Sot. Sci. Med. Vol. 28, No. 9, pp. 963-970, Printed in Great Britain.

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AYURVEDA:

A MULTILECTIC

INTERPRETATION

CAROLYN R. NORDSTROM Peace and Conflict Studies, University of California, Berkeley, CA 94720, U.S.A. Abstract-Ayurveda, in practice, comprises far more than a medical tradition in Sri Lanka. It provides, in addition to a manuscript for health care, a popular knowledge paradigm by which the population addresses social, epistemological and ontological issues in their lives. The concept of health expands to include the many existential levels that are basic to a definition of the self and the many arenas of life in which it is made evident. The concept of multilectic process is introduced in this paper to explain this dynamic that characterizes popular Ayurveda, a dynamic that Sri Lankans specify as consisting of a fundamental complex interplay of mutually interrelated factors that are capable of referencing multiple meanings and life contingencies neither contradictory, dichotomous, nor unidirectional in nature. Because of the extent to which Ayurveda is embedded in the everyday lives and fundamental conceptual frameworks of the Sri Lankans, it is likely to remain an integrating knowledge system and a powerful explanatory paradigm in their general lives as well as for their health care dilemmas.
Key worcis-Ayurveda,

health epistemology, Sri Lanka, multilectic

INTRODUCTION: THE ARGUMENT When I arrived in Sri Lanka to study the countrys complex plural medical system, I expected people to tell me about Ayurveda, the predominant empirical indigenous medical tradition in South Asia. More often, they used Ayurveda to tell me about themselves. Statements such as the following were commonly heard in conversations among Sri Lankans: The political system is like the body, and the parties are like humors: if they are maintained in a balance, the system is healthy. But if one gains ascendancy over the others and begins to dominate, the balance is lost and abuses can follow-the system can become unhealthy. In another vein, people say: He is a sema person (sema is the humor or water of phlegm)-you know, he is overweight, congested, sweats a lot, but usually maintains a cheerful expression. In a third example; one day, after a particularly severe drought season that had resulted in critical water shortages and epidemics, the first rain fell heralding the start of the monsoon season. An older woman in the house I lived in looked out onto the rain, smiled and said Balanna, sanipai (Look, it is health). The argument will he developed in this paper that

the traditional medical concepts used to explain illness and health are not restricted to the level of the biological or the realm of the medical during episodes of disease among the Sri Lankans. Bather, these concepts exist in a complicated interrelationship with broader social issues facing individuals. The interplay between these various levels of human interaction provides knowledge and conceptual frameworks that are used to address epistemological and ontological concerns as well. Because of this complexity of health ideology, health care operates on several levels for the Sri Lankans. On one level are the infrastructural elements of the health care system: the institutions, practitioners, clinical formats, and medical traditions

and doctrines that patients navigate in an attempt to gain and maintain well-being. Equally important, but existing on another phenomenological level, is the popular body of knowledge maintained within the general society that orients the average person to critical issues of illness and well-being and to the broader systems defining health in the country. Specifically, the article addresses the idea that because the Sri Lankan concept of self is defined as comprising an extensive number of interactive levels that include social, environmental, and cosmological relationships as well as more personal and biological ones, the dynamics of health and illness, and the medical traditions that define and treat these states, are more complex and multifaceted than a simple perusal of the medical institutions themselves. As these relationships are interactive by nature, the various traditions of health care addressing different arenas of illness etiology must be integrated as well into a comprehensive framework. What is of interest in this paper is the popular body of knowledge based on the tenets of Ayurveda and Sinhala beheth (Sinhala medicine), but not confined to the textual tenets of these traditions. Not only does this body of knowledge explain the health issues facing the Sri Lankans, it provides metaphors [l] that are used to explain the many aspects of life that impinge on notions of personhood and its expression in the daily world. This popular body of knowledge, understood by practitioners and lay alike, is not only a knowledge system that elucidates illness and health care processes as experienced by the patient during illness episodes and the ongoing maintenance of health, but is also a meaning system that orients the general population towards questions of a more comprehensive epistemological nature, regardless of the medical tradition specifically utilized or the relative proximity of an illness. I will use the term multilectic to emphasize the fluid and dynamic relationships which exist among conceptual categories in Sri Lankan orientations
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CAROLYN

