In the Bonesetter's Waiting Room Read online

  Hydroquinone is recommended for the gradual bleaching of areas of hyper-pigmented skin – spots of uneven skin tone, for example – although many, even most, users of the product apply it to their whole face. The effect is not permanent and, though the compound is approved for human use, laboratory and animal tests indicate that possible side effects may include some cancers or DNA modification.

  Many of the women of typically marriageable age in Rashmi’s clinic did seem to be there for various skin issues, though at least they were consulting a professional rather than taking the DIY route.

  Occasionally, well-off teenagers will ask Rashmi to carry out even more invasive procedures.

  ‘I tell them to go away,’ she said. ‘Here, even kids have access to money. The parents give it and no one asks them how they spend it. It’s like maybe how we went to a hairdressers or a beauty salon, they go to the cosmetic surgeon. They haven’t finished growing yet and their faces are going to change. They ask for very specific things some of them, sixteen-year-olds wanting certain parts of their faces sculpted or filled. “Make it thinner here, put in fillers there.” I ask them why and they say, “Because I don’t like my face at that angle. It doesn’t look good in selfies.”’

  When I thought about it, it made a lot of sense that teens were feeling an increased pressure to go to extremes in the name of appearance. Like the rest of the world, Indian teenagers post ‘fat-shaming’ photos on Facebook and some young victims have been driven to suicide. For the selfie generation, everyone is in the limelight.

  As I left Rashmi to her continuing influx of patients the very beautiful, Brooklyn-born, half-Czech Bollywood actress Nargis Fakhri was due through the door. Seeing her on the Cannes red carpet a few weeks later, statuesque, with her characteristic filler-plumped lips, brought to mind her endorsement of Rashmi’s book Age Erase: ‘There’s always extra pressure when it comes to being in the limelight. Not to mention just being a woman who will inevitably go through life’s processes. We all want to look and feel young …’ In an interview on the web, she made her reflections on cosmetic surgery even clearer. ‘Things fall, gravity happens,’ she said. ‘You kind of need an extra something as you get older … so listen, I think technology is great, you know … I think it’s nice to have that option. And I think, why should we not look as hot as a twenty-five-year-old when we are forty-five.’

  Rashmi Shetty and Satish Arolkar’s Mumbai patients would surely have agreed, but such ideas have their critics too. In the words of one protester in Bangalore, ‘If a woman is judged only by the size of her breasts and her hips, then it is shameful not just to Indian women, but to women all over the world.’ But if the projections for the unrelenting rise of the most commercialised area of Indian medicine hold true, then there is no turning back now.

  In the meantime, across India’s great cities, a phenomenon even newer than cosmetic surgery is also gaining pace: the rapid rise of smartly outfitted gym franchises that provide a slower, tougher but healthier route to making the body changes we now crave. Although India’s largest gym chain started (in Mumbai) as long ago as 1932, within the last 5 years Talwalkars has more than doubled the number of its offerings, now with 146 ‘ultramodern branches’ across 80 Indian cities. Toward this expansion into India’s new urban demographics, in 2012, it partnered with Britain’s David Lloyd Leisure Group, with whom they consulted on providing leisure and sports clubs in high-end residential developments, gated community townships and corporate campuses. Fitness First launched in 2008, followed by Gold’s Gym and other independent five-star offerings that included women’s-only areas or sessions and the type of yoga classes restyled for the West and reintroduced to the new world of fitness in India alongside new staples such as Pilates and Zumba. Even today the concept still has a beautiful novelty. Talwalkars alone now has in excess of 125,000 members who contribute to the company’s 28 million USD revenues, but there is much more growth to come: as a nascent fitness market, only around 0.05 per cent of urban Indians have a health club membership, compared to 3.11 per cent in the Asia-Pacific region, 13.2 per cent in Britain, and 17.5 per cent in the USA.

