Chronic illness in South Asia: rethinking discourses of risk, evidence, and control

Abstract

This special issue brings together five original research papers on chronic conditions in South Asian contexts with a view to rethink dominant discourses of risk, evidence and control surrounding the category of chronic conditions. Focusing on the multiple and contradictory (re)definitions of what counts as illness, specifically in the context of the rising burden of chronic illness, the papers in this issue deal with a range of health care practices from individual patients negotiating with ‘healthy diet’, to policy questions about the etiology of emerging disease burden and appropriateness of pharmaceutical interventions in ‘traditional’ sites of healing. While some of the chronic illnesses addressed in this special issue have received considerable attention from anthropologists (e.g. mental illness, diabetes), others, like leucorrhea have rarely been studied by anthropologists, despite the growing literature on ‘chronic illnesses’.

Keywords:

• Chronicity
• South Asia
• medical pluralism

Introduction

Writing about chronicity at the time of a relentless and global pandemic is no starker indication of the fluidity of categories like ‘chronic’ and ‘acute’ illness, or communicable and non-communicable diseases. The COVID-29 pandemic is an illustration of how infectious, communicable diseases can assume the character of chronic illnesses in a manner that is typically expected of non-communicable diseases. With emerging findings about ‘long COVID’, we are seeing how the conventional distinction between acute and chronic conditions doesn’t hold any more. It is this dynamic, temporal and shifting nature of chronicity that this special issue focuses on.

This special issue brings together five original research papers on chronic conditions in South Asian contexts with a view to rethink dominant discourses of risk, evidence and control surrounding the category of chronic conditions. Focusing on the multiple and contradictory (re)definitions of what counts as illness, specifically in the context of the rising burden of chronic illness, the papers in this issue deal with a range of health care practices from individual patients negotiating with ‘healthy diet’, to policy questions about the etiology of emerging disease burden and appropriateness of pharmaceutical interventions in ‘traditional’ sites of healing. While some of the chronic illnesses addressed in this special issue have received considerable attention from anthropologists (e.g. mental illness, diabetes), others, like leucorrhea have rarely been studied by anthropologists, despite the growing literature on ‘chronic illnesses’.

At the heart of this special issue is a reflexive examination of the terms ‘chronic’ and the idea of ‘chronicity’ itself. While some scholars like Manderson and Smith-Morris (2010) have questioned the deployment of a single hegemonic conceptualization of chronicity in dominant public health discourses, others working in the area of mental illness have cautioned how the term ‘chronic’ has the danger of essentializing the patient (von Peter 2013). More importantly, in line with Manderson and Warren (2016), the contributions here offer new ways of thinking about ‘risk’, through attention to structural factors that predict the chronicity and recursivity of chronic conditions. We see this as a significant shift from discourses that conceptualize chronicity only in terms of the lifecycle of the illness.

In fact, the tendency towards individualization is seen in commonly encountered recommendations about ‘control’ and ‘management’ of chronic conditions, where the burden of responsibility for managing lifestyle disorders is typically placed on the patient. Such responsibilization discourses (Manderson and Warren 2016) tend to prioritize individual choice, without regard to the structural constraints and contexts within which people exercise agency in their own health care. Thus, while ‘control’ continues to be a key theme in thinking about chronicity (Whyte 2012), papers presented here invite reflections on the constraints or continuing negotiations within which people seek to manage (or control) their chronic conditions.

Contributions

Murphy Halliburton’s paper describes efforts by ayurvedic practitioners in Kerala, India to push for greater recognition of and access to ayurvedic mental health in the wake of the increasing push towards the expansion of mental health services in India from both global and local contexts. Halliburton’s research takes place against the backdrop of the Movement for Global Mental Health (MGMH) which has been making a strong case for scaling up psychiatric services in low-income countries such as India. In turn, the Indian government has been investing in community mental health interventions, with a concomitant expansion in the provision and delivery of psychopharmaceuticals. And Ayurvedic practitioners have taken several steps in an effort to claim a greater role for Ayurveda in mental health care, whether it is by combining Ayurvedic and biomedical treatments in their practice, or by disseminating awareness about Ayurvedic concepts, or by learning about the mental illnesses that affect people. Ultimately, what emerges from these observations is that it might be the availability of pluralistic healing options that might be the most powerful element about mental health care in India.

