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Abstract
This article explores the potential conflict between allopathic (‘Western’) medicine and rural beliefs in village goddesses, given that each demands blood for diagnostic purposes and sacrifices, respectively. Our objective is to understand the experiences and attitudes of rural residents to blood tests, blood donations and blood transfusions. We explore the specific question of the extent to which poor villagers in Wardha district, Maharashtra, might be supportive of or opposed to point-of-care blood testing at their doorsteps. We began by asking them about their religious practices, including the sacrifice of animals and offerings of blood to deities. Such values could affect their perspectives on human blood and allopathic medicine. After that, we asked whether they had any fears about modern medical treatments and technologies—such fears might be driven by anxieties about angering goddesses if human blood was used for non-sacred purposes. Our investigations took us into an inquiry about villagers’ experiences with hospitals. We came to realise that for villagers, despite the costs of hospital diagnosis and treatment, hospitalisation had become a source of new knowledge about blood. And, finally, we asked villagers what they thought about the value of point-of-care blood testing at their doorstep. We were told that the high cost of hospital treatment means that villagers support technologies that can be used at their doorstep and work towards improving their health and longevity.
Acknowledgements
We thank Dr. Oliver Mendelsohn (La Trobe University), Professor Gordon Whyte (Monash University), Dr. Jacob Copeman (University of Edinburgh), Professor Michael Lipton (IDS, Sussex University) and Vivien Seyler for their feedback on earlier versions of this article and Professor Kama Maclean for her later input. We also extend our thanks to two reviewers for South Asia for their valuable comments on an early draft.
Disclosure statement
No potential conflict of interest was reported by the authors.
Notes
1. World Bank, ‘Table for Rural Population (% of Total Population): All Countries and Economies: India, 2019’ [https://data.worldbank.org/indicator/SP.RUR.TOTL.ZS, accessed 25 April 2021].
2. Rs1,400 per birth was available to women from the ten poorest, most economically backward Indian states and half of that amount to women in the other states, including Maharashtra.
3. Sukumar Vellakkal et al., ‘A Qualitative Study of Factors Impacting Accessing of Institutional Delivery Care in the Context of India’s Cash Incentive Program’, in Social Science and Medicine, Vol. 178 (2017), pp. 55–65 [62].
4. For a classic statement on this, see Helen Lambert, ‘Medical Pluralism and Medical Marginality: Bone Doctors and the Selective Legitimation of Therapeutic Expertise in India’, in Social Science and Medicine, Vol. 74 (2012), pp. 1029–36.
5. A comprehensive discussion about this can be found in David Hardiman and Projit Bihari Mukharji (eds), Medical Marginality in South Asia: Situating Subaltern Therapeutics (London/New York: Routledge, 2012).
6. AYUSH practitioners are those recognised by the new Ministry of Ayurveda, Yoga, Naturopathy, Unani, Siddha, Sowa-Rigpa and Homoeopathy set up in November 2014. The ministry seeks to extend to these medical approaches the professional recognition given to allopathy.
7. In earlier times, the blood sacrifices of the Kolis included planting rice and millet at the entrance to the famous Koli temple of Mumbadevi at the start of the Hindu calendar month of Ashwin (October–November). The fledgling crop was sown at the end of Ashwin when the ‘pale seedlings’ were pulled out and presented to the goddess: see Raghunathji, The Hindu Temples of Bombay (Bombay: Port Printing Press, 1900: repr. by Phiroze Ranade, 2003), p. 30. As Shulman explains, blood is seed and also milk and all three embody sacred transformative powers: David D. Shulman, Tamil Temple Myths: Sacrifice and Divine Marriage in the South Indian Saiva Tradition (Princeton, NJ: Princeton University Press, 1980), pp. 103–7. The buffalo demon Mahisasura symbolises the shedding of blood in war and is the equivalent of the less violent image of the harvesting of grain: Shulman, Tamil Temple Myths, p. 11.
8. Perundevi Srinivasan, ‘Stories of the Flesh: Colonial and Anthropological Discourses on the South Indian Goddess Mariyamman’, unpublished PhD dissertation, The George Washington University, Washington, DC, 2009, pp. 3, 7, 19, 143. This thesis is based on extensive fieldwork in Tamil Nadu and Puducherry: see Map 1, p. 30.
9. Babagrahi Misra, ‘“Sitala”: The Small-Pox Goddess of India’, in Asian Folklore Studies, Vol. 28, no. 2 (1969), pp. 133–42.