  WITH INCREASING INTEREST in looking good by getting fit, wearable tech is also beginning to explode: in 2015, more than 72 million wearable devices were shipped to India, with FitBit, Samsung, Xiaomi and Apple products leading the way. Reports are that Indian manufacturers are not far behind: Micromax-owned YU Televentures, makers of mobile phones and related tech, for example, is betting on its health tracker, YuFit for future growth. As the company’s tag line and web address, Yuplaygod seems a resonant echo of Bollywood celebrity Rakhi Sawant’s rationale for using medical technology to improve the things god didn’t quite get right.

  Via the scalpel, elliptical trainer or app, as the pressures on Mumbaikars to become and stay beautiful remain enormous, the quest for physical perfection in India’s wealthiest city has never been so popular, or so accessible.

  3

  Knowledge for Long Life

  SOUTH OF MUMBAI, the skyscrapers of the city are soon replaced by verdant mountains and then lithe coconut palms which frame the sea and envelop the land. As the Konkan route exits Maharashtra, it runs past the modest homes, churches, mosques and forests of three more states – Goa, Karnataka and finally, Kerala. The two-day drive is undeniably beautiful and opens a window onto an India very different from the traffic-clogged, unrelenting urban sprawl of Mumbai. Much like the rich blue of the sky, shades of green on the ground are a welcome respite to the eye and a delight to the lungs. The Ghat mountain range that flanks India’s western coast ranks seventh in the world’s biodiversity hotspots, and along it the variety of plant life flourishing in this part of India becomes apparent. Among the prolific coconut palms are mango trees and cashews; Flame of the Forest trees crowned with mushroom clouds of crimson; emerald expanses of rice paddies; grand jack-fruit trees, heavy with enormous, reptilian-skinned dark green fruit and with their trunks masked entirely by black pepper vines.

  Such plants have been used in Indian medical traditions for thousands of years, and in particular by Ayurveda. I was making the journey to discover more about the use of herbs in one of India’s oldest native medical practices – and how the ancient discipline was faring against mainstream medicine. I knew that Western doctors had been studying and working with Ayurveda much longer than many suppose: in fact, the trade in the precious ‘black gold’ from the pepper vines and other medicinal spices I had seen was one of the great draws for fifteenth-century Europeans seeking out medicines, as well as exotic flavours. The lure of these valuable substances would also bring them into contact with a natural world largely unknown and mysterious, as well as diseases such as cholera and dysentery that they had never encountered before.

  The medicine practised in Europe at the time was based on a very different system from that of today. Medical knowledge in Europe during the Early Modern period was based on the 2,000-year-old tradition influenced by the writings of Hippocrates, Aristotle, Galen and Avicenna. According to their classical medical theories, it was imbalances in the four humours – blood (hot and wet), phlegm (cold and wet), black bile (cold and dry), yellow bile (hot and dry) – that were the cause of fevers and disease, and they were remedied through diet, purges, bleeding and plant-and mineral-derived remedies. The concept of balance restoring health and imbalance undermining it would have been familiar in Asia and one upon which much of India’s folk and scholarly medical theory was also based. Many of these ideas were recorded in core Indian medical texts like the Sushruta and Charaka Samhitas dating between the ninth and sixth centuries BCE (and lost books it refers to, like the Atreya, and Agnivesa treatises). But they were also rooted in key ‘books’ of the Hindu scriptures – the Rigveda and Atharvaveda – which preceded these medical texts by around a thousand years.

  On 12 March 1534 a young doctor from a Portuguese Jewish family boarded a ship at Lisbon, bound for the west coast of India. It is likely that Garcia de Orta, who
had been forcibly converted to Christianity under the reign of terror of the Spanish Inquisition, chose to escape persecution by taking a job 4,500 nautical miles away, as attendant physician to his military patron, Martim Afonso de Sousa, who had also commanded the first official Portuguese expedition to Brazil. De Orta served de Sousa during campaigns from the Kathiawar peninsula north of Mumbai, along the Arabian Sea to the south-eastern tip of India and into Sri Lanka.

