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Social Science & Medicine 74 (2012) 1029e1036

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Social Science & Medicine

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Medical pluralism and medical marginality: Bone doctors and the selectivelegitimation of therapeutic expertise in India

Helen Lambert*

School of Social and Community, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol BS8 2PS, United Kingdom

a r t i c l e i n f o

Article history:Available online 25 January 2012

Keywords:IndiaMedical pluralismBonesettersHealth systemsExpertiseTraditional medicineHealth policyHuman resources

* Tel.: þ44 117 928 7332; fax: þ44 117 928 7236.E-mail address: h.lambert@bristol.ac.uk.

0277-9536/$ e see front matter � 2012 Elsevier Ltd.doi:10.1016/j.socscimed.2011.12.024

a b s t r a c t

Current health policy initiatives in India advocate medical pluralism and seek to address a lack of skilledhuman resources for health care provision. This qualitative study investigated a form of indigenoustherapy that does not fit into officially recognised categories of ‘Indian medicine’ but is a popular sourceof informal medical care. Semi-structured interviews and ethnographic observations of 30 ‘bone doctor’(haad vaidya) practices were conducted in the capital city of Rajasthan, north India in 2009e2010together with historical analysis of changes in state policies for the registration of Indian medicinepractitioners. Contestations over legitimacy among individual practitioners and hierarchies of authoritybetween different medical traditions are shown to rest on conceptions of what constitutes authentic‘expertise’. The findings demonstrate a progressive restriction over time in official definitions of medicalexpertise, towards a reliance exclusively on formal qualifications rather than experientially acquired andinherited skills to demarcate legitimate therapeutic knowledge. This case study contributes to ourunderstanding of the nature of non-professional expertise and its implications for pluralistic health carepolicy and the human resourcing of Indian health systems.

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Introduction: medical pluralism in India’s current health carepolicy

The medically diverse character of India’s health care landscapehas long been a focus for social scientists seeking to characteriseparticular aspects of its extensive ‘medical pluralism’ (for exampleBarratt, 2008; Halliburton, 2009; Leslie, 1976, Leslie and Young1982; Nichter, 1992), although this term flattens out power differ-entials between component medical traditions (Khan, 2006). Thispaper identifies significant hierarchies of legitimacy betweendifferent therapies as well as among practitioners of one particulartherapeutic specialization and relates them to conceptions of whatconstitutes authentic ‘expertise’. Since Independence, a smallproportion of India’s health budget has been devoted to the supportof ‘Indian Systems of Medicine’ (Ayurveda, Unani and Siddha) andadvocates of these systems have long complained of a govern-mental policy of persistent neglect. Recently, however, India’s non-biomedical traditions have received renewed attention in govern-mental policy initiatives to upgrade public sector health careprovision. A stated aim of the National Rural Health Mission(NRHM), launched in 2005, is to ‘revitalize local health traditionsand mainstream AYUSH into the public health system’ (Ministry of

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Health and Family Welfare, n.d.:4) and discussions on nationalinitiatives now include an explicitly pluralistic model of publichealth care provision. The Government of India is finalizing itshealth strategy for the next Five-Year Plan 2013e2018 which willlikely include a similar National Mission for urban areas, and policyoptions contained in the latest Annual Report on Health(Government of India, 2010) advocate, ‘systemic changes.’, as partof a process of ‘moving towards a system for universal access tohealth care, which provides space for medical pluralism andrational integration of systems.’ (Government of India, 2010 :5).These changes include a shift of emphasis away from provision offully qualified biomedical practitioners at all levels of the healthsystem that has been a core component of government policy afterIndependence (Rao, Rao, Shiva Kumar, Chatterjee, & Sundaraman,2011:588), towards the use of ‘skilled’ and ‘trained’ healthproviders from a variety of medical traditions. Given the possibleincommensurability between true ‘medical pluralism’ (whichimplies the co-existence of epistemologically diverse therapeutictraditions) and ‘rational integration’, it is apposite at this junctureto ask what kind of ‘medical pluralism’ is envisaged for one of theworld’s most populous countries and to examine how ‘local healthtraditions’ may come under the purview of the state. This paperseeks to do so via a case study of a single non-professional medicaltradition that has historical and epistemological links withAyurveda.

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In the past two decades, indigenous or ‘traditional’ medicine inIndia has come to be identified almost exclusively with a State-defined group of medical forms collectively designated by theacronym ‘AYUSH’ (denoting Ayurveda, Yoga and Naturopathy,Unani, Siddha and Homeopathy). The expanded governmentalrecognition of traditions previously designated as ‘Indian Systemsof Medicine’ (ISM e officially denoting Unani, Ayurveda and Sid-dha) to the more eclectic range denoted by the acronym AYUSH,constituted a singularly successful act of rebranding by theMinistryof Health and Family Welfare in its 2003 Departmental reorgani-zation. In 2003 the Department of Indian Systems of Medicine &Homeopathy (ISM&H), created in 1995, was renamed the Depart-ment of Ayurveda, Yoga and Naturopathy, Unani, Siddha andHomeopathy, or ‘AYUSH’ (Government of India, 2003). ‘Ayush’ inSanskrit also means ‘long life’ and the acronym has rapidly becomethe accepted single-term referent for all forms of non-allopathichealth care among health care professionals, policy makers andacademic researchers. Governmental recognition of indigenousmedical traditions has thus expanded from three to six, and nowseven, components in under a decade (as Sowa Rigpa, a Tibetanmedical tradition, was added to the list in 2010).

