‘Don’t throw the baby out with the bathwater’ Quack doctors in Sri Lanka

By Prof. M.W. Amarasiri de Silva

The surge in unregistered medical practitioners practising allopathic medicine and Ayurvedic, homeopathy, and indigenous medicines has become a growing concern in Sri Lanka, particularly in rural areas and low-income urban sectors as claimed by the GMOA. Estimates from various sources indicate a significant number, ranging from 50,000 to 80,000 such practitioners (Sunday Times, Feb 12, 2012; Daily News, Feb 7, 2012; Newswire 23, 02, 2024) are available in Sri Lanka, particularly in rural areas.

Alarming reports have prompted the Government Medical Officers Association (GMOA) to express apprehension over individuals impersonating doctors and providing treatments for severe conditions like cancer, kidney, and heart ailments. These unauthorised practitioners not only prescribe medicines but also pose a life-threatening risk to patients, according to the GMOA, which has brought this matter to the attention of the Ministry of Health, providing recommendations to address the issue. However, the GMOA regrets that the Health Ministry has been slow to resolve this critical and potentially dangerous situation. The need for swift and effective measures to curb the activities of these unregistered practitioners is imperative to safeguard the health and well-being of the public, as stated by the GMOA.

The prevalence of unregistered syncretic practitioners in Sri Lanka surpasses the number of registered biomedical practitioners (20,000) and registered Ayurvedic doctors (17,000), as reported by the Sunday Times on Feb 12, 2012.

This article aims to shed light on the reasons behind the rise in their numbers and the social acceptance of such treatments, particularly in rural areas.

Sri Lanka’s medical system, recognised as a plural medical system, incorporates diverse treatment modalities, including Ayurvedic, Western allopathic, and indigenous treatments. This dynamic landscape provides an intriguing context to explore various healthcare providers and treatment types in different cultural settings, encompassing rural, urban, and estate communities. The country also hosts distinct communities such as the Veddas, Purana villages, fishing communities, and settlement communities in the northern districts, each with unique socio-cultural and economic systems.

The new settlements in the Mahaweli area face challenges in healthcare facilities, lagging behind the more developed districts like those in the Western Province. Health priorities in rural villages of the NCP differ significantly, with many health issues being environmentally induced and linked to factors intrinsic to the dry zone climate and socio-cultural settings. During the formation of settlements, particularly in the Mahaweli Development area, health challenges arose due to the transient status of settlers living in temporary houses with poor hygienic conditions, a lack of potable water, dietary changes, and the absence of familiar foods. The ecological shift from rainy, green vegetation areas to the dry zone brought additional problems, with wild elephants often destroying houses, paddy fields, and vegetable gardens. Separation from original villages, living with unknown individuals, and the lack of social support due to family dispersion contributed to health challenges, including a high incidence of suicides in the early phases of settlement.

Although families are now considered settled in their new homes, remnants of the transient culture persist. People maintain connections with their original villages while adapting to the culture of the settlement villages in the NCP. Local rituals, such as the worship of the god Pulleyar and reliance on traditional treatment systems for various health issues, including snake bites, kidney disease, dysuria, skin problems, and somatic disorders, are prevalent in these villages. Diseases categorised as wind diseases (vata roga), phlegm diseases (sem roga), and skin diseases (kusta roga or charma roga) are often not addressed in urban hospitals, as they do not align with the expectations of residents who were raised in remote villages where traditional healing systems, including Ayurveda, were practiced. The healthcare landscape in these settlements reflects the intricate interplay between environmental, socio-cultural, and historical factors.

Traditional Ayurvedic physicians or village-based Ayurvedic doctors (vedaralas) were notably scarce in the agricultural settlements, as they did not choose to establish residency in these areas. Similarly, assistant medical officers, nurses, hospital attendants, and dispensers, who play vital roles in village medical systems, were seldom found in the new agricultural settlements in the North Central Province (NCP).

The allopathic, hospital-based medical system introduced to the settlements approached health problems from a biomedical perspective. However, for settlers, the hospital represented a bureaucratic system. The process involved commuting to the urban area where the hospital is located, waiting in queues, obtaining a numbered ticket, completing forms at the outpatient desk, and then waiting for their turn (identified by number, not name) to see the doctor. The doctor’s brief diagnosis often resulted in a prescription that the settlers found challenging to decipher. This prescription was then taken to the hospital dispensary, where another queue awaited them to collect the prescribed medicine—typically categorized as peti (tablets), karal (capsules), or watura (liquids). The entire process consumed the whole day, from leaving home to returning.

