Time to sensitize medical graduates to the Indian Systems of Medicine and Homeopathy

“Traditional” medicine is a system of medicine that has been practiced in its country of origin for many years, while “complementary and alternative” medicine (CAM) refers to a traditional system of medicine that is practiced in a country other than the country of its origin, like Tibetan medicine when practiced in India.[1] Traditional medicine includes diverse health practices, approaches, knowledge and beliefs. It often integrates indigenous plant, animal and mineral based medicines. It may involve spiritual healing practices, manual techniques and exercises. These are used to treat or prevent illness. In India, Traditional medicine and CAM has been used for thousands of years for prevention, diagnosis and treatment of a wide variety of illness. It now provides an important health care service to patients, especially those with limited geographic or financial access to the “Modern System of Medicine” (allopathic medicine).[1]

India has a rich and living tradition of healing. A vast amount of medical knowledge has evolved in India over thousands of years, through trial and error, exchange and assimilation between diverse cultures. Some of these evolved systems are Ayurveda, Unani, Siddha, Yoga and Naturopathy. Ayurveda has existed in India since about 4000 BC. The other systems also date back to hundreds of years. Homeopathy, although of German origin, is also widely practiced in India. Many of these systems also take into consideration psychological, ethical, philosophical and spiritual well-being of a person. They encourage healthy living, which is living in harmony with nature. These concepts resonate with the World Health Organization's definition of health.

Ayurveda was the prevalent system of medical care in India well into medieval times. It was only during periods of political instability, due to external invasions, that it's use and development started to decline. By mid-19^th century, British policy marginalized these indigenous systems of medicine. Later, as medicine was taught in the new medical colleges to students from the upper classes of Indian society, it was this Western system of medicine that was taught. European Medicine became the official health care system of India under British Rule, and Indian systems of medicine (ISM) were allowed to dwindle.

Recognizing the disservice that had been done to the traditional systems of healing and to promote their use, the Government of India created the Department of Indian Systems of Medicine and Homeopathy (ISM and H) in 1995 which was renamed as the Department of Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homeopathy (AYUSH) in 2003.[2] India thus gave official recognition to multiple systems of medicine. Despite the existence and recognition of AYUSH by the Government of India, there is a lack of understanding and even awareness about them among practitioners of Allopathic medicine.

There are at present more practitioners of AYUSH (about 7 lakhs), than of Allopathy (about 6.5 lakh) in India. The number of undergraduate teaching institutes offering AYUSH courses are about 439 with about 30,000 AYUSH students graduating every year. Contrast this with about 387 medical colleges offering Allopathic medicine with about 50,000 students graduating every year.[2,3]

The doctor patient ratio in India is 1:1700 if only allopathic doctors are considered, but if the AYUSH practitioners are added, then the total number (about 1,315,000) makes this ratio 1:800, which is better than the WHO recommendation of 1:1000. At present, there is an acute shortage of allopathic doctors in the country and this is going to increase in the years to come. The distribution of allopathic doctors is also skewed, with very little presence in rural and remote areas. Practitioners of AYUSH however have a much wider presence.[3]

To meet the shortage of doctors in India, the Government has been encouraging and promoting the use of AYUSH in the public health system. In many states, AYUSH practitioners are the only practitioners in some remote Primary Health Centers where they provide primary health care to needy people.[2]

Despite the coexistence of the AYUSH and Allopathic systems for many years, doctors of one system are totally oblivious of what the other systems have to offer. Often patients take treatment from practitioners of many systems of medicines at the same time. Yet the treating doctor is often ignorant of what their patients are taking. This is because allopathy and AYUSH systems are taught in different medical schools and many practitioners of one system are unaware of the other systems. It is well known that drug interactions can occur with herbal medicines and synthetic drugs. MBBS students are only exposed to AYUSH in an introductory class on the history of medicine (that includes history of medicine across all civilizations). In many medical colleges, even this is not done.

Not only this, surveys have shown that both allopathic and AYUSH practitioners prescribe medicines from other systems of medicines. Well known examples are prescriptions for LIV 52 for liver disorders and Cystone for renal calculi by allopathic doctors and analgesics, corticosteroids and antimicrobials by AYUSH practitioners. A study done in KEM hospital Mumbai showed that 99% resident doctors did not know the basics of Ayurveda but 67% of them prescribed ayurvedic medicines to their patients.[4]

Legally also in India confusion prevails regarding prescribing of medicines by practitioners of different systems of medicines that is, allopathic medicines by AYUSH practitioners and AYUSH medicines by allopathic doctors, the so-called “Cross-pathy.” Doctors should ideally not prescribe medicines that are not from the system they have received training in. The reason for this is that when a person has not received training in a particular system of medicine, she would not be fully informed and hence, not be in a position to prescribe a medicine from that system. This is to avoid harming the patients. This was clearly stated in the judgment of the Hon’ble Supreme Court of India, in the case of Poonam Verma Vs Ashwin Patel and others. The court said “the doctor must not only be qualified, but he must also be registered with the appropriate Medical Council in order to practice as a doctor. A homeopath would not have knowledge about allopathic medicines and its drug actions, so administration of allopathic treatment by a homeopath would be proof enough to establish negligence”.[5] As per this judgment homeopathic doctors are not legally permitted to prescribe allopathic medicines.