R. NORDSTROM Ayurveda affords toward this end. The broad-based social dynamic rooted in popular Ayurveda that emerges in this paper reflects the fundamental views held by practitioners, patients, and the general population alike: it is an integral part of the basic social knowledge by which people articulate themselves vis-ci-vis their world and their health in general. The following sections are a condensation of the Sri Lankans own words. I have stated elsewhere [3] that the sophisticated knowledge the average Sri Lankan holds concerning health care and ideology, and the ease with which they can articulate this is in large part responsible for the very high indices of health enjoyed by the Sri Lankan people (41. As my interest in this paper lies primarily with the popular knowledge and meaning systems operating in Sri Lanka, and not with the more formal textual traditions defining medical care, I have chosen not to delve into lengthy explanations of the formal philosophies defining medical traditions that are basically relegated only to educated practitioners. For more in-depth works on these topics, the reader can refer to Obeyesekere [5,6]; Nordstrom [7]; Wijeratne [8]; and Wanninayaka (91 on Ayurveda; Amarasingham [IO]; Waxler [1 I]; Yalman [12]; and Obeyesekere [ 131on health care processes; and Carter [14]; Gombrich (15, 161;De Silva [17]; Ratnapala [IS]; and Wickramasinghe [19] on Buddhism; and Daniel [20] on Tamil knowledge systems.
I-HE CONCEPT OF SELF IN ILLSESS AND IN HEALTH

toward Ayurveda. These conceptual categories derive their dynamic quality from their openness, receptivity, and mutually influential interrelationships, and from their ability to encompass multiple meanings at the same time. In contrast to the idea of a dialectic in which opposition and contradictory processes, or what Hegel [2] might term determinate negation, are central to perception, Sri Lankans perceive noncontradictory relationships among categories which Westerners might view as discreet (Martin, personal communication). A primary example of this developed in this paper is the Sri Lankan conceptualization of the self and its interaction with fundamental attitudes toward health, and more specifically, in the notion of state as it is used to discuss simultaneously a persons physiological condition, their existential and phenomenological realities in life, and their relations as a collection of people bounded by social-level ideas of state or nationhood. This kind of conceptual fluidity reinforces the centrality and power of the notion of health in Sri Lankan culture which concomitantly strengthens the viability of traditional medical epistemological frameworks rooted in Ayurveda.
INTRODUCTION: THE DATA

Data for this paper was collected during 2 years of study in Sri Lanka in 1982-83, and in subsequent field visits each of several months duration in 1985, 1986 and 1988. Research was conducted in an area in the southern part of the island, and included both urban and rural settings. In an attempt to understand the full dynamic of the Sri Lankan health care system, extensive interviews were conducted with people representing all aspects of the health care system: with cosmopolitan, Ayurvedic and indigenous practitioners, and with both patients and people from the general populace not currently suffering an illness. Attention was given to addressing as broad a representation of the population as possible, and interviews crossed a full range of caste, class, occupation, age, and gender divisions. The area I worked in is predominately Sinhalese, but my work included Tamils and Muslims living in the area as well. As Siddha and Unani medicines are not well represented in the south, few health care distinctions along these lines were evident among groups, and thus unless the materials collected reflect a distinctly Sinhala Buddhist orientation, the term Sri Lankan, rather than Sinhalese, is used to denote commonly held general assumptions shared throughout the community. The Ayurveda medical tradition of Sri Lanka is broadly similar to that operating in India with two exceptions. Over the centuries, the medical practices and conceptualizations in Sri Lanka have adapted to the specific health care problems and lifestyles of the island, and, for the Sinhalese, reflect an intersection with basic Buddhist philosophies. In order to understand the full dynamic of Ayurveda and its influence on the lives as well as the health of the Sri Lankans, it is important to understand the concept of self these people hold, the way in which this intersects with the demands created to maintain this self in health, and the mechanisms