Thus AYUSH is simultaneously a singular and a plural entity.Each component is taken to constitute internally unified andhistorically discrete knowledge traditions, while together theycollectively represent the State-recognised alternative to biomed-icine, or allopathy. Nonetheless historians and social scientists havedocumented selective processes of legitimation ongoing since atleast the 1860s, whereby particular traditions of indigenousmedicine undergo reformulation into professionalised andaccredited knowledge systems (see for example Attewell, 2005,2007; Banerjee, 2009; Hardiman, 2009; Langford, 2002; Leslie,1976). What the ‘AYUSH’ traditions actually have in common issimply that they are not biomedical and are regulated through Stateaccreditation of training institutions and official recognition ofdegrees. Insofar as sociological theory has shown the developmentof the professions to be strongly associated with state formation,the processes by which selected medical traditions become healthprofessions can be seen as part of modern governance.

Unregulated therapeutic traditions not falling under the cate-gories of professional AYUSH have also been recognised in recentgovernment policy, with ‘support for revitalization of local healthtraditions’ (Planning Commission, 2008:114) specified underAYUSH planning strategy in India’s eleventh Five-Year Plan. Thecharacterization of uncodified traditions as requiring ‘revitalisation’(Planning Commission, 2008 ) is in keeping with the longstandingview of such traditions as residua that, in modernist narratives ofprogress, are always-already disappearing. The only activitiesspecified in National Rural Health Mission policy documents(Ministry of Health and Family Welfare, n.d.) in this regardemphasise the retrieval, testing and promotion of medicinal plants,implying that what needs revitalising is ethnobotanical knowledge.How far do these assumptions concerning the character of ‘localhealth traditions’ accurately reflect reality? The case of ‘bonedoctors’ offers an example of a specialization that, operating at themargins of state regulation, can illuminate processes of legiti-mation and illustrate the nature and complexities of uncre-dentialled, subaltern medical expertise in contemporary SouthAsia.

Methods

The material presented in this paper draws on fieldwork con-ducted between October 2009 and April 2010 in and around Jaipur,the capital of the northern Indian state of Rajasthan. During thisperiod I interviewed and observed a total of 30 bone doctor

practices in the Jaipur urban area and periphery. This material wassupplemented by interviews with three Delhi-based and one ruralpractitioner for purely indicative comparative purposes concerningthe distribution of specific technical features (this supplementarymaterial is not included in the present analysis). The study wasa follow-up of previous research on medical pluralism in Rajasthanwhich included a 12-month period in Jaipur from January 1984 toJanuary 1985, including roughly eight weeks observing and inter-viewing a single bone doctor who was re-interviewed twice in therecent study, and related ethnographic research in rural areas ofRajasthan over a 16-month period from 1985 to 1986, witha follow-up visit in 1995, that focused on folk and popular thera-peutic traditions including bonesetting. Ethical approval for thisstudy was provided by the University of Oxford with my doctoralsupervisor acting as guarantor and from the Indian Council forSocial Science Research, which provided research clearance.

During the research reported in this paper attempts were madeto obtain a complete sample of all specialist practitioners in thearea by snowballing contacts, initially from my original key infor-mant and from another practitioner to whom an introduction wasfurnished by a locally prominent family of Unani medical practi-tioners. Each contact was asked for details of other practitioners ofthe same type, references to any new practitioners were triangu-lated and all those identified were visited, while other practitionersin the area were also asked about practicing bone doctors, so thatover the research period, as far as possible the great majority ofestablished practitioners working in this urban area were identi-fied. All interviews were audio recorded, transcribed and subse-quently translated into English. The software package NVIVO 8 wasutilized to code a subsection of transcripts for emergent themesand further analysis of transcripts and field notes deriving fromobservations and secondary documentary material (such asnewspaper clippings provided by informants) were undertakenmanually, using an inductive and reflexive approach to thematerial.

The origins of specialist expertise: doctoring wrestlers

Across India, a variety of local therapeutic traditions focus onbonesetting and the amelioration of other musculo-skeletal prob-lems. To date these have been little documented, other than brieftreatments in earlier accounts (Lambert, 1995, 1997) and in onerecent study exploring the work of ‘traditional orthopaedic prac-titioners’ in South India (Unikrishnan, Lokesh Kuman, & Shankar,2010). One possible reason for their absence from studies ofhealth practices is the common misapprehension that the ‘profes-sional’ (textually codified) medical traditions represent the totalityof Indian medicine, while other therapeutic forms are exclusively‘ritual’ (Barratt, 2008:120). In urban centres across north andwestern India however, a class of secular practitioner popularlyreferred to as pahalvan, literally ‘wrestler’, specialises in treatingfractures, sprains, injuries and muscular/’nerve’ (nas) problems.Amongst themselves and amongst other medical specialists theyare referred to as haad vaidya (haddiyon ka vaidya), literally ‘bonedoctor’ or ‘bone physician’.