10. Tulasi Srinivas, ‘India’s Goddesses of Contagion Provide Protection in the Pandemic—Just Don’t Make Them Angry’, The Conversation (15 June 2020) [https://theconversation.com/indias-goddesses-of-contagion-provide-protection-in-the-pandemic-just-dont-make-them-angry-139745, accessed 7 Sept. 2021].
11. Shulman, Tamil Temple Myths, pp. 104, 107.
12. ‘Point-of-care testing (POCT) is a form of testing in which the analysis is performed where healthcare is provided close to or near the patient. Various definitions have been provided in the medical/scientific literature and alternative descriptions include: near patient testing (NPT), bed side testing, physician’s office testing (POL), off site testing, alternative site testing, etc.’: Department of Health, ‘Definitions—Point-of-Care Testing’ (Canberra: Department of Health, 2013) [https://www1.health.gov.au/internet/publications/publishing.nsf/Content/qupp-review∼qupp-definitions, accessed 5 Sept. 2020].
13. Marika Vicziany and Jaideep Hardikar, ‘Point-of-Care Blood Tests: Do Indian Villagers Have Cultural Objections?’, in Frontiers in Chemistry, Vol. 6, no. 505 (2018), DOI: 10.3389/fchem.2018.00505.
14. Fieldwork was undertaken from November 2017 to March 2018.
15. A. Kleinman et al., ‘Culture, Illness and Care: Clinical Lessons from Anthropologic and Crosscultural Research’, in Annals of Internal Medicine, Vol. 88, no. 2 (1978), pp. 251–8.
16. Maharashtra State Databank, ‘Below Poverty Line Families in the Rural Areas’ (2010–11) [https://mahasdb.maharashtra.gov.in/SDB_Reports/Wardha/PDF/2010-11_Wardha_DSA_5_17.pdf, accessed 12 Mar. 2018]; and Maharashtra State Databank, ‘Below Poverty Line Families in the Rural Areas’ (2012–13) [https://mahasdb.maharashtra.gov.in/SDB_Reports/Wardha/HTML/2012-13_Wardha_DSA_8_28.html, accessed 21 Mar. 2018].
17. Maharashtra State Databank, ‘Area under Irrigation by Various Sources’ (2010–11) [https://mahasdb.maharashtra.gov.in/SDB_Reports/Wardha/PDF/2010-11_Wardha_DSA_5_17.pdf, accessed 12 Mar. 2018].
18. Dalit refers to former untouchables whose official designation now is Scheduled Castes. The proportion of tribal and Dalit families in our study is higher than the average for Wardha district because we set out to do this, given that these social groups are normally the poorest. For Wardha district, the 2011 Indian Census reported that 11.49 percent were tribal and 14.52 percent Dalit, i.e. a total of 26 percent of the population: see Census of India 2011, ‘Wardha District Population, Maharashtra’ [https://www.censusindia2011.com/maharashtra/wardha-population.html, accessed 20 Aug. 2018].
19. Farmer suicides in Wardha district are the highest in the Vidarbha region, reflecting high levels of crop failure, mounting debt and the failure to receive compensation: see Vaibhav Ganjapure, ‘Over 7,700 Vidarbha Farmers Committed Suicide in 6 Years’, The Times of India (29 Mar. 2019) [https://timesofindia.indiatimes.com/city/nagpur/over-7700-vidarbha-farmers-committed-suicide-in-6-yrs/articleshow/68621181.cms, accessed 27 April 2021]. See also Jaideep Hardikar, Ramrao: The Story of India’s Farm Crisis (Delhi: Harper Collins India, 2021).
20. International Institute for Population Sciences, National Family Health Survey 2005–2006: India, Vol. 1 (Deonar/Mumbai: Government of India, 2008) [https://dhsprogram.com/pubs/pdf/frind3/frind3-vol1andvol2.pdf, accessed 25 April 2021]. This report showed that 25 percent of rural women cited distance as the main obstacle to using a health facility, pp. 447–8.
21. Named after Kasturba Gandhi, Mahatma Gandhi’s wife.
22. Ananya Barua, ‘Sushila Nayar, Gandhi’s Doctor Who Spent Her Life Giving Medical Care to the Poor’, The Better India (1 July 2019) [https://www.thebetterindia.com/187641/sushila-nayar-doctor-mahatma-gandhi-woman-health-minister-india/, accessed 25 April 2021].