While Halliburton’s research illustrates how Ayurvedic care for mental illness in India have been impacted by global mental health discourses, Shubha Ranganathan’s paper alludes to their impact on community mental health in religious shrines in western India. Here, the imperative to expand access to mental health services has resulted in a unique project involving religious healing and biomedical treatment for mental illness. Through the establishment of a psychiatric clinic within a shrine, psychiatric treatment is made available for pilgrim-patients. Yet, these pluralistic possibilities, such as the availability of religious healing and biomedical treatment within one site are not without costs for it also means the fostering of chronicities. Thus, paradoxically, a ‘community mental health’ program becomes the basis for cementing chronic relationships in which patients seem to keep returning for more medicines with little sign of recovery.

Moving on from a religious shrine to community contexts, Sudarshan Kottai and Shubha Ranganathan expand on the medicalization of mental illness in a community mental health clinic in Kerala, India. Here, new actors come into the picture – mental health NGOs and pain and palliative clinics. While the former may be seen as a newer form of biomedical governmentality, the latter have strong local foothold in the region. With the emergence of medicalized understandings of mental illness, local forms of care increasingly get illegitimized and recede into the background. Conflicting perspectives emerge, leading to questions about what constitutes effective ‘care’ in community mental health contexts.

While the above three papers focus on chronicity in the context of mental health, the papers by Varley and Majumdar unravel the dynamics of chronicity in the context of reproductive health. Varley’s paper on leucorrhea in Pakistan explicates how vaginal discharge (‘weeping wombs’) comes to be associated with and represent the chronic tensions that women are subjected to in relation to their reproductive health and fertility. Women in Pakistan negotiate between the medical diagnosis of leucorrhea and a more social diagnosis that locates this condition in the unmitigated chronicity of the dysfunctions and insufficiencies inherent to women’s everyday lives, and the effects of ‘tension’ on the body and uterus (bachidani) in particular. The ‘weeping wombs’, thus, becomes a language through which women articulate their distress and legitimize their need for care. Interestingly, in Varley’s work, biomedical as well as folk and ethnomedical nosologies collapse into each other in hybrid forms that are increasingly observed in medically pluralistic landscapes.

Finally, Majumdar’s paper explores how the discourse associating infertility with certain kinds of ‘chronic lifestyles’ means that infertility, in many ways, comes to be rendered as inevitable, and thereby chronic, requiring, in turn, ‘chronic care’ through recourse to assisted reproductive technologies (ARTs). Here, too, what becomes evident is the idea of chronicity, and, by extension, infertility as discourse. Increasingly, in middle and upper middle classes in India, chronic lifestyles have been posited as fostering disease, debility, disability, and distress (see Pathak and Nichter 2015). And such positioning is not without moral judgements about the kinds of lifestyles presumed to be ‘unhealthy’. The discourse of lifestyle thus makes individuals responsible for their condition, for it is their unhealthy patterns or ways of living that come to be medicalized and pathologized.

Two central arguments are drawn from the contributions of this special issue: first, global discourses about risk and lifestyle related to chronic conditions are altering the thresholds for what counts as ‘illness’; and second, notions about what forms of treatment are ‘appropriate’ are resulting in changing local health practices as much as changing notions of ‘chronic’ illness conditions in South Asia. Drawing on field work from health clinics, religious shrines, and community contexts, the papers capture the global-local interface in examining notions of risk, cure, care and healing through the perspectives and experiences of patients, practitioners, caregivers, and healers. For instance, while global discourses tend to streamline health care practices under the garb of risk identification and prevention, such homogenizing trends encounter a range of responses in culturally diverse and pluralistic therapeutic settings in South Asia.

One of the common threads shown in the papers is the continuing relevance of medical pluralism in the therapeutic landscape of South Asia specifically for chronic conditions, with creative amalgamation of medical systems by patients and practitioners in fields ranging from reproductive health to mental illness. Thus, while mentally ill patients in western India seek to blend the power of biomedicine with ritual efficacy of a healing shrine in their journey for healing, in south India, an increasing hegemony of biomedical psychiatry is being countered by practitioners in Ayurveda who are claiming a larger stake in mental health care. Such therapeutic pluralism however is marked by tensions and contestations over notions of evidence and efficacy, cultural identity and the politics of knowledge.

Taken together, these papers seek to contribute to the field of chronic illness/conditions through examining politics of knowledge around diagnosis, care, cure and control, the tensions between the global discourses and local practices and the continuing reformulations of normalcy in lifestyle discourses.

Disclosure statement

No potential conflict of interest was reported by the author(s).