Saturday, February 9, 2008





The Life of Ancient Egyptians
For Every Malady a Cure


Of all the branches of science pursued in ancient Egypt, none achieved such popularity as
medicine. Homer put it aptly in the Odyssey (IV, 229-232):
That fecund land brings forth abundant herbs, Some baneful, and some curative when duly mixed.
There, every man's a doctor; every man Knows better than all others how to treatAll manner of disease ...
There was even a degree of specialization quite remarkable for the time, if we are rightly
informed. Herodotus (II, 84) asserts that "The practice of medicine is so divided among them that
each physician treats one disease, and no more. There are plenty of physicians everywhere. Some
are eye-doctors, some deal with the head, others with the teeth or the belly, and some with
hidden maladies...'
The usual term for a doctor was sunu, written with an arrow-shaped symbol that, it had been
suggested, was an allusion to the use of arrowheads to lance abscesses. Some doctors belonged to
the priesthood, including priests of the goddess Sakhmet, patroness of diseases, remedies and
physicians, and of the lector-priests (khery-heb). Some again were counted among the scribes, as
shown in such titles as 'chief doctor and scribe of the word of god'. Many enjoyed ecclesiastical
as well as lay titles.
Like other professions doctors had their hierarchy. Besides ordinary doctors there were senior
doctors, inspectors, overseers and masters of physicians and the 'Chief of Physicians of the
South and the North', a kind of minister of health. Royal and palace doctors had their special
hierarchy and titles.
The Belgian scholar Frans Jonckheere counted 82 doctors known by name, many with titles
suggesting specialization in some defined area. Hermann Grapow, however, is probably right in
thinking of them as simply exemplifying the various skills which the doctor might possess.
Thus the 6th-dynasty court physician and high priest Pepyankh, known as Iry, was not only
'doctor to the king's belly' and 'shepherd of the king's anus', but also 'the king's eye-doctor'.
There has been much dispute recently as to whether dentistry ranked as a separate calling; there
are only five references to it in the Old Kingdom and another isolated one in the 2 6th dynasty.
Nor has it yet been settled whether any of the doctors known to us conducted research.
There were no female nurses to help the doctors, but we do know of male nurses, dressers,
masseurs and lay therapists. It would be wrong to see connections between the medical profession
and that of the embalmers, priests of the god Anubis. Contrary to older ideas that Egyptian
doctors took part in the preparation of mummies to improve their knowledge of anatomy, it must be
re-emphasized that most of their information came from ancient texts in which descriptions of the
internal organs were based on analogy with animal bodies.
The embalming procedure had nothing in common with medical autopsies. The physician learnt his
trade in the Houses of Life, notably at Per Bastet in the New Kingdom and at Abydos and Sais in
the Late Period. He was no doubt given some practical experience, but chiefly he had to study
what was already written. As the Ebers Papyrus says: 'His guide is Thoth, who lets the scrolls
speak for themselves, compiles treatises and expounds knowledge to the savants and doctors who
follow in his path.'
Diodorus too confirms this (I, 82, 3): '[They] administer their treatments in accordance with a
written law which was composed in ancient times by many famous physicians.' From his further
statement that 'on their military campaigns and on their journeys in the country they all receive
treatment free of charge', it appears that for some people, at least, there was a system of free
medical aid, such as we know existed also at Deir el-Medina. But on other occasions doctors
expected to be handsomely reimbursed, as we can tell from a scene in the I 8th-dynasty tomb of
the doctor Nebamun at Dra Abu el-Naga. There we see a patient, supported by his wife, (both
dressed in Syrian style), being handed some medicine by Nebamun's orderly.
Behind this group and on another register is a file of servants bringing the doctor his fee - a
copper ingot, a set of vessels (full, no doubt) and several little slave-girls.
The medical texts were not only the fount of professional knowledge but an insurance against
possible failure. Diodorus saw this clearly (I, 8 2): 'If they follow the rules of this law as
they read them in the sacred book and yet are unable to save their patient, they are absolved
from any charge; but if they go contrary to the law's prescriptions they must submit to a trial
withdeath as the penalty.'
Of the eight extant medical compendia the most important is the Ebers Papyrus, a collection of
about 700 prescriptions for treating internal diseases arranged according to the organ concerned.
This was built up between the 4th millennium BC and the New Kingdom through the continual
addition of fresh material. The Hearst Papyrus, by contrast, probably represents the memoranda of
a practicing doctor of the I 8th dynasty in which he had written out remedies from other works,
the Ebers Papyrus among them.
The Edwin Smith surgical papyrus shows a profound empirical knowledge of the different types of
injuries and how to treat them: this is a copy from the Second Intermediate Period of a work at
least 1000 years older. Other medical documents include the Great Berlin Papyrus, the London
Papyrus, Chester Beatty Papyrus NO.VI, Papyrus Ny Carlsberg NO.VIII and theKahun Papyrus, the last dealing with gynecology. These are largely copies of Old Kingdom
treatises made during the Middle and New Kingdoms.
Examination of both medical and non-medical documents has convinced many investigators that the
ancient Egyptians knew their anatomy in fair detail. In addition to externally visible features
there are many names of internal organs well known from butchery and cooking.
Notions of physiology and disease were all anchored in the concept of the heart as the center of
the organism. It was the site of the soul, the reasoning faculty, qualities of character, and
emotions. It was through the heart that god spoke, and the Egyptian received knowledge of god and
god's will. The heart was one's partner: it spoke to a person in his or her solitude.
It was at the same time the engine of all the bodily functions, not only of one cardinal
function, the circulation, as modern science revealed. From the heart proceeded channels (metu)
linking all parts of the body together.
These channels, the Egyptians believed, conveyed not only the blood, but also air (reaching the
heart from the nose, they thought), tears, saliva, mucus, sperm, urine, nutriment and feces, as
well as harmful substances (wehedu) conceived to be the agents of pain and illness. Not only
blood vessels were considered as metu, but also the respiratory tract, tear duct, ducts of
various glands, spermatic duct, the muscles, tendons and ligaments.
The female organs were likewise seen as tubes open into the internal cavity; the eye was supposed
to communicate with the car and the only purpose of the brain was to pass mucus to the nose,
with which it was also thought to be connected. The Egyptian idea of the human body, then. was as
a network of interconnecting channels and analogous to the branches of the Nile and the
artificial canals of their own country. It was soon realized that in some of the metu the heart
'spoke' and a doctor could 'measure the heart' from this beat. But he could only tell if the
heart was going faster or slower by comparing the patient's pulse with his own.
The concept of circulation was still beyond the Egyptians' knowledge, since they did not
distinguish between arteries and veins, nor appreciate that the blood returned to the heart. The
precondition of good health, they thought, was free flow through the metu: ailments arose when
they became blocked, just as with irrigation canals.
Thus if a woman was infertile this was because the sexual channel was closed, and constipation
or accumulation of the blood were likewise causes of disease. Harmful substances might find
their way into the metu through the natural orifices, mainly by the ingestion of bad food. But
they could also originate inside the gut, and doctors were therefore much exercised to ensure its
regular evacuation. Sometimes seeing worms in the stool, they deduced that these too might have
come into the body through the mouth and cause a disease.
With externally visible damage like wounds and fractures the causes were often obvious. But with
many internal ailments doctors were at a loss, so they imputed them to irrational influences,
usually gods - either hostile and malignant deities, or well-intentioned ones who sent down
plagues as a punishment for wrongdoing. Sickness might also be the work of evil demons, or of an
envious neighbor's evil eye.
It would far exceed the scope of this chapter even to enumerate the diseases of ancient Egyptians
that our researches have so far revealed. The evidence comes from several sources; from
identification of their names and from their description in the texts, from their characteristic
appearance in portrayals of the human body, from the study of pathological tissues in mummies
and, in the case of diseases of bones and teeth, from the examination of human skeletal remains
from burial sites. The study of all these sources constitutes the recently defined discipline of
paleopathology.
According to medical texts the ancient Egyptians recognized some 200 types Of sickness, though
there is no mention of diseases of the lungs, liver, gall-bladder, spleen, pancreas or kidneys -
the symptoms evidently eluded them. We can of course never be sure what any named disease refers
to unless its symptoms or recommended treatment are mentioned in the same context.
The descriptions of external lesions and in particular of wounds are fairly clear. A wound is
said to have a 'mouth' and 'lips' and may 'go as far as the bone'. It is usually accompanied by
bleeding, which in the case of severe injuries to the skull, may come from the nose and ears too.
The Ebers Papyrus (Case 8) mentions that a skull fracture hemorrhaging into the brain can cause
paralysis, on the same side of the body it says, not the opposite side - perhaps this was a
copyist's error.
The Smith Papyrus (Case 7) quotes a man with a gaping head-wound as showing the symptoms of
tetanus: 'His mouth is locked tight ... his brow is convulsively contorted and he has the
expression of a man crying.' The Egyptians distinguished simple fracture, sedj, where the bone is
broken in two, and complicated fractures, peshen, resulting in numerous fragments.
Conditions characterized by a bulging of the affected part were classified either as shefut,
commonly translated as 'swellings' but in view of some scholars references to a liquid content
possibly including abscesses too, or as henhenet and aat, thought
to denote tumors. The former were treated with dressings, the latter by excision. Most of the
ophthalmic and internal maladies mentioned in the texts are difficult to identify with certainty.
The only unambiguous ones are constipation, inflammation of the rectum, cystitis, and blood in
the urine, usually due (in Egypt) to bilharzia, equated by Ebbell and Jonckheere with the disease
aa.
We are on safer ground where we can find illustrations drawn by artists with a feeling for
characteristic changes of appearance. The Queen of Punt, familiar to us from a relief in the
temple of Hatshepsut at Deir el-Bahari, suffered from abnormal obesity, probably lipodystrophy.
The eunuchoid appearance of Akhenaten towards the end of his reign suggests Frohlich's syndrome
resulting from malfunction of the pituitary gland or of the mesencephalon, most probably due to a
tumor. There are many depictions of dwarfs, distinguishable from the ethnic pygmies of Africa by
their abnormal proportions.
One important achievement has been the examination of fragments of lung tissue overlooked by the
embalmers when they were removing the soft parts from inside the body. It has shown that Egyptian
lungs, like ours, contained coal dust in the lymphatic nodules (anthracosis), probably through
inhaling smoke from open fires. Hypertrophied connective tissue between the alveoli, and the
lymphatic vessels of other mummies proved to contain minute sharp-edged particles of silicates,
felspars and other granite minerals (silicosis).
In other cases lungs were found to be covered with dust of fine desert sand (pneumoconiosis).
Other mummies again showed changes characteristic of pneumonia, sometimes complicated by
pleuritis or pericarditis.
The Life of Ancient Egyptians
Bounty of the Black Earth
The Egyptian landscape is scenically among the most extraordinary in the world. A relatively
narrow strip of fertile valley spreads out into the Delta in the north, and to the south cuts
through the endless expanse of the Sahara.
Its fertility does not depend on the amount of rainfall, which suddenly decreased from the end of
the Neolithic wet phase in Upper Egypt and Nubia till it virtually came to a stop. Regular floods
bring about the Nile valley's annual miracle, when nature is reborn and the fields turn green and
then gradually golden with the harvest.
As early as the fifth millennium BC, the Egyptians realized the extraordinary fruitfulness of
their fields and the secret behind it - the deposits of black silt borne down by the river in
flood time. Hence they called the soil of the Nile valley 'black earth' (kemet), as distinct from
the 'red earth' (deshret) of the desert.
In their black land they felt content and safe. They were satisfied that a host of gods,
originally regional gods, kept guard over its fertility and that Khnum, the god of the First
Cataract, would ensure the punctual onset and adequate height of the flooding. The regular cycle
of natural events conferred a rhythm on their lives which was part of the maat, the eternal order
of things.
The red land, by contrast, was to be shunned as far as possible. From the western wilderness a
scorching, destructive wind, the khamsin as we now call it, would sometimes blow down on them.