While hospital medicine offered temporary relief for issues like diarrhoea and fever, settlers observed that these problems often recurred. Loneliness from being away from their original villages and kinsfolk compounded the settlers’ health challenges. Other complaints, including an inability to work and concentrate, physical weakness, vertigo, dizziness, sleeping difficulties, skin diseases, and bone fractures, remained unaddressed, counselled, or discussed at the hospital.

This context created a demand for healers akin to the traditional village vedarala or Ayurvedic doctors, leading to the popularity of quacks or unregistered doctors (UDs) in the settlements and in remote rural villages. These UDs, known to the settlers, and rural villagers engaged in more extensive discussions about their problems, offered informal counselling, shared similar sentiments, came from comparable social and cultural backgrounds, and spoke the same vernacular vocabulary. While providing Western medicine like that from hospitals, UDs explained it in terms more understandable to the settlers, often incorporating elements of Ayurvedic or homeopathic treatments to enhance perceived effectiveness for the specific illnesses the settlers sought treatment for.

It is a factual observation that the quacks or Unregistered Doctors in Sri Lanka do not originate from the upper-middle class, setting them apart from qualified allopathic doctors, who predominantly hail from upper-middle-class urban backgrounds. The UDs typically have roots in rural villages, and their land ownership is limited, often not exceeding a quarter of an acre. The parental occupation of most UDs revolves around traditional agriculture or trades like carpentry or masonry, occupations that carry minimal prestige within their village communities. In contrast to the small nuclear families characteristic of urban middle-class backgrounds, UDs often belong to large extended families. This socio-economic disparity underscores the diverse backgrounds and origins of UDs in comparison to their allopathic counterparts.

There is a prevailing belief among the people that Western medicine provides quick relief but fails to address the root cause of illnesses, offering only temporary (thavakalika) solutions. Many believe that it is essential to complement or replace Western medicine with Ayurvedic treatments for a lasting cure. Sole reliance on Western medicine (dostara / ingirisi behet) is often associated with a higher likelihood of disease recurrence or the emergence of undesirable “side effects.” It’s common to hear people express concerns about becoming thin (kettu) or experiencing a sensation of having “dried up” (diravala giya) after using Western medications. This perspective reflects a broader sentiment that Ayurvedic medicine is perceived as providing more holistic and sustainable solutions compared to the perceived limitations of Western medical approaches.

There is a widespread belief that the use of Western medicine to treat upper respiratory infections can lead to the “drying up” (karavenava) of phlegm (sema) in some individuals. While Western medicine may offer quick relief and cure, this effect is often considered temporary. The accumulation of excessive or “bad” phlegm disrupts bodily elements’ natural harmony or homeostasis, emphasizing the perceived need for Ayurvedic treatment in patients with phlegm-related diseases.

Patients seeking rapid relief from Western doctors for phlegm-related conditions may concurrently or subsequently opt for Ayurvedic treatments. Some doctors employ secret formulae, including mixtures and ointments, comprising allopathic, Ayurvedic, and sometimes homeopathic medicines. According to these UDs, the preparation of these medicines involves using Ayurvedic medicinal herbs to control or neutralize the ‘bad’ or ‘poisonous’ (visa) effects of allopathic and homeopathic medicines.

The UDs argue that using these combined mixtures is preferable to relying solely on pure allopathic medicines, primarily for wounds, cough, constipation, and stomach problems in infants. The formulation of these secret medicines may be passed down through family traditions, originate from a secretive book in the doctor’s possession, or even be revealed in a dream by an ingenious person. The patient histories provide insights into the prevalent practice of combined therapy in rural Sri Lanka.

The recent institutionalisation of the Ayurvedic system in Sri Lanka, facilitated by trained doctors from the educated elite critical of the local treatment system (Sinhala vedakama), has resulted in the establishment of government-supported institutions, training colleges, research facilities, and hospitals. This system operates independently alongside the allopathic biomedical medical system in Sri Lanka. The creation of the Ministry of Indigenous Medicine reflects a nationalist approach to medical systems, serving as an identifier of Sri Lanka’s independent identity in medicine and disease management. However, there is no such institutionalisation of quacks or UDs, which I think is essential to properly organise the unregistered doctors and obtain their services in remote villages and settlements. These quacks or UDs can be considered ‘community doctors’ providing care in the absence of trained biomedical doctors in remote rural communities.