In Jaipur, the capital city of Rajasthan State, a majority though byno means all the practitioners of this kind were Muslim and formany, though not all, their medical work was a family occupation,traceable for several generations, as was a familial relationshipwithwrestling. As such they have in common with other Indian tradi-tions of bonesetting an association with sporting and martial artstraditions, such as Marma medicine in Kerala which has beenrelated to fencing (Zimmerman, 1978:98) and Kalarippayattu(Zarrilli, 1998). Many of those I interviewed referred to Jaipur’sproverbial ‘52’ now mainly defunct wrestling schools (akhara) and

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traced the source of their familial expertise to the head (ustaad) ofa particular wrestling school who had developed specialisedknowledge in this form of treatment. This teacher’s great-grandson(the current haad vaidya in his family) is recognised by a group offormer wrestling families as the head of their fraternity of wres-tlers, although the wrestling schools with which they were onceassociated no longer exist. Now disused, part of the wrestling ring(akhara) still exists in the family house where patients are treatedin a small room off the internal courtyard and where a dozen menonce compounded medicine, bandaged fractures and generallyassisted the master in the care of in- as well as out-patients.

A few interviewees were either themselves former wrestlingchampions or their predecessors had been, but most practitionershad never been wrestlers and had no association with the sport(which is largely extinct in the region where the study was con-ducted, although it remains popular in some districts of south-eastRajasthan and Uttar Pradesh). Some families had historical associ-ations with the Jaipur court through patronage relations prior toIndependence and there are connections between particular line-ages, Jaipur State and the spread of familial expertise throughnamed disciples of individual practitioners who were so employed.Thus one practitioner, reputedly aged 102, recounted how hisfather had been employed as a wrestler by the Jaipur court (darbar)on a salary of Rs.2/- per day, a post he in turn held himself untilIndependence. Another practitioner explained that the large house(haveli) in the walled city where his family still live (and wherepatients are treated in a room off the courtyard), was gifted to hisgrandfather when the latter was retained by the court to providetreatment to the members of the women’s section (zenana diyodi)of the royal household.

Such connections with the palace are plausible, wrestling asa sport having been supported largely by royal patronage untilIndependence; an ethnography of wrestling among Hindus inBenares describes the importance of this form of patronage (Alter,1992), while Sharma (1968) notes that in the medieval period‘princes’ employed boxers and wrestlers on monthly salaries. Theaccounts of other Jaipuri haad vaidya attest to the provision of suchsalaries to members of their families for employment in a variety ofcapacities at the Jaipur court and/or the provision of houses in thecity where they could live and work. Most hereditary service rolessalaried to the royal court were terminated following Indian Inde-pendence and the princely States of Rajputana were formally dis-solved in 1949 to become the State of Rajasthan. The emergence ofhaad vaidya as a specialist class of medical practitioner catering tothe public may be associated with the collapse of courtly patronagefor wrestling, leading these families to seek alternative means oflivelihood. Much more recently, there are indications that thedecline in wrestling as a popular and State-supported sport has ledto a corresponding growth in the numbers of pahalvan trading onthe name of wrestler to set themselves up in practice with a newsource of livelihood. This has critical implications for the adjudi-cation of what constitutes authentic expertise, further discussedbelow.

Bone doctoring as contemporary occupation

‘Wrestlers’ (in client terminology) are a popular source oftreatment among both the urban and rural poor and among middleclass people. Among the 30 practices reported in this study, 11worked out of dedicated premises (shops in the bazaar or smalllockup rooms located near their residences), six practiced at homeand a further 13 worked out of doors (in temporary structureserected on the pavement, in city parks or gardens, at gatehouses ofthe old walled city or near major road junctions). The best knownand well-reputed of these practitioners see a steady stream of

patients at their shops or homes, which are mostly located quitecentrally in or near commercial areas of the old city and stay openfrom around 9am until early evening. Patients come to obtaintreatment from the urban periphery and from outlying villages upto around 3e4 hours’ journey away, as well as from the immediateurban environs. The outdoor pahalvan practice at fixed locations,not only picking up passing trade but treating local clientele withwhom many have an established relationship. The complex andambiguous relations between these two varieties of practitioner arefurther described below.

Practitioners generally charge around Rs.50/- ($1) for an initialconsultation, at which they initially examine the problem at handandmay be asked to give an estimate of the time period likely to berequired for treatment. This is usually calculated in terms of thenumber of ‘bandages’ (patti) required, each bandage being equiv-alent to a visit; a characteristic feature of this treatment modalitybeing that the limb is unbandaged, checked and treated at frequentintervals so that patients obtain continuous care for the duration oftheir complaint. Since payment is given per visit, the number of‘bandages’ required implicitly indexes both the duration and cost oftreatment. Many hereditary practitioners work alongside one ormore other family members and the most senior practitioner oftencarries out home visits in the afternoon or eveningwhile the shop isattended by a son or nephew. Home visits cost more than clinic-based treatment e generally, at least Rs.100/- per visit, plus travelexpenses if necessarye and these visits are said to be for thosewhoare immobilised and cannot visit the shop in person. Howeverhome visits also seem to be undertaken for wealthier patients andfor women in parda or thosewho do notwant to undergo treatmentin a public place; thus the socio-economic profile of those attendingthe shops does not necessarily accurately reflect the full range ofclientele.