  From the age of fifteen until he left Iberia at thirty-four, Garcia de Orta had studied and then lectured in medicine and natural and moral philosophy. As his captain general’s military campaigns ended, he settled in Goa and set up a lucrative medical practice that he would oversee until his death thirty years later. As well as working as a doctor, de Orta dedicated himself to recording the use of more than eighty drugs, fruits, spices, minerals and medicinal preparations either found in India or employed there. He was clearly fascinated by the ancient and sophisticated medicines he had found in the subcontinent, planting botanical gardens both at his home in Goa and on his estate in Mumbai – very close to where the British-built Mumbai town hall stands today. He had agents – shopkeepers, traders, soldiers, translators, travellers, missionaries – send him plants and seeds from around India and he gathered information from discussions with Indian physicians, slaves, servant boys, cooks and gardeners. The information he collected was published in 1563 as Colloquies on the Simples and Drugs of India and it provided the Western and Eastern worlds with an early opportunity to explore the interaction both between old and new forms of knowledge and between Indian and European medical systems.

  In India, both Portuguese migrants and Indian aristocracy came to de Orta suffering from conditions he would never have encountered in his own country. Undaunted, he adapted to his new practice: using taste and smell, he deduced what balancing properties – cold, hot, dry or wet – his new collections of herbs, seeds and drugs might have and prescribed accordingly. He experimented both on his patients and on himself, turning to Indian medical practices when his European methods failed and making their medicinal herbs famous among Westerners in India as well as back in Europe. By the time Goa’s Royal Hospital opened in the sixteenth century, both Indian physicians and folk healers were working alongside European doctors. The hybrid medical knowledge established there was enormously successful, and being adopted by the Portuguese seaborne empire, had spread to the hospitals of Lisbon and Coimbra by the eighteenth century.

  I first came across de Orta through an exhibition hosted by the National Centre for Biological Sciences in Bangalore, which examined botanical interaction between the East and West during the pre-colonial period. Among botanical illustrations, prints and maps was the Hortus Indicus Malabaricus, a study of the medicinal plants of the Malabar (a region beginning in south Goa and encompassing Kerala) between 1678 and 1703. Commissioned by Hendrik van Rheede, an aristocrat who had been governor of Dutch Malabar, it was an ordered catalogue of nearly 800 paintings. Van Rheede had left home aged fourteen to join the Dutch East India Company and had developed there a strong and mutually respectful relationship with Indian scholars and physicians, three of whom became contributors to his text. He also worked with Itty Achudem, traditional physician from the lower-castes who was an expert on local plants used in medicinal and culinary formulations, and whose medical palm leaf manuscript is thought to have been handed down through his family to the present day.

  Curious to learn more about the pre-British colonial history of Indian medicines, I spoke to the curator of the exhibition, Dr Annamma Spudich, a scientist formerly of Stanford University who was born and raised in Kerala. I was fascinated by how – and why – a geneticist who had built her career firmly within the American university system had switched to the study of Indian scientific traditions. We chatted about the long trips she takes several times a year to Europe, Bangalore and Kerala, where she has been recording the work of India’s few remaining Ashtavaidyas, practitioners of a specialist branch of India’s Ayurvedic medicine.

  The Ashtavaidya’s tradition had arisen from a historic interaction between text-based Ayurveda practices and regional folk medicine that drew on Kerala’s medicinal flora. Roughly translating from the Sanskrit as ‘the science of longevity’, Ayurveda is based on a theory of medicine originating in Brahmanic tradition and set down in Sanskrit texts in the early centuries of the Christian era. Its medical theory is based on humoral, physiological and pathological principles of a body in health and disease. Ayurveda covers an enormous number of practices and philosophy, from physical exercise and meditation (yoga) to diet, but at its heart it revolves around the three concepts of dosha, dhātu and mala. Dhātu are the body’s tissues and mala are its waste products. Dosha is a little more tricky to capture, but it is often equated with Hippocrates’ humours – though in Ayurveda there are three, not four. The doshas are semi-fluid substances in the body which regulate its state of balance. Of them, pitta and kapha seem to align with bile and phlegm, while the third, known as vāta, represents wind. The doshas interact with the body’s waste products and what are referred to as its seven constituents, namely blood, chyle (a milky fluid of lymph and emulsified fats), flesh, fat, bone, marrow and semen. Balance through moderation in all things is the way of Ayurveda – followers of the system are recommended only ever to take reasonable quantities of food, medicines, sleep, sex and exercise, so that the central process of the body, digestion, can do its work, allowing ojas, energy, to be extracted.