According to the Section 2 (ee) of the Drugs and Cosmetics Act Rules, allopathic medicines can be prescribed only by a Registered Medical Practitioner (RMP). Three categories of RMPs are defined in three sub-clauses of this Rule. Sub-clause (i) and (ii) are practitioners holding a qualification and registration for practicing modern medicine. Sub-clause (iii) however allows practitioners who are registered in a medical register (other than a register of Homeopathic practitioners) of a State, who although not falling within sub clause (i) or sub-clause (ii) is declared by a general or special order made by the State Government in this behalf, as a person practicing the modern scientific system of medicine for the purposes of this Act. Thus according to this sub-cause (iii) or Rule 2 (ee) of the Drugs and Cosmetics Act Rules, practitioners of ISM, so declared by the respective State Government, are legally permitted to prescribe allopathic medicines.[6]

Many State Governments have issued such orders and thereby permitted practitioners of AYUSH to prescribe allopathic medicines. Such State Government orders have been upheld as valid by the Hon’ble Supreme Court in it's judgment in the case of Dr. Mukhtiar Chand and Others vs The State of Punjab and Others 1998.[7] The Maharashtra Government has amended the Maharashtra Medical Practitioners Act to regularize a gazette notification of 1992 that allowed Ayurveda practitioners to prescribe allopathic medicines. These regulatory changes are being opposed and contested in courts in States where the Government has permitted the prescribing of allopathic medicines by practitioners of ISM.

In the absence of a cohesive policy about the training, curriculum, practice, prescribing of medicines among different systems of medicines in India, such regulations would probably do more harm than good. What is certain is that practitioners of all systems of medicines are needed to take care of the health problems of the country. The problem is the lack of awareness of practitioners of different systems about other systems of medicines. Lack of adequate quality control of education and training of different systems of medicines, further adds to the problem.

Contrast this isolation and segmentation of medical education in India, to many countries across the globe where medical education itself is integrated. In China, every allopathic medical college contains a department of traditional medicine, and every traditional medical college contains a department of allopathic medicine. Around 15% of teaching time in allopathic medical schools is allocated to traditional medicine. A greater emphasis is placed on allopathic medicine in colleges of traditional medicine, where about 30% of the time is allotted for its teaching.[8] In the USA, over 50 Universities and medical schools including Harvard University, Stanford University and the University of Maryland are now offering courses in integrative or alternative medicine.[9] The curricula for this have been prepared by the Education Working Group of the Consortium of Academic Health Centers for Integrative Medicine (CAHCIM). CAHCIM is a consortium of 23 academic health centers working together to help transform health care through vigorous scientific studies, new models of clinical care and innovative educational programs that integrate biomedicine, the complex systems that integrate to create human beings and the rich diversity of therapeutic systems. It comprises of faculty from leading medical colleges in USA.[9]

While we are at present in no position to start integrated medicine, we could at least begin sensitizing our MBBS students towards AYUSH. There are many reasons why we need to do so and do so urgently.

1. Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homeopathy are an integral part of our health care system and have been for hundreds and some for thousands of years.

2. Patients have been using and will continue to use these systems of medicine, often along with allopathic medicines.

3. Other systems of medicine may have favorable or unfavorable interaction with allopathic medicines, and we need to know this.

4. Knowledge about other medical systems will enable doctors to offer more treatment options to the patient. For example if there is no cure for a particular condition in one system, the doctor could refer the patient to another system, if he is aware that there is a viable treatment option for the patient there.

5. The Government of India has accepted AYUSH and has been promoting their use in public health facilities since 1995.

6. There are costs involved in all systems of health care. Doctors need to be aware of this. The most cost effective therapy for a particular condition needs to be offered to the patient who may be in another system of medicine.

It is now a necessity that doctors know the basic principles and approaches of other systems of medicine widely prevalent in India. This sensitization would not equip them to prescribe medicines from other systems of medicine, but will increase their understanding of what the other systems are trying to achieve and what they have to offer, thereby increasing the treatment basket with which the physician can heal his patient.

To begin with classes of a few hours could be introduced to sensitize medical graduates to AYUSH. Since four components of AYUSH involve the prescribing of medicines – Ayurveda, Siddha, Unani and Homeopathy, these introductory lectures could be taken up by the Department of Pharmacology, in the 5^th semester. There are many allopathic doctors who have an interest in these systems, they could be invited to take guest lectures. Guest lectures could also be arranged by inviting faculty from colleges of other systems of medicine. Integrated CMEs on different systems of medicines could be organized. These CMEs could focus on treatment of diseases and not diagnosis. Research on the effect of combining allopathic and AYUSH medications in different conditions also needs to be done, to elicit both beneficial or harmful effects of such combinations. This may seem too simplistic an approach, but at least we could begin.

The same is true about the pharmacy curriculum in India. Pharmacists are a vital link between a doctor's prescription and the patient. In many instances, pharmacists are also advising the patients about what medication to take. Pharmacy curriculum at present is also a drug focused and not patient focused. Awareness about medications belonging to different systems of medicines and how they work is not a part of their curriculum even though pharmacists may be handling prescriptions of medications belonging to different systems and selling these products thorough chemist shops. For overall improvement in the patient care, it is imperative that knowledge of the various systems of medicine be incorporated in their curriculum.[10,11]

This monolog may seem a little out of place coming from a doctor-teacher of Pharmacology, but the time has come to think outside the box. The world has moved on toward a greater integration of various systems of medicine. The aim of any health system is to provide the best possible treatment option to a patient. We definitely cannot do it when we don’t even know what the other medical systems of medicine have to offer.