Many practitioners provide treatment for a wide range ofcomplaints including, for example, skin conditions and sexualdisorders but the great majority of patients who consult havesprains, fractures, injuries to limbs, or musculo-skeletal pain.Practitioners tend to self-calibrate the range of injuries andimpairments that they treat, with those who lack extensive expe-rience or hereditary knowledge refusing to reduce fractures at alland confining their treatment to muscular aches, strains andsprains. None of those interviewed were willing to treat compoundfractures or injuries that involve breaks to the skin and if such casespresent, they are generally advised to seek hospital care. A key skillnoted by many practitioners in contradistinction to biomedicine isan ability to diagnose manually (a process that includes carefulobservation of patient reactions to touch and gentle pressure) butfew regarded X-rays as entirely unnecessary; some acknowledgedtheir value in situations of uncertainty and in many cases clientsanyway obtain X-rays at private diagnostic facilities on their owninitiative and bring them to consultations, just as they would if theywere to visit a biomedical facility.

For treatment all practitioners use oil, ointments (lep, marham)and cotton wool to cover the affected area prior to bandaging, aswell as cardboard or bamboo for splinting in cases of severe sprainor simple fracture. Almost all practitioners claim to make up theirown medicinal preparations using indigenous herbal ingredientsand it is these medicaments, rather thanmanipulative skill, that areregarded as the basis of therapeutic effectiveness. Medicinal recipesare carefully guarded and are generally committed to memory,although a few practitioners testified to having inherited hand-written books that record the ingredients for different medicines,while two practitioners referred to the use of printed texts. Mostpractitioners characterized their medicinal knowledge as Ayurve-dic and only three were observed to recommend or provide allo-pathic medicine to patients in the form of over-the-counter

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painkillers. Particular emphasis is placed on the ability to maintainsuppleness and movement in fractured limbs and greater speed ofhealing, in contrast to conventional allopathic treatments involvingimmobilisation of the limb in plaster. Informal observation andquestioning of clients indicated that many patients seek treatmentfrom these practitioners for restricted mobility of a limb followinga fracture that was set in plaster using conventional biomedicaltreatment at a public or private hospital. The provision of treatmentthat allows continued movement, is rapidly effective and henceenables working people to continue to get around and earn a livingwas particularly remarked upon and the following remarks explainwhy many people find bone doctors’ mode of treating fracturepreferable to that of allopathy:

Now what happens is that even in a sprain they [doctors] willput plaster til here [indicates below knee]. After plaster, one canonly rest. He cannot walk about. He cannot do anything. In ourplace, if you have a sprain, the patient can walk about becauseour bandage is small and light. It is convenient for him to walkalso. It provides relief. The person can wear slippers also andmove around outside. Some people [..] can even drive them-selves. This is not possible with plaster because plaster is thickand the leg may be unevenwith it also. (PM2211I; italics denoteuse of English term in original)

Similarly, the greater speed attributed by both patients andpractitioners to this mode of treatment compounds the lowereconomic costs associated with this form of treatment in compar-ison with biomedical care, the expense of which was repeatedlynoted:

[With a plaster it] needs to be put in a sling because of which thearm becomes stiff. One is unable to raise and lower it til it heals.Then they have to do exercise and a lot of time gets spent; onemonth for treatment and one month for exercise. It takes a lot oftime. But in our place, we give clarified butter and medicineswhich keep the muscles soft and heal the fractured bone. Also,themuscles in the side and the nerves are kept soft with this andthis makes movement easy because of which the treatmenthappens faster. (2PL2311M)

We do small work only like when it is dislocated, or scratched.We treat that and our treatment is faster than a doctor’s. Supposesomeone has a sprain and they go to a doctor, then it will takeabout 2e3 weeks. If they come to us then we will treat them in7 days. [.] The expenses are higher in hospital and problemsare many. Ours is cheaper and more convenient. (PM2211I)

Reputation, legitimation and the ambiguity of expertise

Despite the close historical association between wrestling asa sporting institution and this therapeutic specialization, mostcontemporary practitioners are adamant that one need not bea wrestler (pahalvan) in order to be a bone physician (haad vaidya).Many informants were emphatic that their therapeutic expertise isentirely discrete and autonomous from the sport out of which theirspecialization originated historically in the days before the devel-opment of biomedicine, when the heads of wrestling schools had tominister to students who suffered injury during training. Certainteachers were held to have developed particular skills and medi-cations for this purpose and gradually acquired renown for theirability to treat muscular and bone problems, taking on apprenticesin this therapeutic modality. One specialist explained:

‘There’s no relationship with wrestling, exercise is a separatething, it’s not necessary that those who wrestle all know thiswork. (PM2211I)

His son, one of twowhowork alongside their father, elaborated:‘Our great-grandfather put in 20-25 years of practice from hisyouth in learning this work, then he learned this thing, it’s notjust that you’ve done wrestling and now there are a lot ofcountry folk and bodybuilders they don’t know this work, this isa separate practice a separate experience, and it is a differentline of work.’ (PM2211I)

Not only do hereditary, or ‘familial’ (khaandaani) haad vaidyaregard these ‘country folk and bodybuilders’ as inauthentic butthey regard inexpert practice as dangerous to their reputationamong the public at large and the allopathic profession: ‘Thereare many people who call themselves wrestlers and sit here anddomassage. They sit and do this work and don’t understand thatthis gives our work a bad name.’ (PS2011X)

