82. Unavey Marunthu, Marunthey Unavu

There is a saying in Siddha medicine: உணவே மருந்து, மருந்தே உணவு (unavey marunthu, marunthey unavu), or food is medicine, medicine is food. Marunthu (medicine) in modern usage refers to pharmaceutical drugs, but many of these drugs are inspired by or synthetically derived from South Asian cooking staples. Amma merged the rhetoric of healthy food in the U.S. with the values of Ayurveda or Siddha medicine, incorporating plants and herbs with anti-inflammatory, antiseptic, and analgesic properties into our routine diet. Growing up, I chewed bay leaves, cardamom pods, soaked methi (fenugreek), and fennel and ate curry leaves before I knew about their pharmacological effects. I unwittingly catered to my dosha — Vata, prone to a sensitive immune system — by gravitating to Vata-balancing foods: dark chicken curry, beef curry, salmon curry, shrimp curry, tuna, duck, eggs, bananas, coconut, mango, tamarind, beets, black olives, cooked spinach, pumpkin, zucchini, pancakes, oats, rice, yellow dal, miso, soy sauce, urad dal, ghee, butter, cashews, peanuts, and most spices. I loved salty foods, which are Vata-balancing as well. Before every grocery shopping trip, Amma asked what Anji and I wanted and catered to our requests, so I primarily ate the Vata diet that my body craved.

American healthism underscores premium, fresh, organic foods with particular amounts of vitamins and nutrients. In our veedu, the healthiness of a meal depended on dosha, rasa, and the distribution and balance of the six Ayurvedic tastes: sweet, spicy, sour, salty, bitter, and astringent.

Amma taught herself to cook by remembering the meals in her Batticaloa household. She never explicitly named this cooking philosophy, but it applied to everything she made. She had specific recipes for sickness, pain, and malaise, rich in plants and herbs revered in Ayurvedic and Siddha medicine: ginger (anti-inflammatory, anti-nausea, antioxidant); garlic (antibiotic, anti-inflammatory); turmeric (analgesic, anti-inflammatory); coriander (digestive aid); star anise (anti-bacterial, anti-fungal, anti-inflammatory); bay leaf (anti-inflammatory); Ceylon cinnamon (digestive aid, stimulant); fennel (anti-inflammatory, digestive aid); cardamom (anti-inflammatory, antioxidant); tulsi (immune system support); bitter melon (anti-diabetic, anti-inflammatory); chili powder (analgesic); manioc (digestive aid, immune system support); cloves (anti-nausea, antioxidant, digestive aid); fenugreek (digestive aid); curry leaf (analgesic, anti-bacterial, anti-nausea, antioxidant); saffron (antioxidant, mood support, sedative); cumin (anti-nausea, digestive aid); and black sesame (bone support, menstrual support). She incorporated these plants and herbs in meals, brewed them in teas, or urged us to simply chew them.

In ancient medical systems like Siddha, Ayurveda, and Deshiya Chikitsu, medicinal herbs might be served as a salad with ground coconut, like ivy gourd or gotu kola; ground and mixed with rice and curry, like crepe-ginger; added as seasoning to meals, like curry leaves; or made into tea or mixed with ghee, like tulsi (Waisundara, 2019, pp. 9-10, 17, 36, 82). Indigenous and local food customs in Eelam have shifted due to years of war-led shortages, but my parents left Sri Lanka before the ethnic conflict intensified. I have never associated a specific meal or taste with war-related trauma. I never ate food named for artillery, like mithivedi — a flat roll stuffed with egg and potato filling devised in Jaffna during the war. I could complain about idli and sothi, clamor for pittu, appam and idiyappam. I could linger over the short eats — fried, stuffed rolls, cutlets, or patties ubiquitously peddled in Sri Lanka — that Amma cooked and plated for us in the afternoon. Vada were snacks, not a means of survival.

I taught myself to cook the same way Amma did, asking her for recipes, attempting to recreate the Sri Lankan meals she made for us. Consequently, I reproduced her medicinal approach to cooking. In addition to more "American" herbs — like sage, tarragon, thyme, and rosemary — my own pantry contains all of the above, along with Ashwagandha (adaptogenic, cognitive support), Arjuna bark powder (anti-ischemic, antioxidant); jaggery; barberry root (antioxidant, gastrointestinal support); neem (anti-bacterial, digestive aid); and Gotu Kola (cognitive support). I reach for herbal concoctions for pain relief and energy support as often as I do Advil, Celebrex, or Tramadol.

