Health for India: Search for appropriate models

What is health?

The state of health of individuals and communities is determined by the four pillars: nutrition, lifestyle, environment, and genetics, in addition to access to health-care. Process of health seeking requires active participation of individuals and cannot be built merely through medical-care. Therefore innovative primary health-care programs, in addition to medical-care to counter diseases, should aim at building the four pillars of health. Ayurveda has strongly advocated healthy behavior (swa-stha vritta) involving ethical conduct and daily regimen as well as seasonal variations to diet and lifestyle.

Let us look at the basic definition of health to have a glimpse of what Ayurveda can contribute. The World Health Organization (WHO) has defined health in a very comprehensive way as a state of physical, mental, and social well-being and not just the absence of disease and infirmity. In contrast, the concept of health in Ayurveda, which is based on positive view of ‘Swa-sthya’ described as ‘prasanna aatmendriya manah’ involving inextricable meld of mind, body, and spirit seem more profound.

The real problem is to discover viable strategies for preventive and promotive health and furthermore, to develop measures of monitoring not just disease but the health status. The primary health-care is expected to promote clarity between its two main functions including the prevention and the treatment; former is a domain of public health while the latter falls within the domain of medicine. Probably, the cure-centric approach of mainstream medicine to primary health-care has created avoidable dependencies on drugs and technology. This has introduced new challenges of availability, accessibility, and affordability of medical-care in India's health-care sector.

Who is a doctor?

Do we have sufficient number of human resources in the health sector for an integrative health-care program? Do we have a uniform understanding of term ‘Doctor’? Have we carefully studied the requirements of various categories of doctors from primary-care to superspecialist? It is estimated that nearly 600,000 registered and practicing Allopathic medical doctors are available for over 1.2 billion Indians. The WHO suggests an ideal ratio of at least one physician to serve a population of 1000 and India is not even half way. The Government of India is planning several strategies including adding new medical schools to improve this ratio.[1 It must be appreciated that national health cannot be planned without involving AYUSH sector closely.[2] Presently, India has uneven distribution of the health work force, which has led to a major urban-rural divide. Ironically, the doctor to patient ratio in urban areas is much more than many developed countries, in contrast, the rural and underserved areas continue to face acute shortage of doctors. However, in addition to the Allopathic doctors, India is also home to over 700,000 licensed, registered practitioners from the AYUSH systems of medicine, many of whom are already working in rural areas.

Role of AYUSH

In India, we cannot dream of health without AYUSH sector. Inclusion of AYUSH doctors by recognizing their services would certainly help India not only to reach the internationally expected doctor to patient ratio but also to improve availability, accessibility, and affordability for quality health-care. Therefore, merely meeting the ratio is not enough for India without inclusion and mainstreaming AYUSH system. Such inclusion has been the practice in many countries like China and Korea wherein the practitioners other than Allopathic medicine are involved to provide various levels of health-care. This is done by imparting integrative medical training and knowledge whereby all the registered and licensed doctors can offer services, at least at the primary level of health-care.

In India during the 12^th five-year plan (2012-17), the Planning Commission has proposed some important recommendations to address the issue of shortage of medical practitioners and to improve the quality of health-care by mainstreaming of AYUSH doctors. Such integration, however, needs to be dealt with extreme prudence. The role of each category of doctors in the public health system at primary, secondary, and tertiary levels must be clearly defined and practiced. The levels of knowledge, experience, and skills must determine these roles rather than mere academic degrees.

It must be recognized that the historical, cultural, and epistemological difference in the knowledge systems will require significant effort to build bridges because, in fact, they cannot be mechanically integrated. World views, principles, methods, concepts, and strategies of both Allopathy and AYUSH need to be protected and respected. Thought leaders of AYUSH as well as from Allopathy must accept principles of evidence-based medicine within the framework of modern science.

Integration through education

At present, the AYUSH systems curriculum includes several common basic subjects like anatomy, physiology, biochemistry, and applied subjects like pathology and general medicine. Strategic integration through education is possible if the AYUSH sector also gives special emphasis on modern laboratory diagnostic procedures, pharmacology as well as clinical and epidemiological research methodologies as integral parts of curriculum. It is important that claims regarding efficacy of AYUSH treatments are supported by proper and appropriate studies with a central clinical registry. Similarly, the allopathic curriculum should include basics of AYUSH systems. Many leading medical schools in the USA and Europe have introduced modules on Complementary and Alternative Medicine modules. However, in India, the Western Allopathy medicine curriculum does not include the AYUSH component, although majority of population still depends on these systems. The Medical Council of India had taken few positive steps in this direction, which need more thrust for actual implementation. The diverse groups of pathies or systems should integrate in such a way that there is only one medicine, which is in the best interest of people. This should clearly be the future of medicine.[3]

What could be an appropriate model?

At a functional level, the AYUSH systems may offer better management of chronic and metabolic diseases, psycho-somatic conditions, disease prevention, and health promotion. Allopathy, in contrast, has valuable contributions for emergency medicine, infectious diseases, diagnostics, and surgical interventions. However, at the primary medical and health level, practitioners of both the streams can play a vital role without compromising the scientific spirit and evidence-based practice. Developing an informed code of conduct for cross referral systems would also be an essential measure at all levels, primary, secondary, and tertiary. It is also important to address key action that points to progress in the direction of Ayurveda for all Indians.[4]

Indian institutions engaged in basic and translational research, education, and clinical services need to adequately embody the spirit of Ayurveda. Their work need to sufficiently reflect, in content or form, innovation that is so critical for modernization. Innovation implies relating to other modern medical knowledge systems, designing contemporary, credible, affordable, and accessible applications of Ayurveda. New models of modern Ayurveda institutions are much needed where inner confidence and interactive capabilities with Western knowledge systems to focus attention on the emerging health-care challenges of the new millennium. India needs to demonstrate a unique model for health- and medical-care where the advancement of modern medical technology is integrated with the holistic concepts and strategies of AYUSH systems in the best interest of the Indian and global community.

In summary, world over, health-care and medical-care are not precisely segregated. They mostly function together leading to the present curative medical-care centered scenario where health-care remains neglected to a considerable extent. Countries like India are facing crisis-like situation due to rising costs of medical-care and increasing proportions of out of pocket expenses putting considerable burden on common people. The medical fraternity need to mutually respect individual territories with scientific yet broad mind and should rise above the limited issues of cross practice in the best interest of people. A dream of healthy India, which is not just free from diseases but where the people have higher degrees of happiness at physical, mental, and spiritual levels will be possible only with the help of proper integrative strategies involving Western Allopathy together with indigenous AYUSH systems. The Journal of Ayurveda and Integrative Medicine is committed for this cause in the interest of health for Indian and global community.