Then, as now, it would raise clouds of fine sand and dust, blinding men and animals alike, and
sometimes drying out their fields.
No wonder they saw the desert as the domain of malignant forces disruptive of the established
order and personified in the Late Period by the baneful god Seth. It was of course the peasant
farmer whose links with the soil were strongest. He had learnt to cultivate it to perfection and
gradually extended the area of his fields to wherever the annual floods reached. He would clear a
course for as much water as he needed and steer the surplus back to its riverbed. In the passage
of time the size of his harvests and his herds grew to the point where, even in predynastic times
(4000--3000 BC), part of the population could turn to other employment.
This second social division of labor (following the first, that between men and women, which went
far back into prehistory) continued up to the threshold of the historic period. But even then the
majority of the population was still tied to agriculture and the rest of society lived on its
produce.
Egypt is the 'gift of the Nile' and her harvests depend on its floodwaters. These were the
fundamental pacemaker of the Egyptian farmer's life. It was the farmer, above all, who hadvested interest in the calendar, an invention which - thanks to the regularity of natural events
- this country was one of the earliest in the world to possess.
People knew from long experience that this was about the time for the level of the Nile to start
rising. Just before this, flocks of white ibises would have appeared on the fields as they
returned from the south. If they came late or not at all, farmers would see this as a bad omen
foreshadowing low floods and a poor harvest. So they regarded the wise bird that knew the secret
of this vital phenomenon as an embodiment of the learned god Thoth.
The Nile floods are in fact triggered by sudden monsoon downfalls on the Ethiopian plateau, the
source of the Blue Nile, and to a lesser extent by those around Lake Victoria and the Ruwenzori
mountains where the White Nile originates. Heavy rain and surging waters bring down the fertile
soil which the overflowing Nile then slowly deposits over the fields in its calm lower reaches.
Chemical analysis explains the fertility of the Nile mud, containing as it does all the important
ingredients which would otherwise have to be added to the soil by artificial manuring. Egyptian
farmers prayed to the hermaphrodite god of the Nile, Hapy - portrayed as a man with women's
breasts in symbolism of the apparently spontaneous fruitfulness of the river and its flood-plain
- to ensure that the yearly inundation were just right: not too deep, not too shallow.
If they were too shallow, the floods would not reach the thirsty fields, but if too much water
came rushing down it would sweep away the laboriously constructed dykes, tear up the fields, and
even threaten low-lying villages.
According to the theory accepted until quite recently, it was the very need for centrally-managed
canal construction and maintenance, and central allocation of water supplies, that played the
paramount role in bringing about the rise and continuance of the ancient Egyptian state. This
view ascribed the chief decision--making power to the king and his vizier, detailed supervision
of the work being entrusted to officials chosen from among the nobility and scribes.

It was even proposed by the Polish archaeologist Krzyzaniak that artificial irrigation started as
early as the second half of the Predynastic Period. As evidence that canals existed even before
the country was unified many writers have adduced the mace-head of King Scorpion, one of the last
rulers of a separate Upper Egypt, which may depict him officiating at the ceremonial opening of a
new canal.
Recently, however, the evidence for artificial irrigation has been analyzed independently by two
German archaeologists, Erika Endesfelder and Wolfgang Schenkel. The first-named has noted that
pyramid texts (the oldest being on walls of late 5 th-dynasty pyramids) do use the terms for
'canal', mer and henet, but only in the context of waterway traffic. Schenkel agrees that canals
existed in the Old Kingdom for traffic, and possibly also for the drainage of marshes.
Royal decrees of the 6th and gilt dynasties make no mention of labor squads being seconded for
the construction of irrigation canals, but simply make the distinction between two kinds of
fields: those that were flooded every year, and higher-lying ones that only came under water in
years of exceptionally high flood.
A part from reliefs showing gardeners watering vegetable patches as in the mastaba of Mereruka,
there are no scenes in Old Kingdom tombs of artificial field-irrigation or canal- and
dyke-building.
It appears indeed that no artificial irrigation was needed as a rule up until the end of the
Neolithic wet phase around 2350 BC. The Nile floods functioned quite regularly, supplemented by
occasional rain. It was only a series of low floods during the First Intermediate Period, when
rain ceased falling in Upper Egypt too, that famine occurred and radical measures were clearly
needed.
Water from this canal would have been distributed over the fields by the system of
basin-irrigation to be described later. It is under the Middle Kingdom that we first come across
terms for irrigation-- related works: a (canal), meryt (embankment), denyt (dyke) and others. In
contrast to the earlier notion that irrigation was a centralized affair, recent findings show
that it was promoted by local initiative which sometimes exacerbated parochial rivalry.
Canal-building, maintenance and water allocation were in fact managed by local consortia with no
one higher than a regional prince at the head. Nor do any later documents suggest the existence
of a central state institution dealing with these matters and we find no relevant titles in the
biographies of nobles or priests. On the contrary, every peasant had a share of responsibility
for water--management.
The Book of the Dead expressly makes it a great offence to obstruct another person in the use of
water or illegally to block his supply. If the central authorities concerned themselves over the
height of the Nile floods it was likely to be for fiscal reasons (since it was the basis of
harvest forecasting) or religious ones. But they were of course involved in any projects of
nation-wide importance.

Thus some investigators believe that a dam was built below Memphis soon after the town was
founded as the capital of a united Egypt. In the course of the 3rd and 4th dynasties the area of
land under cultivation grew through 'internal colonization', namely the draining of the Delta and
the utilization of land previously lying untitled.
In inter-flood periods water would flow out of this lake onto the surrounding fields through a
system of irrigation canals. The extension of cultivated ground in the Faiyum was completed under
the first Ptolemaic kings.
The development of an irrigation canal network made possible not only improved supplies of water
to fields that had enjoyed Nile flooding in earlier times but, more importantly, an increase in
the arable acreage in more remote and elevated areas. While under the Old Kingdom only natural
irrigation had existed, in the Middle Kingdom a distinction could be made between low-lying
fields flooded by nature and higher land watered artificially.
In the New Kingdom two further categories were recognized, of 'used' and 'fresh' fields.
Herodotus, who had personal knowledge of Egypt in the 5th century BC, evidently saw it during the
period of copious flooding. Hence his rosy view of the farmer's life there: 'Now, of course, they
reap the fruits of the earth with less effort than anywhere else in the world ... They do not
have to plough the furrow or dig the soil, they can dispense with the tiresome labor in the field
that other people must endure ... As soon as the river has risen of its own accord, watered the
arable land and receded again, each of them sows his own plot and drives pigs on to it to tread
the seed in. Then he awaits the harvest.

A textbook passage from a scribes' school, by contrast, paints the peasant's lot in much darker
colors - exaggerating perhaps by way of propaganda for the happy career of the scribe: 'When [the
farmer] returns to his fields he finds them in good condition. He spends eight hours plowing, and
the worms are already waiting. He cats half his crop himself, the rest is taken by the
hippopotamus. There are many mice in the fields, and locusts descend on them.
Even cattle devour his harvest and sparrows steal it. Then the scribe-officer arrives to count up
the harvest: he has bailiffs with him who wield sticks, and black men with palm-stalks. "Give us
the grain, " they say. "There is none." So they hold him by the legs and beat him, then tie him
up and throw him in the ditch. His wife is bound too, and his children, and their neighbors make
haste to abandon them so as to save their own grain.'
In tilling his land the peasant made do with a small range of simple tools, many of which are
used in almost identical form by the fellah of today. First and foremost was the indispensable
hoe for loosening the soil, its broad, thin sharp-edged blade of hard wood set at an acute angle
to the long wooden shaft to which it was bound with plant-fiber cord.
The oldest sign of its existence is a plough-shaped hieroglyph of the 2nd dynasty. The plough
consisted of a fairly long blade of hard wood fastened at its lower end to a pair of wooden
stilts slaved out toward their upper end, on which the plowman would lean to drive the blade into
the soil to the required depth and guide it along the furrow. A long pole extended from the lower
end of the stilts to the yoke over the necks of the draught animals.
For cutting the corn farmers originally used an almost straight or slightly curved wooden sickle
with a longitudinal groove in which a row of flint blades were set close together. These were
gradually superseded by copper and then, from the Middle Kingdom on, bronze sickles.
For wood-cutting, ground stone axes were used, the heads being tied to J-shaped handles. Other
agricultural implements included wooden shovels for tossing grain, wooden pitchforks for loading
the sheaves, wooden rakes for collecting the cut cars, plant-fiber nets and bags, leather or
canvas sacks for transporting both sheaves and grain, large wooden tubs for measuring grain and
cords for field-surveying.
The cereals the Egyptians cultivated were three kinds of wheat (einkorn, emmer and spelt) and
several of barley, notably the six-rowed variety. They devoted ample acreage to flax, their main
source of textile fiber. For a second crop, or in garden plots, a wide variety of vegetables were
grown, including onions, garlic, leek, Egyptian lettuce, radishes, cabbage, asparagus, cucumbers,
lentils, peas, beans and many spices. Valuable vegetable oils were extracted from sesame, flax
and castor-oil seeds. The floods meant a period of rest for the farmer, unless the pharaoh called
him up into army service or public works.
At the height of the floods, usually in mid-August, each farmer would row around his land closing
the vents in the surrounding dykes. Then when the Nile subsided the water would slowly run off,
deposit all the enriching mud it had brought with it and soak down deep into the soil. After
about a month-and-a-half he would come again to release the water, now turned brackish through
evaporation.

Once the water had completely seeped away and the ground was firm enough to walk over, the farmer
and his family would start hoeing it up again or deep--plowing it at intervals. Then it was ready
for sowing. The scribe in charge of the granaries would measure out the quantity of grain
allotted to each farmer and keep a written record. Then the vizier, through his officials and the
town and village headmen, would give the order for sowing to commence.
The ceremony symbolized at the same time the ritual burial of the god Osiris, who had died at the
hand of his brother Seth but came to life again thanks to his wife (and sister) Isis. Grain, the
symbol of Osiris' body, appears to have no life till it sprouts anew. Hence, in the harvest
festivals, the generous praise for Isis, to whom credit was due for the revival of the grain.
This popular belief was reflected in the little flat clay figures of the prostrate Osiris which
were 'sown'; the appearance of green corn was seen as an analogue to Osiris' resurrection.
So now the farmer could start sowing. With his grain in a leather bag slung across his left
shoulder, or in a basket held in his left hand, he would scatter it in wide swathes over the
prepared ground. Lest it stay on the surface to be pecked up by birds, he would invite a herdsman
to come onto the field with his flock of sheep or goats so that they could tread the grain in
with their hooves.
Sometimes the sun's heat had drawn off all the moisture before then. This was particularly liable
to happen on elevated sites beyond the flood's reach, or in years when the floods were poor
anyway. Unlike the Delta and central Egypt, where there would be an occasional brisk shower,
usually in November or December, the rest of the valley in Upper Egypt and Nubia had never
experienced a proper downfall since the Neolithic wet phase. So there was nothing for it but to
fetch additional water from the river or the irrigation canals.
The first mechanical device for conducting water to high-lying fields from the canals dates from
the Persian Period (after 525 BC). This was the tanbur or Archimedes' screw, a helix that could
be revolved inside a sloping cylinder. This provided a many times larger, faster and more
continuous flow of water, but as the corn between his fingertips and pronounces it ripe.
Harvest-time means mobilizing the village's entire labor force, women and children included.
From the New Kingdom onwards slaves and violators of royal decrees will have been roped in too,
and in an emergency even army units might be detailed to lend a hand.
The start of the harvest involved celebrations in honor of the fertility god Min. These were
opened by the king himself, who reaped the first ears of grain with a sickle. Diodorus tells us
that even in his day, the 1st century AD, peasants maintained the old tradition of setting up
stocks with the first corn harvested, beating their breasts and calling upon the goddess Isis.
