Week 15 – Translating technique: Mediating medical apprenticeship at the intersection of biomedical and traditional practice

This early draft was authored by Pooja Venkatesh.

This draft draws from two months of fieldwork in Udaipur, Rajasthan. Through an organizational training program and health camp, older and younger bone setters/rathodi (local massage) practitioners are introduced to a biomedical massage therapy (Myotherapy). This, and similar such initiatives, seek to ‘bridge’ public health needs and legitimize local health traditions. In following local practitioners alongside organizational activities (training, camps) this draft focuses on the conceptions of apprenticeship emergent across and between communities of practitioners. Learning encounters are collaborative, but vary in the actors that become part of the collaborative process; these encounters highlight the distinctions across lifeworlds of multiple participants—patients and community, local and biomedical practitioners. These distinctions co- constitute the process of treatment and thereby enable the diagnosis to be led by encounters with patients; oftentimes, eschewing talk (diagnostic talk) and incorporating patient feedback across a therapeutic spectrum. In foregrounding the implicit role of touch, personal experience and treatment of patients in the transmission of knowledge, this paper seeks to how such flexibility emerges and sustains itself in medical apprenticeship.

*

This draft attempts to unpack a ‘knowledge exchange’ meet between two groups of massage practitioners—traditional bone setters/rathodi malish practitioners (locally known as gunis) and Myotherapists from an Australian university—as an example of technique negotiated in a context unlike its origin (a university setting). The main site of these knowledge exchange meets is an organization in Udaipur city, Rajasthan, which has, over three decades, been working to strengthen primary healthcare within the district, among other community development initiatives. Interestingly, the project, facilitated and funded by the university in Australia, has been conceptualized by the local organization as ‘Aaditherapy’, where ‘Aadi’ is intended as ‘original’ or ‘the first’. Within the umbrella of the project, a four stage Guni training initiative has been developed through the organization’s history with complementary healthcare as well as input from faculty Myotherapists.  

Why have biomedical massage techniques been adopted among guni practitioners? How are they situated within the context where gunis work with the community? How does attention to the layers that constitute practice reflect back on Myotherapy?

This draft preliminarily puts forth these questions and attempts to build a case for considering Aaditherapy as a point of departure into the flexibility of apprenticeship.

Contextualizing Aadi—‘the original’—therapy: What is ‘Aadi’ in the training?

Aaditherapy, a project that grew from previous work in complementary healthcare,  was coined in 2013 as part of a proposal that sought to focus on strengthening the network of gunis, enabling the continuity of practice and, as a broader aim, to ensure access of health care in the villages. It is modelled along the lines of the ‘barefoot doctor’ system, with the vision of one guni for every 500 households. The gunis offer treatment through herbal preparations and massage therapy; while there are variations in practise, the combination of these two main forms of treatment mark the standard that the Aaditherapy training program advocates. The organization’s website reads, “Working for the last 30 years to revitalize traditional systems of medicine… these traditional healers, named Gunis, have been treating common illnesses utilizing local medicinal plants in India for hundreds of years…Gunis possess remarkable skills in solving common rural health issues, including bone setting, skin diseases, asthma, snakebites, sciatica and chronic pains.”[1]

While the curricula for Myotherapists is descrbed as “including deep tissue modalities, myofascial techniques, trigger-point therapy, dynamic cupping, dry needling, neurodynamic mobilisation, prescriptive and rehabilitation exercises, joint mobilisation, and pain management techniques.”[2], the funding agency that supports the cross- collaboration emphasizes the training of graduate Myotherapists: “Gunis are trained in techniques to reduce musculoskeletal pain and discomfort. The HoHA initiated Sustainable Treatment and Training Program (STTEP) is implemented to treat and train the community while providing a sustainable income source to graduates… this is an ongoing programme in which graduates continue to build upon their skills through engagement with international and local health practitioners.”[3]

It is against this background that the four stage training is planned: The initiative is aimed at both older and younger participants, selected by agua (elder) community members across the villages of Udaipur district. The selection of older participants is based on their role in their community, with a preference for those who are identified as gunis, reliable advisors or agents to the assistance of healthcare (for example, mobilizing resources in emergencies), or a more general awareness of common illnesses. The training is envisioned as a space for facilitating dialogue across generations, and the inclusion of younger learners into traditional healthcare. The curricula begins with defining the role of the guni, studying herbal recipes (through note taking and demonstration) for common ailments and moves into physical anatomy, and basic massage practices (aimed at specific conditions—headaches, back and knee pain). The instructors, who are core members of the organization, rely on their training from faculty Myotherapists.

The health camp as a knowledge exchange meet

The driveway outside the clinic was cleared out and watered, repeatedly; with the portable fans turned up, massage tables were being unpacked from their recently delievered cases. With a tent as a makeshift partition towards privacy, two gunis, five trainee and two faculty Myotherapists set up: gunis, with home made massage oils; interns, with clinical intake forms and needling equipment. For the event, gunis were encouraged to dress up in their best traditional attire; Bhagwan ji had wore his red turban; an image found on the website and in brochures. Aishwarya, Neerav and I moved between the entrance to the building, the clinic and the tent, accompanying patients as they trickled in; the pace, we were told, was slower than usual, as the health camp had not been advertised widely because of the visa restrictions that the group from Australia had to observe. The complaints varied from chronic pain as a result of occupational difficulties to more severe conditions of paralysis. Acting as translators, we moved alongside Myotherapists, aware of the gunis movements and dialogue with patients, seemingly from the outside in: an asymmetry that mirrored the day’s event.