23. Ramachandra Guha, ‘The Mahatma on Medicine, The Telegraph’, Ramachandraguha.in, 2017 [http://ramachandraguha.in/archives/the-mahatma-on-medicine-the-telegraph.html, accessed 25 April 2021].
24. B.S. Garg, ‘Village First: Community Empowerment on Health and Development Based on Gandhian Approach—An Experience of Working in a Few Villages of Wardha District, Maharashtra’, in Indian Journal of Medical Research, Vol. 149, suppl. (Jan. 2019), pp. S63–7, DOI: 10.4103/0971-5916.251659; and Ira Klein, ‘Death in India, 1871–1921’, in Journal of Asian Studies, Vol. XXXII, no. 4 (Aug. 1975), pp. 639–59.
25. Sudha Ramani and Muthusamy Sivakami, ‘Community Perspectives on Primary Health Centers in Rural Maharashtra: What Can We Learn for Policy?’, in J Family Med Prim Care, Vol. 8, no. 9 (2019), pp. 2837–44, DOI: 10.4103/jfmpc.jfmpc_650_19: 10.4103/jfmpc.jfmpc_650_19.
26. PHCs and sub-centres do not employ private doctors, but many government practitioners in rural India run their own private clinics: personal communication from TISS scholar, Mumbai, 31 Aug. 2021. Government doctors can be appointed with degrees in allopathic (Western) medicine or they can be from the AYUSH degree system (Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homoeopathy). There is a widespread complaint by medical professionals and government and health experts that due to the shortage of allopaths in remote, rural and tribal areas, these different medical systems end up in ‘mixed’ practices and mixed drug use. See, for example, Milind Bansode et al., ‘AYUSH and Health Services Policy and Practice in Maharashtra’, in Economic & Political Weekly, Vol. 53, no. 37 (15 Sept. 2018), pp. 20–4 [https://www.epw.in/journal/2018/37/commentary/ayush-and-health-services.html, accessed 1 Sept. 2021]. The Maharashtra Medical Council has emerged as a strong defender of keeping the different medical systems of India separate and protecting the professional status of the MBBS (Bachelor of Medicine, Bachelor of Surgery) degree: Garima, ‘Allopathy vs Ayush in Maharashtra: Medical Council Order Sparks Controversy’, in Medical Dialogues (8 Sept. 2020) [https://medicaldialogues.in/state-news/maharashtra/allopathy-vs-ayush-in-maharashtra-medical-council-order-sparks-controversy-72668, accessed 1 Sept. 2021].
27. Enakshi Ganguly et al., ‘Quality Assessment of Private Practitioners in Rural Wardha, Maharashtra’, in Indian Journal of Community Medicine, Vol. 33, no. 1 (Jan.–Mar. 2008), pp. 35–7, DOI: 10.4103/0970-0218.39241.
28. Interview with Uday Meghe, Wardha town, 8 Aug. 2021.
29. Interview no. 2, Aamgaon-Khadki village, 15 Jan. 2018.
30. Before railways appeared, the Banjaras ran bullock trains to facilitate India’s inland trade. When displaced by technology, they used their knowledge to steal cattle, for which the British Indian government classified them as ‘criminal tribes’.
31. Interview no. 4, Chandani village, 26 Jan. 2018.
32. Similar beliefs have persisted in urban areas. Parry reported that in the steel city of Bhilai, local workers distinguished between two different kinds of sacrifices (bali): voluntary (pujwan) and forced (bhakh). Many of the industrial accidents at the steel plant were attributed to bhakh or forced sacrifices extracted by deities who resented the fact that they had been ignored by factory owners and workers and received no pujwan: Jonathan Parry, ‘The Sacrifices of Modernity in a Soviet-Built Steel Town in Central India’, in Anthropology in This Century, no. 12 (Jan. 2015) [http://aotcpress.com/articles/sacrifices/, accessed 14 May 2018]. Urban Kolis in Mumbai also continue to sacrifice chickens to goddesses and water spirits: Marika Vicziany et al., ‘Ekveera Devi and the Son Kolis of Mumbai: Have the Kolis Appropriated the Karle Buddhist Chaitya?’, in Ian Mabbett and Jayant Balachandra Bapat (eds), Conceiving the Goddess: Transformation and Appropriation in Indic Religions (Melbourne: Monash University Publishing, 2017), chap. 11, pp. 225–57.