There is, perhaps, a correlation between my pain intensity and my physical and financial ability to prepare my meals this way.

Like ancient Middle Eastern and Asian physicians who used these plants and herbs before Western physicians exulted over "the conquest of pain" (Morris, 2000), my parents employed indigenous remedies for painkillers instead of over-the-counter NSAIDs. Many plants native to Sri Lanka have pharmacological properties and have been incorporated into commercial pharmaceuticals. Indian mint, used to relieve pain and inflammation, has a mechanism and effect structurally similar to hydrocortisone, the hormone cortisol supplied as a topical medication or prednisone. Leaf of life, whose pharmacological properties and mechanisms are under investigation, is traditionally roasted and topically applied to relieve inflammation, joint pain, and gut ailments. Extracts from the leaves and roots of the chaste tree are used in gels or capsules for arthritis and joint pain, with a dose-dependent central analgesic action like ibuprofen or phenylbutazone, and it has been incorporated into commercially available products (Waisundara, 2019, pp. 24, 29-35).

When I started treating my fibromyalgia with pharmaceutical drugs, I didn't balk at the idea of taking drugs for the rest of my life — maybe because I thought of food as daily medicine with influence over my mood, energy, and acumen — but I did wonder for the first time how drugs might alter my personality. The pharmaceutical industry is incessantly tinkering with chemical compositions, dosages, and combinations of drugs to perfect the body. In Ayurveda, preventive care and holistic balance are everything, and treatments are personally tailored to patients based on their proportion of the three doshas (types of substances present in the human bodymind). The patient is a unique entity born with an individualized prakruti, a unique (im)balance of the three doshas established at conception. Treatment is tailored to a patient's underlying prakruti.

By contrast, the pharmaceutical industry aims to restore or create chemical balances that optimize patients' bodies and lower their health risks through a one-size-fits-all approach. Drugs are classed by condition and experimentally prescribed to a patient without foreknowledge of that patient's sensitivities or the imbalances that drug might create. Resultant imbalances are addressed with other drugs. Thus, polypharmacy, the concomitant use of multiple drugs to treat a single condition, is common, but combining medications doesn't necessarily result in the sum of their effects. One drug might activate certain cellular mechanisms that reduce the efficacy of a second drug. A second drug might exacerbate the side effects of the first or lead to paradoxical drug reactions, where the effect is opposite to the expected result. In a patient with multiple illnesses, multiple drugs become necessary, and ensuring the correct chemical balance in the body becomes essential. Sometimes a drug is given to counteract the side effects of another drug. Sometimes a drug's side effects are as desirable as its intended effects. Even the idea of a drug can affect the body through the placebo effect (MacDougall, 2011, pp. 2-5). Thus, a prescription for Lyrica might come with Remeron, Ativan, Savella, or low-dose naltrexone as an adjunct treatment for side effects like nausea or lethargy; methotrexate, which depletes the body's folate, is given with folic acid supplements; the side effects of prednisone, like sleep disturbances, can be offset with Lunesta; and sulfasalazine monotherapy is less effective than sulfasalazine and methotrexate combined.

Let's try it and see is the prescriber's refrain. It's a lucrative business model. I know very few people today, disabled or nondisabled, who haven't engaged in polypharmacy, by doctor's orders or personal experimentation.

I myself have gone on and off 24 medications (discounting nutritional supplements) in 15 years of illness. This number is comparatively low but the process felt eternal. I've organized this process chronologically below, as a vertical timeline designed to emulate the interminable trial-and-error experience of pharmaceutical treatment.

Presumably, the goal in conducting all this experimentation, across diverse patients and medical conditions, is to create the perfect daily cocktail to treat diseases and preempt them, recalibrating subjects to their lowest risk and highest productivity and rendering them permanently dependent on the pharmaceutical industry. Ceronetti (1993) suggests: "By altering the nervous system after temporarily suppressing pain, analgesics and anesthetics create another pain, more suited to the new sensibility" (p. 64). Khakpour (2018) writes:

There are ways that drugs can coat all sorts of problems. You can think of drugs as pain relievers, and most of them are in some way or another. The body is asking for something, and drugs deliver something, but rarely that thing the body needs. In the end the needs of the body are unheard and another need opens to be filled. Drugs make holes so they can fill them for you later. (p. 54)

Commercial pharmaceuticals might be derived from medicinal plants and herbs like the ones that belong to local knowledges in Batticaloa, but their epistemological and ontological premises are incompatible. Pharmaceutical drugs are organized by category of disease and effect: analgesic, anti-psychotic, anti-seizure, beta blockers, corticosteroids, sedatives, sleeping drugs. You need a specific diagnosis or set of diagnoses to obtain prescriptions, and the pharmacological paradigm might still be characterized as "one disease target; one drug." By contrast, systems of Ayurveda and Siddha medicine emphasize that disease nomenclature is useful but inessential, as treatment is patient-centered and multimodal, based as much on etiology and symptomology as a general understanding of the patient's history, physical body, psychic energy, sensory organs, and soul (Brooks, 2018; Loukas et al., 2018).