Another practitioner who runs a successful family practicewhere treatment is provided and a popular medicinal oil is man-ufactured for sale to patients and other practitioners, explained:

No they are not from wrestler families, but people have takenthe name of wrestler [although] mostly those people are notfrom families of wrestlers, nowadays what’s happened is thatpeople’s livelihoods are finished so .. what people have done issit in various places and have written [on signboards] that I ama wrestler too.but those people don’t have much experience,they don’t have practice, many wrestlers come to us to take ourmedicine from here, and they just massage,.. (PR2611B)

The targets of such assertions are the practitioners, also knownto the public as ‘wrestlers’ (pahalvan), who have open-air pitches.Several of these sites have in fact been held over generations, sothat familial expertise becomes associated with them and thesepractitioners too have acquired expertise through exposure sincechildhood. Other outdoor practitioners laid claim to the title of‘wrestler’ on the grounds that they had taken up this work after anearlier amateur career in actual wrestling, sometimes after retiringfrom other (generally manual) occupations. One notable distinctionbetween such practitioners and most of those who have inheritedtheir occupation was their lack of familiarity with the term ‘bonedoctor’ (haad vaidya); when asked for the name of their occupationthey simply described themselves as ‘wrestler’ (pahalvan), whereasthose with hereditarily acquired skills emphasized that they are notwrestlers (pahalvan) but ‘bone doctors’ (haad vaidya). All those notworking from enclosed premises tend to be regarded by familialbone doctors (haad vaidya) as inauthentic:

‘What happened is that these people who don’t know anythingstarted sitting on the footpath. They pretend to be wrestlers [i.e.bone doctors]. They don’t do proper treatment and our namegets spoilt. Now I sit here inside [his treatment room at home]and there is nothing written that treatment is done here. But youhave seen people coming here. I treat them well which is whythey come. [..] these people just get those herbs from themarket and mix it in artificial oil and start applying it. But theywill not know how to set bones. They can get themedicines fromme but they will not know how to set a bone, keep it in thatposition and how to set it in every angle. Only the trained peoplewill know how to do that. (2PL2311M)

Clearly, the inherent ambiguity between wrestling as a sportand bone doctoring as a medical specialization poses a problem forauthenticating expertise in this uncredentialled field. The use ofphotographs and other items associated with wrestling such astrophies are almost ubiquitous in bone doctors’ shops and providea form of implicit authentication, while reference to the intergen-erational transmission of expertise provides an important source of

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legitimacy for practitioners. Thus the signboards which announcetheir occupation usually state the name of the ancestor whoestablished the practice or the master from whom the currentincumbent learned his skills; many signboards do not display thename of the present practitioner at all. There are clear continuitiesin this respect with Unani, one of the elite codified systems ofIndian medicine, in regard to the appeal to lineages of expertise asauthorizing individual practitioners (Attewell, 2007). In a few cases,personal names have effectively become a brand name fora distinctive medicinal preparation manufactured by that family ofbone doctors.

As the above quotations show, the problem with drawing onpopular associations between wrestling and bonesetting in publicadvertising is, of course, that not all wrestlers have expertise inbone doctoring. There are signs that in an increasingly crowdedmedical market, some practitioners are responding to this ambi-guity by discarding such associations. The style of a new clinicrecently established by one hereditary practitioner away from thefamilial home (where his ancestors practiced and his fathercontinues to see patients) suggests an attempt at repositioning. Thenew signboard is strikingly distinct from that of the traditional haadvaidya, which always shows a hand-drawn bandaged arm and legand describes the practitioner as ‘wrestler’ (pahalvan); it isprofessionally produced, heavily laminated and announces (inDevanagari script) ‘Fracture clinic’ (‘Frektur chikitsa’), flanked oneither side with a red cross and a pair of photographic imagesdepicting an arm in a neatly tied sling, reminiscent of cosmopolitanbiomedical treatment styles. The term ‘wrestler’ does not appear onthis practitioner’s signage and his language is replete with medicaland English terminology such as ‘inflammation’, ‘lumbar’ and‘cervical’ regions; but he is vociferously critical of allopathy’sapproach and is a strong adherent of the benefits of the haad vai-dya’s approach as a distinct treatment modality (pathy). Similarly,the business cards of two other practitioners depict biomedicalcolour images of a meniscus and a backbone respectively, ratherthan the traditional iconography found on other cards.

The grounds of expertise and its selective legitimation

As several of the preceding quotes indicate, familial practi-tioners emphasise the need for extensive experience as thegrounding for expertise in bone doctoring. It is understood asacquired through everyday exposure to, and gradually increasingparticipation in, therapeutic practice as a consequence of it beinga familial specialization. This mode of acquisition of ‘contributoryexpertise’ (Collins & Evans, 2007) through apprenticeship modes oflearning as a consequence of participation in a kin-based‘community of practice’ (Lave & Wenger, 1991) is characteristic ofmany forms of occupational specialization in South Asia, as else-where. Recent work on the nature of expertise in the sociology andphilosophy of science has demonstrated that while qualifications(credentials) are commonly understood to define expertise, one canbe an expert without holding qualifications and experienceconstitutes a more important core criterion for delineating exper-tise (Collins & Evans, 2007:52, 68). Bone doctors have expertise inthe eyes of the patients they treat, but they are not authorised toprovide care, since the modern State takes formal qualifications tobe the sole criterion for recognition of expert status. Analysis of thehistory of legislative approaches to uncredentialled practitionersshows that bone doctoring has been rendered a marginal practicethrough a relatively recent shift in the grounds for legitimatingmedical expertise.