Harvest scenes are depicted on the walls of many tombs, nowhere more fully than in the
15th-dynasty tomb of Menna at Sheikh Abd el-Quma. We shall now take these as a guide.
Before the sickles plunged into the standing corn the assessor-scribes led by the 'Overseer of
Fields' turned up to check the position of the boundary-stones and measure the size of the field
with a calibrated surveying cord. From these data they worked out the probable yield, which would
be compared with the actual yield after the threshing was done. This was clearly done to prevent
any part of the harvest being 'mislaid'.
The harvesters usually worked in a straight row, advancing steadily to the rhythm of one of the
songs documented for example in the tombs of Ty (5th dynasty) or Mereruka (6th dynasty) at
Saqqara. The song-leader was accompanied by a flautist and the harvesters probably chanted in
response. (We can hear Egyptian laborers singing today in the same fashion during the tedious
work of removing sand from archaeological sites.)
Grasping a bunch of stalks in his left hand the harvester would slice them through 9 at a level
just above his knees, then toss the cars aside to be picked up by the helpers. These would pile
the eared stalks alternately end to end, so that a compact sheaf forfned that required no binding
- the Ty relief shows this very clearly.
The sheaves were in turn loaded into nets or baskets to be taken on donkey back for threshing.
The threshing-floor was sometimes out on the field, sometimes next to the farmhouse. It was a
circular arena of trodden clay ringed with a low clay wall. The sheaves would be loosened, the
cars thrown on to the ground and cattle or donkeys driven into the enclosure to thresh out the
grain with their trampling, while the men stood outside in a circle urging the animals on with
cries or prodding them with sticks.
The grain released in this way was still mixed with chaff, straw and other impurities. Cleaning
was done on a breezy day on some well-swept piece of flat ground. It was usually a job for young
girls, who tossed the corn into the air with short-handled wooden shovels. The wind carried off
the lighter chaff and so on while the heavier grain fell back on the ground. This winnowing could
also be done by shaking the grain in sieves - usually a man's task. Once again the scribes now
came 3 on the scene to measure the volume of grain in standard wooden tubs. Finally it was sacked
up and carried, by manpower or donkey power, to the granaries.
The oldest type of granary, known from Archaic times, was a round-based cone with a domed top. It
was made of seasoned wood, often plaster-lined, or of mud bricks. The largest ones had steps
leading up to the filling hole, or else a ladder was laid against them.
All grain earmarked for the next sowing was stored in granaries of a different, trapezoidal shape
so that there was no danger of it being ground in error. Among Middle Kingdom models we find
another, four-cornered design of granary, standing in a row against one side of a house
courtyard. One such granary is shown with a flat roof and five filling-holes through which women
are pouring sacks of grain while a scribe, seated nearby, keeps a tally and a guard looks on,
stick in hand.
At times when central authority was weakening, especially after the Third Intermediate Period,
several royal or temple priests, army veterans and others were able to acquire land, initially to
cover their own needs for the rest of their lives. This land could however be passed on by
inheritance and in the course of time it came to be regarded as transferable and then as
saleable, the state no longer having enough authority to re-annex it to the state farming
enterprises.
The Egyptians had a high regard for flowers and trees and devoted great care to planting,
tending and protecting them. To sit in hot weather under the canopy of a tree was a favorite
recipe for relaxing body and mind.
It was popularly thought that trees were the abode of supernatural beings or much-loved gods. The
Books of the Dead linked this tree with the rising sun and with the sky goddess Nut, or at other
times with Isis or Hathor.
Even humble village houses had little gardens next to them. Where buildings were close together
the owners might have to be content with a few trees or flower-beds, or simply grow flowers and
small shrubs in clay pots or wooden troughs in the courtyard.
When the heavy trusses of golden fruit appeared among the crown of fronds, men would clamber up
the trunk with knives between their teeth to cut down the strings of dates. There is a painting
on the wall of Rekhmire's tomb that shows this being done. Here one man is shown plucking the
fruit with both hands and another is carrying it away in pans hung on a yoke. In the royal
gardens they even employed tame monkeys for this job.
An important oil-bearing tree was the baq, probably synonymous with the horseradish tree. Apart
from cultivated kinds, many valuable trees grew wild, including acacias, tamarisks, mimosas,
willows, palms and lemon trees. Most of the native broad-leaved trees yielded only inferior
timber that was too knotty, brittle or prone to split for use other than for stanchions,
roof-beams and some domestic furniture - chests and coffins.
When Egypt gained control of these lands in the early New Kingdom she developed tree-felling
there on such a scale that it helped to denude the entire coastal region.
Few gardens were without grapevines, which were also grown in separate vineyards. Many Old
Kingdom, and even more New Kingdom, tomb murals show bunches of grapes being gathered in baskets
and brought to the wine-press. This was a square vat lined with smooth mortar. The grapes were
thrown in and the juice trodden out by groups of barefoot men hanging on to ropes suspended from
a wooden frame so that they should not lose their balance and tumble into the pressings as they
inhaled the heavy vapor.
After this the must was filtered through cloth into fermentation vats and left for a time, heat
sometimes being applied to speed up the fermentation. Finally the mature wine was again filtered
through canvas and improved by the addition of spices or honey, then conveyed throughout the
country in wine amphorae whose frequent appearance in archaeological sites shows how popular the
drink was, especially from the New Kingdom on and even more so in Roman days. Masses of them were
found during the excavation of the Ramesseum storerooms, in the tombs of Theban dignitaries, at
Abydos, Tell el-Amarna and other places. Inscriptions on some amphorae give the vintage year,
type and quality of grape, locality and owner of the vineyard etc.
The ancient Egyptians were familiar with many wild shrubs and herbs and used them as drugs, for
making dyes and wickerwork - mats, baskets, bed matting, osier stands, sandals and so forth.
Many kinds of flowers were tied into bouquets for the living or the dead - cornflowers, poppies,
chrysanthemums, mandrakes, mallows, irises, larkspurs, jasmine, ivy and above all papyrus reeds
and lotus lilies.
The dense growths of papyrus and lotus in fens and marshes were a typical feature 113 of the
Egyptian landscape. Papyrus, particularly common in the Delta, became the heraldic plant of Lower
Egypt while the lotus, found all along the Nile, was the symbol of Upper Egypt. The close union
of the two parts of the country is proclaimed in reliefs round the plinths of colossal statues of
the king, which show the Nile god Hapy tying up bunches of papyrus and lotus together.
Papyrus thickets were also favorite hunting grounds. In the branches of the Nile in the Delta
maze little muddy islands developed which continually changed shape or shifted. In mythology the
papyrus came accordingly to symbolize the earth arising from the primeval ocean and hence, by a
shift of meaning, youth and happiness.
Amulets in the shape of papyrus bundles were popularly worn as a protection for the living, and
were credited with magic power to confer eternal youth and everlasting joy on the dead as well.
Papyrus bouquets stood for victory and for joy.
The Egyptians certainly appreciated the black earth that had yielded them so much benefit, and
they took care to husband it. New villages were most commonly sited on the very edge of the
fertile areas, where the desert sand began, or on flat islands of sand alluvium. In this way the
Egyptians minimized the encroachment of damp into their houses, while ensuring that not a scrap
of unable soil was wasted.
The Egyptian peasant's habit of working half-naked in the blazing sun, wearing only his short
kilt, shows how immune his skin had become to sunburn, and apparently they were not accustomed to
cover their heads to avert sunstroke. They stood up equally well to fierce winds, and were
resistant to common colds from the alternation of daytime and night-time temperatures. Their
diet, based on bread, green stuff and milk products, was balanced and biologically sound,
containing plenty of vitamins and minerals with little animal fat or harmful ingredients.
We know from their portraits that they enjoyed slender, wiry frames and athletic physique. A
peasant might also fall foul of one of the several kinds of scorpion that hid under the stones.
Their stings also have a neuro-toxic effect, like that of the cobra in the larger species, more
like a bee's in the smaller ones. Since neither preventive nor curative medicine of any value was
available, people resorted to charms, spells, magic knives and - in the Late and Graeco-Roman
Periods - to magic steles on which the god Horns is shown battling victoriously with snakes and
scorpions.
Perhaps this was why venomous snakes were sometimes embalmed as mummies. In truth most patients
could only hope to survive if the snake had already voided some of its poison in biting an
earlier victim.
Glass Making
There is still some doubt as to when and where glass was invented. The tradition passed on by
Pliny locates the event on the Phoenician coast, in modem Lebanon, where there later grew one of
the most important glass-making centers.
In Egypt, the first glass we know of, as a component of faience ware, dates from as far back as
the Neolithic Badarian culture at the turn of the 5th and 4th millennia BC. Glass is produced
from a mixture of silica-sand, lime and soda, colored with the copper ore malachite and fused at
a high temperature.
In the oldest Egyptian faience ware a skin of this substance was applied to a core made of
silica-sand and clay, or of the stone steatite. This was used at first only for beads, but later
on for amulets, shawabtis (the little figurines of the attendants of the deceased), other figures
and inlays (shapes inserted into the sides of vessels, wooden objects, or into plaster).
Particularly in the Middle and New Kingdoms a faience glaze was often applied to complete vessels
and statuettes.
Pure glass as a separate material came later, in predynastic times, in the form of translucent
beads. In the Old and Middle Kingdoms glass jewelry, amulets, little animal figures, mosaic
stones and similar things made their appearance.
Not till the reign of Tuthmosis I in the New Kingdom, however, is there any record of glass
vessels being made. The innovation was probably due to Egyptian expansion in the Middle East.
There Egyptian soldiers and administrators would have come across advanced centers ofglass manufacture and brought back local craftsmen, probably as slaves. This view is reinforced
by the fact that production of glass vessels started in Egypt as a royal monopoly serving the
court, top dignitaries and the high priesthood. Such 18th-dynasty workshops as have been
discovered were very close to royal palaces, such as that of Amenophis III at Malqata or
Akhenaten's residential quarter in Akhetaten. Further 19th-dynasty factories have been found at
Lisht, Menshiya and possibly Gurob.
Unlike those of other crafts, portrayals of glass production are conspicuously missing from
drawings and reliefs. (Alleged illustrations of glass-making that have been reproduced from time
to time are in fact metal foundries.) This was no doubt because of the royal monopoly. Since the
aristocracy owned no glass workshops, the subject did not feature in their tombs, and in New
Kingdom royal tombs non-religious scenes were very rare. The methods of glass manufacture would
thus have remained a mystery but for archaeological research and the extant glass vessels
themselves.
The glass factory found at Lisht yielded fragments of crucibles, conical clay stands for holding
the crucibles during fusing, pieces of slag from the ovens, samples of the pigments added to the
glass, little discs with well-worn edges used for finishing the surfaces, over too glass rods of
various colors, pieces of unfinished faience ware and nearly 200 sherds of glass vessels. There
are traces on the inside of some vessels of a clay-and-sand core, revealing the technology used.
Manufacture proceeded as follows. The raw glass was heated in pans up to 750'C and then again in
crucibles to as high as 1000C. A clay-and-sand core was made in the shape of the cavity of the
intended vessel, covered with cloth and stuck onto a metal rod. This was plunged into the molten
mass and given several quick twists to spread the glass evenly over it. (This did not always work
out, as we can see from the uneven thickness of some vessels.)
If decoration was required, one or more thin colored rods were wound spirally over the glass
while it was still soft. Before these rods hardened they were moved up and down with metal pins
to produce waves, garlands, arches and leaf or feather patterns. Sometimes a comb was drawn
across the rods, producing a series of vertical ribs. The whole job was then reheated and rolled
over a smooth stone block to produce an even surface. Finally, edge and foot could be pulled out
and handles fused on. Once the object was cold, the core had to be scraped out.
Ancient Egyptian glass was usually tinted with pigments added to the raw glass. A milky-white
color was produced with tin or lead oxide, yellow with antimony and lead, or ferrous compounds,
red or orange with oxides of copper, violet with manganese salts, greenish blue (in imitation of
the prized turquoise) with copper or iron compounds, dark blue (in imitation of lapis lazuli)
with cobalt com-pounds and black with a larger proportion of copper and manganese, or with ferric
compounds. The finished artifacts - little bottles, vases, goblets and bowls - were chiefly
destined to hold cosmetics and fragrant unguents in the boudoirs of queens and high-born ladies.