The Sinhaleses conception of self is multifaceted and, in essence, multi-existential. Made up of five basic universal elements (water, fire, air, earth, and space), people are no more than a collection of chemical elements, and no less than an essential part of the universe. Because of this, they affect, and are affected by, processes taking place in their world and the universe they exist in. This is an orientation infuses Buddhist philosophy alongside that compatible Ayurvedic concepts into general cultural traditions basic to the Sinhalese. People thus conceive of themselves as being comprised, and as existing, simultaneously on these dynamically different but fundamentally complimentary phenomenological planes. They are, in essence, equally detined by these varying realities, and being so defined, they likewise define the world and the universe they comprise. They equally determine, and are determined by, the universe they populate. The Sinhalese state they do not draw sharp mind/body, individual/social, or personicosmos distinctions in their assessments of personhood. All these levels coalesce to define a person. People are made up of biological, mental, and emotional processes. They interact in life through a series of social role associations, and are a fundamental part of the society and the environment (both physical and social) they live in. They are shaped by religious and philosophical epistemology, and are an inherent part of a larger metaphysical and cosmological world. In popular conception, the Sinhalese tend to see all of these domains, from biological to social and cosmological, as processes which run according to the

Ayurveda: a multilectic interpretation

same basic principles. This view tends to focus on concepts of synergistic, interrelated configurations and the effects of balance and imbalance, harmony and trouble. Balance and harmony themselves are comprised of many elements: of the properties of heat and coolness that affect the health of a system, of sweetness and bitterness that give it flavor, of order and disorder that characterize it, and of the positive and negative alignment of parts that defines its nature at any given point in time. This orientation represents a multilectic approach to issues of an existential nature. Each of these phenomenological domains is essential to defining being, yet makes sense only in its definitional relationships to the other domains it is perceived as being in interaction with. This entails a set of mutually influential interrelationships that exists in a dynamic such that each of the categories maintains a coherency of nature, while at the same time being fundamentally defined by the nature and characteristics of the other related processes and the composition of the whole. This is not a directional process, as is usually associated with the dialectic, but one that is necessary to the maintenance of the integrity of the whoIe as it exists over time and space. The multilectic does not stand in oppostion to the dialectic, nor is it intended to replace it: it addresses a different order of conceptual categories and their related phenomenological processes. While they can be used separately in theory and analysis, they represent compatible concepts that can be used together to highlight the relationships of phenomenologically divergent processes. While a multicausal orientation is basic to this approach, it is not sufficient in explaining it. The process is more complex in that discrete factors cannot ultimately be identified as basic components in a process of reduction: to the Sri Lankan, the part cannot accurately be distinguished as isolated from the whole, nor the cause separated in explanation from the effect. In the multilectic, a universe, and a universe of knowledge, is being continuously created and maintained by the various parts and parts-aswholes simultaneously, and as well by the processes and dynamics of the relationships themselves as they generate and define existential domains. Given the fact that all of the aspects of life and self as defined by the Sri Lankans are perceived as existing in a dynamic relationship, a disturbance in any of these realms can jeopardize an individuals immediate well-being. Well-being, then, is not assessed solely in terms of an individuals physical and mental health, but as a set of positive relationships with the people and processes in the persons world. This includes not only a rounded intellect and balanced emotional states, but also fulfilling social relationships, a clean environment, a stable society, and a proper conliguration of supernatural and cosmological forces. Though the Sinhalese recognize the physical suffering of illness, they may trace its origins to disruptions taking place in any of the many levels of existence that define the self. In the same way, friction in any of these realms in and of itself is ultimately a signal of unhealthiness for the people who are a part of it.

