Brigitte Sébastia
email: bsebastia@yahoo.fr

Coping with diabetic patients in Tamil Nadu Case study of two traditional siddha practitioners

Keywords: nutrition transition, diabetes, siddha medicine, dietary prescription, medication Coping

It is often after a first recourse to biomedicine that Indians turn to traditional medicines, notably to siddha. Siddha practitioners are mostly consulted for joint and bone disorders, digestive and sexual troubles, and skin diseases. However, they are increasingly approached for the treatment of diseases related to metabolic syndrome which have emerged over the past two decades as the result of rapid change in diet and lifestyle. If siddha doctors who have studied in colleges are better equipped to treat these pathologies thanks to their training which integrates biomedical disciples and the study of recently developed diseases, traditional siddha practitioners have to develop their own means because they have not inherited any knowledge for treating these diseases which were too rare in the past. Based on the observations of two reputed traditional siddha practitioners, this article intends showing how they adapt to the need of their diabetic patients by calling on their traditional as well as other sources of medical knowledge.

Introduction:

Type2 diabetes and its allied diseases are little covered in the studies on Indian traditional medicine, despite the increasing number of diabetic patients who consult its practitioners. Some articles deal with the subject, but always with the focus on plants potentiality to reduce blood glucose level [START_REF] Chacko | Culture and therapy. Complementary strategies for the treatment of type-2 diabetes in an urban setting in Kerala, India[END_REF][START_REF] Sood | Ethnic Indian Plants in Cure of Diabetes[END_REF]. They never question how practitioners treat this unfamiliar disease and its allied ailments that may present a challenge for them, notably for traditional practitioners who inherited their knowledge from ancestors and/or through kurukulam system (disciple-guru educational system). These practitioners are traditionally consulted for joint and bone disorders, digestive and sexual troubles and skin diseases for which they have obtained a range of medicines from their family or gurus. However, they have not inherited any knowledge to treat type2 diabetes as it was very rare at the time of their ancestors/gurus. Conversely, doctors who learnt in Indian medicine colleges are better equipped to manage diabetic patients thanks to their education which ‗mimics' the biomedical system, a term used by [START_REF] Langford | Medical Memesis: Healing Signs of a Cosmopolitan ‗Quack[END_REF] to describe the transformation of ayurveda so as to conform to the ‗scientific' criteria laid down by the British. They learnt physiopathology and anatomy both in traditional medicine and biomedicine, treatment of diseases recently developed such as type2 diabetes, for which they prescribe medicaments developed by pharmaceutical companies specialized in Indian medicine. The means developed by traditional practitioners to cope with diabetes are of great interest, more particularly when one addresses siddha medicine because its practice is mostly in the hands of this category of healers. As shown in an article on the institutionalization of siddha medicine, this medicine was scarcely taught compared to ayurveda at the School of Indian medicine at Madras established in 1923, and it was only in 1964 that a college was funded for it (Sébastia forthcoming). The feeble institutionalization of siddha medicine is brought out by the figure for January 2005 published by WHO, which fix the ratio of registered non qualified/qualified practitioners at 71.7% for siddha medicine and 22.7% for ayurveda (WHO 2007) (1). The predominance of ayurveda teaching in the School of Indian medicine is explained by the fact that it is extended all over India, while Siddha is prevalent only in Tamil Nadu, and the two systems share diagnostic and therapeutic methods, concepts on physiology, nosology and longevity and a large part of material medica.

The physiological concepts of these medical systems are based on the principle that everything in the universe is composed of five basic elements (pañcapūtam) (2), ether, air, fire, water and earth. Food and air supply basic elements which, converted into a juice (racam), produce successively the seven body constituents (tāttukkal ̣), chyle, blood, muscle, fat, bone, marrow and semen; each constituent resulting from the degradation of the precedent. The balance of tāttukkal ̣, and concomitantly, of the three tōs ̣a (vāta ‗wind'-pitta ‗bile'-kapa ‗phlegm') depend on the appropriateness of the diet and proper way of life (Thirunarayanan no dated, Uthamaroyan 2005). Siddha medicine however differs from ayurveda in its extensive usage of metals and minerals, specific medicinal preparations developed from iatrochemistry, and tantric philosophical tradition. The word ‗siddha' which means in sanskrit ‗realized', ‗one who is endowed with supernatural faculties called siddhi', refers to groups of tantric yogis who have acquired supernatural powers through austere ascetic practices [START_REF] White | The Alchemical Body. Siddha Traditions in Medieval India[END_REF]. The Tamil tradition is based on eighteen cittarkal who are considered the authors of manuscripts on medical disciplines (diagnosis and nosology, pharmacopoeia and therapeutics, alchemy, acupressure etc.), on astrology, philosophy, yoga and magic [START_REF] Ganapathy | The philosophy of the Tamil Siddhas[END_REF][START_REF] Venkatraman | A History of The Tamil Siddha Cult[END_REF]). Because of their root in alchemy, tantrism and magic, siddha practitioners are reputed to be dangerous and quacks. If the institutionalization of siddha medicine has permitted its doctors to get rid of bad reputation, traditional siddha practitioners continue to be ostracized. There are accused of ignorance and of practising a false medicine by those who avoid their treatment as well as by siddha doctors who lay claim to the true medical knowledge. During my five-year study on siddha medicine, I met practitioners who may be qualified as quacks like those described by [START_REF] Langford | Ayurvedic Interiors: Person, Space and Episteme in Three Medical Practices[END_REF]1999). Quite often from siddha practitioner families, they have developed interest in their ancestral medicine only after their retirement from government service. After having picked up scanty knowledge from various practitioners and from some courses related to complementary medicines, they open a ‗clinic' in which they exhibit diplomas obtained by correspondence courses and siddha icons collected in their family or bought from practitioners (photos of cittar; mortar; palm leaves manuscripts; practitioner' portraits) for recreating the link with their family tradition. In contrast, other traditional practitioners well skilled spare no effort to improve the treatment of their patients. The objective of this article is to show how two reputed traditional siddha practitioners, who have not inherited any knowledge for treating diabetes, respond to the need of their diabetic patients by calling on their traditional as well as other sources of medical knowledge. They are very different in their practices as one, Jeyaram, runs a hospital with a large in-and out-patients clientele in a village of Kanniyakumari district, while the other, Rattinammal, who is established now at Madurai, is consulted only by few patients, mainly diabetics. Their differences mirror the heterogeneity as well as the diversity in practice and knowledge observed along this study on siddha medicine. This article is based on my involvement in consultations during several two-week stays at Rattinammal's and also at Jeyaram hospital where my accommodation within has facilitated interactions with hospitalized patients and nurses, and observations of food preparation at the canteen, treatment (massages, distribution of medication and meals, bone setting, varma therapy) and preparation of medicines.

As a preamble, the prevalence of diabetes in Tamil Nadu will be briefly presented in order to justify the focus on the contribution of siddha medicine for managing this disease. Then, from the observations conducted at Jeyaram hospital, it will expose why and for what problems diabetics turn to siddha medicine. The two last chapters will document the treatment provided by Jeyaram and Rattinammal, i.e the medication and the dietary prescriptions given that food is central in traditional medicine as it is considered as a therapy and an ally to strengthen drug efficacy.

Type2 Prevalence of diabetes and its specificities in India

It is observed that type2 diabetes in India is increasing since the 1980s. The first study carried out at the national level in 1972 by the Indian Council of Medical Research (ICMR) estimated that 2.1% of the urban population and 1.5% of the rural were affected by this disorder [START_REF] Mohan | Urban rural differences in prevalence of self-reported diabetes in India-The WHO-ICMR Indian NCD risk factor surveillance[END_REF]. The data from a second national level survey carried out thirty years later, between 2003 and 2005, conjointly by WHO and ICMR (ibid.) indicate the average prevalence of diabetes in urban and rural areas at 7.3% and 3.1% respectively. Regarding Tamil Nadu, Chennai Urban Rural Epidemiology Studies (CURES) reveal a sharp increase in its prevalence: 8.3% in 1989, 11.6% in 1995, 13.5% in 2000and 14.3% in 2004[START_REF] Mohan | Secular trends in the prevalence of diabetes and impaired glucose tolerance in urban South India-the Chennai Urban Rural Epidemiology Study (CURES-17)[END_REF]. Diabetes increasingly affects also Tamil rural population as its incidence rose from 2.2% in 1989 to 6.36% in 2003 [START_REF] Ramachandran | Temporal changes in prevalence of diabetes and impaired glucose tolerance associated with lifestyle transition occurring in the rural population in India[END_REF].