Both food and drugs have biological, psychological, social, cultural, and other systemic effects, impacting both users and people who don't rely on them, but food never hole-punched my memory like these drugs. I relied on field notes written in private journal entries, emails, Google Chats, and social media posts, under the influence of drugs taken as mono- or poly-therapy. It begs the question MacDougall (2011) asks: "Can we ask in any systematic way what it's like to be a person who maintains a regular dosage of [medication] if we have never been that kind of being?" (p. 2). In other words, what is it like to encounter the flesh of the world with flesh soaked in Lyrica, LDN, Celebrex, Tramadol, prednisone, with their individual and coadjutant effects on ways of doing, being, and being enabled?

Once the bodymind acclimates, the memory of its prior perception fades. From the field notes that constructed this timeline, I know that I met the world as a wrung dishrag (sulfasalazine), a noodly stick-person (Flexeril), a kshatriya in bright gold armor (Lyrica), a jack-in-the-box surprise (Savella), a bullet train (prednisone). My descriptions illustrate improvements or reductions in cognitive capacity, speed, mobility, self-protection.

As pharmacological compounds in concentrated form, drugs — more strongly than food — function as constitutive environments for their users, perceptual technologies that intervene in the system of flesh-meets-world (MacDougall, 2011, pp. xv, 2, 8). Eating and medicating are culturally distinct but complementary practices; however, both revolve around consumption. The bodymind is a receptive environment co-constituted by what it consumes, absorbs, and internally circulates. Unavey marunthu, marunthey unavu attempts to reconcile the relationship between food and medicine, often conceived as a dichotomy between Western "rational" medicalization of food (science and professional expertise) and non-Western "uncivilized" indigenous foodways (culture and lay expertise). In Ayurveda and Siddha medicine, this boundary is blurred. It's not that food was medicalized, but that ancient systems of medicine and indigenous foodways and contests over expertise existed in historically and culturally specific configurations.

Siddha literature describes many varieties of vali diseases, including musculoskeletal disorders, with polyherbal powders and potions that account for an herb's pharmacological properties, its seasonal availability, its phytoconstituents, and the properties of the soil where it grows. Botany is an integral part of the Siddha medicine curriculum in Sri Lanka, but in the U.S., especially in urban areas where medicinal herbs aren't readily available or easily home-grown, commercial pharmaceutical pills are easier to obtain and take than indigenous powders or potions (Waisundara, 2009, p. 57).

Derkatch (2016) observes that, today, "one reason why such great numbers of patients choose to take dietary supplements is to gain a greater sense of control over their health within a medical system that is sometimes rhetorically disabling" (p. 139). Chronically ill patients are often denied diagnoses and, thus, prescriptions for commercial pharmaceuticals. Commercial nutritional supplements in pill or capsule form, such as gotu kola or Ashwagandha, aren't medically regulated and don't require a prescription. They do, however, require local knowledges about preparation and administration. I take Epicor and ABX Support, proprietary postbiotic and probiotic pills for immune support, as instructed by a physician; but family and folklore taught me how to make golden milk with a sprinkle of gotu kola, Arjunarishta, and ellu urundai, how long to hold chili, garlic, or ginger in the mouth, and how to use castor oil and camphor blocks. I know not to tell my allopathic physicians. Bourdieu (1984/1988) contends that "The faculty of law and the faculty of medicine, which, being able to provide the government with 'the strongest and most durable influence on the people,' are the most directly controlled by the government, the least autonomous from it at the same time as the most directly entrusted with creating and controlling customary practice" (p. 62). Medicine, a dangerous and powerful discipline, requires strict regulation by federal entities; gatekeeping of pharmaceutical knowledge is strenuously enacted in the clinical encounter. Asking for or about prescription drugs — particularly controlled substances — without prompting by a physician is frequently viewed with suspicion. The same holds for asking about contraindications between medicinal plants and prescription medication.