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For example, a healthy mental/emotional balance is as important to physical health as is a strong constitution, and the two are not separated by the Sri Lankans

966

CAROLYN

R. NORIXTROM stressful or antagonistic work environments, and being away from family and home and feeling lonely or unhappy in circumstances one doesnt like are a few examples of the many situations that can affect ones health and well-being. On a broader scale, another commonly voiced opinion about the impact of the society on the individual was summarized by the person who explained to me: If the government is good a healthy nation exists. But if it is bad, if it is corrupt and selfish, jobs will not be available,
schools will not be properly staffed, land will not be developed and cared for, and the people will be unhappy. They will sicken and die, or they will revolt. If there is lighting among the people and antagonisms between groups, everyone will suffer. It is an unhealthy state then.

Issues of environmental cleanliness are closely related to religious principles of purity and wholesomeness and are fundamentally tied to notions of health and illness for Sri Lankans. The Gods do not like dirty environments, and neither do the Sri Lankans. The public generally recognizes the vectors of many infectious diseases, and during an outbreak they may explain the ultimate etiology as a Gods wrath, but realize the immediate etiology as pathogenic infection. They will thus direct their energies to isolating patients and monitoring the cleanliness of food, water resources, and sanitary conditions as well as conducting rituals to appease the God(s). During one survey I conducted in both an urban and a rural area in the south of Sri Lanka, I asked people what request(s) they would present the Minister of Health if he came to their homes inquiring about how to improve health standards in the community. In conducting this research, I was careful to interview as representative a sample of the population as possible, and spent as much time with the more rural, economically poor, and less formally educated families as I did with the more affluent urban populace and the health care practitioners. One of the more surprising aspects of this study was that virtually everyone I talked with had a fairly welldeveloped explanatory model that shared the same basic elements of the body of popular knowledge described here. The sentiments outlined here reflect commonly held views regardless of peoples gender, economic, occupational, or educational background. In answering the above question, many of the people, after responding that the Minister of Health would never come to their house in the first place, and that was one of the proplems, said that if such a thing were to pass, one of the first requests they would make would be that he clean the environment and provide clean water. Population pressures, people said, cause an excess of garbage, and garbage attracts insects and animals that can introduce and transmit disease.. Water becomes polluted as too many people are forced to wash clothing and household items, bathe, and evacuate in one area. Pollution fouls the air and the soil, and increasing demands for food resources prompts the use of petrochemicals and insecticides that introduce poisons into the foods people eat. People were not as concerned with population growth, and the concomitant pressures caused by this in and of itself, as much as with the aforementioned consequences, and with the fact that polluted and poorly managed agricultural and environmental programs hampered the communitys ability to meet basic subsistence needs. These concerns are wellgrounded. Though Sri Lanka has one of the highest sets of health indices for all Third World countries, 50% of the children are malnourished and it is estimated that over half of the major diseases suffered are water-borne [22,23]. In a more specific example, the Superintendent of Health of the district I worked in told me that in recent years there had been a tremendous increase in the number of cases of severe insecticide poisoning (through skin contamination) in field workers. Social environment is as important a concept to health as is physical environment. Impoverishment,

THE

SRI LANKAN PLURAL MEDICAL SYSTEM

The Sinhalese have an extensive plural medical system tailored to these myriad levels of ill-health and disorder. While it may seem that many of the forces that impinge upon health, such as those of a social, metaphysical, and cosmological nature, are not easily changed so that positive health may accrue, in fact, all of these can be influenced by the services of specialists so that the amelioration of ill-health can take place. Because these forces exist as dynamic phenomena, and not as static properties, their nature and the concomitant impact they have on individuals change over time, and they are amenable to curative rituals. Within the encompassing framework of health care, each of the healing traditions is directed toward a specific arena of care defined by the etiological agent(s) deemed responsible for the dis-ease. Cosmopolitan (Dostora) and indigenous traditions of Ayurveda and Sinhala medicine (Veda) are empirical means to reestablish health within the body [6]. The latter two medical traditions also emphasize preventive health care [9]. Local-level healers, informally trained primary health care specialists, help correct personal problems and everyday physiological and emotional complaints [24]. Buddhist priests (Hamaduruwa) and lay priests (Kapurala) attend to supernatural and metaphysical disturbances, and are responsible for the spiritual and emotional well-being of the communities they serve [13, 14, 17,251. Exorcists (Adura) control the evil and demonic when it disrupts the world of the living to cause misfortune and disease, and they help to rectify negative cosmological patterns influencing the well-being of individuals and communities (261. Astrologers (Gurunnanse) assess planetary patterns and cosmological relationships, and advise on ways of correcting negative influences in these realms (271. Oracles (Pena-karaya) and fortune-tellers (Shastra-karaya) discern interpersonal, social, and supernatural problems and ascertain solutions for them [9, 121. AI1 of these categories of healers and traditions of diagnosis and treatment described above tend to come into play during the course of a Sri Lankans life [lo]. For any given illness, one or more causal factors may trigger the disease process. For each specific domain of etiological agent involved in an