The first legal Act to regulate medical practice in India was theMedical Registration Act of 1915 (Jeffery, 1988) which, although itbecame notorious for its purported intention to outlaw non-

biomedical forms of medical practice, applied only to biomedicaldoctors. It was not until around the time of Independence that theIndian State first attempted to regulate indigenousmedical forms. Anumber of State Governments established Boards of Indian Medi-cine in the 1940s and early 1950s and passed laws that aimed toregulate the practice of medical specialists. In view of the heredi-tary, apprenticeship-based nature of much indigenous medicaltraining, these Boards provided two alternative types of registra-tion to accommodate those without formal qualifications (B graderegistration) as well as those who had received formal training inmedical colleges leading to the acquisition of an accredited degree(A grade registration). In Rajasthan, with the passing of the JaipurAyurvedic and Unani Tibbi Practitioner Act 1953 (which replacedthe first registration Act, passed in 1943) a State Indian MedicineBoard was set up to regulate these practitioners through registra-tion (Board of Indian Medicine, Rajasthan 1953). The board, con-sisting of 11 members including hakim and vaidya as well asbiomedically qualified practitioners, was responsible for deter-mining whether indigenous practitioner applicants, including haadvaidya and other specialists as well as vaidya and hakim, qualifiedfor registration. Until 1976, ‘experience-based’ registration underSection B of the Act was permitted on the basis of five yearsexperience and the passing of an oral examination conducted bythe Board members (Dr. Raghunandan Sharma, President of CentralCouncil of Indian Medicine, personal communication; Attewell,2005:413 gives some examples of similar policies in other States).

Certificates of practice from this Board, mostly dating from the1950s and 1960s, are displayed on the walls of a number of haadvaidya treatment rooms in Jaipur; the incumbents or their forbearshad been awarded certification on the basis of oral examination.One older practitioner described the process whereby he obtainedthis form of registration:

There used to be a proper examination. 2 vaids [Ayurvedicpractitioners], 2 hakeems [Unani practitioners], 2 Unaanihakeems (Unani practitioners) used to sit in the panel andquestion us: What is it that you want to do? How will you do it,tell us? How is medicine made? If an arm is broken, then howwill you fix it? In what way will you hold the fixture together?How will you tie the bandage? (PJ2111A)

Government registration under the Deshiya Cikitsa Act 1953(Provision 1936 Subsection 1K) meant the practitioner was entitledto provide patients with a certificate valid for the purposes ofobtaining leave from employment or medical compensation. TheAct covered registration of practitioners of an Indian system ofmedicine, defined as hakim and vaidya, and of midwives (Board ofIndian Medicine, Rajasthan, 1953); enquiries from the office ofthe Board of Indian Medicines, Jaipur established that haad vaidyawere registered as Ayurvedic practitioners under the Act. Theestablishment of the Central Council for Indian Medicine in 1971marked federal level recognition and control of Indian medicinedegrees and medical college syllabi and ‘experience-based regis-tration’ under Section B of the 1953 Act was formally discontinuedin 1976.

The demise of experience-based registration was stronglyopposed by hereditary practitioners of Ayurveda and Unani, since iteffectively debarred thosewho lacked amedical degree awarded bya recognised institution from practicing medicine. Litigationagainst the Rajasthan State Indian Medicine Board was brought bya number of practitioners who lacked recognised qualifications, asa result of which some of these ‘unqualified’ vaidya actuallycontinued to practice legally until 2010, when the case was finallydecided by the Government of India’s Supreme Court against thelitigants. This regulatory legislation de-recognised what had untilthe mid-twentieth century been the dominant mode of indigenous

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education, long-term apprenticeship to a skilled practitioner (akathe guru-shishya model of education). This aspect of the history ofmedical regulation is well known to historians and sociologists ofmedicine as it affected the codified traditions of elite indigenousmedicine, due to the high profile of Ayurveda as a symbol andvehicle of nationalism. What has not previously been recognised isthe effect of compulsory professionalization (through the enforcedestablishment of college-based training) on non-textually basedtraditions of the kind with which this article is concerned.