The prevalence of type2 diabetes in India is mostly associated with the rise in metabolic syndrome (3) due to the rapid change in food and way of life linked to urbanization. In a study on Tamil Nadu, Allender and his colleagues (2010) have shown that urbanicity favours the increase of non-communicable diseases, notably the supranormal blood pressure and obesity, metabolic disorders that some traditional siddha practitioners take cognizance of in their investigation. Tamil Nadu is one of the Indian States that experience the most rapid economic development related to urbanization; it is estimated by the Census of India 2001 to have grown at 3.56% annually during the decade 1991-2001. Another factor for prevalence of diabetes is the transition from malnutrition at the fetus stage to high caloric consumption during adult stage which has been proposed by [START_REF] Barker | Foetal origins of coronary heart disease[END_REF] as an aggravating cause of the risk of metabolic syndrome. According to an estimate by UNICEF and WHO in 2000 [START_REF] Wardlaw | Low birthweight. Country, Regional and global estimates[END_REF]), India accounted for 7.8 million low birth weight babies per year, and other studies (Deadon et al. 2009;[START_REF] Hopper | Changing Food Production and Quality of Diet in India, 1947-98[END_REF] revealed that the consumption of a large part of its population shifted rapidly to more high caloric foods made up of fat and carbohydrates. Due to the Green revolution programme that promoted the cultivation of rice and wheat to fight famines and under-nutrition, and to the Public distribution system that provides only rice as cereal, meals of Tamil urban and rural population is made up of 80 to 90% and 81 to 98% of rice respectively (NNS Report). Millets which occupied an important place in the diet, now find less favour because of their deemed crude taste with the result that their consumption and cultivation have drastically declined [START_REF] Ramasamy | Improved Cultivars of Pearl Millet in Tamil Nadu: Adoption, Impact , and Returns to Research Investment[END_REF]. Their decrease in the diet and their replacement by highly refined rice and wheat aggravate malnutrition issues and diabetes due to the reduction of micronutrients and fibers [START_REF] Mohan | Can the diabetes/cardiovascular disease epidemic in India be explained, at least in part, by excess refined grain (rice) intake?[END_REF]. Aware of the consequences of the diet changes on health, siddha practitioners, and notably Jeyaram and Rattinammal who continue to favour traditional foods in their meals, repeatedly advice their patients to change their dietary habits. This aspect will be examined in the last part of the article, but before this, I want to document the reasons for which diabetic patients consult siddha practitioners by turning to Jeyaram Hospital that receives ten to fifteen diabetic outpatients daily.

Who are diabetics who turn to siddha practitioners: study at Jeyaram hospital

Jeyaram has specialized in siddha and varma therapies. Varma therapy which is very widespread in Kanniyakumari District consists of acupressure on energy points for treating bone and joint injuries, muscular dystrophy and neurological disorders and is associated with massages of different types using medicated oils and fresh plants. Jeyaram is fifty years old and learnt siddha medicine from the age of fourteen from his father and grandfather, both very renown ācān (practitioners sought by disciples for their extensive knowledge) in this area. After high school, he went to a private college near Nagerkovil where he learnt homeopathy for one year. Due to family problems, he gave up his study and established a small hospital on the vast land of his grandfather. His hospital has now eighty rooms, and possesses a radiography room and a laboratory for basic clinical tests (glycemia, lipids, hematological parameters) that Jeyaram has established ‗to reinforce the trust of patients in siddha medicine'. With his wife, Neela, who holds a BSMS degree (Bachelor of Siddha Medicine and Surgery) and is the legal owner of the hospital as he has no diploma in siddha medicine, he receives daily eighty to hundred patients of various socio-demographic categories. Sixty percent of out-patients and ninety percent of in-patients suffer from fracture and dislocation, and diseases called metaphorically vāta because they result from an increase in vāta in the body (osteoarthritis and neurological disorders such as paralysis, memory deficiency, epilepsy). Diabetes occurs in about ten percent of his clientele. My observations have led to the classification of diabetic patients into three categories according to their health issues and their expectation. The first group (5-10%) consists of patients not identified as diabetics, a situation very widespread in India where patient awareness of this disease is feeble and preventive measures are deficient [START_REF] Venkataraman | Challenges in diabetes management with particular reference to India[END_REF]. They come to the hospital with complaint of joint pain, arthritis, dry itchy skin, nausea, tiredness, etc., a range of troubles which are traditionally treated by siddha medicine. Well informed that these symptoms may appear in diabetic condition, Jeyaram/Neela prescribe glycaemia, glucosuria and some blood tests (lipids; hematological parameters) to patients of forty and above, and measure their blood pressure. Although Jeyaram claims to be capable of detecting blood pressure by pulse reading, he uses sphygmomanometer, but less frequently than Neela who admits to being poorly trained in pulse reading at college. According to Jeyaram, he uses sphygmomanometer and stethoscope to reinforce the confidence of his patients and in response to their request as they are now familiar with biomedical tools. Blood sample is analyzed in the hospital laboratory so that patients can be put on an antiglycemic treatment if an abnormal glucose level is detected, conjointly with a medication for treating the primary complaints. Jeyaram/Neela do not treat patients with glycaemia higher than 2.0g/l and urge the patients to consult biomedical doctor. The second category (85-90%) consists of identified diabetic patients who are under biomedical medication and visit this hospital for treatment of diseases related to diabetes, notably osteoarthritis, hemiplegia and diabetic ulcers. Jeyaram/Neela focus on treating the patients for the disease complained of and prescribe antidiabetic siddha drugs to complement biomedical medication. They ask the patients to come back for follow-up, and in the event of a significant decline in glycaemia, they reduce biomedical medication, except for the patients under insulin. Patients are hospitalized depending on the severity of the disease complained of. At each of my stays at the hospital, I observed two to four diabetics with oesteoarthretis or hemiplegia and one to two with diabetic ulcers. The third category (5%) consists of diabetics who wish to switch from biomedical drugs to siddha medication. Jeyaram/Neela follow the same practice as previously noted: they give medication only to the patient with glycaemia less than 2.0g/l and reduce biomedical drugs according to the antiglycemic effect of their medicaments. Fear of iatrogenic effects resulting from the long intake of biomedical drugs is the reason for the patients turning to siddha medicine. Side effects are indeed the main criticism leveled against biomedical medication which, on the other hand, is preferred for its supposed immediate relief.

Treatment of diabetics who shift to siddha drugs is a heavy responsibility on siddha practitioners. Jeyaram and Neela are confident in the effectiveness of their anti-glycemic treatment, but they stress that, without adherence to posology and food rules inherent to their medication, its action is reduced. Thus, they never advise discontinuation of biomedical treatment unless they are sure that the patient has enough faith to unfailingly follow their recommendations on medication and diet.

Jeyaram/Neela and Rattinammal medication: a combination of medical systems

At Jeyaram hospital, diabetic patients affected by osteoarthritis, diabetic ulcer or hemiplegia are administered medicines developed by Jeyaram's family as these ailments are traditionally treated by siddha practitioners. Patients with osteoarthritis and hemiplegia receive siddha medicaments that include medicated oil taken with kaśāyam (strongly concentrated decoction) and cūranam (powder of dried medicinal plants) mixed with honey, and two sorts of massages. External diabetic ulcers are cleaned and anointed with antibacterial medicated oil, and the internal ones are opened by the application of a paste of crushed fresh leaves. These medicines are traditionally used for treating wounds and opening carbuncle or deep infection. On the other hand, for managing diabetes, Jeyaram and Neela use medicaments bought from the representatives of siddha and ayurveda pharmaceutical companies who regularly visit them. Jeyaram justifies his recourse to the market by the fact that he has no time to create his own formula. He also points out that his increased difficulties in finding medicinal plants due to the high urbanization of the region and in recruiting appropriate staff for collecting plants and preparing medicines do not allow him to develop other medicines. Jeyaram/Neela's antiglycemic treatment takes into account the constitution and condition of the patient, and aims at purifying the blood, improving digestion and reducing blood sugar. The practitioners provide antiglycemic tablets from the market selected according to the condition of the patient, and for blood purification and enhancement of digestion, their family medicines which consist of kaśāyam that varies depending on the patient's constitution. They record on the patient medical card the finding from pulse reading, laboratory tests results, blood pressure and their medication so that they may adjust drugs according to the therapeutic effect. If consultations are free of cost, patients have to pay for medicines. Medicaments from the market are never sold in their original packing. Tablets and capsules are removed from their wrapping and put in an impersonal packet so that the patients can not differentiate between medicines from the market and those from the hospital. Jeyaram justifies: -Patients have not confidence in the medicaments from the market and thus to ensure that these are taken, it is better to give these medicines in the same way that you give ours.‖ I have indeed often noticed that patients who go to traditional practitioners turn down marketed medicines that they consider as having poor efficacy because they are allegedly made with adulterated ingredients by overheating machines that destroy the potency of the products. These patients, conversely, hold the traditional practitioners' medicines in high esteem because they are supposed to be produced according to the inherited formulae which have built the reputation of practitioner families. Jeyaram, who dispenses some medicines purchased from the market, can yet retain his clientele and maintain his family's reputation by repackaging the commercial drugs under his hospital's name.

Rattinammal, an eighty-six year old siddha practitioner, conversely, does not provide any medicine from the market. She prepares all her medicines with the help of her śiśya (disciple), a retired advocate who wants to learn siddha medicine as he claims ‗for the service (cevai) of my people'. Rattinammal belongs to a raja vaittiyar family. She holds the knowledge that she acquired from her mother and grandmother, and later, from a guru, a practitioner well-versed in alchemy. She used to practise at home in her village to the south of Madurai, but after her husband's death, she moved to her daughter's house in the city. She continues her consultation, but her clientele is small, three to five patients per day made up of urban middle class. She never applied for registration. She considers that registration is required only for commercial practice, whereas her objective is to give cevai for common people. Despite her age, she is very open to share her experience on medicine preparation, diagnosis and treatment with everyone who approaches her and by participating to conferences organized by NGOs and by associations of siddha students or practitioners. And thus, during one of my stays with her that I had devoted to learn about her understanding of and treatment for diabetes, a disease for which one tier of her clients consulted her, she took great pains to share her knowledge with me. From the first day of my stay, I was lucky that Rattinammal was approached by a new patient, a woman with a diabetic ulcer. The treatment of this woman and some other diabetics has largely substantiated her discourses.