The concentration of the Ayurvedic system in rural areas has been attributed to the perceived poor availability of trained biomedical doctors in these regions. However, this spatial shift may also be a deliberate strategy to avoid direct competition between the Ayurvedic and allopathic systems for clientele. Like their Western counterparts, the newly trained, college-educated Ayurvedic doctors may hesitate to establish practices in impoverished rural areas, particularly in the scattered purana villages of the dry zone or newly irrigated agricultural colonies.

Traditional vedaralas in purana villages often conducted essential treatments in these areas, but the scarcity of such practitioners in newly established settlements and remote villages created an opening for UDs. These UDs, with their unique blend of traditional and contemporary medical knowledge, stepped in to fill the gap left by the absence of a formalised traditional medicine system and an inadequate allopathic medical infrastructure in these rural settlements. The role of UDs in these underserved areas becomes crucial for addressing healthcare needs where other systems might not have gained traction.

The UDs in the settlements served the diverse medical needs of the settlers, adopting roles akin to allopathic doctors, ayurvedic doctors, vedaralas, and homeopathy doctors. This multifaceted approach, which I refer to as the system of ‘combined treatment and therapy’, represents a unique and adaptive form of healthcare delivery.

The concept of combined therapy is not entirely novel within the Sinhalese treatment culture. In the traditional village setup of Sri Lanka, Ayurveda, astrology, and exorcism were distinct yet interconnected subsystems within the broader Sinhalese-Buddhist treatment culture. Despite their separate identities, they coexisted and often complemented each other. Practitioners, such as vedaralas, sometimes fulfilled roles as both exorcists and astrologers. This integrated approach was a part of the larger cultural milieu.

In the context of the settlements, the UDs faced minimal competition from allopathic practitioners, who were largely absent in these areas. The biomedical system struggled to connect with the existing treatment culture of the settlers, lacking both philosophical alignment and practical integration. The traditional therapeutic systems, rooted in thridosha vaadaya (doctrine of the three doshas) and the panchabhuta system (five-element theory), offered diverse explanations for the causes of diseases. These systems encouraged utilising various treatment methods, including those rooted in astrology and exorcism.

The prevalence of the belief that diseases could have multiple causes likely contributed to the establishment and acceptance of the combined therapy system as practiced by the UDs in the settlements and remote communities. This adaptive and inclusive approach aligns with the pluralistic nature of traditional Sinhalese medicine, where multiple streams of knowledge converge to address the community’s complex and varied health needs.

The hallmark of these doctors lies in their remarkable adaptability to various treatment methods and medicines. Their guiding philosophy is grounded in the belief that different medicines or treatment regimens exert distinct effects on individual patients. Consequently, they advocate for effectively combining different medicines and treatment approaches to address each patient’s unique needs. The amalgamation of these diverse interventions is intricately tailored based on the patient’s individual characteristics and the practitioner’s wealth of experience. This personalised and flexible approach underscores the dynamic nature of their medical practice, reflecting a commitment to optimizing patient outcomes through a holistic and individualized treatment strategy.

In conclusion, the complex healthcare landscape in Sri Lanka, particularly in rural areas, reveals a multifaceted reality where unregistered doctors (UDs) or quacks play a significant role in addressing the diverse medical needs of the population. While concerns raised by the Government Medical Officers Association (GMOA) about unauthorised practitioners impersonating doctors are valid, it is essential to approach the issue with nuance.

The prevalence of UDs stems from a variety of factors, including the inadequacies of the formal healthcare system to meet the specific needs of rural settlers. The settlers’ reluctance to engage with the bureaucratic hospital-based system, coupled with a belief in the holistic approach of traditional medicine, has contributed to the popularity of UDs in these underserved areas.

The socio-economic background of UDs, often originating from rural villages and engaged in traditional occupations, highlights the diverse origins of healthcare providers in Sri Lanka. The gap between registered biomedical practitioners and the healthcare needs of the population underscores the necessity for a more organised and institutionalized approach to integrating UDs into the healthcare system.

Recognising the unique role of UDs as ‘community doctors’ providing valuable care without trained biomedical professionals, there is an urgent need to institutionalise these practitioners. Establishing guidelines, training programmes, and support systems for UDs can help bridge the gap between traditional and formal medicine, ensuring their services are safely and effectively integrated into the broader healthcare framework.

In addressing the concerns raised by the GMOA, it is crucial not to dismiss the entire practice of UDs outright but rather to work towards a comprehensive and collaborative approach that leverages the strengths of traditional and modern healthcare systems. The challenge lies in finding a balance that ensures public safety while acknowledging the valuable contributions that UDs make in catering to the unique healthcare needs of rural communities.