Professional regulation and the delegitimation ofperformative expertise

The editors of a recent volume on the regulation of healthprofessions define the professions as ‘special kinds of knowledge-based occupations’, noting further that, ‘Of course, knowledge isnot unique to professional groups and only those occupations thathave been successful in obtaining a licence to practice from thestate are regarded here as professions’ (Allsop & Saks, 2002:4). Thepreceding historical account demonstrates that treatment modali-ties that may now be considered ‘local health traditions’ have notnecessarily always existed unchanged as forms of ‘folk medicine’ ina temporal vacuum but have become marginal through theirexclusion by the state. In this sense, the short period during whichbone doctors became subject to regulation by Indian MedicineBoards, thereby gaining access at least in principle to registrationand formal recognition as a medical speciality, can be seen asa historical moment in which accreditation briefly becamea potential possibility for bone doctors. Wholesale legitimation,however, would have required professionalization (Last, 1990) viathe formalisation of practitioners’ performative expertise intoa discrete, terminologically distinct speciality, as occurred for thetextually authorised indigenous traditions of Ayurveda and Unaniin India (and for other osteological traditions such as osteopathyand chiropractic elsewhere in recent decades). Instead, with thewithdrawal of ‘experience-based registration’, bone doctors, unableor unwilling to achieve credentialed expertise sanctioned throughthe development of formal training and accredited learningcurricula leading to professional qualifications, did not disappearbut continued to practice without official sanction. Sociologicalwork on the professions elsewhere has treated professionalizationas part of processes of modern class and state formation. This casestudy offers an inverse instance of exclusion, wherein a specialistoccupation fails to achieve legitimation through professionalizationbut continues to operate at the margins as a subaltern practice. Ifthe margin of the state is conceptualized as ‘a space betweenbodies, law and discipline’ (Das & Poole, 2004:10), the space thatbone doctors now occupy can be seen as situated at the peripheryboth of the sovereign force of law (as manifested in repeatedsporadic attempts to regulate medical practice) and of disciplinarypower (in regard to the medical discipline that the state seeks toimpose on its population).

Such an account acknowledges the sense in which medicalexpertise requires authorization in order to be recognised aslegitimate (cf. Hogle, 2002). The case of bone doctors demonstrateshow certain forms of expertise are valorized over others. Anthro-pologists have tended to focus on distinctions between ‘profes-sional’ and ‘lay’ expertise, but this formulation fails to find purchasein cases such as bone doctoring where expertise is clearly speci-alised but is not professional. Moreover, as Collins and Evans(2007:48e53, 142) have argued, the notion of ‘lay expertise’ isessentially tautological, since the boundaries of actual expertise‘are not coextensive with the boundaries of accredited expertise’(Collins & Evans, 2007 :142); they propose replacing the term ‘layexperts’ with ‘experience-based experts’, a phrase strikingly

reminiscent of that used by the Rajasthan Board of Indian Medi-cines. ‘Experience-based’ registration constituted an attempt toprovide an avenue for authorization of what Weinstein (1993) hasdistinguished as ‘performative expertise’ (what one does), incontrast to ‘epistemic expertise’ (what one knows).

In the process of formalizing medical knowledge, ‘epistemic’expertise that can be acquired from secondary sources and testedthrough written examination inevitably becomes valorized over‘performative’ expertise that is acquired through experientiallearning. If expertise is enactment (Carr, 2010), the process ofinstitutionalization required for any external authorization ofexpertise seems to require the rendering of knowledge formerlyknown and enacted through bodily practice into verbal perfor-mance (ibid. 2010:19). In this way the experience-based, perfor-mative expertise of bone doctors has been progressivelydelegitimated, while professionalised systems of Indian medicineare incorporated into health systems through formal qualificationsthat are notoriously weak in ensuring the acquisition of practicalexpertises, but enable official accreditation.

The establishment of Boards of Indian Medicine composed ofelite practitioners to evaluate the expertise of other, unqualifiedpractitioners such as haad vaidya in the post-Independence period,is also indicative of important hierarchies among different kinds ofmedical specialist. The indigenous traditions of Unani and Ayur-veda have widely been regarded as subordinate in both status andpower to biomedicine in India’s contemporary health carearrangements, but these professionalised traditions in turn had thecollective authority to adjudicate on the legitimacy of a range ofmedical traditions on behalf of the state. As Hogle has noted(2002:237), the interactions between groups, concepts and prac-tices both produce expertise and establish authority. Conflictsbetween different medical traditions are replicated within specificmedical domains, as demonstrated in the above quotes assertinga lack of authentic expertise among outdoor practitioners. Thesecontestations among contemporary bone doctors exemplify thedifficulty in evaluating claims to expert knowledge that restperforce on the informal credentials of lineage-based authority andpublic repute. Uncredentialled practice-based specialisms such asbone doctoring that rest on informal acquisition of expertisethrough experience-based learning, lack external criteria uponwhich to base such claims.

Many bone doctors articulate trenchant critiques of biomedicaldoctors’ venal tendencies and disrespectful treatment of patients,while describing the merits of their own treatment modality andcharacterizing their work as a form of service to clients. Yetindividually, their concerns focus on inauthentic practice amongother practitioners of the same treatment modality; with norecourse to collectively agreed criteria for appraisal, hereditarypractitioners locate the source of the poor perceptions held ofthem among health professionals in the inferior care provided bycolleagues, who they consider illegitimate representatives of thistherapeutic speciality. Similarly, no external authority would beable to discriminate between practitioners for purposes of iden-tification, validation or reinforcement (as recommended innational policy on Indian Systems of Medicine, Government ofIndia, 2002) without instituting either the discredited forms oforal examination upon which registration once depended, orintroducing new forms of standardised training that incorporateindependent appraisal.

As this study demonstrates, however, while bone doctorsremain largely invisible both in the eyes of the state and inacademic scholarship, both north Indian haad vaidya and practi-tioners of other bone doctoring traditions found elsewhere in Indiaare popular avenues of medical resort. Their lack of credentialledexpertise is clearly no bar to utilization for the local population.

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Among clients and among bone doctors, reputation and lineagecontinue to constitute more salient sources of authority thanformal qualifications.