Rattinammal, like Jeyaram, did not inherit drugs for treating diabetes. Twenty years ago, when she lived in her village, she decided to develop formulae for treating increasing number of diabetic patients who approached her. She consulted several books, especially those attributed to Pōkar, the famous alchemist-cittar that she venerates, to inventory and study plants specified for nīrilivu (diabetes). Gradually, after testing their effect on patients, she developed a cūranam she called cakkarai cūranam. This cūranam is made of thirty-one ingredients among them thirteen are mentioned by other practitioners and used by siddha pharmaceutical companies for their antiglycemic properties. Rattinammal prescribes cakkarai cūranam with two other cūranam, one to purify the blood and the other to regulate function of the ‗five king organs' (kiṇruppācān). She explains:

Sugar is due to rise of pitta when the liver fails. Subsequently, pancreas fails and all the king organs (kiṇruppācān), lung, heart, liver, pancreas and kidney are affected. When these king organs work in cooperation then no disease affects the body, but if one fails, all will fail. That is the reason I give medicine, not only for sugar, but also to cure the five organs and to purify the blood. If the patient has BP (high blood pressure), cholesterol, kidney problems, he will be cure by this treatment.

To increase the efficacy of her cūranam, Rattinammal adds a small quantity of what she called muppu. Muppu is the mystical substance of the cittarkal comparable to the philosopher's stone of the western alchemists. Its formula is not known, but traditional Siddha practitioners involved in alchemy proudly claim that they can make muppu and show their product as proof of their great knowledge. They attribute to this substance which contains pūnīr (earth-water), a salt collected on full moon night from certain secret places, a catalytic power to purify metals and minerals used in the preparation of drugs against degenerative diseases. Rattinammal's muppu is her own innovation because she laments that she is too old to collect pūnīr for preparing her mother's muppu, which she admits to be more in keeping with tradition, but she considers hers as very effective.

In addition to medication for diabetes, Rattinammal provides various medicines from her family to treat certain diseases that she associates with diabetes after reading the pulse, examining and questioning the patient. She explains: Sugar disease is rarely alone. It is often associated with vāta or with kapa or with vāta and kapa. So to treat sugar patient, I check his condition and I treat sugar disease, vāta and kapa separately. If I treat only sugar, without treating vāta and kapa, sugar disease will not be cured.‖ Her explanation reflects the reputation of Indian medicine practitioners for their holistic approach towards the disease and their sensibility to take into account its complexity of in the treatment. The psychological disposition of her patients is also an aspect that she pays a particular attention to. She uses Bach flower remedies which are supposed to act on the mental and emotional states. She discovered this therapy when, at the age of 20, she attended a lecture given by a disciple of Dr. Bach. The method she uses combines principles of siddha medication which highly favours the mixing of medicinal ingredients for enhancing efficacy, and of homeopathy: she impregnates globules contained in a small vial with four-five different flower essences. Although Rattinammal knows the Western origin of Bach remedies, she considers it as an integral part of siddha medicine, because both medical systems use flowers and pay attention to patient's psychological disposition.

Rattinammal has also perfected an elaborate treatment for diabetic ulcers using a combination of ingredients to each of which she assigns specific properties. I witnessed her treatment of the diabetic ulcer that had infected the toe of a patient who was advised by her doctor to have it removed. The fear of amputation as I have often noticed is the main reason for which patients turn to siddha practitioners. First, Rattinammal disinfected her hands with a juice extracted from fresh leaves and cleaned the wound with the same extract. She then prepared an ointment by mixing with nīm oil (Azadirachta indica, antiseptic and antidiabetic), copper sulfite and alum to destroy dead skin, a cūranam to promote flesh regeneration, and another powder to improve regeneration of blood vessels, tendons and nerves and to inhibit pus formation. She filled up the wound with it and bandaged the toe. After ten days of the same treatment, when she noticed the improvement of the wound, i.e. when flesh was well irrigated, she applied raṇa kaḷimpu, an ointment of her mother used to treat wounds and to which Rattinammal added one plant thought to have antiglycemic properties. And two days after, she gave raṇa kaḷimpu to the patient for continuing the treatment at home till the wound was completely healed. Rattinammal prescribed her antidiabetic medication in order to complement patient's insulin treatment and to avoid any ulcer formation, and also two vials of Back flowers: one to remove her fear of amputation and the other to instill confidence in her treatment.

Rattinammal is very proud of her knowledge of the medicinal plants that she claims to be capable of treating many diseases with. Like Jeyaram and Neela, she emphasizes that in the case of diabetics, her medication needs the cooperation of the patients and notably their strict observance of her dietary prescriptions. Tirelessly and with authority, Rattinammal as well as Jeyaram/Neela try hard to convince their diabetic patients to adopt healthy food and life habits.

Diet and healthy food habit: a fundamental therapy allied to medication

The relation between food and health is expressed in a Tamil adage ‗food is medicine and medicine is food', that siddha practitioners often quote to emphasize food intake rules. In siddha texts, foodstuffs are classified according to various properties (hot/cold/wet/dry; heavy/light; taste, potency) which condition the character, constitution and activity of the individual (Nitcher 1986, Uthamaroyan 2005). Nevertheless, dietary prescriptions provided by Jeyaram/Neela and by Rattinammal are little individualized and use food concepts of siddha medicine as well as of western dietetics. These practitioners advise diabetics to avoid sugar and sweets and to reduce drastically intake of oily items. They urge them to replace rice partly by millets, sorghum, and whole grain wheat, and to increase their intake of pulses, green leaves and vegetables. They also recommend certain vegetables such as bitter gourd and spices such as cumin, turmeric and asa foetida which are used in medicines for their antiglycemic proprieties. They forbid consumption of meat because of its character of heat that increases pitta in the body, which is already high in diabetic condition, but encourage consumption of all dairy products for their cooling property which lowers pitta. Unlike nutritionists, they do not draw menus in which weight, size and number of items are clearly stipulated. Their prescriptions follow the rules of pattiyam/apattiyam (do/don't). The interest of these prescriptions is to strongly encourage intake of traditional foods which are rich in micronutrients and fibers and help to prevent and control diabetes as well as to fight malnutrition which affects a large part of Indian population whatever the socio-economic status [START_REF] Singh | Micronutrients deficiencies in India[END_REF]). Nevertheless, these recommendations are not often followed by patients, and practitioners must use of a lot of arguments to convince them on the beneficial effect of the food on their health. But patients often justify their non-compliance by citing the unavailability and high cost of certain ingredients, bad taste and lack of time as reasons: ‗Only Rice is available to us and it costs only 2 rupees per kilo (in public distribution system); how can I buy kampu or ragi (pearl, finger millet), dal, vegetables?' ‗Doctor, we not pay for vegetables, pulse, milk, they are so expansive…' ‗It is too long to prepare ragi (finger millet), and it is difficult to bring it to the office' ‗I have too much work, how can I manage to prepare two kinds of food, one for me and another for my children? My children want to eat only rice, they don't like vegetables. They refuse to eat bitter gourd; they say it is too bitter'. If the defense is understandable by the high inflation which affects pulses, vegetables and dairy products in particular, the change in taste of the young and the lack of time of working women for preparing food, the practitioners conversely are more critical of patients' behaviour. As Rattinammal says:

People now have become very lazy. They do not want to make any effort to change their habits. They want to eat whatever they like: rice, large amount of rice with meat, fish, oily snacks… They do not want to change anything. They take medicines and continue eating as before. But with our medicines, this is not acceptable; they work only with appropriate diet.

The non-compliance with prescription is an important issue for managing diabetes in India. A study on biomedical field conducted in 1999 quoted by Venkataraman and her colleagues (2009) points out that only 30% of diabetic patients are compliant with medication, 37% with dietary prescription. Therefore, if dietary prescriptions are important tool for siddha practitioners due to their crucial role in therapy, they may be a drawback if the patients do not respect them. One traditional siddha practitioner who has a large clientele confined to me that, although she has developed a formula for reducing glucose level, she refuses to treat diabetics because of their reluctance to change their food habits. But her attitude is an exception. Like Rattinammal, she has no means to force the patients to follow her recommendations. Jeyaram and Neela conversely take advantage of the hospitalization of diabetic patients to educate them about the food pattern that they should follow. During the hospitalisation which is long, one to several months, patients must eat the food prepared in the hospital canteen. The preparation of meals strictly adheres to the prescriptions of the practitioners. Thus, the diabetic patients get accustomed to the change in composition and taste and practitioners expect that, by observing an improvement of their health, they will be encouraged to adopt their new dietary pattern and will be more confident of siddha treatment.