Ayurveda: a multileetic interpretation illness episode, the appropriate healer must be consulted to ensure that health is regained. For example, negative planetary influences may foster emotional disturbances in a person that leave him or her open to demonic attack. Such an attack may upset the correct balance of the bodys three humors, and the resulting imbalance can produce a physical disease. Medicine given for the physical problem alone will not successfully cure the disorder, for the underlying causes have not been treated. In addition to medicine, the services of specialists who are able to determine the exact root cause(s) of the problem, and can either treat these or refer the patient to practitioners who can, are essential in regaining health. Thus a patient may consult a cosmopolitan physician and/or a Veda, an astrologer, and a religious and/or ritual specialist in the course of a single illness. None of the healing traditions, in and of themselves, can address all the levels that constitute a person and determine well-being. Both the practitioners and the formal doctrines that define their practice are formally restricted to specific domains of diagnosis and treatment, as described above (although in actual practice there are health specialists that amalgamate several different healing traditions). Within the general society, however, these various traditions are not seen as complete healing systems by themselves in that they do not address all of the levels of illness etiology, and thus the various healing traditions are not viewed as competing systems of medicine. Rather, they are seen as complementary options variously available to patients depending on their needs. (Practitioners, as distinct from the general population which holds the above views, do not always have such an expansive view of the plural health care system, and may view the different traditions as competing as far as their practice is concerned. This, however, holds only for their professional orientation, for when practitioners themselves become sick and revert to a patient status, they tend to employ the same popular paradigms of health care knowledge used by the general populace and approach the health care universe as a more integrated comprehensive whole.) The ability to synthesize these various healing domains into a coherent encompassing framework rests, then, on the general patient population and on the popular paradigms of health they maintain in defining illness and health care options. The relationship between illness episodes and treatment choices is an interactive one: the assessment of what etiological agent(s) underlay the development of the illness dictate which healers a patient will seek out, and the efficacy of the ensuing treatments will determine if the initial assumptions are supported (the illness responds to treatment and the patient improves), or if further causal factors are explored and treatments sought (the illness doesnt respond to the initial treatments). In the latter case the initial decisions concerning etiological agents and treatments are not deemed inaccurate, but simply incomplete, and an expanding framework of causal factors and related treatments ensues until the patient is finally cured.
POPULAR PARADIGMS OF HEALTH KNOWLEDGE