The decline of royal power after the end of the New Kingdom put a stop to glass production for a
time. Not till the Graeco-Roman Period did new Egyptian glass centers arise in the Hellenistic
cities of Alexandria and Naucratis. These enjoyed close links with centers in Asia Minor and
their extant Greek-style products show that they followed the international market of their day.
Around the beginning of the Christian era molded glass bowls appear, and another innovation was
millefiori glass made from variously colored glass rods fused together.
The revolutionary invention of glass-blowing took place, probably in Syria, during the 1st
century BC, though the technique did not reach Alexandria until the latter half of the following
century. As a rule clear glass was used, either of the natural greenish hue or with additives to
make it colorless. It was cut with a copper wheel and ground with emery powder. The new discovery
increased production many-fold and glass then ceased to be either a rarity or an upper-class
prerogative.
What the social status of glass-makers may have been we can only speculate. It was a highly
artistic craft and gifted individuals had a chance to become acknowledged masters. Though the
glass-factory employees appear originally to have been slaves, and for the most part foreigners,
skilful workers were probably freed at an early stage and imparted their secrets to Egyptian
colleagues among the royal artisans.
The work was doubtless strenuous and damaging to the health of its practitioners. The intense
heat produced by fusing glass on open fires could injure the body-fluid management; the cornea
and retina of the eye suffered from the glare, and skin burns were no rarity. Glass-blowing
exerted a back-pressure on the lungs that could lead to emphysema and circulatory trouble at an
early age, shortening a worker's life considerably.
While Beit El-Sennari was built in 1794 by Ibrahim Katkhuda El-Sennari, a Sudanese occultist, it
is famous for another reason. In 1798, Napoleon invaded Egypt bringing with him an army of
scientists, scholars and artists to establish a French culture base in Egypt. Soon, they began
their mission of making the first European study of Egypt which they published as Le description
de l'Egypte. Beit El Sennari was used to house many of the French artists and scholars at the
time. It became the center of the French study of Egypt, and therefore a very important monument
to early Egyptology.
The house was allowed to deteriorate until, in 1995, the first restoration of it was undertaken.
It had suffered much from neglect, air pollution and subterranean water damage. It was also
severely damaged during an earthquake in 1992. However, because of the efforts of the Egyptian
government with French assistance, it was faithfully restored and opened to the public in 2000,
though some restoration work continues.
Beit El Sennari is not well known by many tourists who visit Egypt. Situated on a small lane
named Haret Monge, just off of a downtown street called Khairat, there are very few tourism
attractions nearby. Perhaps the easiest way of reaching it is by using the metro to go to Sa'ed
Zaghloul Station.
This was exactly what I did. After leaving the metro I had to walk for about 15 minutes before
reaching the house. All the people I asked didn’t know Beit El Sennari or even Haret Monge
Street. I kept walking until I reached the Sayeda Zeinab Mosque and square. There, I found a very
old man sitting on a chair next to a shoe store, who knew Beit El Sennari
I walked in Haret Monge for a couple of minutes before I found myself next to a very beautiful
mashrabeya window to my right. I knew then that I had reached Beit El Sennari because there
aren’t any other older Islamic sites in the area. This mashrabeya screen looked older than many
of the other screens I have seen. Under this screen, there is the original door to the house but
it is closed these days. One must enter the house through a small door to the side of the
mashrabeya screen.
Upon making my way through this door, I found myself in an old garden that I found out later was
the main garden of the house. Here, I found many old palm trees, along with some construction
work, as the museum is still under restoration. I began looking around and found many brown
mashrabeya windows all around the house but I was lost as I didn’t know where to begin my
exploration.
Suddenly a cute girl appeared asking me what I wanted. I suppose, due to the small number of
tourists visiting this place, she didn’t understand that I just wanted to tour the house. I did
have to buy a ticket, which costs one pound for Egyptians and five for foreign tourists. Then she
showed me the way into the house.
Inside, what struck me first is that I was the only visitor. There wasn't another person in the
house, so I was free to roam about, unimpeded by any tourists. At first, I found myself in the
open air hall usually found in old Islamic houses and called a sahn. Typically, the rest of the
house surrounds this open courtyard, and it was used, particularly in the mornings, as a
reception place. The sahn of El Sennari House is very beautiful. There is a very old fountain in
the middle that seems very ancient.
The sahn is an excellent place to see most of the mashrabeya screens of the house, as they are
built to overlook the courtyard. These are some of the most beautiful ones I have seen in Cairo.
There are many mashrabeya screens all around the house and in a very good state. They are of the
finest variety, made of very small pieces of wood in tight patterns, and many have additional
arabesque carvings within the wood. To the left on the second floor, one's eyes are drawn to a
very attractive balcony with wood work all around it.
Under the balcony, there is a small display of pictures of the house as it appeared in the past.
It gives one an idea of just how effectively the restoration process improved the condition of
the house.
Afterwards, I entered a room near the main door of the house. This room has a hole in the ground
at the end of it, which I believe was a water well or a place to keep water because this area is
connected to all the other stores of the house. They used to transfer water all over the house
from this place.
From here, I found myself on the same balcony I had seen from the sahn. It is a big open air
space with the traditional Islamic decorated ceilings. Hanging from the ceiling are two charming
lanterns much like the famous fanoos of Ramadan. Strikingly, there are few objects such as
furniture within the house. Here, there was only a lonely wooden sofa where they used to sit in
the summer beside the wooden cupboards one would normally find in many Islamic houses.
The next chamber is the main salamlek, the guest room of the house. It is similar in its design
to the summer guest room in Beit El Suhaymi. It has a fountain and pillows to the right and left
of it to sit on. It's window is covered by the largest mashrabeya screen in the house. It is one
of those I spotted prior to entering the house and for those who love these screens, this one is
a masterpiece. I spent a few moments admiring the mashrabeya and then I was off to see the rest
of the house.
The bathroom was an interesting place. It has the same ceiling as in Beit El Suhaymi with the
colored glass all above you with the sun rays lighting the place through them. There is a second
bathroom, with rectangles cut into the ceiling and inset with small pieces of colored glass. It
was lovely, appearing almost like an electric lamp pasted to the ceiling. Like the rest of the
house, this bathroom was bare but for a big water container.
The next room was the main haremlek, a private room where the women of the house would have spent
much of their time. It had two mashrabeya screens to the left overlooking the sahn. To the right,
there are some wooden cupboards that were used by women to keep their precious items. Here, I
really began to notice the interesting doors of the house, which are made of old wood and
decorated beautifully in the Islamic style.
The third floor of the house wasn’t really interesting as it only had a few empty rooms and a
little open air hall in the middle. I soon found myself returning to the sahn, one of the most
pleasing areas of the house, to explore it a bit more. Here, I found what almost seemed like a
tunnel that leads to the old main door of the house.
I left the house feeling a bit empty, just as the house seems so empty of life, seeing very few
tourists and having so little content. It was not an unpleasant visit. I very much enjoyed the
mashrabeya screens and the old doors, but there is precious little else here. In the past, Beit
El Sennari hosted many works from different Egyptian artists. In 1917, a permanent exhibition
displaying Napoleon Bonaparte's personal collection was on display here, but that was removed in
1926. It also housed many other exhibits over the years.
And this is what this old, famous house is in need of today, along with some additional attention
to its garden. It needs some content, and specifically items to remind us of its real importance.
As both a historical house, and the center of work surrounding the scholars in the Napoleon
expedition, it deserves, and will probably someday receive, more attention. But probably only
then will it find an audience of tourists. Nevertheless, even today it does have its charm, but
only those very interested in such places will appreciate its appeal.
Ancient Indian thoughts, philosophy a developed with a rational synthesis an gathering into
itself new concepts. Spiritual was the foundation of India’s cultural histo spirituality, dharnza
(ethical conduct accordi state) was the most important concept of Indi Both are, unfortunately,
on the decline.
With the coming of the Europeans, and especially during the colonial rule, imitation of what the
rulers did and practised became more and more popular. But, there was also resistance to this
wholesale copying of the foreigners’ practices. ‘Reverence for the past is a national trait.
There is a certain doggedness of temperament, a stubborn loyalty to lose nothing in the long
march of the ages. When confronted with new culture or sudden extensions of knowledge, the Indian
does not yield to the temptations of the hour. but holds fast to his traditional faith, importing
as much as possible of the new into the old. Conservative liberalism is the secret of the success
of India’s culture and civilization(1).
The value systems in India have been influenced by all the religions, but mostly by Hinduism.,
the major religion (82.64% of the population), contributing to the philosophy and ethics of the
people of’ the country. The fundamental basis of ethics arises from the Hindu belief that we are
all part of the divine Yaranzatman; we have in each of us Atman, part of that Paramatman.
The ultimate aim is for our Atman to coalesce with Parmatman or Brahman to become one. According
to the Vedas (4000 RC to 1000 BC), the call to love your neighbour as yourself is ‘because thy
neighbour is in truth thy very self and what separates you from him is mere illusion (maya). ’
Closely allied to Hinduism are Jainism and Buddhism. These religions proclaim Ahimsa Paramo
Dharma. Most important of all our actions is alzinzsn, non- violence. Patanjali defined ahimsa
asSarvatha sarvada sarvabutananz anabhidroha(1) , a complete absence of ill- will to all beings.
Ayurveda is the ancient science of life. It lays down the principles of management in health and
disease and the code of conduct for the physician. Charaka has described the objective of
medicine as two fold; preservation of good health and combating disease. (2) Ayurveda emphasised
the need for healthy life- style; cleanliness and purity, good diet, proper behaviour, and mental
and physical discipline. Purity and cleanliness were to be observed in everything: jalasuddi
(pure water), aharasuddi (clean food), dehasuddi (clean body), manasuddi (pure mind) and
desasuddi (clean environment).
Ayurveda calls upon the physician to treat the patient as a whole: ‘Dividho jayate vyadih, Sariro
manasasthatha, Parasparanz tavorjanma, Nirdvadvam nopalahhyate.(Diseases occur both physically
and mentally and even though each part might be dominant, they cannot be compartmentalised).
Ayurveda treats man as a whole body, mind and what is beyond mind. The earliest protagonists of
Indian Medicine, such as Atreya, Kashyapa, Bhela, Charaka and Susruta have based their writings
on the foundations of spiritual philosophy and ethics. But the one teacher of Ayurveda who
established the science on the foundation of spirituality and ethics was Vagbhata, the author of
Astanga Hridaya(3) .Vagbhata says:Sukarthah sarvabutanam, Matah sarvah pravarthayah, Sukham ca na
vina dharmat, thasmad dharmaparo bhavet_( All activities of man are directed to the end of
attaining happiness, whereas happiness is never achieved without righteousness. It is the bounden
duty of man to be righteous in his action).
Charaka Samhita prescribes an elaborate code of conduct. The medical profession has to be
motivated by compassion for living beings (bhuta- daya)“. Charaka’s humanistic ideal becomes
evident in his advice to the physicians’. He who practices not for money nor for caprice but out
of compassion for living beings (bhuta- daya), is the best among all physicians. Hard is it to
find a conferor of religious blessings comparable to the physician who snaps the snares of death
for his patients. The physician who regards compassion for living beings as the highest religion
fulfils his mission (sidhartah) and obtains the highest happiness.
Informed consentThere is a general belief among the doctors in India that a conflicting situation that it is not
possible to get informed consent because of rampant illiteracy. They believe that the patients
are unable to make a reasoned choice because they cannot appreciate the intricacies of
alternative medical treatment, procedures or drug trials. Often a paternalistic view is taken:
‘The doctor knows best. ’
Dr. Srinivasamurthy and colleague8 at the National Institute of Mental Health and Neurosciences,
Bangalore, conducted a study into the relevance of obtaining informed consent. Almost all (99%)
of the subjects invited to participate in a drug trial gave a clear choice whether to participate
or not. Patient’s level of understanding and decision- making related to the amount and quality
of information provided. They did not correlate with social, economic, educational or other
background characteristics.