33. Interview no. 1, Dorli village, 13 Mar. 2018.
34. Interview no. 2, Dorli village, 13 Mar. 2018.
35. Jacob Copeman, ‘Violence, Non-Violence, and Blood Donation in India’, in Journal of the Royal Anthropological Institute, Vol. 14, no. 2 (2008), pp. 285–6; and Vicziany and Hardikar, ‘Point-of-Care Blood Tests’.
36. Interview no. 4, Dorli village, 13 Mar. 2018.
37. The Marathi word for needle is sui, a noun, but locals prefer to use the verb tochan which means ‘pricking’ and so is more expressive. Similar fears have been reported for urban blood donors: Jacob Copeman, Veins of Devotion: Blood Donation and Religious Experience in North India (New Brunswick, NJ/London: Rutgers University Press, 2009), p. 23.
38. Ibid.
39. Interview no. 1, Chandani village, 26 Jan. 2018.
40. Traditional midwives have been replaced by hospital births: 56 percent of rural births occur in government hospitals, 24 percent in private hospitals and 20 percent at home: National Sample Survey Office, Health in India, NSS 71st Round Jan–June 2014, No. 574 (New Delhi: 2016) (hereafter, NSS 2014), p. iii and Statement 4.3 [http://mospi.nic.in/sites/default/files/publication_reports/nss_rep574.pdf, accessed 15 Sept. 2021].
41. The Marathi word for medicine is aushadhi or golya meaning pills.
42. Interview no. 2, Chandani village, 26 Jan. 2018.
43. Interview no. 1, Aamgaon-Khadki village, 15 Jan. 2018.
44. Blood in India is stored in bags, but this woman spoke about receiving a ‘bottle’ of blood—for her, it was the same thing.
45. It is not unusual amongst Dalit and tribal families for the women to act as the heads of households, a custom that reminds us of their matrilineal past.
46. Interview no. 3, Aamgaon-Khadki village, 15 Jan. 2018.
47. Interview no. 3, Salai village, 1 Feb. 2018.
48. Interview no. 1, Talegaon village, 23 Nov. 2017. The Nanda Gawali tribe used to be traditional pastoralists, but they now also farm.
49. Interview no. 2, Talegaon village, 23 Nov. 2017.
50. Notions of good and bad blood have also been reported in the Delhi Nirankari Sikh movement—the pure blood and heart of the devotees is used to explain why the community’s blood donations are accepted by local doctors. Devotees see the infusion of Nirankari blood as a way of converting others to the movement. These ideas are not, however, related to notions about caste purity: Copeman, Veins of Devotion, p. 97.
51. Interview no. 3, Talegaon village, 23 Nov. 2017.
52. Interview no. 4, Talegaon village, 23 Nov. 2017.
53. People in Delhi who are not au fait with biomedical science, especially manual labourers, believe that they have a deficit of blood (khoon ki kami) and hence they do not wish to part with any of it: personal communication from Jacob Copeman, 13 May 2018.
54. Interview no. 5, Chandani village, 26 Jan. 2018.
55. J.V. Hebbar, ‘Blood Formation—Causes of Impurity, Diseases, Treatment—Charaka Sutra 24’ (2018) [https://easyayurveda.com/2014/07/18/blood-formation-causes-of-impurity-diseases-treatment/, accessed 24 Mar. 2018].
56. Interview no. 5, Talegaon village, 23 Nov. 2017.
57. The politicisation of India’s medical system is also noted by Copeman: MLAs in Delhi often ring blood banks to organise transfusion blood for their constituents despite blood banks complaining that this means they miss out on replacement donations and payment for their services: personal communication by Jacob Copeman, 13 May 2018.
58. Interview no. 1, Dorli village, 13 Mar. 2018.
59. G.R. Howard, ‘Socio-Economic Factors Affecting Utilization of a Rural Indian Hospital’, in Tropical Doctor, Vol. 8, no. 4 (Oct. 1978), pp. 210–20.
60. ‘Sickle cell disease (SCD) is a rare blood disorder…characterized by the presence of sickle, or crescent-shaped, red blood cells (erythrocytes) in the bloodstream. These crescent-shaped cells…block blood flow in the very tiny blood vessels… This prevents the normal flow of nutrition and oxygen’: Rare Disease Database, NIH GARD Information: Sickle Cell Disease [https://rarediseases.org/rare-diseases/sickle-cell-disease/, accessed 19 Oct. 2021].