There is a reason I omitted my use of homemade Ayurvedic and Siddha preparations in the timeline above. They're "alternative" therapies in American healthcare, coopted into contemporary discourses of health and wellness and biohacking, and exoticized and commercialized in ways they (of course) aren't back home.

Nevertheless, patients invent and share counterstrategies to receive certain drugs and avoid other ones, to calibrate their doses through splitting pills or emptying and resealing capsules, to supplement or replace a prescription drug with a medicinal herb or dietary "dupe" (Dumit, 2012, p. 85). I used to scroll through the chronological images on Toronto-based artist Kat Sing's (2017) collaborative art project on Tumblr, Message in a Bottle. Like the PostSecret of the medicated commons, chronically ill people mailed in empty prescription bottles with redacted labels and anonymous anecdotes about their experience on the drug folded up inside. My timeline represents a singular experience that I have in common with anyone who has taken any of these drugs to similar effect; like Message in a Bottle, it aims to push the needle further on destigmatizing prescription medication use, particularly for academics and people of color, who, as Sing recognizes, are noticeably absent from her project. Without representation, being a chronically ill Tamil graduate student and professor who takes medication multiple times a day makes me feel like the last unicorn, when I know there's enough of us to form a magical herd (Wong, 2016).

Dumit (2012) suggests that we have adapted to lifestyles in which the level of risk required to be "at risk" has been lowered to more easily add prescription medications to our lives, as part of the shift from individual health to mass health. In an almost Marxian construction, healthy patients who don't need prescription medication aren't valuable to the pharmaceutical economy — what's valuable is the social perception of the at-risk, inherently ill patient in need of treatment now (pp. 155-156). Clinical trials define high risk by identifying new biomarkers; the media sensationally reports these findings; good patient-workers want to treat these "prediseases"; and a pharmaceutical market emerges, where drugs approved to treat a condition codify the reality of that disease, as the FDA's approval of Lyrica did for fibromyalgia (Dumit, 2012, pp. 160-164; Graham, 2009). The social perception of chronic illness as long-term but treatable (instead of an incurable downward spiral) might owe something to the pharmaceutical industry, which redefined illness and treatment as risk and risk reduction and a patient's responsiveness to a drug as evidence of either an underlying condition or predisease (Dumit, 2012, pp. 115-116).

Chronic illness treatments generate large amounts of revenue for pharmaceutical companies, even if physicians become discouraged by their inability to cure the condition and resist treating it further (Greenhalgh, 2001; Dumit, 2012, pp. 5-7; Dickinson, 2016). As is evident from this timeline, in Western biomedicine, the answer to all ills becomes more medication. Drugs are intended to cure disease, ontologize a disease, reinforce a diagnosis, reduce our need for more or more intense drugs. Each drug I took accurately or inaccurately implied a condition I was being treated for, based on the labeled use: for instance, Lyrica straightforwardly points to fibromyalgia, but nortriptyline, Cymbalta, and Savella suggest psychiatric disorders (Graham, 2009). Each drug mediated my capacities and my chemical transmission of affects (Dumit, 2012, p. 85).

Fibromyalgia and myalgic encephalomyelitis require prescription medication to manage pain, energy deficit, and brain fog, but drugs don't always achieve the neoliberal goal of returning patients to the workforce (Morris, 1991, 2000). As the risk factors for FMS and ME are still little understood, these disorders can't be approached from mass health's predisease perspective, and even if they could be, we are "a waste of time" for many physicians, costly for insurance companies, and only lucrative for pharmaceutical companies if we are wealthy enough to afford that monthly prescription (if we are lucky enough to get one) in perpetuity.

I've never had to ask who have I become by eating this food? because I know: unavu makes me Eelam Tamil. But who am I on these drugs, once so overprescribed that Amma pointed to my overstuffed medicine cabinet as proof of my Americanization? The longer I engage in pharmaceutical polytherapy, the less I know. Race is an inflection point that creates biomedical hierarchies in pharmacology, transforming populations that share the same biological needs into those who can live and those who must die (Foucault, 1963/1994; Rose, 1994; Tremain, 2005). I can say with certainty that I wake up a stony creature in a blindfold and latticed mask and take my morning drugs and the fog dissipates, the deadbolts in my trigger points unlock; I take my nighttime drugs before I go to bed and the boundary between my skin and my sheets dissolves, I sleep without waking more than three times. I can say these drugs reduce the barriers to an inaccessible world. I can't say that I don't benefit from consuming indigenous medicinal plants and herbs. Fetishized as ancient nutrition is these days, marunthey unavu remains the only acceptable part of the aphorism.