Charaka advises the physician to take into confidence the close relatives, the elders in the
community and even the State officials, before undertaking procedures which might end in death of
the patient. The physician is then to proceed with the treatment.Can the doctor withhold
treatment, if there is no informed consent? Can a man refrain from benefiting from medical
treatment and forfeit saving his life? Will the doctor be assisting suicide? On the contrary,
does not the patient have the right to control what shall be done to his/ her body?
What is the status of informed consent when a patient is admitted to the hospital in a critical
condition but in full possession of his/ her senses? Can the surgeon who diagnosed the condition
requiring immediate surgery refrain from operating on the sole ground that the patient had not
given his/ her consent for the operation? If the patient later dies, what is the liability of the
doctor?
An interesting case came up in the State of Kerala. A patient with acute abdominal pain was
admitted to a district hospital. He was examined by the surgeon, who diagnosed perforated
appendix with general peritonitis, which required an immediate operation. But the operation was
not performed by the surgeon and the patient died the next day. The relations filed a petition in
the court against the doctor personally and against the Kerala Government vicariously. The
doctor’s defence was that the operation was not performed as the patient did not consent to it.
The court rejected this plea and granted a decree against the doctor. The decision was confirmed
by the Kerala High court in the appeal preferred by the doctor. Two specialist surgeon who were
called as expert witnesses stated that they would have operated on the patient without the
explicit consent.
In contrast is the view that every human being has a right to determine what shall be done with
his or her own body. A surgeon who performs an operation without the patients consent commits an
assault for which he is liable? Indian physicians who are trained abroad or have imbibed this
principle find themselves in a conflicting situation.
What is the ancient teaching in such circumstances? Charaka advises the physician to take into
confidence the close relatives, the elders in the community and even the State officials, before
undertaking procedures which might end in death of the patient. The physician is then to proceed
with the treatment.
In India, great trust is reposed in the doctor, but more and more people are questioning the
practice. Trust based on ‘goodness’ of the doctor is slowly giving way to the concept that making
the decision is the right the patient.
AdvertisementThere are instances of unethical advertising by doctors. Such doctors are frowned upon by their
colleagues but little action follows. The Medical Council of India and the state medical councils
are to look into such matters but because of technical flaws, the doctor often escapes. Of late,
advertisements by hospitals and diagnostic centres are coming up in a big way proclaiming their
superiority over others.
Diagnostic aidsThere is a growing supermarket in diagnostic equipment. Sophisticated equipment is bought at
great expense of scarce foreign exchange. Most of the imaging equipment currently in use in the
various hospitals and diagnostic laboratories is in excess of the needs. Yet another problem with
the purchase of equipment from abroad has been the difficulty of servicing and maintenance.
Doctors trained abroad in the specialities ask for such equipment, but should these requests not
be tempered by the realities of the situation? Is it ethical for the doctor to order costly,
sophisticated equipment, which is not likely to function, utilising scarce foreign exchange? Is
it ethical for firms to supply these items without back- up service? This is a problem in most
third world countries. Thairu(6) suggests that an ethical code should be agreed on by both
(manufacturers and users) regarding the sale of equipment.
Drugs and pharmaceuticalsThere is a huge proliferation of drugs in the Indian market, with more than 60,000 formulations.
They are manufactured by large, medium, small and tiny factories - multinational and national.
There are many drugs in the Indian market which are banned in other countries. There are drugs
which were banned in India itself but continue to be marketed, after getting stay orders from the
courts. Legal proceedings take years. During this period, doctors continue to prescribe these
hazardous drugs, patients continue to take them and the firms continue to make huge profits.
Many of the drugs in the market are spurious or of substandard quality. It has been reported that
as a rule 20- 30 percent of the samples tested are substandard. Government agencies take a long
time to test the samples and to announce the details of the substandard drugs. Manufacturers are
expected to give the indications, contra- indications, side effects and adverse effects. They
often do so but in such a way that it will not attract attention; the greater the hazard, the
smaller the print.
One of the most distressing aspects of the present health situation in India is the habit of
doctors to over- prescribe or to prescribe glamorous and costly drugs with limited medical
potential. It is also unfortunate that the drug producers try to push doctors into using their
products by all means - fair or foul. These basic facts are more responsible for distortions in
drug production and consumption than anything else. If the medical profession could be made to be
more discriminating in its prescribing habits, there would be no market for irrational and
unnecessary drugs.
The drug firms do not generally follow the WHO ethical criteria for drug promotion. Gift giving,
almost universal, raises many ethical issues as in other countries(8 ) ; the effects are much
more pronounced in a poor country.
In the past, medicines were prepared under the personal supervision of the physician or by the
families of the patients. There were strict guidelines for the collection of herbs and other raw
materials and for the processes. Medicines thus prepared were reliable for quality and purity.
Right to healthEveryone has the right to a standard of living adequate for the health and well- being of himself
and of his family, including food, clothing, housing and medical care and necessary social
services - Article 25 of the Universal Declaration of Human Rights. If health is a fundamental
human right, it becomes the responsibility of the State to protect and promote the health of all
the people. There has to be an irreducible minimum of health care services to all. There is need
to close the gap between the ‘haves’ and ‘have nots’, achieve more equitable distribution of
health care resources and attain a level of health for all. The Alma- Ata Conference declared:
‘Governments have a responsibility for the health of the people, which can be fulfilled only by
adequate and equitably distributed health and social measures. ’
The right to health brings on the issue of distributive justice to make available an acceptable
and affordable care to all. One important aspect of such service is the provision of qualified
persons for providing health services where such services are not available at present. Can the
physician be compelled to provide service in villages where there are no doctors? The State and
the institutions generally subsidise medical education. Even if there is no subsidy, the doctor
has been provided an opportunity, not available to many. But opposing questions arise. The doctor
is not owned by the people or the institution. Can the doctor be deprived of the right to earn
legitimately as much as he or she can and where he or she can? Can a person be compelled to act
against his or her wish as long as no harm is done to the Society? The consensus is that the
doctor owes a duty to serve the people in the areas where they are needed but the medical
profession, in general, is not in favour of mandatory service. Health is included in the
Directive Principles of State policy, which is considered as the ‘conscience’ of the Indian
Constitution. Article 39 of the constitution directs the State to ensure health; article 47
requires the improvement of public health to be among the primary duties of the State. In
pursuance of these articles the Government had issued a number of policy statements and
programmes. The latest in the series is the National Health Policy (1982).
Health policyThe stated health policy of the Government of India has been frustrated by poor implementation.
The allocation of resources to the health sector has been very small. Often, the priorities are
assigned not on the needs of the people but on what is fashionable and on who has the maximum
political leverage. Very little allocation is made for control and treatment of infectious
diseases such as tuberculosis, malaria and kala- azar (especially prevalent in the villages of
Bihar, Orissa and West Bengal).
Questions arise: Who shall receive what health care? What resources can be allocated, how and to
whom? How do we set our priorities? What is an acceptable form of health care? Who should decide
on health policy?
Many issues are being debated currently. There is a demand for more equitable distribution of the
benefits of medical knowledge. Against it is the much more powerful force for the use of
sophisticated, spectacular and costly technology for the benefit of the few. Newer technology is
pushing skyhigh the expenses for diagnostic and therapeutic procedures. Patients are made to feel
that, unless they go through a whole array of expensive diagnostic procedures, a correct
diagnosis is not possible. There are wide networks of costly diagnostic laboratories, aided and
abetted by doctors who often get kickbacks.Patients are completely mystified by the advice they
get from their physicians. They shell out huge sums of money (relative to their earnings) which
they can ill afford. The onus for this unethical practice rests squarely on the medical
profession.
Does an individual have the right to buy expensive technology to the exclusion of others who
share the same resources? Is it right that the scarce resources of qualified and experienced
personnel, money (including foreign exchange) and materials be used for the benefit of a few
while the large majority of people are not able to get even simple primary health care services?
All religions advocate the care of the poor and needy. Christ declared: ‘When you have done this
to the least of my brothers, you have done it to me. ’ Gandhiji said: ‘I will give you a
talisman. Whenever you are in doubt or when the self becomes too much with you, apply the
following test: recall the face of the poorest and weakest man you have seen and ask yourself if
the step you contemplated is going to be of any use to him. Will he gain anything by it ?’ Kabir
said: ‘The valiant fighter is only he who fights for justice to the poor.’
The debate on distributive justice goes on. Shall the State purchase ten renal dialysis machines
(which will maintain the life of a few sick people) or employ fifty community health workers (to
help 50,000 people primary health centres have trained laboratory technicians who can spot the
malaria parasite? Shall the hospital buy one lithotripter or expand its programme for oral
rehydration for children affected with diarrhoea? The cake is small. How shall it be cut?
Has the medical profession any ethical responsibility in influencing the health policy? The
doctors in India are often passive spectators in the fight for social justice and against
discrimination in health care.
Educating the public on genetic engineeringWe must not imply tc the public that we are going to chase with the genome project, with somatic
DNA therapy, all the ills of man. It is surely ethically more acceptable, in both the developed
and the developing world, to tell the public that in the foreseeable future genetic engineering
will not provide practical and affordable solutions to these problems. Scientific responsibility
demands recognising this and not misleading the public with false promises and unattainable
hopes, as has happened in several biomedical projects of immense dimension during the past half-
century. There have been a number in my own field.
One has just been discussed at length in a recent book by Desowitz called The Malarial Capers,
which describes... the malaria ‘felons’. The story starts a century ago, with the catastrophic
prima donna- like contention for the Nobel Prize between Grassi in Italy and Ross in England. All
the chicanery that went on then in research reminds one of what the newspapers tell us today. The
story continues to 1991, with the molecular biologists promising much too much to the public and
Third World governments - that a practical subunit vaccine was just around the corner. One
billion dollars went into the project and we are still nowhere near. And none of the scientists
has loudly and clearly proclaimed that it ain’t going to happen soon and, it it ever does, it
will be for generals and armies and not for the general population in the Third World. No one has
dared to say this because it would interfere with the project and our careers.
D. Carleton Gadjusek
Gajdusek DC: Scientific responsibility. In: Fujiki N, Mater D (Eds.) Human genome research and
society. Proceedings of the Second International Bioethics Seminar. Eubios Ethics Institute,
Fukui, Japan. 1992. Pages 2052 10.

The Sukhadeo Thorat Committee, constituted to enquire into the alleged harassment of students
from the scheduled castes and tribes in the All India Institute of Medical Sciences, found
widespread evidence of such harassment (1). To make matters worse, the committee found that the
faculty, largely from the forward castes, were also involved in systematic denigration of
students from the scheduled castes and tribes. The complete report makes sad reading. The
harassment is in many ways: soon after new students join the college they are the target of
systematic verbal and, sometimes, physical attacks by higher caste students. They are frequently
told that they are inferior and do not deserve to be in the institute. They are given very little
space in sports and cultural activities. In the hostels, due to repeated harassment, these
students have been ghettoised into two floors. There is very little healthy social interaction
among students of higher castes and these students.
In the academic sphere they are the victims of scorn by the faculty. For example, the institute
has a system of continuous evaluation of the students and an end semester examination. There is a
widespread feeling among the students of the scheduled castes and tribes that they are
discriminated against in these evaluations. Systematic bias is also encountered in the junior and
senior residency posts and in recruitment to the faculty.
The basic proximate cause of this behaviour by the forward caste students appears to be that they
feel that the students from the scheduled castes and tribes have been given an unfair advantage
in selection to the course. They hold the view that the system of reservation or quotas is unfair
and results in the selection of inferior students. This feeling is shared by many of the faculty.
They feel that such students can never be good doctors. In short, casteism has a strong grip.
