or women in state run or reputed private Ayurvedic institutions. They too interact with strange men in close clinical settings. While a general moral panic about women’s work outside the family continues to frame their work participation and curtail their entrepreneurial opportunities, women in the tourism sector is particularly vulnerable as tourism is popularly associated with moral transgressions. Women physicians who worked elsewhere also blamed the tourism sector, which they disapprovingly described as ‘resort Ayurveda’, for spreading negative stereotypes about Ayurvedic massages and about women Ayurveda practitioners in general. The youngest group of women, the medical students of Ayurveda colleges, too agreed that many practices designed to suit expectations generated by Western spiritualised forms or ‘wellness/de-tox’ forms for tourists as distortions of their rich therapeutic system. Yet, in their determination to pursue a career in Ayurveda were not averse to taking up jobs in the tourism sector although that was not their preferred career destination. In contrast, male students were of the view that globalisation posed no threat to the ‘authentic’ Ayurveda in Kerala as the authentic and the inauthentic are operated from distinctly different institutions. They viewed diversification and proliferation of institutions as enhancing employment opportunities for them. Such male responses are anticipated as men in tourism sector are not subjected to the negative gender stereotypes that restrict women’s employment and affect their identities and subjectivities.

Women performed multiple roles in the diversified and expanded Ayurvedic sector in Kerala not all of which are economically remunerative as in the case of the ‘agency practice’, as employees of pharma companies. Women are in large numbers in the state Ayurvedic medical bureaucracy and as tutors in colleges are role models for young women, especially from marginalised backgrounds. Women are also engaged in training Western doctors for the globalised Ayurveda. A Christian missionary woman, with a BAMS degree from a reputed Ayurveda college, was engaged in training German doctors in Ayurveda. Her proficiency in German and Sanskrit languages and expertise in Ayurveda made her the lead trainer of this programme aimed at meeting the demands of globalised Ayurveda in Germany. As reported by Frank and Stollberg (2004) and Chopra (2008), biomedical doctors in Germany undergo various training programmes to hybridise their therapeutics with Ayurveda in response to the CAM requirements in their country. Thus, women physicians are found actively engaged in every segment of the field serving the demands of an increasingly diversified Ayurveda.

In an overall environment that favoured commercialisation and globalisation of Ayurveda, there were also views that critiqued such trends. Several teaching faculty at the medical colleges and individual private practitioners, both men and women, were vehemently opposed to the spiritualised new age Ayurvedic wellness clinics or massage centres. But the private Ayurvedic establishments, irrespective of the clients they served or therapies they offered, tended to create a certain spiritualised ambience drawn from Hindu higher caste culture, in the welcome rituals, decor, attire of the staff, idols and lamps displayed and the meals offered. Some of them had small temples within the premises with morning and evening prayers which patients/clients were free to participate. Such ambience does not necessarily impede the medical services offered in these institutions but is indicative of the influence exerted by the spiritualised and globalised Ayurveda.

Within Kerala, we may identify three types of institutional settings in which Ayurveda currently operates. First is the strictly medical institutions run by the state and some of the private agencies that operate without any explicit cultural or spiritual symbolism. Second is perhaps the largest sector that provides Ayurvedic medical care offered in a manner in which patients/clients experience elements of local Hindu cultural, religious or spiritual elements. The third category is one in which spiritual elements are consciously incorporated into the Ayurvedic care and procedures in the form of religious rituals, chanting, meditation or prayers. The field data suggest that globalisation of Ayurveda and the local promotion of Ayurveda through tourism have both contributed to the expansion of the second category of institutions. This sector seems to be the most feminised one where Ayurveda is projected as caring, soothing and rejuvenating offered from institutions that resemble idealised family settings and gender relationships. The nature of Ayurvedic expansion therefore demands that the women of diverse caste and communities negotiate their identities to work under a Hindu spiritualised ambience and conduct their professional career within the gendered structures and norms of femininity, marriage and domesticity that continue to characterise women’s lives in Kerala society.

Conclusion

Women’s engagement with Ayurveda in Kerala in the last 50 years has been intense and complex and the particular dynamics and effects must be understood as these are shaped by specific socio-historical contexts. Kerala has managed to build reasonably good infrastructure, governance and public health systems, besides mass education, while successfully preserving core patriarchal elements through its modernised gender system. Until a few decades ago, only men of specific castes, and preferably with a medical family lineage, were considered legitimate inheritors of Ayurveda. However, the twentieth-century social reforms that encouraged women’s education, secularisation of Ayurvedic institutions and importantly, men abandoning the field of Ayurveda for newer career options together produced conditions for women’s entry and pursuit of a career in Ayurveda.

The participation of women from across various castes, classes and religion in Kerala not only contributed to making the field democratic and cosmopolitan but also served the demands of the emerging Ayurvedic market. It should be noted that their role in preparing the grounds for globalisation has been particularly significant. Legal restrictions, gender systems within the globalised Ayurveda, and the patriarchal ideologies of domesticity and femininity within Kerala however limited women’s full participation in the expanded Ayurveda sector. Even under the circumscribed conditions, many women successfully utilised the opportunities provided by the new Ayurvedic labour market, negotiated patriarchy to become successful physicians and made historical contributions to the strengthening Ayurveda that was weakened by the hegemonic rise of biomedicine and other forces of modernity in the last century, in Kerala. If globalisation is about increasing consumer choices, creating new cultural demands globally, then the contributions of these women physicians to these processes have been noteworthy. But if it is about increasing women’s agency and individuation through an expanded globalised labour market, then women Ayurveda physicians in Kerala have yet to experience that in any significant ways.