  In general, the medicines used in Ayurveda have plant and animal origins. In some formulations, minerals and metals, including sulphur, arsenic, lead, copper and gold, have a central role, an innovation that was introduced around CE 1000. Around the same time, opium (historically prescribed for diarrhoea) began to be adopted, it is thought from Islamic sources. As this suggests, India’s most ancient living medicine has continually experimented, evolved and absorbed elements from other systems of treatment. Neither has it been uncritical of itself – Ayurveda today has been shaped by revisions and criticisms from within as well as from outside sources. As early as 1698 a vaidya (Ayurvedic doctor) by the name of Vīreśvara published a text debating illness and health in which he questioned the whole theory of humoral balance of doshas, adding for good measure, ‘it resembles the babbling of lunatics’.

  I asked Anna about the idea that the study and veneration of plants were part of the culture of India. ‘Absolutely,’ she said. ‘I grew up in Kerala. On my mother’s side we had many friends who were traditional physicians, vaidyas. We would call the vaidya as often as we went to the medical doctor. The vaidyas might prescribe a thailum, an oil, or maybe the extracts of two or three plants. We’d go to them for a large number of ailments. Of course, if you had appendicitis you’d go to the medical doctor, but from the vaidya we learned about plants that could help us. But this is how we learnt about plants – for an upset stomach, say, my grandmother would tell us to go to the garden and pick these leaves.’

  I KNEW THAT, for minor ailments, my mother’s family in Tamil Nadu also called this pattivaidyam (granny doctor) or veetuvaidyam (home doctor). In their part of India this involved a mix of a system known as Siddha medicine. This is a system similar to Ayurveda in theory of causes of disease but different in origin; in the types of medicines used and in the ways they are processed; and with its own texts written mainly in Tamil, not Sanskrit. As well as Siddha, there were folk medicines handed down the generations and prescribed by mothers, grannies and relatives within the home – often simply from the spice cupboard in the kitchen. Like the Ashtavaidyas’ practice of Ayurveda, these home remedies were the result of an interaction between Indian medical theory and folk knowledge.

  ‘THAT’S ALSO PART of the folklore of medicine’, Anna said. ‘Indian food is medicine. There is that overlap between them, inbuilt into the cuisine. There have always been these medical traditions, botanical-medical knowledge, massage therapy and so on. I was delivered by a local midwife, and for a
ll of the problems that arose these women knew what medicine to administer. All this was part of our traditional systems – a new mother was bathed for thirty days with extract of certain leaves and roots, some of which helped with the contraction of the uterus – these women had a list of procedures and medicines of their own.

  ‘It wasn’t until I was a teenager that a medical college was opened in Kerala. Now there are many medical schools and biomedicine is the dominant system. People want immediate relief with a single-molecule drug rather than wait for the lower concentrations found in traditional medicines to work.’ Anna’s point was a significant one. Despite the fact that, according to the World Health Organisation, seventy per cent of people in India still use traditional medical therapy as a first line of defence, the way of thinking about medicine and the time frame in which results are expected have changed significantly. We want quick fixes rather than the protracted lifestyle changes that Ayurveda prescribes.

  ‘You should come to Kerala with me and see how the physicians practise. There is a young Ashtavaidya who is trying very hard to preserve the traditions. He’s studying at an Ayurveda college. There is not much of the real tradition left.’ Anna knew better than most how threatened the history of Ayurveda had become. She’d been devastated to discover that the palm-leaf manuscript that Achudem spoke of in the Malabaricus had recently been thrown away by his family. ‘It seems to have been suspended in the main house in a hanging basket and they weren’t sure what it was, so they put it in the rubbish. It was very sad,’ she said, clearly frustrated. Perhaps even more sad is the fact that the loss of Achudem’s treasure is by no means an isolated case.