Competence, caring and equity in medical education
The assumption that reservation of seats for the less privileged castes would lead to a dilution
of standards has been disproved by the experience of Tamilnadu, where 68 per cent of seats in
medical courses are reserved for almost 40 years. Yet Tamilnadu has among the best health
indices. Medical care is not the only reason for this but surely does play some part. In the
curative sector, Chennai is a centre which draws patients from other states, notably from north
India.
The primary purpose of medical education is to train doctors to treat and prevent illness among
people. All over the world, competition to get into medical school is fierce and societies
everywhere try to select the best possible students. What are the desirable qualities that should
be looked for in students who will become doctors? To this apparently simple question there
appear to be no simple answers (2).The qualities that patients see as desirable in doctors are
humaneness, competence and accuracy, patients' involvement in decisions, and time for care (3,
4). In India, by and large, the only criterion used to select students is the marks scored in
examinations. Earlier attempts to use interviews as an additional tool failed because of
perceived widespread misuse by which the most influential candidate was selected, not the best
one. This gave rise to the idea that merit, defined as performance in examinations, was the only
fair criterion to apply. This has helped buttress the widespread notion among the forward castes
that all forms of quotas for castes which had been the victims of oppression were unfair as the
marks that they require to get into a medical college are lower than those required by student
from the forward castes. It is another matter that the influential ensured a loophole for
themselves by creating so-called self-financing colleges where those with money or influence
could qualify for a medical degree.
Marks in qualifying examinations are a good method of ensuring selection of capable medical
students who will make competent doctors. But they are not enough to ensure good doctors (5,6).
In many countries, for example Canada, France, Australia and South Africa, policy makers have
clearly stated that a secondary aim of medical education is to ensure equity and affirmative
action (7). These objectives are seen as desirable in themselves to build a healthy society.
Underprivileged people who enter the health sector not only ensure the economic security of their
own families but also make a favourable impact on their community (8). Schemes to ensure that
underprivileged sections of society will get adequate representation in medical school placement
are in place in most countries in the world. They all make provision for the fact that
disadvantaged sections of the student community will not score grades as high as the more
privileged will, even if they are equally intelligent (6). The concept that those who require
quotas are not as intelligent as those who do not shows an ignorance of the social determinants
of success in examinations. It ignores the effect of the advantages of class (and, in India,
caste), facilities and opportunity, all of which have been well-documented. (6). To understand
quotas as providing an unfair advantage is to be blind to the unfair disadvantages that certain
communities in India have been victims of. To understand quotas as opening the gateway to
training incompetent people ignores the basic fact that there is a minimum standard for
qualification.
At independence, a section of those who were instrumental in policy making, notably Dr. B R
Ambedkar, pointed out that certain sections of the populace were the victims of long-standing
oppression of the most demeaning kind and ensured that some provision was made for them to catch
up in the educational sphere and also in the struggle for jobs. Unfortunately, many influential
people in society, particularly the bureaucracy and politicians, have never really accepted this
view. In the 60 years since independence, many castes which were considered backward at
independence have been able to assert themselves through new political formations. However, the
dalits continue to remain marginalised.
Equity in service provision
There is clear evidence to show that doctors from less privileged backgrounds are more likely to
serve underserved populations (9, 10). In a society like ours, which remains primitive in many
ways, it is likely that the scheduled castes and tribes feel more comfortable seeking medical
advice from one of their own community. A time will come when caste has no relevance in India,
but the time is not yet.
Considering the dramatic maldistribution of doctors, with a majority being located in the cities,
a policy which will encourage provision of medical services to the poorly served is welcome.
The All India Institute of Medical Sciences and caste
The All India Institute of Medical Sciences was set up in 1956 with the intention of nurturing
excellence in all aspects of healthcare. It would seem to be obvious that this would include an
understanding of the causes of sickness and health that go far beyond the germ theory and into
the social and economic context of it. That this has not happened, and that in fact the institute
was the centre of activity against providing affirmative action for the less privileged, should
be a matter of great concern. The involvement of the faculty in the movement against quotas is
particularly disturbing. They are expected to be role models for students. If they perpetuate
ideas of caste superiority and the intrinsic unfairness of reservations, they do harm not only to
their students but to society as a whole. An American clinical teacher has said, “Ultimately
teaching is all about the learner, not the teacher. Thus effective clinical teachers aspire to a
sort of selflessness whose tangible expression is kindness to learners, especially when assessing
them (giving feedback).” (11) Doctors should have a broad view of the causes of ill-health.
Nothing in the present way that doctors are trained helps in this. The All India Institute of
Medical Sciences, instead of providing a lead in broadening the understanding of health and
disease and showing the way in producing good doctors, has become a centre of bigotry. The
ill-effects are felt all over the country. The time has come for a major shake-up in medical
education in general and in the Institute in particular.
The National Drug Policy (NDP), 1982, of Bangladesh was expected to make available essential,
good quality drugs at affordable prices. This article gives an overview of the situation today,
more than two decades after the Drugs (Control) Ordinance, 1982, was promulgated to implement the
NDP. While there have been some successes, many of the goals of this initiative are yet to be
achieved. Inadequate supply of essential drugs, substandard quality, uncontrolled drug prices and
inappropriate uses of drugs are major problems in Bangladesh.
Unethical drug promotion and marketing of substandard and unnecessary drugs in Bangladesh were
very common before 1982. Instead of producing essential drugs, most drug manufacturers
manufactured non-essentials such as vitamins, tonics, enzymes, gripe waters and cough mixtures.
To stop these practices, Bangladesh formulated a pioneering National Drug Policy (NDP) in 1982
(1). The Drugs (Control) Ordinance, 1982, was promulgated subsequently to implement the NDP (2).
The principal objectives of the NDP were to make available essential drugs; ensure good quality
drugs; control drug prices; ensure rational use of drugs; develop an effective drug monitoring
system; improve the standard of hospital and retail pharmacies; and ensure good manufacturing
practices (1, 2). Before the NDP, eight multinational companies (out of 166 licensed companies)
had about 75 to 80 per cent share of the drug market. Many of them abandoned their operations in
Bangladesh after the NDP. Today, local pharmaceutical companies dominate the drug market with a
share of more than 75 per cent (1). The NDP has had some success in regulating the drugs market
of Bangladesh, but many of the goals of this initiative are yet to be achieved.
Access to essential drugs
Although official documents indicate that 80 per cent of the population has access to affordable
essential drugs (3), there is plenty of evidence of a scarcity of essential drugs in government
healthcare facilities. One study conducted in four district hospitals and one medical college
hospital showed that only eight per cent of patients received the prescribed medicines from these
facilities (4) In another report, two major hospitals in the capital city of Dhaka were operating
without essential medicines for eight consecutive weeks (5). There are countless such incidents
relating to the supply of essential medicines in Bangladesh. In most such cases, government
officials and health professionals are responsible for the shortage as they often sell
government-supplied drugs to local drug stores instead of dispensing them to poor patients (6).
The government must be cognisant of this fact, but rarely takes any action.
Quality of available drugs
Of the 300 pharmaceutical companies in Bangladesh, only the 20 to 25 top ones produce drugs of
standard quality (6). Reports show that numerous small companies market substandard drugs in the
country (7). Fake or substandard medicines, including lifesaving ones, with an estimated worth of
US$ 150 million per year, are flooding the domestic market (8). In its annual testing in 2004,
the government laboratory detected 300 counterfeit or very poor quality drugs out of 5,000 drug
samples. A recent assay involving 15 brands of ciprofloxacin showed that 47 per cent of samples
contained less than the specified amounts of the active ingredient (6). Another report noted that
69 per cent of paracetamol tablets and 80 per cent of ampicillin capsules produced by small
companies were of substandard quality (9).
Good manufacturing practice (GMP) is a major criterion to maintain standard quality in drugs, and
it was one of the principal objectives of the NDP to ensure standard manufacturing practices for
drug manufacturers. But there are some 265 pharmaceutical companies in Bangladesh that do not
follow or comply with GMP (10). It is widely alleged that adulteration flourishes in the country
because of poor government vigilance and supervision over drug manufacturers and sellers.
Unfortunately, a section of corrupt physicians and government officials is involved in these
underhand dealings. The government states that it has limited manpower and facilities to cope
with the country's fast expanding pharmaceuticals sector (11). In fact, the regulatory authories
have given scant attention to quality matters in Bangladesh.
Lack of control over drug prices
In Bangladesh the maximum retail price (MRP) of every essential drug is fixed by the Directorate
of Drug Administration (DDA); for all other drugs the DDA endorses the companies' quoted prices
(2). Drug prices are quite high in Bangladesh in comparison to neighbouring countries. The drugs
control authority is apparently reluctant to negotiate with the companies to fix prices (12). The
regulatory authorities have virtually no control over drug prices in Bangladesh. Indiscriminate
pricing can be observed in all therapeutic classes of drugs. For example, prices of various
ciprofloxacin brands range from Taka (Tk) 5 to 14 (US$ 0.07 to 0.20) per unit (13). The price of
dexamethasone eyedrops extends from Tk 24 to 90 (US$ 0.34 to1.29) per 5ml, and diclofenac eye
drops are available at a price range from Tk 40 to 200 (US$ 0.57 to 2.86) per unit (6). These are
a few of the existing price discrepancies in the country.
Patterns of drug use
To ensure rational and appropriate use of drugs in Bangladesh was another prime concern of the
NDP. But there has been no drug use study in the country (14). Clinically inappropriate and
inefficient use of medicines is a serious problem. More than half the medicines in Bangladesh are
inappropriately prescribed, dispensed or sold (15). Despite legal prohibitions (1), numerous
drugs with similar or no significant benefits are available in the market. As a specific example,
there are seven members of the angiotensin-converting enzyme (ACE) inhibitors available in the
country. The efficacies and chemical structures of these molecules are more or less similar, but
their price vary significantly (13). The drug policy clearly prohibits the production of
multi-ingredient preparations of vitamins and minerals with the exception of B-complex vitamins
(1). But a mixture of 32 vitamins and minerals including selenium, vanadium, molybdenum, tin and
many other unnecessary ingredients has been marketed in the country for a few years, violating
the principles of the NDP. The need for these trace elements in Bangladesh is not established
whereas nutritional deficiencies are mainly related to vitamins A and B-complex, iron, calcium,
iodine and zinc (13). Irrational prescription and use of antibiotics are rampant throughout the
country, with an estimated half of all antibiotics being sold without prescriptions (16).
Self-medication is widespread, and all types of medicines can be purchased without a prescription
(17). There are about 30,000 illegal (6) and 80,000 unlicensed (8) drug stores operating in the
country. It is alleged that both legal and illegal drug dealers are engaged in selling fake,
smuggled and adulterated medicines in the country (6).
Conclusion
Inadequate supply of essential drugs, substandard quality, uncontrolled drug prices and
inappropriate uses of drugs are major problems in Bangladesh. The drugs control authorities
should be better equipped and more vigilant to cope with the situation. Health professionals and
drug manufacturers should be more committed in order to achieve the goals of the NDP.
Bioethics, which is the title of this national conference, is a term that implies far more than
medical ethics which dominates its sessions. What is bioethics? It is no more and no less than
the ethics of living or ethics of life, which evolved from non-life over millions of years.
Humans are a product of the evolutionary process like all other species, but they are unique
insofar as they not only participate in the evolutionary process but also command and determine
the future, as brought home so vividly by global warning. Nevertheless, as Professor Hubert Markl
remarked, there is a circular relationship between nature and humankind because human concepts
are nature's concepts. Human technological and economic inventiveness is no more than nature's
way of acting upon itself and shaping its own future. The outcome could be glorious success or
disastrous failure - in either case, nature acting through humankind bears partial responsibility
for the outcome. This is fundamentally an ethical question. Are we right, for example, to cause
the profoundest changes in biodiversity in all the 3 billion years of evolution by the mindless
destruction of all living species to accommodate 10 billion human beings and their domesticated
slave species of animals and plants? To make a sustainable future, we have an obligation to act
in accordance with the dictates of reason and moral norms, and remain responsible for what we do.
