Development without Institutions: Ersatz Medicine and the Politics of Everyday Life in Rural North India
by Sarah Pinto
That something so preposterous could be happening in modern times at a place barely 100 km from the capital makes it all the more scandalous.—Times of India, March 5, 2001
In much of rural North India, government and nongovernment health institutions are part of the fabric of everyday life, and their ideals and symbolics are integral to the self-reckonings of the rural poor. But in many spaces, the absence or uncertain presence of official institutions means that, for many, they exist primarily as points of imagination and longing. This is all the more apparent in a context of globalization and structural changes in health care marked by privatization, the “rolling back of the state” (Qadeer et al. 2001:31), reliance on foreign donors and their agendas, and structural orientations toward profit and short-term interventions (Dr`eze and Sen 2002; Qadeer 2001; Sen 2001). Many rural people seek health care from practitioners who are neither “quacks” nor legitimate doctors but who invent roles for themselves as medical authorities and representatives of development.
Self-made medical authority is also common in urban India, but it takes a particular shape in rural areas where it is imbricated with the structure and ethos of development. Lacking official certification, seemingly ersatz doctors cross the permeable boundaries of institutions. Though some include elements of indigenous medicine in their practice, most work in a biomedical frame outside systems such as Ayurveda and Unani. This article addresses the slippery shape of institutional authority in the Sitapur district of Uttar Pradesh, India, where I conducted field research in 2000–2001. Here, I explore the complexities of medical practice in rural locales by considering persons who work on the margins of legitimacy, practicing medicine and health-education, opening clinics, calling themselves “doctors,” claiming the authority of development and medical institutions but without their formal sanction.
Given nearly two decades of change in national policy and international flows of funds, ideology, and regulation through North India, the definition of development is up for grabs at the local level, even as it is, at a more global level, being further constrained within neoliberal visions.1 As part of the development matrix, medical practice is part of a complex vision of institutionality in rural India, encompassed in the Hindi terms arkar. Strictly speaking, sarkar is translated into English as “government.” But in North India its practical usage is more complex and contextual (see Guha 1983 for historical aspects of sarkar). It can refer specifically to the government of India and its agencies or more broadly to state and nonstate institutions or authority itself. Sarkar can be a form of address (most often heard in films, plays, television, and radio) signifying the authority of the addressee and lower status of the speaker and conveying an old-fashioned—sometimes ironic—tone of obsequious self-deprecation. In rural Uttar Pradesh the meanings of sarkar point to different valences of institutional authority and power. The term describes something concrete and constraining and also something ineffable and just beyond reach. It is possible to imagine “governmentality” as inherent to its authority—to use Michel Foucault’s term for the ways state forms of power are extended into everyday domains of life, practices that economize life at the level of self-regulation (Foucault 2000). It is also possible to sense in sarkar a magical power outside the range of technique, an inscrutable yet palpable essence that, as Michael Taussig suggests, links God, economy, and the state as “abstract entities we credit with Being, species of things awesome with life-force of their own, transcendent over mere mortals” (1997:1). (337-339)
Pinto, Sarah. "Development without Institutions: Ersatz Medicine and the Politics of Everyday Life in Rural North India." Cultural Anthropology 19, no. 3 (2004): 337-364