Conclusion

The comparison of practices of Jeyaram/Neela and Rattinammal has shown an important heterogeneity in regard to the personality of healers, the situations in which they work, their ambitions, and their endeavour for recognition of their medicine. Their differences illustrate the diversity of practices that I observed in about twenty other practitioners. Some, who run large hospitals like that of Jeyaram/Neela, use similar biomedical diagnostic methods and take recourse more or less to products from pharmaceutical companies to complement their traditional drugs, inherited as well as developed by them. In a way, their use of biomedical tools and marketed Indian medicine drugs may remind the practice of institutionalized siddha doctors. Others share some characteristics of Rattinammal, such as her involvement in alchemy and in the transmission of siddha knowledge, her holist approach to patients' diseases, her use of non conventional therapies and her medical ethic entirely turned to the care of patients.

The use of biomedical tools in Indian medicine has been frequently underlined in studies and often explained as a consequence of the hegemony of western medicine (in books of Leslie 1992 andLeslie andYoung 1998;[START_REF] Langford | Ayurvedic Interiors: Person, Space and Episteme in Three Medical Practices[END_REF]. Despite his large clientele and the faithfulness of his patients which is attested by the medical records, Jeyaram often complains about the strong attraction exerted by biomedicine on his patients and their decreasing interest in siddha medicine. Quite often, he receives patients who come to him only after undergoing a long course in biomedicine. He has not only to treat diseases that are sometimes in an advanced stage, but also to heal them quickly in order to avoid the patients' dissatisfaction which may further discredit siddha medicine. This is in this difficult context of competition, that Jeyaram's use of biomedical tools and of some strategies to strengthen his patients' belief must be understood. Unlike Rattinammal, he never uses components related to alchemical knowledge, magic, non conventional treatment which might brand him as a quacks. The fact that he has no formal diploma to practise siddha medicine may explain his prudence to avoid risks and critics which could ruin his reputation. The context in which Rattinammal practises is very different. She has no expectation of material benefit and her limited middle class patients seek her because of their particular attraction towards Indian traditions; her age, her family background as well as her practices being the testimony of her roots in tradition. Therefore, by their diversity of practices and knowledge, siddha healers attract a large variety of patients who approach them either with pragmatic or ideological motivations. Thanks to their capacity for adaptation, their flexibility to use all means that may improve their treatment, their knowledge regarding a wide range of ailments notably chronic diseases, traditional siddha practitioners play an undeniable role in health care. Although my position as an anthropologist has not allowed me to evaluate the efficacy of their medication on diabetes, I have observed the rapid result of their medicinal products on the treatment of diabetic ulcers and on the relief of osteoarthritic patients. Their awareness of the risks related to diabetes that I have noticed during consultations confirms their important contribution in the care of this disease, a disease become a major public health issue in India as well as in the world for its morbid consequences.

Acknowledgements:

To the three traditional practitioners from whom the writing of this article has been possible, Jeyaram, Neela, and Rattinammal, I express my deepest gratitude for their time, open explanations, confidence and friendly. They always give me a warm welcome, inviting me and my husband to share meals, tea and delicacies, to taste some traditional foods, and to accommodate me in order to improve the quality of my observations. I also express my thanks to the reviewers of Anthropology and Medicine for their insightful comments on the earlier version of the article which has allowed to recontextualize and clarify my arguments.

Notes

(1) Indian medicine practitioners were registered in 1933. Those trained in colleges (qualified) were classified in class A while the non-institutionalized practitioners in class B (literate) and C (illiterate). The registration of non-institutionalized practitioners was stopped by the notification No. V. 26211/4/1976 dated 10.9.76 of the IMCC Act of 1970 but the Tamil Nadu board of Indian medicine continued the registration until the central government asked it to cease this illegal practice (Sébastia forthcoming).

(2) For Tamil words from Sanskrit, this article uses Tamil transcription by following the rules defined by the Tamil Lexicon, University of Madras (1982). The plural form is -kaḷ (kkaḷ after vowel; ńkal ̣ after consonant m, kaḷ after other consonants).

(3) Metabolic syndrome is set of risk factors that includes: abdominal obesity, insulin resistance, dyslipidemia, hypertension, increased risk of clotting, pro-inflammatory state. People with this syndrome are prone to develop cardiovascular disease and/or type2 diabetes [START_REF] Gogia | Metabolic syndrome[END_REF]. Regarding Indian specificity see also [START_REF] Misra | Metabolic Syndrome in Asian Indians: Current Issues in Definition and Risk Correlation[END_REF].


6

Competing for medical space Traditional Practitioners in the Transmission and Promotion of Siddha Medicine

Brigitte Sébastia

The Universe of the Hereditary Siddha Practitioners

Siddha medicine is the main traditional medical system practised in Tamil Nadu and in some Indian States and countries where an important Tamil community resides. It shares many features with ayurveda such as physiological theories, diagnosis, therapeutic methods, concepts of longevity and nosological causality and a large part of its material medica. Nevertheless, it differs from ayurveda by an extensive usage of metals and minerals in its medicaments resulting from iatrochemistry i , and an allegiance to a tantric ii philosophical tradition. The word "siddha" is Sanskrit and means "realized", "one who is endowed with supernatural faculties called siddhi". It refers to a class of tantric yogis who would have acquired supernatural powers through austere ascetic practices [START_REF] White | The Alchemical Body. Siddha Traditions in Medieval India[END_REF]).

The Tamil tradition of siddha is based on eighteen cittarkal iii who are considered by Tamils as the authors of manuscripts on medical disciplines (diagnosis and nosology, pharmacopoeia, therapeutics, alchemy and acupressure or varmaccikiccai iv ) and on astrology, philosophy v , yoga and magic [START_REF] Ganapathy | The philosophy of the Tamil Siddhas[END_REF][START_REF] Madhavan | Siddha Medical Manuscripts in Tamil[END_REF][START_REF] Venkatraman | A History of The Tamil Siddha Cult[END_REF].

Traditional medicine in the Tamil region was probably known as medicine in general and acquired the prefix "siddha" not very long ago. The term siddha medicine is notified for the first time in the committee report of Muhammad Usman who was appointed in 1923 by the British government to evaluate the relevance of establishing a school of indigenous medicine at Madras (Usman 1923). In the previous reports, it is referred to as "Tamil medicine" or "Tamil ayurveda" [START_REF] Hausman | Siddhars, Alchemy and the Abyss of Tradition: 'Traditional' Tamil Medical Knowledge in 'Modern' Practice[END_REF]. The mention of "siddha medicine" in 1920s suggests that it would have been coined during the revival movement for Tamil identity in the first decades of the twentieth century vi [START_REF] Weiss | Recipes for Immortality. Medicine, Religion and Community in South India[END_REF]).

In the beginning of the twentieth century, ayurveda practitioners promoted their medicine "on a nationalist platform by arguing its unique connection to Indian cultural identity" (Langford 1995: 333). Traditional practitioners of all medical systems protested against British imperialism and demanded that their disciplines be recognised and supported [START_REF] Hausman | Siddhars, Alchemy and the Abyss of Tradition: 'Traditional' Tamil Medical Knowledge in 'Modern' Practice[END_REF][START_REF] Ramanna | Systems of Medicine. Issues and Responses in Bombay Presidency[END_REF][START_REF] Weiss | Recipes for Immortality. Medicine, Religion and Community in South India[END_REF]. These contestations led to the institutionalisation of traditional medicine by creating schools/colleges for learning ayurveda/siddha and unani. While institutionalisation has assigned a place to Indian medicine in the modern education system, it has induced two consequences: a strong disadvantage for traditional practitioners who, if not registered before 1970s, cannot legally practise medicine; a diminution of the knowledge base by severing links with highly experienced and knowledgeable traditional practitioners (maruttuvarkal) vii .

The loss of knowledge was mentioned several times by my informants among the PhD students in cirappu maruntuvam (special medicine) viii that I met at a Government Siddha Medical College. They complained about the poor knowledge of varmam, pulse reading, medicine preparation that they were acquiring in the college, and invited me to visit traditional practitioners in Kanniyakumari: "In Kanniyakumari district, there are many good paramparaiya ix cittamaruttuvarkal, you must go to Narendran hospital. I use to go weekly for varma courses."

Cittamaruttuvarkal x are traditional siddha practitioners who have acquired their knowledge and practice from their ancestors, gurus or from both ancestors and gurus.

With the exception of younger generation practitioners, cittamaruttuvarkal have never gone to government and private siddha colleges. They consider their knowledge and know-how as much more extensive and authentic than that taught in institutions.

The aim of this article is to offer a view of the clinical practice of four cittamaruttuvarkal of Kanniyakumari district, three men, Jeyaram, Narendran and Sivanarayan and one woman, Mahesvariyammal xi , belonging to nātār caste. While ayurveda has received a lot of attention from academics, there are very few works on contemporary siddha practice,notably, in Kanniyakumari district. This region, strongly urbanized, has a concentration of traditional practitioners among whom numerous specialists in varma therapy and bone-setting may be found. Biomedicine is also well established here and every small town possesses one or several private hospitals often with a traumatology/orthopaedic ward. Yet the cittamaruttuvarkal have a steady clientele though the size varies from one practitioner to another. Nearly ninety percent of them possess a small clientele that they consult in their house, in a shop where they also sell their own medicines or in a small cottage where they may hospitalize one to three patients. Some others run a large hospital of forty to sixty beds and treat fifty to hundred patients every day. Jeyaram, Narendran and Sivanarayan belong to this last category, while Mahesvariyammal manages a large clientele but does not run a hospital.