The plan of the massage, among Myotherapists, was realised not just through collaboartive input on anatomical specificities (a shared curriculum), but through the common ground of touch:

“Feel this!”, Sarah told me, “It feels like a tightly wound rubber band.” She directs my hand to a point on the lower back of a middle aged women with arthiritis. “I need to get someone to feel this (for a second opinion)”, she continued. I move out of the room, and past the husband patiently waiting outside and look for someone.

Fiona, a few years senior to Sarah, comes over; Sarah directs her attention to the same point. “Do you feel that?”, Sarah asks; “Yea, yea..”, replies Fiona, frowning a little. They discuss what could be the best course of action.

Fiona turns to me to say, “Could you tell her she needs to come back again the day after tomorrow?” I translate; the lady, somewhat unsurprisingly, is unsure of why she has to return—Why is one massage not enough?

The pain rating scale (rating pain along 1- 10) was a common technique Myotherapists used towards assessing patient care. Following a massage, their request for a rating would not always be met with a response, even when a pictoral option for rating was made available. The lack of response sometimes hindered further assessment: the need for response was a need to distinguish between ‘true’ pain and ‘referral’ pain and coordinate treatment around specific anatomical points. Touch became collaborative common ground among colleagues, comparing analogies and discussing diagnostic intricacies.

On the other side of the room, Bhagwan ji asks a patient to rate relaxation as they walk slowly following their massage; the rating of relaxation (not necessarily on a scale of 1- 10, but high/ low) is also equally ignored, with patients instead referring back to previous visits with the guni. The relationship with the guni was as much a part of treatment as the massage, herbal medicines or dietary advice, with the relationship extending past the clinical encounter.

‘Bina dawai ki elaj’(Cure without medicine): Patient care as pedagogical

A primary reason for patients’ availing treatment through massage was the alternative option it offered towards invasive, often expensive, surgery and life long biomedical treatment for chronic ailments. When treatment is sought from gunis, the latter might instead be substituted for herbal preparations, sometimes complementary to prescriptions from hospitals. This recognition of alternatives as primary to patient care, including the importance of satsangs, advice offered by agua (elders) and priests, is accessible to the gunis, which reflects in the participatory dialogue that they engage waiting patients in:

Waiting patients are seldom alone, even when they arrive by themselves; seated with other members, everyone inquires with one another—after their commute, after their treatment— yet also participate in communal dialogue around the treatment. The fluidity in accommodating patient views is encouraged, yet not entirely incorporated into the organizational training curricula: For example, older participants informally mentor younger learners by sharing their experiences to build group morale, and all trainees are encouraged to see patients both through health camps and while at home.

Literature in medical pluralism recognizes a therapy continuum—one that accounts for biomedicine but also understands that a multitude of local healing choices can simultaneously be at play (Olsen & Sargent, 2017). The therapy continuum underscores the value of alternative explanations in addition to the efficacy of treatment. Prince (2014, as cited by Olsen & Sargent 2017) attests to the value of a thriving medical pluralism and the recognition of health and healing other than the biomedical: “Biomedicine has had to coexist with these other epistemologies and practices, which locate health and therapy in arenas beyond the biological body, outside the clinic and the hospital and among non-biomedical specialists” (pg. 4). Literature in medical pluralism has recognized the diversity of practice, patient narratives and the therapeutic continuum. It further recognizes the sociality of practice, decision making and its relation to kin, community and the relationship between patient and practitioner (Olsen & Sargent, 2017; Jansen, 1978; Schoepf, 2017). These conversations that enable diagnosis have received attention for the variations they present for the understanding of health, wellness and disease along the therapeutic continuum. The healer- patient relationship guides transmission of practice through the space of negotiation and learning formed in dialogue. The exchange is a pedagogical one, in that expertise is honed through situating the relationship with the patient in the broader context.

While the organization utilizes the Aaditherapy project, as a collaborative funded initiative with a university, to validate and promote the development of guni clinics, participants in the training and practitioners re- negotiate this conception of Aaditherapy both through patient care as well as their personal experiences of illness.