It is this undoubted fact of nature that makes us look for guidance to bioethics, without which
life would be replaced by fossils. I would, therefore, compliment the organisers for placing the
deliberations of this conference against the austere background of bioethics.
A missing domain
The programme of the conference is wide-ranging and covers practically all the vital and
contemporary issues relating to medical ethics in India. However it is silent on one issue of
great importance, which is ethics in the practice of ayurveda. An Indian traditional system of
medicine par excellence, ayurvedic practices were in vogue in Buddha's period when Takshasila was
already reputed as a major centre for the training of physicians. The term “ayurveda”
crystallised in the first century when the Charaka Samhita was written - a text that is taught
even today in ayurvedic colleges. India produces over 15,000 ayurvedic doctors every year from
over 200 colleges and, according to some estimates, 60 per cent of the countryside depends more
or less on ayurvedic practitioners for basic healthcare needs. To survive and flourish even after
2,000 years of varied fortunes, the traditional system must surely have intellectual and ethical
vitality, and its claim to consideration in a national discussion on bioethics would seem
self-evident. An effort is necessary - however difficult and time-consuming it may be - to
develop a unified ethical code that would apply to all forms of healing in India.
Ethics in ayurveda
In the three classic tests of Charaka, Sushruta and Vagbhata there are no separate sections on
ethics. But ethical concepts are ever-present and an ethical undercurrent runs through all the
texts. To distil the ethical content from these large texts is as difficult as extracting sugar
from a cup of sweetened milk. One can only attempt to present gleanings from here and there to
give a flavour of the ethical spirit which animates ayurveda.
Bioethics and ayurveda
On human beings as part of nature; their lives in harmony with nature; the kinship with all forms
of life and so on, ayurveda has plenty to say. Consider the panchabhuta doctrine, so central to
ayurveda: it says that the universe consists of five elements that are the stuff of the stars,
earth, oceans, all living beings and everything that exists. These are, of course, not the
elements of the periodic table, but substances that are perceived by the five senses of sight,
hearing, taste, smell and touch. The sensory experience constitutes the basis of physical reality
or nature - what is extrasensory may or may not exist, but that is not part of nature. According
to ayurveda what exists in the human body exists in nature and vice versa, and their
interpenetration and interaction are constant and continuous. The homology between the universal
macrocosm and human microcosm was carried to extraordinary lengths until humans were regarded as
cosmic resonators. Hurting nature was no different from harming oneself, and reverence for nature
was ingrained in the practice of medicine.
Health and disease
Ayurveda laid a great deal of stress on good health and its maintenance, even as it laid out its
elaborate encyclopaedia on diseases and their management. Health was regarded as a state of
equilibrium that was sustained by a number of component equilibria. These included the
equilibrium of the tissues of the body; of doshas or functional units; of fires that burn in the
tissues and bring about changes such as food into tissues; of the body and its surroundings, and
so on. The human body was designed to maintain this equilibrium, which was its natural state. Any
deviation into disequilibrium, which we call disease, was largely brought on by one's own
misdeeds, and it could be counted upon to resolve and return to equilibrium automatically. All
that the physician could do was to give a helping hand in the process. His task had less to do
with the removal of a cause, which was, according to ayurveda, not the primary objective of
treatment. Causes exist within the body and without, but they are not necessarily pathogenic.
They become pathogenic only when the equilibrium is breached by the imprudent conduct of the
individual. Nor is it possible to sanitise the body and environment of causes. Then why stress
upon a cause to the exclusion of other considerations? Thus argued the ayurvedic texts.
Patients
Patients were seen in their homes or in the residence of the physician. Diagnosis was regarded as
so important that an entire classical text - Madhava Nidana - was devoted to it. History was
taken with great care not only from the patient, but also from his family and messengers who
brought the summons. The illness of a person was, therefore, more than a matter between the
patient and the physician. Having made the diagnosis, the physician had to decide whether the
disease was treatable easily and curable; treatable with difficulty and palliative; or whether it
was incurable and untreatable. He was obliged to inform the patient and family about the
prognosis - especially the palliative and incurable types - before undertaking treatment. If a
hazardous procedure such as the surgical removal of a bladder stone through the perineum was to
be undertaken, the physician also had to obtain royal permission in advance. The Arthasastra of
the third century BC had even prescribed capital punishment for physicians who undertook major
procedures without prior permission that led to the death of the patient. The protocols for
treatment specified the best of procedures and formulations that were apparently costly, and the
physicians were exhorted to provide “no-frills” protocols for those who could not afford costly
treatment. There was no bar on accepting fee for service except from specified categories such as
the king, preceptor, Brahmins, the indigent, etc.
When necessary, patients were admitted to homes for treatment, which were described elaborately
by Charaka. These had a scenic location with plenty of flora and fauna, lakes with clear water,
rooms for the patient, physicians, attendants, kitchen, store, procedures, toilets, etc. The
homes also had in residence storytellers, singers, and friends and relatives of the patients. It
was obviously a friendly place. A physician was enjoined to look on the patient as his own so
that he would develop total trust in him and regard him as his “father and mother” even in
difficult circumstances.
The great emphasis laid on the signs and premonitions of impending death makes one wonder whether
there existed in the remote past a class of physicians who specialised in the care of the dying,
who were summoned when the treating physician felt that his role was over.
Training
Training of physicians took place in the gurukulas or in the universities such as Takshasila and
Nalanda. The qualifications for the teacher and student were stringent, and covered physical,
intellectual, professional, moral and social attainments and background. Students were preferred
from Brahmin, Kshatriya and Vaisya castes, but Shudras were also admitted if the candidates were
bright. On acceptance, the pupil had to take an oath administered by the preceptor in a sacred
ceremony attended by a learned assembly. The oath covered the student's conduct under all
circumstances; his duties to the teacher, patients, friends, relatives, etc; his attitude to
learning and practice of medicine; and his commitment to a virtuous life. The oath represents the
high point of medical ethics in ancient India.
Professional conduct
The ancient texts reserved the harsh language of condemnation for the impostors and quacks who
obviously existed even in those far-off days. Those who paraded their so-called skills and
knowledge; who lacked proper training in theory and practice; who blamed the patient and
relatives for setbacks; who fled if the patient developed dangerous complications; who made false
claims about their lineage and achievements - all these came in for severe condemnation. The
fraudulent physician was looked upon as a messenger of death. The noble physician who was
virtuous, an expert in theory and practice, compassionate to the core and a friend of all was
revered.
General conduct
The life pictured in the ayurvedic texts is that of a people who were happy and cheerful, and who
sought to live for a hundred years in good health and comfort. They celebrated life and enjoyed
themselves without worrying about metaphysical subtleties. These was little place for
self-torture or renunciation, while respect was always shown to the saints. There was a general
belief that diseases were caused by one's own imprudent conduct or the act of gods. Virtuous
conduct which stipulated the avoidance of the overuse, underuse and misuse of the 10 sense organs
- sensory and motor - was prized because it was the sovereign prophylaxis for all ailments, which
could even annul the effects of karma unless they were caused by enormously wicked actions.
Truthfulness, compassion and reverence to learning were held in the highest esteem.
Conclusion
An effort to raise ethical awareness in health care should not be an event, but a never-ending
process. The veneer of civilisation is thin and the atavistic tendencies of man for violence and
cruelty are ever ready to burst forth, as happened in Nazi Germany. The cases reported by Beecher
in the US reminded us that atavistic tendencies could reassert in more “civilised” ways under the
garb of science. What can one say about India where people live in fear of their kidneys being
stolen?
In strengthening our ethical convictions and practices, we are meeting our obligation to not only
the present but also to our past and the future.
Primum non nocere, the Hippocratic dictum, is perhaps the cardinal rule of medicine in general
and of medical ethics in particular. This principle has been honoured by most of its
practitioners in the long history of medicine. Thus, a book which provides a revisionist history
and bunks considerable amounts of accepted or known history needs to be noticed. Medicine has had
more error than it has done things right, says the author, David Wooton, Anniversary Professor of
History at the University of York, England.
Wooton does not write a conventional history. He chooses, instead, selected - but extremely
important - events in medicine to illustrate his theory. For instance, all medical students are
taught that James Lind was the physician who showed that scurvy could be prevented in sailors by
the regular intake of lime on long sea voyages. Likewise, Ignaz Semmelweis is given credit for
showing the aetiologic connection between puerperal fever and the lack of disinfection or washing
of hands by medical students and doctors who examined pregnant women after performing autopsies.
Wooten upsets the apple cart by stating that Lind had little to do with the treatment of scurvy;
our belief that he did so is purely a misinterpretation of known facts. He shows, also, that
Leewenhoek's microscopes and specimen preparations were far superior to what we've always
believed - that they were crude and incapable of yielding good information. Wooton shows that
there was a delay in microscopic pathology, a delay which is unforgivable and must have cost
numerous lives over the decades. In a similar vein, Wooton states that years took place between
the discovery of penicillin (long before Fleming rediscovered it) and the realisation of its
impact on therapeutics followed by its mass production and use. Indeed, many of our medical
heroes seem to have got it all wrong, in this book.
Because physicians refused to accept change and have an open approach to change until 1865, when
Lord Lister changed the course of medicine with his seminal introduction of antisepsis in surgery
, they have been unscientific, claims Wooton. And an unscientific physician is, it is obvious to
us, an unethical one.
And, yet, methinks the man doth protest too much. Is Wooton guilty of evaluating the events of
the past with today's knowledge? I suspect so. There is of course, much truth in what Wooton
states. But is it fair, for instance, to say that Semmelweis is given “more credit than he
deserves” only because “he did not recognise puerperal fever as an infectious disease or
recognise the role of germs”? Opportunities have been lost, mistakes have been made - but that is
what research and progress is all about. What he does not seem to realise is that there are very
few eureka moments in science. Change, when it does take place, is generally slow. This is
probably true not just for medicine, but for other fields as well. Further, making retrospective
diagnoses and offering armchair theories are among the easiest things on earth, be it in
radiology and pathology, history of medicine or in predicting the stock market. It is all too
obvious now that the earth revolves around the sun, but before Copernicus and Galileo changed
that belief, millions of people would have scoffed at the idea. Not for nothing is it said that
when a new idea is introduced it is initially scoffed at, then looked at with some interest and
then accepted as something that was obvious all along.
Wooton himself accepts that psychological and cultural factors worked (and work and will continue
working) against innovation. After all, medicine is a science which develops in a social context
and its history and interpretation cannot be studied in a vacuum.
It is also useful to keep in mind cases which were immediately accepted by medical science - the
use of thalidomide and of frontal lobotomy are only two examples of treatments which created much
misery before being discarded. More bad medicine, perhaps?
Although I do not accept Wooton's thesis - which has been warmly praised by some critics and
blasted with equal fervour by others - I recommend that you read the book. Much of his research
and interpretation is original and teaches that it is always sensible and often useful to
question established theories about known “facts”.
Government policy and medical practice
The character of the medical profession, the manner in which medicine is practised today and the
direction of healthcare are shaped by our environment with all its inequities of caste, class
and gender. This character, this manner and this direction are reinforced by the messages
conveyed in the medical education system, by the incentives of the new economic policies and by
the actions - or inaction - of regulatory authorities. Such an understanding is expressed in
various ways in this issue. An editorial writer comments on the Sukhdeo Thorat Committee report
documenting faculty inaction against caste-based harassment of students in the All India
Institute of Medical Sciences. That the caste and other inequities reinforced in medical school
are expressed in medical practice is illustrated in an interview with the director of a sperm
bank; parents demand - and doctors arrange - sperm of the desired caste and economic background.