They live in hamlets or in a small town around the dangerous traffic highway Kanniyakumari-Trivandrum. These practitioners are genuine managers who conduct their medical practice with extreme competence, self-confidence and prudence, by juggling between tradition and modernity. They are well-off and have succeeded in retaining the heritage of their ancestors both in terms of clientele and property. Their clientele is attracted because of their family"s name and fame in the field and they do their best to preserve this heritage.

Because they do not possess formal registration, these practitioners are not authorized to practise siddha/ayurveda medicine. Nevertheless, they manage not only a large out-patient clientele, but also run hospitals. Two of them, Narendran and Jeyaram often approach administrative officials to improve their hospital infrastructure, to patent their property medicines or to start courses. Regarding the complaints by traditional practitioners of police harassment, the ease with which Narendran and Jeyaram address the administration seems to indicate that the practitioners without any diploma are not disturbed by the authorities if they are well known for their good practices. The profile of these four practitioners in terms of their educational background, family history and their strategies will help in understanding how they get around the difficulties posed by the present institutional arrangements of their medicine. They are aware of the important role their medicine plays for people who are not satisfied with biomedicine, for the poorest who cannot afford biomedical treatment and for those who wish to avoid surgery. They are also aware of the limitations of teaching in siddha colleges especially in areas in which they are specialised and all of them, in various manners (courses, kurukulam system, family transmission), try to transmit their knowledge to the new generations.

Practitioners of Kanniyakumari District: A Siddha/Varma Practice

Well Anchored

The cittamaruttuvarkal of Kanniyakumari district belong mostly to the nātār caste.

According to the classic ethnography by Robert L. Hargrave, southern Travancore was one of the main places mentioned in literature where nātār were established (Hargrave 1969). Kanniyakumari district belonged to the southern ex-Tranvancore kingdom when the states of Tamil Nadu and Kerala were created in 1956. In Kanniyakumari district, villages with three to five siddha/ayurveda xii clinics are very common and it is difficult to explain such a prevalence. The fact that this region was a princely state is certainly an explanation as kingdoms have always patronized traditional practitioners [START_REF] Alexander | Traditional healers in a region of Mysore[END_REF]). Among the practitioners that I met in Kanniyakumari, two of them are descendants of rajavaittiyar, siddha practitioners attached to a kingdom. A large majority of cittamaruttuvarkal of Kanniyakumari district practise a medical system made up of siddha/ayurveda, bone setting and varmam. This triple speciality is particular of the ex-Travancore region and is practised by nātār in Tamil Nadu and by elava and nayakkar in Kerala. The studies on bone setting in Tamil Nadu [START_REF] Nandakumar | Herbs bind broken bones. The Hindu, Folio[END_REF]Poidevin et al. 2009;[START_REF] Radhika | A tradition of bone setting. The Hindu, Folio "Indian Health traditions[END_REF] Jeyaram specifies the link between energy centres and physiology in Indian medicine: "if the patient is taken to us immediately when a varmam is injured, he will be cured; but if he comes after one week, we will not able to do much. The injured varmam will provoke increase of vāta (wind) and the patient will be affected by vāta diseases such as stroke, paralysis, osteoarthritis." This link between varmam and physiological concept of vātapitta-kapa explains thatin South districts of Tamil Nadu and Kerala, bone setters are also siddha/ayurveda practitioners specialised in vāta diseases.

In his book Kanniyakumari. Aspects and Architects, M. Immanuel justifies the relationship between nātār and varmakkalai (Immanuel 2006: 62):

The treatise of Marma Kalari is one among such invaluable treasures of Santors of this region. (…) This "Art" is seen handled commonly by the "Nadans" xiv of the country as an art of self-defence as well as an art of Offence, if so required.

Another explanation by siddha practitioners specifies the link between varma therapy and nātār. Previously called cānār, they climbed to coconut and palm trees to collect the sap which was transformed into fermented (kallu ; alcohol) and nonfermented (patanīr) drinks, or into sugar (karuppatti ). Practising this risky job, many fell and hurt. Varma therapy was developed inside of the community to treat injured people. This explanation concerns only the curative aspect of varmakkalai, nevertheless varma therapists of Kanniyakumari district practise also cilampam/kalarippayattu and perform this art during temple festivals. The link between the martial art and the santors is also established by the fact that they were in some way employed as body guards by the Chera kings (Ghosh 2000: 31) Universe of the Practitioners: Their Environment and Their Knowledge

Acquisition

Jeyaram, Narendran and Sivanarayan are specialised in varma/siddha/ayurveda that they practise in a hospital, while Mahesvariyammal, specialised in mother and child diseases, consults in a part of her house. Although these four practitioners have interesting profile, the article will give a larger attention to Narendran due to his involvement to develop and transmit varma/siddha medicine for which he has instituted many activities.

Jeyaram Hospital

Jeyaram hospital is located on the border of Kerala so that Jeyaram uses more often the term "ayurveda" than "siddha" in conversations. Nevertheless, he considers that siddha that he associates with varma treatment is much more effective than ayurveda that he associates with pañcakarma. As he says: "Siddha massages are very therapeutic while ayurveda ones are preventive". Jeyaram belongs to a very famous cittamaruttuvar family; one of the three best renowned families of Kanniyakumari district since four generations.

He learnt medicine from his paternal grand-father for whom he has a great admiration, and from his father. He managed to buy a large piece of land which belonged to his grandfather and established the first building for out-and in-patients, "to the memory of my grandfather who practised in this place". In 1995, he erected a second building for inpatients from destitute to middle-class, and physiotherapy and yoga rooms. He also built two Keralite cottages for well-off people, quite often Keralites who come for pañcakarma treatment by considering that the treatment provided in this hospital is much more effective and cheaper than that in Kerala clinics. Three new floors come and add to the first building; they are composed of ordinary rooms, two high-class rooms, two operating theatres, as well as consulting rooms for gynaecology, dentistry and traumatology/orthopaedic that are managed by specialists that Jeyaram knows.

The hospital is placed under the name of Jeyaram"s wife Neela, who possesses a BSMS degree from the government siddha medical college. Jeyaram has no medical diploma to run the hospital, as he spent only one year at Atoor (near Nagerkovil) to study homeopathy. Nevertheless, he is very proficient in siddha/ayurveda medicine and varmam which he learnt from his childhood by observing his grandfather"s practice and by helping his father in consultations. Neela considers that her husband"s medical knowledge is much more substantial than hers and that the complementarity of their education background is an important asset for their medical practice. Like many siddha students who expect to find job in biomedicine, Neela, worked two years in gynaecology and cardiology hospital wards after getting her BSMS degree. The professional experience that she transmitted to her husband has favoured the integration of biomedical tools (stethoscope, sphygmomanometer, x-ray, laboratory) in their practice. Jeyaram considers that he does not need these tools as he is capable of detecting fractures and dislocation by pulse reading and touch, but he bemoans thatbecause people have become large consumers of biomedicine, they need to be reassured by "modern" techniques. His words not only mirror the high competition in the medical field, but also his long experience during which he has observed a decline of interest and confidence in siddha/varma. He laments how each time he has to treat a serious cases discharged from hospital without full cure. "My ancestors were capable in few seconds to rescue an unconscious patient and to cure severe injuries. They taught me varma therapy for these urgent cases. But, now people believe only on allopathy xv and I have no longer opportunity to practise these techniques. I lost a lot of knowledge from my ancestors."

Biomedicine appeal is one reason for which Jeyaram has decided to integrate biomedical specialities in his hospital. Thanks to its double speciality, his hospital will receive injured patients that he will be able to treat by varma therapy in the first instance, and if necessary, to send them to his biomedical colleagues. Neela explained to me: "I don"t agree entirely with my husband about his choice to mix biomedicine and siddha. I am afraid that it does not benefit of siddha. But my eldest daughter is like me, she is very interested in allopathy, while my youngest who is close to his father, is interested in siddha. We expect that they will continue our work, and it is for them that my husband decided to build these new wards." The female nurses in the hospital were trained in biomedicine. Along with their conventional jobs such as injection for pain or insulin, medication, bandages, etc., they practise some siddha/ayuvedic treatments such as massages, varma or pañcakarma therapy.

The ailments for which patients come to Jeyaram"s hospital belong especially to the category vāta nōykal "wind diseases", diseases caused by the increase of vāta humour in the body. They concern different types of joint, muscle and bone pains, oedema and paralysis, bone injuries. Patients also come for skin diseases, nervous troubles, gynaecological disorders, stomach ulcers, kidney stone, and more and more often for metabolic syndrome and its allied diseases. When both practise, Neela consults the women and children, while Jeyaram receives male patients. The comparison between

Jeyaram and Neela regarding pulse reading mirrors their difference of training. Jeyaram is very concentrating and self-confident when he reads it and controls the reading on the second wrist, while his wife puts very quickly her fingers on the patient"s wrist and hastens to take her stethoscope to continue examination. For in-patients, Neela oversees medication, wounds care (diabetic ulcers) and takes arterial tension, while Jeyaram manages serious fractures, practises varma or siddha/ayurveda therapies such as nāciyam (sinus cleaning with oil) or talam (poultice of cock blood and herbal powder applied on the head for mental and neurological diseases).