61. ‘Thalassemia is an inherited blood disorder that reduces the production of functional hemoglobin (the protein in red blood cells that carries oxygen). This causes a shortage of red blood cells and low levels of oxygen in the bloodstream, leading to a variety of health problems’: Rare Disease Database, NIH GARD Information: Thalassemia [https://rarediseases.org/gard-rare-disease/thalassemia/, accessed 19 Oct. 2021].
62. Interview no. 6 with a thirty-year-old Dalit wife of a landless villager, Talegaon village, 23 Nov. 2017.
63. Interview no. 1, Salai village, 1 Feb. 2018.
64. Each year, the Australian Red Cross collects 1.3 million units of blood from donors out of a population of around 25 million compared with India which collects 7 million units out of a population of 1.4 billion: Australian Red Cross, Year in Review 2013–2014 (2014) [https://www.redcross.org.au/annualreport_2014/year-in-review/blood-saving-lives.html, accessed 2 April 2018); and J.P. Shrivastava and S. Singh, ‘100% Voluntary Blood Donation in India by 2020: A Difficult Goal to Fathom’, in Transfusion Clinique et Biologique, Vol. 25 (2018), pp. 78–80 [https://reader.elsevier.com/reader/sd/pii/S1246782017304913?token=4528084D68473EDD24A9CBC40B84545FBACBF7927D6774FDC45F7C3FEFB4D5C55ACC64BC0DF7B6BB81BC827D53BCD4B4&originRegion=us-east-1&originCreation=20211019043346, accessed 9 Sept. 2021]. Moreover, India has been recognised as a country with a high rate of haemoglobin disorders relative to Australia, so it needs even more blood donors: Department of Health, 31 Haemoglobin Disorders (Canberra: Australian Government, 2019) [https://www.health.gov.au/resources/pregnancy-care-guidelines/part-f-routine-maternal-health-tests/haemoglobin-disorders, accessed 24 October 2021].
65. Interview no. 1, Talegaon village, 23 Nov. 2017.
66. Interview no. 2, Talegaon village, 23 Nov. 2017. Non-hospital cases incurred 72 percent of rural expenditures on medicine: NSS 2014, p. ii and Statement 3.21.
67. Prachi Singh et al., ‘Report: Medicines in India: Accessibility, Affordability and Quality, Brookings India’ (3 Mar. 2020), p. 19 [https://www.brookings.edu/research/medicines-in-india-accessibility-affordability-and-quality/, accessed 28 April 2021].
68. NSS 2014, p. 45 and Statement 3.25. Note: these figures do not cover hospitalisation for childbirths which are reported elsewhere in the NSS 2014.
69. The official estimated non-medical costs do not include any extra help needed at home during hospitalisation: ibid., p. 15.
70. Singh et al., ‘Report: Medicines in India’, p. 12.
71. This is an unusual case because 90 percent of ailments in India are treated by allopathy: NSS 2014, p. i and Statement 3.12.
72. Some 86 percent of rural patients in India are not covered by any ‘health expenditure support’: ibid., p. ii and Statement 3.26.
73. Interview no. 5, Talegaon village, 23 Nov. 2017. Sometimes Ayurveda and non-Western healers take payment in kind and services rather than in cash.
74. Rural patients ‘not covered by some health protection scheme’ cover the costs of their hospitalisation from the following sources: 68 percent from income/savings; 25 percent from borrowings; 5.4 percent from contributions from friends and relatives; 0.8 percent from the sale of physical assets; and 0.7 percent from other sources: NSS 2014, p. ii and Statement 3.28.
75. The treatment of burns is one of the most expensive hospital procedures and OoP costs are very high: Shankar Prinja et al., ‘Out-of-Pocket Expenditure and Catastrophic Health Expenditure for Hospitalisation Due to Injuries in Public Sector Hospitals in North India’, PLOS ONE, Vol. 14, no. 11 (2019), e0224721, DOI: https://doi.org/10.1371/journal.pone.0224721.
76. Interview no. 5, Talegaon village, 23 Nov. 2017.
77. Interview no. 2, Chandani village, 26 Jan. 2018.
78. Interview no. 3, Aamgaon-Khadki village, 15 Jan. 2018.
79. Personal communication from Jacob Copeman, 13 May 2018.
80. Interview no. 4, Salai village, 1 Feb. 2018.
81. Neelam Taneja and Megha Sharma, ‘Antimicrobial Resistance in the Environment: The Indian Scenario’, in Indian Journal of Medical Research, Vol. 149, no. 2 (Feb. 2019), pp. 119–28, DOI: 10.4103/ijmr.