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Given the fact that the Sri Lankan concept of self, and thus of health, is so broadly defined, a theoretical framework-a popular body of knowledge-must exist that is capable of integrating these diverse realms and the formal traditions that define them. Ayurveda/Sinhala medicine provides the foundation for such an encompassing explanatory model for the general population. As such, it exists both as a medical tradition in the traditional sense of the term, and as well, as a social knowledge system applied generally in the society to address epistemological and existential concerns in a way meaningful to the average person as well as to the more erudite textually-trained practitioners and philosophers. Sinhala beheth is not viewed as more of a folk tradition than Ayurveda in Sri Lanka. Structurally, the two conform more to Leslies [28] model of nonprofessionalized versus professionalized Ayurveda respectively. Professionalized Ayurveda refers to the system whereby practitioners gain a formal education in Ayurveda universities and rely on professional texts, organizations, hospitals and clinics, and manufactured pharmaceuticals in their practice. In nonprofessionalized Ayurveda, practitioners learn their medical skills through a lengthy apprenticeship to a master, often a family member, or from temple schools or informal medical organizations (although the latter two are far less commonly found today). Given the high literacy rate in Sri Lanka ( 197 1: males: 85.2%; females: 70.7%, with current figures showing continuing increases [29]), most nonprofessional practitioners are also trained in Ayurveda and/or indigenous medicine texts written in Sinhala or Tamil, and sometimes Pali (the formal traditional language of Buddhism). To the average Sri Lankan, however, the nonprofessionalized distinction is nonevident: .the arduous apprenticeship process (4 years for a university medical degree sounds remarkably short to many), the well-maintained clinics and shops for consultations and medicines, and the quality of the care associated with the practitioners of Sinhala beheth is as formally professionalized as that offered by university trained and institutionally based Ayurvedic practitioners. In the Sri Lankan context, to label the informal, popular body of knowledge Ayurveda is a misnomer. Among the general populace in Sri Lanka the term Ayurveda has come to signify the professionalized form of the indigenous medical tradition, and one that is often integrationist in policy; that is, it follows a model whereby the principles of Ayurveda are wed to the infrastructural and therapeutic patterns of cosmoplitan medicine. The pure form of apprenticelearned. empirical indigenous medicine is referred to as Sinhala beheth (Sinhala medicine), or Tamil vaittiyam (Tamil medicine). Sinhala beheth itself exists on two planes, although only one is officially recognized. There is a formal empirical medical orientation based on written texts and established therapies for both preventive and curative health care. In addition, there is a more informal popular body of knowledge that orients the average Sinhalese toward the many mani-

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CAROLYN

R. NORDSTROM evaluation of state. The complex nature of the

festations of illness and health that are fundamental to the world as they know it. This includes not only their perception of health concepts, but the episternological systems they use to explain them. This latter system of knowledge is interactive by nature, linking patients both to broader socio-cultural issues in the society, and to the array of infrastructures, practitioners, and ideologies of health care. (This distinction between formal and popular health knowledge is similar to the one that Obeyesekere [30] makes in terms of textual and popular Buddhism, but it is more encompassing in nature as it includes medical, religious, ecological and social traditions.) It is this form of popular Sinhala medicine that provides a paradigm capable of synthesizing peoples complex conceptions of self and health. This body of knowledge is shared throughout the general society, and is distinguished from the more classical doctrines of medicine, religion, and public health that ultimately give definition to it. Its bases in synergistic yet competing parts, in the concept of doss (trouble) coming from the Tridosa (the Theory of the Three Humors), and in balance and harmony and their counterparts, are drawn from Ayurvedic doctrine, but they are not limited to it. Because of this it provides an accessible and comprehensible conceptual framework mediating the diverse medical traditions. This popular body of knowledge is not specifically grounded in any doctrinal base, nor does it exist as an institutionalized or written tradition. Because it is not the textual orientation itself, but the general overlying principles inherent in it that are used to codify diverse sets of information, it can as easily incorporate the pathogenic germ theory of cosmopolitan medicine as it can the demonic possession of exorcistic traditions, the effects of negative karma, or of harmful planetary configurations-all of which can seriously jeopardize the internal humoral balance of individuals and the external social and spiritual relationships they engage in. It is thus capable of rendering whole the myriad levels that define personhood and the diverse healing traditions available in Sri Lanka. The concept of state provides a crux for this orientation. The conceptualization of state is derived from the complex notions of personhood held by Sri Lankans, and derives a more encompassing usage from further extended linkages with notions of illness, health and Ayurveda/Sinhala medical traditions as they are rooted in popular knowledge paradigms. It provides a conceptual framework that is both flexible and dynamic, and yet fundamentally coherent across time and space. As such, it is capable of ordering broad-based existential concepts of being as they are variously expressed when the simple verb innawa-to be-comes to life in its intersection with the complex reality of being. Epistemology becomes ontology in this intersection-the abstracted linguistic symbol, to be, by virtue of its very use is lived, and by thus referencing this fact of being cognitively, it becomes as well a fundamental affirmation of existence for the person constructing an I am. . . statement. This double dynamic of being, as a cognitive construct and as experiential reality, underlies the