The consultation does not take more than ten minutes except if the patient is a friend or expresses some doubts. At the end of the consultation, the practitioners give diet recommendations to the patient and list medicaments (often more than 5). The medical card is given to an employee who prepares the prescription that the patient will take after paying the amount inscribed on the card. According to the payment system commonly used by siddha practitioners, only medicaments are subjected to money transaction. Their price is relatively high due to the number of products, but it is reduced if the patient is poor.

Narendran's Hospital

Narendran and Jeyaram know each other. They studied homeopathy in the same college and Narendran, who developed his medical knowledge from traditional practitioners or ācānkal according to the term used in this region, learnt varmam from

Jeyaram"s father that he considers as one of the most proficient practitioners that he met.

Narendran"s hospital is located in a hamlet not far from Nagerkovil (Kanniyakumari dt.).

It consists in four buildings made up of in-patient ordinary rooms and share rooms for poor, several classrooms, owner"s apartment, room for the storage and packaging of medicinal products, a large waiting room decorated by a series of portraits of traditional fashion-dressed old men called ācān, a x-ray room, a pharmacy, and treatment rooms.

Except that he practises alone in a small room and he encourages less biomedicine, his clinical practice is very similar to that of Jeyaram. Regarding in-patients treatment, massages include varma therapy which is practised by his employees and students trained personally by Narendran. For managing his in-patients, he is helped by a siddha doctor, a homeopath and a biomedical doctor. Like Jeyaram and his wife, Narendran is always smiling and very pleasant to his patients and staff; these practitioners inspire confidence and seriousness.

Narendran is born in 1959 from a medical practitioner family who lived close to his hospital. He is the fifth generation practitioner in his family:

In the olden days, one did not speak about siddha medicine or ayurvedic medicine. In Kanniyakumari district, the medicine was called nāttu vaittiyam

Sivanarayan's Hospital

Sivanarayan lives in a small village near Kanniyakumari. Sivanarayan has developed his father"s clinic which is become a large hospital with only ordinary rooms due to uniform means of his patients. He added an x-ray room and a consulting room for biomedicine. His association with a biomedical doctor who comes only from necessity, allows him to manage the hospital and to use some medication, essentially "pain killer" injections. But unlike Jeyaram and Narendran, Sivanarayan refuses to hospitalize very serious cases patients. As he explained to me: "If a patient dies here, this will be bad for the reputation of this hospital. So, if I think not to be able to cure the patient, I advice the family to take him to hospital."

Sivanarayan"s waiting room is always crowded despite the efficient organisation of the work involving five assistants which favours a quick intervention for each patient.

Sivanarayan is rarely found sitting and all his time is devoted to massage, to bandage, to practise varma therapy and to visit his in-patients as soon as he can. His massages and varma techniques applied on out-patients are simple, rapid and repetitive, but they are more elaborate on in-patients. His knowledge regarding these specialities is lesser than that of Jeyaram and Narendran, but he is considered as a very good healer in the region, both by siddha/varma traditional practitioners and biomedical specialists in traumatology.

Indeed, noticing that many patients were taken to traditional practitioners because of surgery after-effects, I visited some hospitals specialised in traumatology to know if, conversely,doctors received casualties of traditional practitioner malpractice.

Surprisingly, the response was always negative and the name of famous traditional practitioners they often mentioned during these interviews was that of Sivanarayan and sometimes of Jeyaram and Narendran.

Sivanarayan, Jeyaran and Narendran practise bone setting in the same way. They take radiographies "for reassuring patients". Then, if there are slipped bones or dislocation, they practise traction in order to put bones in place; they apply a large quantity of medicinal oil on the injured part; for fracture, they place some splints (in bamboo or metal) before bandaging, they bandage and pour copiously oil on the bandage where is the injury. The use of large quantity of medicinal oil on fracture, sprains and dislocations is specific to southern districts of Tamil Nadu and Kerala. Elsewhere, bone setters apply a paste of grinded fresh leaves [START_REF] Nandakumar | Herbs bind broken bones. The Hindu, Folio[END_REF]Poidevin et al 2009) or a powder mixed with white egg in which the bandage is soaked so that it hardens after drying. Bone setting cost is very low and the practitioners highlight the quality of treatment for a quick cure. But the rapidity of the fracture consolidation is not surprising if we consider that Indians, by lack of trust in government hospitals, prefer to go to private clinics where surgery is carried out even on simple fractures for the sake of monetary remuneration it brings. While at Narendran"s and Jeyaram"s, patients pay a fix price for bandages and medicines, at Sivanarayan"s, patients pay for bandage and medicines initially, but renewed bandages and massages are free because Sivanarayan consider them as a duty, a service (cēvai) for his patients. Many practitioners are conscious about providing non expensive treatment, pointing out that if they ask for too much money, they will loose their "therapeutic power", and they define the price of medication according to the economical level of the patients. However, cēvai is a quality intrinsic to their medical practice which is applied under form of free or low cost hospitalization for poor people. Jeyaram organises monthly medical camps and manages a home for aged while Narendran"s kurukulam provides services to the benefit to patients and also to siddha medicine.

Mahesvariyammal's clinic

Mahesvariyammal"s clinic is located in a small town not far from Nagerkovil. She is a female siddha practitioner specialized in the diseases of women and children (matappini and pillaippini maruntuvam); her clientele is constituted by mothers and their babies, women with gynaecological complaints and often for a range of other diseases.. She learnt her knowledge from her parents both of whom specialized in this field like her grandparents. She possesses several awards in appreciation of her services for women and of her proficient knowledge in siddha medicine, but she practises only with a non renewed enlistment certificate xx provided by the Tamil Nadu government. She is approached sometimes by female students of the government siddha college, Palayamkottai, who want to enhance their knowledge. Her specialties are taught in siddha colleges, yet students find besides Mahesvariyammal an important source of theoretical as well as clinical knowledge. Mahesvariyammal does her best to help students in order that her knowledge will not get lost. She has two sons but none of them has been interested in her work; she is expecting to find a spouse to her unmarried son who will be interested in her knowledge.

Mahesvariyammal consults in a small room separated off the waiting room by a folding screen. When privacy is required, she receives the patients in the adjacent room used for storing medicines and raw material. Like her peers, she uses pulse reading, but for children younger than two years, pulse reading has no validity and thus, she also uses the stethoscope and sphygmomanometer. A large part of her consulting time is devoted to preparing her medication prescription with the help of an employee.

Medicinal Preparations as Emblem of Proficiency of Practitioner

While at Jeyaram"s and Narendra"s, the pharmacy is organized on the biomedical hospital model, dissociated from the consulting room, in Sivanarayan"s hospital and

Mahesvariyammal"s clinic, medicines are exposed in the consulting room at the sight of the public. This is far the most common situation where the image of the practitioner merges with that of the pharmacist. All the four practitioners consider their family formulas as the cornerstone of their reputation. Nevertheless, except Narendran, all medicines provided by these practitioners are not their own medicines and Mahesvariyammal, Jeyaram and to a lesser extend Sivanarayan also sell medicaments from ayurvedic and siddha companies to their patients. Mahesvariyammal and Sivanarayan sell the manufactured medicines directly to their patients, while Jeyaram removes totally the wrappings. He explains: "Confidence is crucial for efficacy of treatment but many patients have no confidence in products from company. So it is better to give them in a simple paper or in a bottle, like we give our medicines." For twentyyears ago, siddha as well as ayurveda practitioners are increasingly consulted for new pathologies such as metabolic syndromes and degenerative diseases for which they have not inherited formulas from their predecessors (Sébastia forthcoming). This situation obliges them to provide medicines from companies or to innovate by creating new formulas from olaiccuvāti or siddha books. Mahesvariyammal has created a formula for the treatment of diabetes, but she complains about the lack of time for developing formulas requested for treating "new" diseases. Regarding Jeyaram, who is also confronted with paucity of time for the development of new medicines, also adds that there are two fundamental impediments, namely, shortage of plants and availability of efficient staff. He explains:

When I was young, there were one or two showers per month. But today, due to the climate change, rains are not enough and it is become difficult to collect all the plants necessary for medicines. For preparing the tailam that I use for bone setting, it needs forty-seven plants, but now it is not possible to collect them. I am very happy when my employee collects forty plants. It is really a problem for traditional medicine. Another problem is to find a person who accepts to prepare medicines. I am looking for replacing one of my employees who is working for us for forty years. But even for a good salary, nobody wants to do this work, it is too exhausting…"

Narendran is not confronted with the same situation as his peers. In 2003, he got the license for preparing siddha and a few ayurvedic medicines under his label "Power Lab India Trust": Twenty-eight proprietary products (his own formula derived from the knowledge of medical texts and manuscrits) and one hundred and fifty six "shastric"products (formula listed in ancient medical treatises). According to the legislation of traditional medicines manufacturing, traditional practitioners have the right to prepare and sell their products directly to patients. But for commercialisation in the market, they have to comply with the Drugs and Cosmetics Act, 1940, andRules, 1945 and to get the Good Manufacturing Practices certificate (as per amendment in 2005) xxi .