The second editorial describes how the inequities in this environment are reinforced by the
government. As private medical care grows it seeks foreign markets; hence the policy to promote
"medical tourism" with tax breaks and other incentives - even as the vast majority of poor
Indians have no access to healthcare
Stem cell "therapy" is another example of an industry promoted by the government policy of
turning a blind eye to its unregulated proliferation. A commentary writer documents the
unjustified claims that prompt the desperate to spend their life savings in the hope of being
cured of a serious disease. Doctors undertake experiments with neither scientific basis nor
ethical clearance in the name of treatment. Regulatory authorities indicate their inability - or
unwillingness - to take action against unethical practices. Another commentary writer describing
his encounters with corruption in medical practice points out that corruption has infiltrated
the profession at every level, including those agencies meant to enforce ethical practice. Those
who benefit from the existing system - within medical practice and in society in general - have
every interest in maintaining the current state of affairs. More than 500 health professionals,
researchers, policy makers and students attended the Indian Journal of Medical Ethics Second
National Bioethics Conference in Bangalore. We carry a report on the conference and comments
from participants.
Medical ethics education in India
Medicine is one of the few professions that sets a code of behaviour for its practitioners. In
the past the relationship between the doctor and patient was paternalistic. Today this has
changed. Advancement of medical science and technology has made a tremendous impact on medical
practice. Rising costs of medical care and scarce resources pose dilemmas to the practitioner of
medicine.
Since the late 1950s there has been an explosion in the field of bioethics. Gone are the days
when problems were resolved by emulating seniors in the profession. Writing in The National
Medical Journal of India, Dr SK Pandya laments that today “unfortunately the number of role
models in the medical colleges is diminishing as unethical practices flourish and this adds to
the frustration of students for they see a divergence between what is preached and what is
practised” (1).
The Medical Council of India (MCI) regulations on undergraduate medical courses emphasise that
medical graduates become exemplary citizens by the observation of medical ethics, and
fulfilling social and professional obligations, so as to respond to national aspirations (2).
This is one of the objectives of medical education. Students need to develop a rational approach
to solve medical dilemmas that they will face in the future. Just as they learn various subjects
to tackle medical problems, they also need ethics to solve the moral quandaries that they are
likely to face in their practice in the future.
The application of the Consumer Protection Act to the medical profession has stimulated
professional bodies to consider medical ethics in their annual deliberations. Media reports of
patients faced with questions regarding transplants, medical negligence, end-of-life issues, etc
highlight the ethical dilemmas of the medical profession as well as those of the public. Reports
of misconduct in research, and the Indian Council of Medical Research (ICMR) guidelines on
clinical trials, have stimulated a keen interest in the study of ethics in the country.
Medical ethics teaching in India: the current scenario
The MCI curriculum does not have medical ethics as a separate subject in any of its courses. In
the curriculum of forensic medicine, the student is expected to “observe the principles of
medical ethics in the practice of his profession” (2). The St John's National Academy of Health
Sciences is one of the few medical colleges with ethics as a separate subject for training of
undergraduates (3). Many universities and medical colleges are making efforts to introduce it in
the curriculum. Since 2004 the ICMR has been conducting sensitisation workshops for students as
well faculty throughout the country. This has created a tremendous interest in medical ethics.
Therefore, we need to act now to fulfil aspirations.
A few law schools have started distance education courses in medical law and bioethics in the
country. These courses are more tuned to law than to ethics. Moreover all of these are
certificate or diploma courses. At present there is also a dearth of teachers and resources for
teaching medical ethics.
Challenges faced in teaching medical ethics
Course
1. At present the MCI curriculum does not have medical ethics as a subject. Only when it is made
a separate subject by the MCI will all the medical colleges and universities in the country
implement it. We need to lobby to implement it.
2. Medical ethics should be made a compulsory course with requisite attendance for the award of
medical degrees. Studies have shown that making ethics an optional course in medical colleges
does not serve its purpose (4).
3. Medical ethics need to be structured in such a way that the student is exposed through out the
medical training period.
4. Evaluation of the course should be left to the faculty teaching the course. Students should
have to be certified by the college, stating that they have successfully completed the course
with the requisite attendance. In my opinion, making medical ethics a university examination
subject adds to the burden of the student and reduces the classroom interactions.
Curriculum
A structured curriculum is necessary for the teaching of medical ethics. The St John's curriculum
has been modified by many universities. The ICMR is in the process of formulating a curriculum
for bioethics in the country. The MCI should develop its curriculum by adopting one of these
curricula. Care must be taken that it is not overloaded with legal issues.
Teachers
A handful of trained bioethics teachers (postgraduates) are available in the country, but only a
few of them work in medical colleges. There is a need to increase this pool. Many medical
teachers have diplomas in medical ethics. There is an acute shortage of trained medical ethics
faculty in the country. There is an urgent need to train staff if medical ethics is to be
introduced as a subject.
What can be done?
1. Organise advanced programmes urgently for teachers who have undergone diploma/certificate
courses in medical ethics.
2. Start master's degrees in medical ethics. Encourage more clinicians to become ethics teachers.
This will, hopefully, improve the standard of ethics practice and there will be better role
models for students to follow.
3. Redress the lack of faculties of law, philosophy and social sciences in medical universities
in the country. Faculty in these disciplines who are working in the regular universities must be
given a dual appointment in medical colleges and they should be actively involved in teaching.
4. Provide additional incentives for faculty who are involved in teaching ethics either in
monetary terms or in terms of career advancement.
5. Encourage medical universities to establish chairs and departments of medical ethics to
develop the subject in the country.
Resources for teaching ethics
There are few Indian textbooks on medical ethics. Most deal with the legal aspects of medicine
rather than ethical ones. Some books are even factually incorrect and misleading. There is a dire
need to have good textbooks on medical ethics in an Indian context.
There is a dearth of articles on medical ethics from the point of view of Indian philosophy.
Research has to be undertaken to identify and interpret Indian philosophy as it relates to
medical ethics.
Writing on ethics in the Indian context is negligible. General medical journals rarely carry
articles on medical ethics. Even if they are written, they deal more with malpractice and legal
issues rather than ethical thought.
Throughout the ethics discourse we need to remember that India is a secular and multicultural
society. Resource materials on medical ethics must incorporate this unique aspect.
Hope for ethics teaching
At present there is a tremendous interest in medical ethics in the country. Many universities are
actively working on developing an ethics curriculum. The ICMR is taking a lead to introduce a
certificate as well as a master's course in medical ethics. It is also in the process of
publishing a book on medical ethics. The response of the medical community to the first national
bioethics conference is another hopeful sign that medical ethics teaching will become important
in the near future. One hopes that the MCI will take the lead and make ethics a part of medical
education.
VIETNAMESE REVIVE ANCIENT MEDICAL ARTS
The Vietnamese, short of medicines, medical equipment and the money to buy them, are reviving and
encouraging the use of the country's ancient healing arts.
''We have 4,000 years of history and more than 1,000 years of written works of traditional
medical practice,'' said Dr. Tran Thuy, the deputy director of Hanoi's Institute of Traditional
Medicine.
''Acupuncture, massage, physical exercise and the use of plants and minerals are all part of
this,'' he added. ''With these, about 60 illnesses can be treated successfully, many in local
clinics.'' Dr. Thuy is an ear specialist with a modern medical training who moved into
traditional medicine out of a life-long interest Intellectual Vietnamese have made native
medicine into a science, but traditional medicine is not limited to government public health
services.
One of the most famous and popular men in Hanoi these days is a 75-year-old Buddhist private
practitioner of traditional medicine who goes by the professional name of Cuu The, ''the one who
saves lives.''
Cuu The holds office hours in a small shop in downtown Hanoi with posters on the walls and a
sidewalk sandwich board to advertise his specialties: liver ailments, rheumatism, asthma and a
host of sexual dysfunctions. His fee is measured in pennies, but his clientele is cosmopolitan.
Cuu The, a chain smoker who is almost toothless, chortles his way through a story about a Russian
who came to him for a cure for infertility. ''He was back this morning to thank me,'' Cuu The
said with a satisfied grin, looking at notes of the case he was recording in one of many school
exercise books.
The old practitioner, one of 18 members of the city's Traditional Medical Care Organization, most
of them private doctors, says that at the root of his success is his Sino-Vietnamese Buddhist
faith. ''If we were all Buddhists we would have peace in the world,'' he says. To that, he adds
yoga breathing techniques from South Asia. ''Good for headaches,'' he said. ''The air pushes out
the poisons.''
''The Buddha taught that on the globe there are rivers, and in the body there are also rivers,''
Cuu The explained. ''When there are no blocks in the earth's rivers, the water flows
continuously. When there are no blocks in the body, there is no disease.''
Cuu The also recommends relaxing massages, ''reasonable'' exercise and proper diet, based on
ancient Sinetic definitions of ''hot'' and ''cold'' foods (not related to temperature) for
traditionally understood ''imbalances'' in the body. Dried foods, he explained, strengthen the
body's ''positive'' aspects (the cause of headaches); water and wet foods, the ''negative.''
''A person will have good health when his body is balanced,'' he said. He also tells patients to
take a lot of vitamin C in the form of lemonade. Told he sounded like a California health-food
advocate, he laughed.
''Vitamin C is an old idea here -followed by papaya to keep the river flowing,'' he said.
''Thirty years ago I predicted foreigners would one day come to Vietnam to study our medicine.''
Cuu The dips frequently into herbal or other natural medicines, drawing on both Chinese and
Vietnamese prescriptions. ''But the basis is Vietnamese,'' he adds, echoing the official view
that Vietnam has nothing much to learn from China. ''Vietnamese medicine is better than Chinese
in both theory and practice,'' he said.
Cuu The said 95 percent of his prescription remedies were based on plant products easily found in
the countryside.
''Chinese medicine has about 1,000 natural materials,'' he said. ''We have 800. I know all of
these. Thirty of them cure difficult diseases.''
The Institute of Traditional Medicine also uses local vegetable, animal and mineral products.
Eucalyptus, mint, ginger and aromatic coleus are among the most widely used plants to treat
common illnesses, according to Dr. Thuy.
Dr. Thuy, whose institute conducts research and trains practitioners, said 23 common ailments
were now treated entirely at the local level by combinations of herbal remedies, massage,
physical exercise and simple acupuncture. More complex ''electro-acupuncture'' treatment cases
are referred to the four-year-old Central Hospital of Acupuncture, which adjoins the institute in
Hanoi.
Foreign medical experts who visit Vietnam as well as Vietnamese doctors say that the country's
most serious problems, especially among children, are intestinal diseases caused by universally
contaminated water and mosquito-borne illnesses, coupled with malnutrition that leads to easy
infection.
Dr. Thuy said 77.6 percent of common diarrhea cases and 86.35 percent of amoebic dysentery
attacks were now treated with traditional medicine. Respiratory ailments, allergies, fevers, back
pain and joint and muscle pains are also among what Dr. Thuy listed as diseases and symptoms that
are first treated without chemical or surgical cures.
''For economic reasons, our chemical industry has not developed yet,'' he said. ''By fully using
trees, the earth and other resources we can save foreign exchange. And there are no chemical side
effects on patients.''
At the Central Hospital of Acupuncture, where nearly 70 patients were sharing 50 beds and about
300 to 400 people crowded the corridors each day as out-patients, Dr. Mai Tue, the director of
specialty departments, showed a visitor people being treated for encephalitis, earache, back
pain, dizziness, loss of appetite, vision and hearing problems and paralysis.
The hospital also uses acupuncture as an analgesic in surgery for appendicitis, colosectomies and
hernias, among other procedures, Dr. Tue said. Two research projects are now under way in
cooperation with the Soviet Union, on optic nerve repair and the treatment of paralysis. The
hospital says it has had much success in both areas.
The hospital makes extensive use of a low-cost electro-acupuncture system its staff devised
themselves, Dr. Tue said. This involves attaching needles to a six-volt power source that
provides automatic vibration. Needles were earlier manipulated by hand.
''We can treat every disease or illness treated by modern medicine,'' Dr. Tue said. ''With our
economy facing so many difficulties, this is the most suitable way to deal with our health
problems.''