COnCept of state as it is used in Sri Lanka derives in

part from the fact that the two perceptual categories defining its parameters represent distinctly different phenomenological and cognitive categories which must nonetheless be considered synergistically in terms of their encompassing coherent relationships in order to make sense. This represents neither a synthesis of divergent elements toward any one unity as in the dialectic, nor a Western-based model of linear process that sequentially analyses single categories as discrete, divided units. The different categories do not exist in contradictory relationships of any kind, but represent different order of phenomena viewed simultaneously as distinct and interrelated complete dynamics. As with the concept of self in health, this represents a multilectic orientation, State can refer to an individuals particular physiological condition at a specific time and place. At the same time it can summarize a persons existential or phenomenological place in life. As well, it can be used in the sense of a collection of people, a bounded sense of nationhood. The state of an individual is ultimately defined by all of these definitions inherent in the term. The first two uses of the concept of state were discussed in examples given above (in the section on The Concept of Self in Illness and Health): the impact that pathogens and humoral imbalances, interpersonal relationships and emotions, gods and demons, and the effects that supraphysical processes have on the health of a person. In the first case, one can be sick (sanipannae; asanipai; leda) [here and now] because of short-term illnesses caused by humoral imbalance, the attack of a demon, cosmological disturbances, or toxic agents carried by such vectors as food and water. In the second meaning of state, one can also suffer more long-term disabilities caused by circumstances more existential in nature: widowhood; the effects of karuma; poverty; polluted environs (both in the sense of pirisidunae, not clean physically, or kilutuwi, impure conditionally or existentially), or unhappy social relationships. Chronic diseases also fall into this category. This includes not only long-term physical disabilities, but more complex socio-physical conditions as well. A daughter, explaining the plight of her mother to me, clarified the latter instance: When my mother attained age (had her first menstruation) she suffered a bad fright, and she has never been the same since. For 25 years now she has had pains in her body,
paralysis at night, and periodic fits. Some say she is a yakleda (patient with an illness caused by demonic attack), others say she has heart problems and high blood pressure. But after spending tens of thousands of rupees on scores of different kinds of practitioners over the years with only limited success, we all agree that the illness has gotten into her bones. We doubt if she will ever get completely better now. The third use of the concept of state, that of a shared socio-political identity (often using nationalistic, ethnic, and cultural constructs to define a society-level membership), also follows the same principles. In its healthiness or unhealthiness, the state in this usage can impinge directly on a persons

Ayurveda: a multilectic interpretation well-being. A graphic example of this is given by Daniel [20] in his discussion of the nationwide interethnic violence taking place in Sri Lanka