Narendran plans to establish in his Community health college a course in medicine preparation that will allow him to recruit permanent employees at the end of their courses and to use students during their training.

Kurukulam System: From Secrecy to Open Transition of Knowledge

The siddha system of medicine in the beginning was taught by "Guru-Sishya" method only. Here, it is important to note that, the Siddha system of education in ancient Tamilnadu was not imparted or organized on the scale of mass education like schools and colleges, but the ideal of education is, to treat it as a secret and sacred process, for the reason that the process of individual growth (inner) can only be achieved by a close and constant touch between the teacher and the disciple in their personal relationship from which the whole world was excluded.

This explanation from a practitioner quoted by Richard S. Weiss (2009: 154-155) concerns kurukulam (sk. gurukula), an education system highly favoured in traditional medicine milieu xxii . In the Monnier-Williams Sanskrit dictionary, gurukula is translated by the "house of the guru" and in the Tamil dictionary by "a school where the disciples live with their teacher". The definitions refer to the traditional system of education by which students lived in their house"s master for learning various subjects during twelve years, in principle. The student had to share his master"s lifestyle and took part to his family works; he left his father"s authority to that of his guru. In Indian context where caste and religion are differentiation criteria, the teacher and the disciple belonged to the same community or adopted certain strategies to not subvert caste protocol xxiii . The guru is considered as taskmaster who requires sacrifices and hard work. Before getting little knowledge, student had to prove his strong motivation and patience, and for a little bit of knowledge, he had to wait for days and for months. The whole process of apprenticeship was cloaked with secrecy. These qualities are especially important for disciplines which have ambivalent effects such as varmam used for injuring or treating, iatrochemistry used to prepare medicines or poisons, or mantras used to cause or remove spell.

Sivanarayan, Jeyaram and Mahesvariyammal learnt medicine only from their parents and grand-parents and did not seek to go to gurus because they considered that their parents were knowledgeable enough. Mahesvariyammal, as a female, was restrained to approach gurus, mainly males. Regarding their involvement in knowledge transmission, Sivanarayan has five assistants, out of which three are his disciples who learn his medical practice and cilampam; he also trains his eldest son when he is free from school. The training mode used by Sivanarayan is very close to that he received from his father: his disciples share a large part of his life, their training remains mostly at the level of observation and they are not allowed to practise. Mahesvari and Jeyaram teach students from siddha/ayurveda colleges who approach them for their respective specialities.

Narendran, on the other hand, is strongly aware of the need to transmit the knowledge acquired from his numerous ācāńkal. But he has to create interest among students of this generation in the profession and its objectives. Thee training system that he has instituted in his Community college is hence much more liberal than that the one he was trained in

To study from ācān was very difficult in the olden times. Now, it is very easy. We have to respect ācān even if he is a mad man. We have to give respect because we are his slave. Hesitate to give money, hesitate to do work; they do not give you a bit of knowledge. We know that ācān is misusing the situation but we have not the right to oppose to his demands. Why? Because our aim is to get some knowledge from them. I spend twelve years, thirteen years, and twenty years besides ācān… You know that this ācān has a great knowledge, so you wait to learn some specialities from; today or tomorrow or not? Never ācān give you fully knowledge. But today, I have no regrets, because they give me records, they show me varma points, they teach me their knowledge.

Gurus emphasize on the importance to stay prudent in the transmission of knowledge which must be distilled step by step to the śiśya until they assess him to be ready and to possess the essential qualities to practise: good morality, pure feelings, humility and total devotion to patients. This method based on the readiness of the student may also facilitate the instrumentalisation of secrecy by the master to strengthen his legitimacy and reputation in traditional medicine milieu.

Narendran welcomes every student who wishes to learn and he teaches them without any consideration on their "moral qualities" and on their caste. The term kurukulam in this context, where the education followed system is close to modern education, is used to emphasize on the traditional aspect of certain topics such as varmam, siddha subjects or medicinal plants, studied in his college. The term highlights that these special subjects are, in principle, learnt through the kurukulam method under the guidance of traditional practitioner, a facility not available in collegiate education of siddha. A second reason is that the students are in contact with many "old-fashion" ācāńkal invited by Narendran to transmit a bit of their knowledge during the meetings of the association. This relationship puts them in the position of śiśya which is much more honourable than that of students, since it involves the notions of elective community which shares a common knowledge and of consideration for those who hold Tamil traditional knowledge; Narendran is today called ācān by his students.

The profiles of students who participate in these courses help to assess the renewed interest for siddha medical knowledge which is intermingled with Tamil cultural revival. Apart from students who come from rural areas and from siddha government colleges, another category follow the courses, but with particular motivations. There are people, quite often cittamaruttuvar"s descendants, who after a career in administration or elsewhere, wish to learn siddha medicine, the "glorious" knowledge of their ancestors.

They go to Narendran"s college and also to renowned practitioners where they learn in a more traditional manner, or they turn to the correspondence courses organized by various universities, private colleges or associations. These "students" aim at practising siddha, for cēvai, "for serving people", but some among them used these opportunities to practise medicine with the expectation to get a name, power and money. In spite of this pernicious effect which reinforces risks of quackery, kurukulam in its various reformulations for adapting to modern world mentality is fundamental to the development of siddha medicine and to compensate some part of its knowledge neglected in colleges.

Practice of siddha medicine varied from one practitioner to another and any attempt of generalisation is difficult. I also noticed many people who open a clinic after learning few months besides practitioners and having taken correspondence courses xxiv .

Nevertheless, the quality of work and services provided by practitioners such as Jeyaram, Narendran, Sivanarayan and Mahesvariyammal calls for a better consideration from siddha doctors. Thanks to their awareness regarding the financial situation of their clientele and their devotion to their patients, they play a fundamental role in the medical world. Numerous patients affected by paralysis, hemiplegia or traumatic injuries come to them after having been discharged from hospitals and are hospitalized for long period, two-three months, often for a small sum. It will be profitable to siddha medicine to accord greater consideration for traditional practitioners who possess a knowledge and know-how which allow supplementing biomedicine. This also calls for efforts from siddha doctors to be more open for exchanging with them and to take interest in the richness of their practices and not only in their icons regarded as identity symbols. Some such as a siddha practitioner trained at Palayamkottai college who is managing a research institute for traditional medicine at Chennai sets great value on traditional practitioners and invites them in seminars to share their knowledge and experience, but they are still rare. In this way, the couple Jeyaram and Neela serves as an excellent model for the complementarity in their practices.

End notes

i Iatrochemistry, which has its roots in alchemy, provides chemical treatment for diseases. The word comes from Greek and was popularised in the west between 1525 and 1650, notably thanks to Paracelsus (1493-1541).

ii Tantra meaning "warp" in Sanskrit, is a system of theories based on the principle that the universe is the concrete manifestation of the divine macrocosmic energy and consists of rituals to channel that energy, within the human microcosm with a view to emancipation.

iii While the number "eighteen" is constant, there are variations in the lists of cittarkal given by different texts so that their number is much higher (Shanmugavelam 1992; Venkaraman 1990). iv The writing of vernacular terms, Tamil as well as Sanskrit follows the convention of the Tamil Lexicon (1982), University of Madras, Madras. The plurals is given by kal which varies with the final letter: kkal after a vowel; kal after a consonant excepted "m"; ńkal after "m". v Anti-ritualist thought is central to siddha philosophy although many siddha practitioners venerate the divine couple Shiva-Shakti as in saiva or tantric philosophy. vi The Dravidian movement was launched to fend off brahmanical hegemony. One may suppose that Tamil medicine was favoured to the detriment of ayurveda which was considered to be emblematic of brahmanic culture. A study on the place attributed to traditional medicine of Tamil Nadu in the proponents" discourses on valorisation of the Tamil culture developed during Dravidian movement is left to do. vii For institution of siddha medicine and registration, see Gary [START_REF] Hausman | Siddhars, Alchemy and the Abyss of Tradition: 'Traditional' Tamil Medical Knowledge in 'Modern' Practice[END_REF] and Brigitte [START_REF] Sébastia | Coping with diabetic patients in Tamil Nadu. Case study of two traditional siddha practitioners[END_REF] viii Cirappu maruntuvam is a speciality of siddha for the treatment of skin diseases (tōl nōy), mental illness (kirikai nōy), yoga, varman, rejuvenation (kāyakarpam). The other siddha medical specialties taught in the colleges are: citta maruntuvappotu (general medicine); kunapātam (pharmacopoeia); pillaippini maruntuvam (pediatrics); nōy natal (pathology); nañcu maruntuvam (toxicology). ix The term paramparai from Sanskrit paramparā is translated as "hereditary succession proceeding from generation or lineage". Richard S. [START_REF] Weiss | Recipes for Immortality. Medicine, Religion and Community in South India[END_REF] mentions that the world in Sanskrit is formed by conjoining param with param, where param means "other", "another" and means the idea of transmission between two people, from one to another.