Fluidity in the Guni’s position: A remark upon apprenticeship

No one slept that night; the celebrations went on till three in the morning and most all woke up for the puja at 7 a.m. The family that arrived in the afternoon—an elder man, his three sons and a grand daughter—were greeted by a near deserted community center. I looked up as Bhagwan Lal ji inquired after them; he had, until then, been in conversation with the office assistant about the supplies he needed for his clinic. The conversation, in a local dialect, was one I could not follow; but the older man moved slow and it seemed certain they had come seeking treatment for him. Bhagwan ji led the way and we followed him to the large room, chairs helter skelter; he began unpacking the newly acquired massage table—an incentive offered by the organization for a high record of patients. He pulled past cardboard, plastic wrapping and dusted it as it straightened out. The elder man continued to narrate his reasons for coming: his daughter was soon to be married and he had to do a hundred namaskarams at the wedding but his knees would not support him. The sons added details about their father’s history and also drew the guni’s attention towards the young girl and inquired about the speech impediment that she had been recently diagnosed with—“Is it curable?” One of his sons informed me that they had heard about the clinic at the community center from an (organizational) fieldworker.

The man settles, face down, onto the cushioned table and Bhagwan Lal ji, hardly hindered by his lack of sleep, begins massaging his legs; teasingly, every now and then, intended to encourage his patient. Pratapi bai enters just as the massage is over and watches as the patient walks slowly back and forth trying to re- assess his pain, at the promptings of Bhagwan ji. The elder man touches points on his back as he walks and Bhagwan ji looks concerned—“Is your back hurting?”
“No, no”, the man replies, now idling, still touching points along his back. “I am trying to remember the points you massaged, so I can ask someone to do it at home for me.”
“It doesn’t work like that”, Pratapi bai calls out, dismissing the remark with a wave of her hand. Bhagwan ji’s attentions have turned to the young girl and he speaks quickly with one of the sons; he asks her to open her mouth and peers into the back of the throat. “There is a medicine for this. Come back and see me in…” The older man’s stray remark doesn’t seem to interest him.

Some days later, the conversation with Anand ji would echo a similar distinction between patient and learner, even as he spoke about the importance of his seven year experience of illness and the chance it gave him to learn from gunis he approached. He explained that he kept a journal in which he noted the details of the treatments that worked for him and offered the same recommendations to patients who approached him for similar problems.

“Being a patient is the first step in learning”, he told me as I sat down following a massage.

Me: How so?

Guni: Recollect what happened in the massage just now.

I recollect the process and add the explanations he gave for some points of the massage. He clarifies some of the points and re- emphasizes them through pausing on touch. The pause drew attention to successive trigger points as he explained the interconnections.

Me: So, every patient can learn this from having a massage?

Guni (gestures ‘no’ emphatically with his forefinger, nodding his head with closed eyes): No! A patient is someone who is on the table—there! (points to massage table).
 
Me: But am I not a patient now as well?

Guni: No. Now you are learning!

The distinction that Pratapi bai and Anand ji make is attentive to both the fluidity of the position of being a guni, while also suggesting that such distinctions are re- negotiated in the everyday of practice. The reliance on personal experience of illness situates learning through legitimate peripheral participation (Lave, 1991). Lave’s (1991) conception of “being a social world” as attempt to rethink learning draws from the need to re- examine schooling and workplaces and, consequently, our assumptions about learning: “Rather than turning to school like activities for confirmation and guidance about the nature of learning, that gaze would reverse the perspective from which anthropologists look outward from their culture into another. It would draw on what is known about learning in forms of apprenticeship in other cultures to consider learning in our own sociocultural, historically grounded world.” (Lave, 1991, pg. 63)

Carr’s (2010) focus on understanding expertise through action distingushes it along four forms– socialization practices (training, apprenticeship), cultural processes of evaluation, validation and authentication, institutionalized ways of seeing and speaking, and the naturalization of specified activities as specialized knowledge– provides a beginning pont towards connecting skill acquistion to broader processes. Making note of Carr’s (2010) analysis and the critique of classical definitions of apprenticeship, this draft seeks to understand how different criteria of expertise mediate learning. This becomes particularly salient when, as Carr (2010) also notes, no one form of expertise forms the sole criteria.

In situating the adoption of Myotherapy techniques in a context unlike a university setting, this draft would like to develop towards a chapter that discusses the flexibility involved in situating biomedical massage techniques and the perspective this further offers into the process of apprenticeship, where apprenticeship locates itself in the social lives of practitioners. Not only is such a discussion relevant towards an understanding of traditional healers, but lends itself to re-thinking conceptions about a biomedical, university based curricula when enacted in a different social context.

---

References

Carr, E. S. (2010). Enactments of expertise. Annual Review of Anthropology, 39, 17-32.

Janzen, J. M., & Arkinstall, W. (1978). The quest for therapy in lower Zaire (No. 1). Univ of California Press.

Lave, J. (1991). Situating learning in communities of practice. Perspectives on socially shared cognition, 2, 63-82.

Olsen, W. C., & Sargent, C. (Eds.). (2017). African Medical Pluralism. Indiana University Press.

Schoepf, B. G. (2017). Medical Pluralism Revisited: A Memoir. In Olsen, W. C., & Sargent, C. (Eds.). (2017). African Medical Pluralism. Indiana University Press.

---

[1] https://jagranjan.org/traditional-medicines/

[2] https://www.rmit.edu.au/study-with-us/levels-of-study/vocational-study/advanced-diplomas/advanced-diploma-of-myotherapy-c6159

[3] https://hoha.org.au/international-projects/india/