Conclusion: reconceiving Indian ‘medical pluralism’ and itspolicy consequences

In this paper I have described how haad vaidya escape, orperhaps defy, ready classification into or out of the official cate-gories of indigenous medicine that in health care policy are rec-ognised as AYUSH, although there is evidence of links withAyurvedic knowledge and with sporting-derived therapeutic skillsof a kind that in parts of South India have received formal recog-nition as Marma medicine. In Rajasthan, bone doctors have onlybriefly and partially been subject to the exercise of governance;‘traditional orthopaedic practitioners’ are ‘ambiguous entities inthe eyes of the state’ (Unikrishnan et al., 2010:194). That bonedoctors remain largely invisible as health care practitioners inregulatory terms, in health policy and in academic research is anindex of their subalternity. The marginality of bone doctors andtheir progressive exclusion from the conceptual possibilities ofwhat constitutes medical knowledge in the state’s definition maybe an inherent consequence of the nature of their expertise.

Despite this absence in academic and policy considerations ofhealth care provision, in the everyday lives of the citizens of theregion ‘bone doctors’ play a valued role in the remediation of injury.While poorly established practitioners may see at best a handful ofpatients per day, more popular and reputable practices attractupwards of 60 clients daily. The continuing appeal of this form oftherapy among the public can be attributed to a wide range ofreasons apparent in the research material collected for this study(reported elsewhere; Lambert, in press) but beyond the scope ofthis paper to describe in detail. These include scepticism about thehealing capacities of biomedical doctors, associated with theirremoteness and pursuit of profit; a refusal to accept elite institu-tionalized medicine as necessarily superior to other forms; and thehigh cost, poor quality and relative inaccessibility of biomedicalalternatives.

Current health policy debates in India highlight a crisis resultingfrom the dearth of ‘skilled’ or ‘trained’ health professionals in thehealth system (Government of India, 2010; Rao et al., 2011:596) andremedies currently being advocated or implemented include notonly the ‘mainstreaming’ of AYUSH professionals into the nationalhealth system but the expansion of medical colleges to train morebiomedically qualified practitioners, a controversial new degree inRural Health Care (Anon, 2010; Dhar, 2010; Jacob, 2010; Ramadoss,2010; Varghese, 2011), universal registration of qualified healthproviders with integration of ‘non-medical health practitioners’into the health system through a national regulatory body (Reddyet al., 2011:763) and a massive increase in nursing education (Raoet al., 2011). The new initiatives seek to address the longstandingsystemic inability to establish universal and equitable provision ofquality health care and the prospect of greater funding for India’slong-neglected government health sector has been widelywelcomed. In discussions of human resources for health, however,‘training’ and ‘skills’ are frequently conflated both with one anotherand with ‘qualifications’, so that those who lack formal qualifica-tions are assumed to lack any kind of skills or training. Moreover,significant distinctions between different kinds of uncredentialledpractitioners are elided, so that those such as bone doctors wholack formal credentials but practice a particular therapeuticspecialization, are equated with the many informal private practi-tioners (often termed ‘Registered Medical Practitioners’) whopractice allopathic medicine illegally without any qualifications(e.g. Rao et al., 2011:3, Sheehan, 2009).

India’s national policy makers have observed that, ‘Despiteconstraints of human resources, practitioners of Indian Systems ofMedicine (ISM), Registered Medical Practitioners (RMP), and otherlocally available human resources have not been adequatelymobilized and integrated in the system.’ (Planning Commission,2008:65) If ‘local health traditions’ are genuinely to be harnessedto the cause of ensuring universal health care provision for India’spopulation, a more comprehensive and nuanced understanding oftheir nature and content is an essential step and this case study isintended as a small contribution in this direction. As recent scan-dals over the fraudulent accreditation of private biomedicalcolleges have illustrated, formal qualifications do not necessarilyequate to the acquisition of genuine therapeutic expertise or ensurethe provision of high quality care. Although evaluation of treatmenteffectiveness is beyond the scope of this purely qualitative analysis,the case study material presented above suggests that conversely,a lack of formal accreditation does not necessarily signify thecomplete absence of therapeutic expertise. Current policy initia-tives that contemplate, for example, provision of shorter trainingcourses to ‘non-physician health care providers’ (Government ofIndia, 2010:31), offer a potential opportunity to harness, ratherthan to marginalize further, human resources that already exist inthe informal health sector if appropriately extended to includecertain non-credentialled specialists. Future policy initiativesshould rest on solid foundations of evidence concerning not onlycontemporary realities of treatment-seeking and treatment provi-sion, but also the history and consequences of legislative changesfor the regulation, exclusion, professionalization and incorporationof diverse medical traditions.

Acknowledgements

I wish to acknowledge the support provided by the University ofBristol and by the Institute of Advanced Study, Jawarharlal NehruUniversity, New Delhi through a Fellowship for the academic year2009e2010. Many thanks go to Anita Rathi, who assisted me withmany of the interviews and transcribed the audio recordings; andto Riddhi Bhandari, who painstakingly translated the transcripts. Iam grateful to all the practitioners who permitted me to observetheir work and interview them with tolerance and good humour.My deepest thanks are to the late Mohammed Aslam Khan (Salang),who took up the search for bone doctors and accompanied me onvisits all over the city and beyond. He is greatly missed.

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