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between the Sinhalese and the Tamils. Daniels discussion centers on a Tamil indigenous medical practitioner. Although this does not represent Sinhala beheth, strong parallels exist between this and Tamil vaittiyam (Tamil medicine) in terms of the popular (as distinct from the textual) body of knowledge discussed in this paper. The following excerpt from Daniels paper is the direct quote of an indigenous medical practitioners analysis of the state of the country in conflict. (The rioting cited here refers to the communal conflict between Tamils and Sinhalese resulting from the 1983 nationwide riots in which over a thousand Tamils were killed.) When there is a lot of sorrow there is a great amount of tears
formed in the body; mainly in the head. If tears dont flow then they coagulate into bile. The heat of anger fires the tears which coagulate into bile. This bile may look like phlegm. But it is mostly bile. But this heat is all internal. It dries up the tears into phlegm and bile, and this phlegm and bile block the channels in the head and in the body, mainly in the head. This is bad. This is what has happened to these boys [involved in rioting]. Look at the weather. It is cool. We have had more rain this year than in any other year. The winds are cool. The amity talks (referring to the attempted peace talks between the Tamils and Sinhalese that was taking place in Colombo) are also like cool breezes. But this is very bad. It drives the heat inside the body. Into the central channels of the body. This is very bad. It blocks the channels. When the channels are blocked you cant remember. To get better we must all remember. The Tamils must remember. The Sinhalese must remember. What we need is a dry spell with lots of dry wind. The people must weep and weep a lot until their tears cool this land. Now the Sinhalese soldiers urinate on our rice fields. The rice field is our god. Urine is hot. Our country is hot. These rains hide the fact that this country is sick with heat. They do not really cool the land. First the land must cool down. It must truly cool down. Only then can human beings cool down. To really cool the land we need tears. Lots of tears to cool it. This land has not wept enough. It is hot. This land is sick. For the Sri Lankans, then, the popular body of knowledge based in, but not limited to, Sinhala/Tamil medical frameworks provides not only explanatory models for medical problems, but is used to orient them toward epistemological and ontological concerns as well. It is the only comprehensive conceptual framework capable of mediating all of the states-all of the levels of existence-that define personhood. In addition, as this exists in the form of popular knowledge that is shared throughout society [31,32] rather than as a formal written doctrine, it provides an integrated basis for social discourse that cross-cuts the various social groupings and hierarchies that are recognized in society. It addresses humans and life in general and is not restricted by any gender, age, or social distinction(s). It thus stands as a mechanism that links the population rather than dividing it. The tradition of Ayurveda/Sinhala beheth that is found in practical application in the villages and homes of Sri Lankans has a fundamental relevance beyond the healing arts delineated in the texts of the tradition. The basic philosophies of Ayurveda provide a series of metaphors that are applicable to any major conceptual system characterized by balance

and disorder, health and dis-ease. Thus Ayurveda does not exist simply as a medical tradition, nor is it confined solely to the discourse of medicine. On one level, this popular body of knowledge provides a mechanism for integrating the various traditions of health care into a coherent encompassing framework for patients. In addition, the impact of Ayurveda extends beyond issues of illness and health in the life of the Sri Lankans to provide an explanatory framework capable of synthesizing the many facets of Sri Lankan life, and concepts drawn from this body of theory are used to explain that life itself. THE ROLE
OF INDIGENOUS MEDICINE IN HEALTH CARE

A number of authors have written that in recent years the practice of cosmopolitan medicine is eclipsing indigenous healing traditions. Some argue that indigenous medicine will fade as a viable option in the future, and others postulate that it will blend with cosmopolitan medicine, forming a sort of composite tradition. Some recognize the importance of indigenous medicine in health care, but say it is generally second in preference to cosmopolitan care [6, 11,33-361. The data from Sri Lanka presented here challenges these assumptions, demonstrating that regardless of the actual healing tradition activated during illness (whether cosmopolitan, Ayurveda, or indigenous), Ayurveda, as a popular conceptual knowledge system, is often the means by which patients orient themselves ais-a-vis the illness episode and the healing endeavors in general. Because this popular body of knowledge is crucial in explaining the relative well-being of a person, and his or her everyday world, it remains central to the lives of the Sri Lankans. AS such, it reflects and reinforces traditions and values that are considered fundamental to the society. For the Sri Lankans, this is not a dynamic that can be reduced to diadic oppositionals and contradictory forces; mind/body, individual/society, or to paired sets of fundamental competing humors or life constituents. It is the interplay of a more complex interrelationship of multiple factors, spanning the many levels on which the self is made evident, and the many arenas in which individuals engage in the course of their days and their lives that is, in essence, a multilectic process. In addition to representing a healing tradition, Ayurveda/Sinhala beheth, as a popular paradigm, is an epistemological and ontological explanatory framework grounded in, and referencing, the most fundamental aspects of life and society for the Sri Lankans. Because of this, Ayurveda and indigenous medicine will in all likelihood continue to exert a profound influence in the lives of the Sri Lankans, and to operate as a central explanatory framework for people confronted by illness, misfortune, and existential angst in a world where they define themselves and their relationship to life in terms of a multilectic orientation based on ideals of health.
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