x I will use the term cittamaruttuvarkal for traditional practitioners in opposition to the termsiddha doctors that I reserve for practitioners qualified from siddha colleges.

xi All the practitioners" names in this paper are fictitious. I would take this opportunity to express my extreme gratitude to these four practitioners for their constant warmth, kindness and generosity during my visits. I also wish to thank them for their sincerity in answering my questions, in clarifying my doubts and for confiding in me about their difficulties and fears regarding the future of siddha medicine.

xii The use of siddha or ayurveda medicine denominations in this region is very flexible; it depends on practitioners" residence which is more or less close to Kerala.

xiii Cilampam is a Tamil term which is considered to come from the long stick used for battle; varma ati , sometimes used, signifies "to hit on varmam"; kalari means in Tamil and Malayalam "battlefield" "place for drama". According to Phillip B. Zarilli (1998: 25): "(kalari ) derives from the Tamil kalam meaning "arena, area for dramatic, gladiatorial, or gymnastic exhibitions, assembly, place of work or business"". xiv "Santor" and "Nadan" are old names of nātār. The term nātār was used from 19 th century by this community for obtaining better status. By changing their name, their work and their habits and by organizing associations for the benefit of the community, they succeeded to uplift their status from scheduled caste to backward caste [START_REF] Hardgrave | The Nadars of Tamilnad. The political Culture of a Community in Change[END_REF][START_REF] Templeman | The Northern Nadars of Tamil Nadu. An Indian Caste in the Process of Change[END_REF].

xv Allopathy is the term used in India for biomedicine, in opposition to Indian traditional medicine despite of its inappropriateness due to the fact that, except homeopathy, other medical systems are allopathic by nature.

xvi Narendran points out that the term "siddha medicine" is recent, confirming my opinion in this question, and he refers to a medicine which mixes different levels of medical practice and knowledge: home remedies/herbal medicines and medicaments highly elaborated from purified metals and minerals.

xvii Centuram is a fine medicinal powder prepared with metal and mineral mixed with plant juice, quite often calcined, and grinded; the final colour is red as the name indicates it. Parpam is a fine power realized from several calcinations of a mixing of metal, mineral and plant juice; the colour is quite often white.

xviii Mantiram refers to magic, tantra to tantric texts to which siddha tradition is linked, cōtitam is astrology.

xix The grandfather/grandchild relationship is highly privileged in the transmission of knowledge. The grandparents are considered to have authentic knowledge, more time to devote to their grandchildren education and to be more emotional and patient to transmit their knowledge. By tradition, grandparents chose the grandchild(ren) who had the best qualities to become a practitioner; this practice continues even to day. xx This certificate which was given in 1990s by the Tamil Nadu Siddha Medical Board is illegal [START_REF] Sébastia | Coping with diabetic patients in Tamil Nadu. Case study of two traditional siddha practitioners[END_REF] xxi The amendment texts are available at: www.whoindia.org/LinkFiles/Traditional_Medicine_Legal_Status_Orders.pdf Regarding amendments and rules on heavy metal, see Brigitte [START_REF] Sébastia | Le passage des frontières de médecines pas très douces. Le problème des formulations iatrochimiques dans la médication siddha : préserver l"innocuité ou l"authenticité?[END_REF].

xxii The word kurukulam is composed of kula "lineage, family" and guru "master, teacher" which is made of gu "ignorance, darkness" and hru "light, complete annihilation" and refers to a person who kills his disciple"s ignorance and elevates his character and ultimately lead him to the path of salvation. The guru is for the śiśya (disciple), incarnation of God in human. xxiii J. [START_REF] Indira | Sri Narayana Guru: A short biography[END_REF] mention the case of Sri Narayana Guru who, because he could not live at his guru"s who belonged to nayakkar caste, had to reside in an elava family during his kurukulam education. Stracey [START_REF] Prickett | Guru or Teacher? Shishya or Student? Pedagogic Shifts in South Asian Dance Training in India and Britain[END_REF] relates that for living with their guru who was isai vellala, a couple of brahmin dancers employed a cook. xxiv I have often noticed these people who move in the Madurai Siddha Vaittiya sangham, an association which has many activities among them to give courses to the traditional practitioners, to give free camps, to help practitioners to get registration.

  mother and four sisters. He replaced his father at the clinic and in parallel to, he prepared some diplomas which allowed him to combine siddha consultation with study: B.Sc. in chemistry (Bachelor in Sciences) at Nagerkovil, a subject in tune with his keen interest in alchemy, and few diploma courses on indigenous Medicine by correspondence course. In 1991, he got DHMS (Diploma in Homoeopathic Medicine and Surgery) and then, the diploma of Medicine Doctor in homeopathy (repertory) MD(H) by correspondence. He also acquired a diploma in Holistic Health Care (DHHC) and in Varma and Massage Science (DVMS M.A.) from Manonmanian Sundaranar University, Tirunelveli, and some certificates: Doctor of Medicine (Alternatives medicines) from the Indian Board of Alternative Medicines, Naturopathy Course of Gandhi National Academy of Naturopathy and registration certificates for ayurveda (1994) and for siddha (1998). The list of diplomas and certificates, mixing formal, informal and distance courses mirrors his insatiability to learn, to deepen his medical knowledge and to be recognized as a proficient practitioner; in brief, as an ācān. Siddha practitioners with homeopathy training such as Narendran and Jeyaram are common in Kanniyakumari district due to courses given at Atoor and facility to get MD (H) degree through a two-year correspondence course after completion of four-year bachelor course. This diploma offers the possibility to open a clinic or a hospital and to practise medicine without being harassed by the police during government offensives against quacks. The medication provided by these practitioners may be a combination of siddha and homeopathy. A few siddha practitioners privilege homeopathic remedies which are much easier and cheaper to prepare than siddha ones, but Narendran as well as Jeyaram provide only siddha medicines because they are more confident in the efficacy of their siddha medicines.

  xvi . My father"s family knew to prepare centuram, parpam xvii recorded in manuscripts. It knew kalari , varma, fracture reduction, and also yoga, mantiram, tantra, cōtitam xviii . My mother"s family practised pattivaittyam and knew only herbal medicine, simple medicines. Her medicines were very excellent; they had a lot of power to cure. My father had many olaiccuvāti and in my mother"s family only some, but in my mother tradition, they were better in siddha medicine than in my father tradition because they were born at Paloor, a very

famous place for medicine. Paloor Karuppanasan, Nadanasan, were my mother"s relations. They were saintly nature, they were called ācān. Here, all practitioners of siddha medicine, varmam, kalari, are called ācān. For four thousand years, that means from Tolkāppiya, this term is used here. It is given to excellent person who gives excellences to others.

Like Jeyaram, since his young age, Narendran learnt siddha medicine from his paternal grand-father xix and from his father. His father used to visit ācānkal and sometimes, he took Narendran with him. After his father"s death which occurred when he was eighteen years old, he continued to visit his father"s ācānkal and many others, fourty seven, as he is proud to mention. When his father died, he had to support his

  His speciality is mostly centred on bone setting and therapeutic massages. His patients, quite often farm labourers, consult him for various muscular complaints, fracture, dislocation, paralysis, i.e vāta diseases according siddha classification. Occasionally, he is approached for treating skin diseases, diabetes and kidney stones. He has completed high school (tenth standard) and he only holds the diploma of Alternative medicines from the Indian Board of Alternative Medicines. Sivanarayan"s family practice is not old and he and his brother are of the second generation. His father, who belonged to a poor agriculture worker family, chose to learn bone setting and varma to escape poverty. He approached a famous nātār ācān who trained him. Thanks to the reputation of the ācān and the large need in this medical field, he was capable to establish a clinic with several rooms. Sivanarayan took interest in his father work since the age of six and he began to practise under his guidance when he was 22 and on his own at 34.

Narendran is aware of the competition in the medical milieu and does not reveal all his "secrets". To clear siddha medicine from its bad reputation caused by its intermingling with secrecy and quackery in public opinion, and to diffuse its knowledge, he has created an association which organizes weekly meetings where ācāńkal are invited for talks and sharing their experiences. For courses, he has instituted a college which belongs to the movement of Indian Community Colleges. These colleges were developed since 1995 and modelled on US community colleges to provide high education for disadvantaged and underprivileged people. Mostly located in rural areas, their objectives are a combination of job-oriented, work-related and skill-based and aim at answering local industry needs and employment requirement [START_REF] Xavier | Indian Community College System: Democratic Response to Globalization[END_REF]). Narendran has founded his college to train students who will be able to find work in his hospital as well as in medical centres of Kanniyakumari district or of Tamil Nadu, to help people of his region (rural students not specifically nātār) to pursue study and to get a job, to transmit his varmam and siddha medicine experience, and also to improve the knowledge of students from siddha colleges where some specialities such as varmam, cilampam, pulse reading are very scarcely taught and practised. His Community college is affiliated to Manonmanian Sundaranar University, Tirunelveli, where examinations are organized. He organizes courses on nursing that follows the curriculum of the university, on siddha and varma concepts for which he has already written a textbook. He is also proposing to start a course on medicinal preparation which has been accepted by the university and for which he is preparing textbooks.

Kurukulam and Valorization of Tamil Culture